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Home My WebLink AboutMiscellaneous - 895 FOREST STREET 4/30/2018 (2)Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. ray I�f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 895 Forest St Property Address Peter Simonson Owner's Name North Andover City/Town Ma. 01845 State Zip Code 4-9-11 Date of Inspection 0,31 slr/,, Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: N. Timothy White Name of Inspector Homepro Northshore Company Name 75 Glen St. ( P.O. box 101) Company Address Rowley City/Town ( 978-948-8428 ) Telephone Number B. Certification APS 1? 'OWN 011 RURTH ANDOV611 HE PH tKIPARTMEW— Ma. 01969 State Zip Code S12015 License Number 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 Inspector's Signature 4-9-11 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. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): na t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 895 Forest St Property Address Peter Simonson Owner Owner's Name information is required for North Andover Ma. 01845 4-9-11 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): na t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 895 Forest St Property Address Peter Simonson Owner's Name North Andover Ma. 01845 4-9-11 Cityfrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below) 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 895 Forest St Property Address Peter Simonson Owner Owner's Name nformarequired for is North Andover Ma. 01845 4-9-11 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: na 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 ❑ i 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 ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: na 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 % day flow t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Insp o Subsurface Sewage Disposal System For GSM ,.•�''r 895 Forest St Property Address Peter Simonson Owner Owner's Name nformatiis North Andover required for every page. City/Town B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes ection Form m - Not for Voluntary Assessments ❑ 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 Ma. 01845 4-9-11 State Zip Code Date of Inspection ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 09/08 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 895 Forest St Property Address Peter Simonson Owner Owner's Name information is required for North Andover Ma. 01845 4-9-11 every page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 150-750 gpd t5ins • 09/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 895 Forest St D. System Information Description: Number of current residents: 4-9-11 Date of Inspection Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) K ® Yes ❑ Property Address ❑ Yes ® Peter Simonson Owner Owner's Name information is required for North Andover Ma. 01845 every page. Cityrrown State Zip Code D. System Information Description: Number of current residents: 4-9-11 Date of Inspection Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) K ® Yes ❑ No ❑ Yes ® No ❑ Yes ® No ❑ Yes ® No 09 & 10- 135,000 gal = 184 gpd ❑ ❑ Yes ® No still occupied Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts H Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 895 Forest St Property Address Peter Simonson Owner information is required for every page. Owner's Name North Andover Cityrrown D. System Information (cont.) Last date of occupancy/use: Other (describe below): na Pumping Records: Source of information: Ma. 01845 State Zip Code Date General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: 4-9-11 Date of Inspection last pumped 6 years information from owner gallons Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy 111= ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , 895 Forest St Property Address Peter Simonson Owner Owner's Name information is required for North Andover every page. Cityrrown State D. System Information (cont.) 01845 Zip Code 4-9-11 Date of Inspection Approximate age of all components, date installed (if known) and source of information: 20 years old Information from owner Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 15 in 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: Material of construction: ® concrete ❑ metal 7 in feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10 long - 5ft wide 5 ft deep 1500 , Sludge depth: 4in t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Owner information is required for every page. t5ins - 09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 895 Forest St Property Address Peter Simonson Owner's Name North Andover Ma. 01845 4-9-11 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) 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 31 in lin lin 16in How were dimensions determined? rulers & measuring rod 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 baffles in very good condition liquid at bottom of outlet invert - no sign of leakage in or out of tank- tank in good condition Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 895 Forest St Property Address Peter Simonson Owner information is required for every page. Owner's Name North Andover Cityrrown State Zip Code 4-9-11 Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): na Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: Design Flow: gallons gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: Date of last pumping: Date Comments (condition of alarm and float switches, etc.): na ❑ Yes ❑ No * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 895 Forest St Property Address Peter Simonson Owner's Name North Andover City/Town D. System Information (cont.) Ma. 01845 4-9-11 State Zip Code Date of Inspection 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 - distribution was equal - no solids carryover - no leakage in or out of d- box - size of d- box 16x16 in 15in deep 20in below grade Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): na Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 895 Forest St Property Address Peter Simonson Owner Owner's Name information is required for North Andover every page. Cityrrown D. System Information (cont.) Ma. 01845 4-9-11 State Zip Code Date of Inspection Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system 3 trenches 50 ft long each Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): dry gravel soil - no hydrulic failure - no ponding system was under right side lawn Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow t5ins • 09/08 ❑ Yes ® No Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17 M Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 895 Forest St Property Address Peter Simonson Owner's Name North Andover Cityrrown D. System Information (cont.) Ma. 01845 State Zip Code 4-9-11 Date of Inspection 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.): t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Owner information is required for every page. t5ins • 09108 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 895 Forest St Property Address Peter Simonson Owner's Name North Andover Ma. 01845 4-9-11 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand -sketch in the area below ❑ drawing attached separately Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 895 Forest St Property Address Peter Simonson Owner Owner's Name information is required for North Andover Ma. 01845 4-9-11 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: from original grade groundwater at 84 in eshgw 43in Please indicate all methods used to determine the high ground water elevation: 14 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 office& last title v report - test pit #72 - 102 in water at 84 in - test pit # 73 1 14i no water found Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Ir Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 895 Forest St Owner information is required for every page. Property Address Peter Simonson Owner's Name North Andover Ma. 01845 4-9-11 Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments . RECEIVED r` Subsurface Sewage Disposal System Form Inspection results must be submitted on this form or on the official ritle 5 Inspection Form d ted 6/15/2000. Inspection forms may not be altered in any way. NORTH ANDOVER A. Certification HEALTH DEPA Important: When filling out 1. Property Information: forms on the computer, use 885 Forest St N. Andover only the tab key Property Address to move your Per Oines cursor - do not Owner's Name use the return key. 885 Forest St Owner's Address N. Andover Ma 01845 City/Town State Zip Code Date of Inspection: Date 5-7-05 Date 2. Inspector: N . Timothy White Name of Inspector Homepro Northshore Company Name P.O. Box 101 Company Address ROWLEY Ma 01969 City/Town State Zip Code 1-978-948-8428 Telephone Number 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 IV\, L'� 5-7-05 Inspector's Signature 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 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M 5v y A. Certification (cont.) 885 Forest St Property Address N. Andover City/Town Per Oines Owner's Name Ma State 5-7-05 Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: 01845 Zip Code ® 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 Cityrrown Per Oines Ma State 5-7-05 Owner's Name Date of Inspection B) System Conditionally Passes (cont.): 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: 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 1$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 Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 885 Forest St Property Address N. Andover Cityrrown Per Oines Owner's Name Ma State 5-7-05 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: 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 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 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 % 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 Title 5 Official Inspection Form Not for Voluntary Assessments r` 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 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 Commonwealth of Massachusetts WRI - Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Checklist 885 Fortest St Property Address N. Andover Cityrrown Per Oines Ma State 5-7-05 01845 Zip Code 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 C. System Information 885 Forest St Property Address ® N. Andover Ma 01845 City/Town State Zip Code Per Oines 5-7-05 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 600 gpd Number of current residents: 5 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 (gpd)): 260 gpd Sump pump? ❑ Yes ® No Last date of occupancy: still occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: NA 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): Date per day (gpd) ❑ 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 C. 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: Type of System: 01845 Zip Code last pumped 2 years information from owner gallons ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Yes ® No ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative 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 vears 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 City/Town Per Oines Owners Name Building Sewer (locate on site plan): Depth below grade: Material of construction: ❑ cast iron ® 40 PVC Ma State 5-7-05 Date of Inspection 22in feet ❑ 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 ❑ 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 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 Property Address N. Andover City/Town Per Clines Ma State 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: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness NA feet ❑ fiberglass ❑ polyethylene ❑ other (explain): 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 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 City/Town State Zip Code Per Oines 5-7-05 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 - distribution was equal - no evidence of any solids carryover - no evidence of leakage in or out of d- box f) — 13�v 13 /f DC --LC,,.,— Gds I ,L -S(DF 01;2Fqy cy Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ 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 Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 885 Forest St Property Address N. Andover Ma 01845 Cityrrown State Zip Code Per Oines 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 ❑ 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: 1200 SQ FT 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 bV'�� ` Subsurface Sewage Disposal System Form C. System Information (cont.) 885 Forestv St Property Address N. Andover Cityrrown Per Oines Owner's Name Ma State 5-7=05 Date of Inspection 01845 Zip Code 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 NA 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 City/Town State Per Oines 5-7-05 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: Please indicate all methods used to determine the high ground water elevation: 0 C Obtained from system design plans on record If checked, date of design plan reviewed: Date 01845 Zip Code 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 4 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 01845 N. Andover Ma State zia code city/Town 5-7-05 Per Oines Date of Inspection Owner's Name 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 f Title 5 Offtal inspection Form: Subsurface Sewage Disposal System t5insp.doc • 11/2004 Page 15 of 1F _ COMMONWEALTH OF MASSACHUSETTS ` EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 � 3n� ARGEO PAUL CELLUCCI Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: f54?J FSR5 S 1 N� Aye Name of Owner J Date of Inspection: I) q�d� Address of Owner: !Y" t�11111 Name of Inspector: (Please Print) N rT' i Mr)+' hXr h i t e 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Home Pro Northsho MailingAddress: P . 0 . BoX 101, Row ey , MA 01969 Telephone Number: (978)948-8428 TRUDY COXE Secretary DAVID B. STRUHS Commissioner A/c 4f -4j V 1F%1 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: fh l► Date: 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 sent to Vm system owner• and copies sent to the buyer, if applicable, and the approving authority. . NOTES AND COMMENTS revised 9/2/98 Page 1 of 11 0 Printed on Rec*led Paper 23 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:16aj� F0nn05% S l Nr 4'vQ;Uir� Owner: j ea,, Date of Inspection: I (cl Aatc-) INSPECTION SUMMARY: Check A, B, C, " A �7ESEM PASS: have not found any information which Indicates that any of the failure conditions described in 310 CMR 1.5.303 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 pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than fourtimes a year due to broken or obstructed pipe(sY. The i yvem wiltpass- inspection if (with approval of the Board of Health): • •.. •. broken pipe(s) are replaced obstruction is removed Y revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: S ej> FcAR 6$T s I' Nt IA, tv leo V Owner: 394fv Ma R1 N Data of Inspection: K-) I 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 15.303 (1)(b) THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH MALL PROTECT THE PUBLIC HEALTH.AND SAFETY..AND THE ENVJRONMEN-T_ 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 ENVIRONMENT: - The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil' absorption system and the SAS is within 50 feet of•al 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 Y revised 9/2/98 Page3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A • CERTIFICATION (continued) • Property Address: 9S' t�c nrt S i N, :�yfL v Owner: Date of Inspection: D. SYSTEM FAILS: 61 L ci 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 intofacility or system component due .to an overloaded orcloggW-SAS- or-cesspoo). _ 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 anoverloaded or clogged SAS or cesspool. Liquid depth in cesspool is less 'than 6" below invert or available volume is less than 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less -than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for -coliform bacteria, volatile organic- compounds, ammonia nitrogen -and nitrate nitrogen. - E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is -within 200 feet of•"butarytoa surfaceArinking-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 information. r revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: �(S f n(i e-5;( S l Owner: Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Ye No Pumping information was provided by the owner, occupant, or Board of Health. • _ None of the system -components haMebaen puaqwMbFatdeast two -weeks and•thwarystern has.traea%mceiviwg9mmal -flow rates during that period. Large volumes, of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. V _ The facility or dwelling was ins acted for signs. of sewage back-up. _ The system does not receive non -sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were. uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on -the site has been determined based on: (Y _ 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) The facility owner (and. occupaats,lf differaW from..owner) wera.prnvided with information nn tha proper maintenaar�-0f SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: qs Fcnrte5-1 $-r- tat A-ry 0c -,V P�1 Owner: ��,,,� MCJ Kt ti Data of Inspection: 1 1 —1 ICU FLOW CONDITIONS RESIDENTIAL: Design flow: 1 SV g.p.d./bedroom. Number of bedrooms (design): Number of bedrooms (actual): Total DESIGN flow (�00 Number of current residents: 3 Garbage grinder (yes or no): 1V0 Laundry (separate system) (yes or no):Nv;: if yes, separate impection.required Laundry system Inspected (yes or no) Seasonal use (yes or no): Nv J �. q Water meter readings, if available (last two year's usage (gpd): � � -► b b � I J.'�✓� Sump Pump (yes or no) -fid PC Last date of occupancy: COMMERCIALANDUSTRIAL: Type of establishment: Design flow:gpd ( Based on 15.203) Basis of design flow 6� Pr -6 Da� Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non -sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: PUMPING RECORDS and source of \ V a on GENERAL INFORMATION ed al System pumped as part of inspection: (yes or no)_vv If yes, volume pumped: gallons Reason for pumping: Gkj-u TYPEO SYSTEM 16 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 APPROXIMATE AGE of all components, date instalied{if known) -and source of,information: �.�,S�n� Li -� ti1=-n��AT1cW Fel Ov..U� Sewage odors detected when arriving at the site: (yes or no) A./v revised 9/2/98 Page 6of11 %- pI-4ti5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property address: ' r—cvR(I E.ST -51- N, 610Y %/V, Owner: Date of Inspection: l M v R r n! BUILDING SEWER: (Locate on site plan) Depth below grade:_ Material of construction: _ cast iron _ 40 PVC _ other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, -etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade:2/ ! � 9S M AS l � Cc -u-IN Material of construction: ✓concrete _metal _Fiberglass _Polyethylene _other(eiplain) If tank is Metal, list age _ 1s.age.confirmed by Certificate of Compliance_ (Yes/No) Dimensions: l U j Lx�.A, 6 Q ,$' b r2QPJ S uu G 6L Sludge depth: I 7r Distance from top of sIV ge to bottom of outlet tee or baffle: 7.1 ` —• Scum thickness: I Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 1 How dimensions were determined: f'L L oL. fzti S P-% 6W,,A I Al 6 f >° S G {C Comments: (recommendation for pumping, condition of inlet and outlet tees or -baffles, depth of liquid level in evidence of leakage, etc.) T A V %4- p&135 NvT A/ F&G_0 'ti 6a 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: to outlet invert, structural-intearity. Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outint invert, structural integrity, evidence of leakage, etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C • SYSTEM INFORMATION (continued) Property Address: qj Cin RAS, sT N , A tiCtjv 9*-. Owner: Date of Inspection: �1 Ct )sem TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order: Yes _ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:^ a V 6 �t�,w G'.�qq� (� �(��f /�,� ID&FSJ'H- IJ (locate on site plan) Depth of liquid level above outlet invert:_�L Comments: (note•if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) D- _ a ,L 1&14S L Ff U gA- W -O fts 6 0 L,#, t_ /vu - &U, ID &A -/CF- O•,C, p�j Se, L b S�R� � n�cw AW a..F I.. GC,stC4"Cr-- It,/ e w crv1r c PUMP CHAMBER:_ (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �� F�-nRas-rr .57T— Owner: n� f� i Date of Inspection: 16 I I q ` SOIL ABSORPTION SYSTEM (SAS):— (locate SAS)_(locate on site plan, if possible; excavation not required, location may be approximated by non -intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers, number: leaching galleries, number: / leaching trenches, number, length: Ir0 sa 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.) ,.Svlt_ w43 0 r -+ Md 14q DmA.jI-(c =All. c. AQ — Nc-- A -0A N CESSPOOLS: _ (locate on site plan) Number and configuration: - Depth -top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of •vegetation, etc.) PRIVY: _ (locate on site plan) Materjals 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 PART C • • SYSTEM INFORMATION (contirwed) Property Address: Owner: �' �' Aw- ►Mcv R j w Date of inspection: ►ct SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: `I,S F -6n n g$T $ Z` /V c Owner: Date of Inspection: NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells i mated De t6i to Groundwater � Feet se i icate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed.Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) aA T �s i P cT' -- 173 revised 9/2/98 Page 11 of 11 P -Wb of �►F..o�.Tc-1 -C FOIR& ST, Sr ,�OAfJiTiOtis : Di �4 PPRo vEp R�4SoNS WQTE� SO PPLI Q wls L T 5 Prl c Sy sTE" PE -S► 6,-,) ,P�RogED O'YE5 D WO 4 C,3:r z- �,,,� PA -r6- APR�ovw6 Aurhoi;�iry (2 c��icl5 6( (ter dared `'G� SrPT't � SySTENI 1 � STA �-LQT ►0�1 C-YCAV4TO J )NSPI�-G T fOAj N _ 7-3SS Fi41L PwAL t 1� SpF�rlon� PFRO VE1>-P/3TC- 0_� APFi�l7v�^�G �4D�IT(D�AL ��15t�c., IpNS �� A►-�y) ruST. M.f�i�,lA7' Rj�&So MS FVAL APPf�pvAL DA rC D,oT� 1-1 I- . AppxwvJ6 16u;HoR, -t-Iq? Commonwealth of Massachusetts = D, City/Town of System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be 'used, but the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/ Right front of house, Left/ Right near of house, Left side of house Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address 186 Cityfrown 2. System Owner. Name a � , State Zip Code Address (if different from location) Cityfrown Stat C , -�gde \ �•:. Telephone Number B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Date -( 4-(Y — 2. Quantity Pumped; eptic Tank Cesspool(s) Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No. 5. Condition of System:— -Qc) ,4�j 6. System Pumped By.- Nell y: Neil Bateson Name Bateson Enterprises Inc Company 7. LKhere contents were disposed: F5821 Vehicle License Number Date t5form4.doe- 06103 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts = City/Town of No.Andover W° System Pumping Record ` Form 4 M Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Q �etron APR 132n-) TOWN OF NORTH ANDO �rq Ll'. �.. __ DEP has provided this form for use by local Boards of Health. Other information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information 1 MUUMaa No. Andover Ma W886 City/Town 2. System Owner: Name Address (if different from location) City/Town State State Telephone Number B. Pumping Record s ��2 1. Date of Pumping ate 2. Quantity Pumped: 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes/z No 5. Condition of Syst m : 6. System P ed By: Name Stewart's Septic Service Company 7. Location where contents were disposed: Zip Code Zip Code 1 4q) Ilons ❑ Grease Trap If yes, was it cleaned? ❑ Yes ❑ No ;r7l )r Vehicle License Number Stewart's Pre-treatment Plant, 20 So. Mil: Bradford, Ma 01835 Signature of Ha Signature of Date Date t5form4.doc• 03/06 \ I System Pumping Record • Page 1 of 1 Comingme,alth of )Ift4ax/�-Massachusctts System Pumping Record System Owner System Location Date or Pumping: �'—�a'� jof-e-'i Quahtity Pumped: Cesspool: No Yes LI Septic Tank: No U System Pumped by: varedert 5mmhie 4 License # Contents transrerrred to : Greater Lawrence Sanitary District llate: __ Inspector- l��gallons Yes ;:';•w: h.'..'i•j: ;ik:!.'i9•: 'J1Xl.Ci',}'p; :"'.II(^ ,P r:i:. ;a,: - rn ! �. ..I, 'G: y 1..Y ,'!i r%':� p ';,+1.'<61 :•li'y:`};'a'i':' ,'.ie.: .. `^-•�^-_^-�-.—�..—._�_�_ ..t: "i, y'!G,} r(i'.�'yr �'✓,''11 ��+ ''f"r .•�1i •,'!,v „1. ,.}i. !,1. .+1j:p: %. t: I. !.i\7 +�� .IY� �/ '�rh�, J.cJ-w g .S ,t;r�'',t,.dr(,. _t: r:; •'%'t;;,;i. �,,:,.C.' h;�>+'r:�l "4.r•�� .ySiY. t �, a� ,r.�'1'17r !i) Y j 1�•�'? �.>J.d,:. 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