HomeMy WebLinkAboutMiscellaneous - 91 FULLER ROAD 4/30/2018Commonwealth of Massachusetts
North Andover, Massachusetts
System Pumping Record
System Owner & Address:
Randy Ellis
91 Fuller Road
North Andover, MA 01845
Location of system: Front yard
Date of Pumping: April 13, 2013
Type of system: Septic Tank
Gallons Pumped: 1500 gallons
System pumped by:
Service Pumping & Drain Co., Inc.
S Hallberg Park
North Reading, Ma
License #: BHP -2013-0098,0100,0765,0096,0097,0099,0101
Contents transferred to: Greater Lawrence Sanitary District
RECEIVED
APR 2 2 2013
TOWN OF NORTH ANDOVER
HEALTH DEPARTAAchrr
Date:: April 13„ 2013 Pumping Technician: MW
This is PROPRIETARY and CONFIDENTIAL information that may
be used only by the Board of Health for regulatory purposes
S
TO: NORTH ANDOVER, MASS. December 19 19 80
BOARD OF HEALTH
FROM: DESIGN ENGI14EER Re: Soil Absorption Sewage
Disposal System
This is to certify that ' I have inspected* the construction of said disposal
system at Lo t� Fuller 1'oad
SITE LOCATIO14
North Andover, Mass.
�fiRA.
The grades and construction are as specified'in A%.qs and specifications
dated December 19 19 80 P�� ties\
AN v y
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Reg. P pri��i �y Reg. Sanitarian
*As built grades and location
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DATE
SUBSURFACE DISPOSAL DMGN CHWK LISr
DISAPPROVES DATE
Reasonss '—'
R
LOT
The submitted plan must ahow as a minimums —r
a) the lot to be served-area,dimensions lot
b location and log deep observation hoi t ,abutters
-IC) location and results percolation tests -distance to ties
design calculations do calculations showing � ties 4
e location and dimensions of g required leaching area
' f� existing and proposed coof reserve area
S) location ntours
v wet areas xitMz 100, of se
disclaireer-check wetlands gypping Wage disposal system or
h) system surface
Or disclaimer drains within ' of sewage disposal
6-5 location any drainage easements within �
system or es of a
disclaimer -Planning eimge disposal
ij) kaov,n sources of taterBoard filessystem or disclaimer '� within 200 of sevage disposal
k) location of arm propOBed X11 to serve
P37location of water lines on -10 lot -100' from leaching facility
m) location of benchmark Pr`°pgrty_10' i�om leaching facility
n) driveways
ID
garbage disposals
�P no PVC to be used in construction
�Q) Profile of system -elutions of basement, plumb
distribution box inlets and outlets distribution field
tank
Otter elevations ' piping and
r) maximam ground water elevation in area s
s) Plan must be prepared by, a professional evage disposal systems ---
suc
Eagin
Prepare h planProfessional authorized by lawaw to P P re eer n other
a
b)
C)
d)
S tic Tis
access, ep�ing of flow, water {,able; tees, depth of tees,
cleanout
101 from cellar wall or inground EUL=Ming Pool
�5' from subsurface drains
Distribution Boxes
s�p8
a) greater 0.08
b) sum
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FORM U - IAT 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 local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: 67LL ro r i M PNOEL.L Phone 6 g9 -`d l,o I
LOCATION: Assessor's Map Number 61.) Parcel
9
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Subdivision Lots) 4=4 Z/
Street 91 ROAD St. Number 91
************************Official Use Only************************
' RREECOMMENDATIONS OF TOWN GENTS•
C/ Date Approved 14121
Conservation Administ r Date Rejected
Comments
Date Approved
Town Planner Date Rejected
Comments
od Inspector -Health
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Septic Inspector -Health
Date Approved
Date Rejected
Date Approved 154h% /
Date Rejected
Comments SS DS IN F oN,T O� /fOUS� BOG /GG
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Public Works - sewer/water connections
- driveway permit
Fire Department
Received by Building Inspector Date
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JNSTALLkT�CK CHMK UST LOT
Reammst
1. Distance Tot
a. Wetlands
b. Drains
c. Well
2. Water Line Location
3. No PVG Pipe
4. Septic Tank -oat Covers.
a.. -Tees i --Length & To Clean Both Sides of Tank
b. Cement Pipe to Tank - Ola BO
5. Distribution Box
a. Covers & Box - No Cracks
b, All Lines Flowing Equal Amounts
c. No Back Flow
6.- Leach Field or Trench
a. Dimensions
b. Stone Depth
c. Capped Ends
d. Clem Double Washed Stone'
7. Leach Pit!/
a. Dimensions
b. Stone Depth
co3ash Pads
d,
6. Cment pipe to pit Both Sides,
Ile
Clean Double Washed Stone
8. No Garbage Disposal
9. Final Grading Inspection
lo. Barricading Covered System
3.1. As Built Submitted
a. Lot Location
b. Dimensions of System
c. Location with Regar&to Perc.Test
d. Elevations
e: Water Table
16
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1&1
206 ANDOVER ST., SUITE 11
ANDOVER, MA 01810
(508) 475-1237
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION
�!AR 2 61997
Property Address: 91 Fuller Road, North Andover, MA
Address of Owner (if different): N/A
Name of Inspector: Peter F. Reilly
Company Name, Address, Phone #: F.P. Reilly & Sons, 206 Andover St., Suite 11
Andover, MA 01810 (508) 475-1237 / (508) 475-4370
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information is true,
accurate and complete as of the time of inspection. The inspection was performed based on my training and
experience in the proper function and maintenance of on-site sewage disposal systems. The system:
✓ Passes
N/A Conditionally Passes
N/A Needs Further Evaluation By the Local Approving Authority
N/A Fails
r
Inspector's Signature: Date: 3/10/97
eter F. illy
The system inspector shall submit a copy of this inspection report to the approving authority within thirty (30) days
of completing this inspection. If the system is a shared system of has a design flow of 10,000 gpd or greater, the
inspector and the system owner shall submit the report to the regional office of the Department of Environmental
Protection. The original should be sent to the system owner and copies sent to the buyer', if applicable and the
approving authority.
INSPECTION SUMMARY:
A. SYSTEM PASSES:
✓ I have not found any information which indicates that the system violates any of the failure criteria as defined
in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
— SERVING ANDOVER & VICINITY FOR OVER 40 YEARS —
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION (continued)
Property Address: 91 Fuller Road, North Andover, MA
Owner's Name: Elliott Mandell
Date of Inspection: 3/10/97
B. SYSTEM CONDITIONALLY PASSES:
N/A One or more system components need to be replaced or repaired. The system, upon completion of the replacement or
repair, passes inspection.
Indicate yes, no, or not determined (Y, N, ND). Describe basis of determination in all instances. If "not determined", explain
why not)
N The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
N Sewage backup or breakout or static high 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):
N/A broken pipe(s) are replaced
N/A obstruction is removed
N/A distribution box is leveled 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):
N/A broken pipe(s) are replaced
N/A obstruction is removed
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 environment.
1. SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT
FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY
AND THE ENVIRONMENT:
N/A Cesspool of privy is within 50 feet of a surface water
N/A Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh.
2. SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF
APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT
PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
N/A The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or
tributary to a surface water supply.
N/A The system has a septic tank and soil absorption and is within a Zone I of a public water supply well.
N/A The system has a septic tank and soil absorption and is less than 100 feet but 50 feet or more from a private
water supply well, unless a water 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.
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION (continued)
Property Address: 91 Fuller Road, North Andover, MA
Owner's Name: Elliott Mandell
Date of Inspection: 3/10/97
D. SYSTEM FAILS:
N/A I have determined that the system violates one or more of the following failure criteria as defined in 310
CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
N Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
N Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool.
N Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
N/A Liquid depth in cesspool <6" below invert or available volume < 1/2 day flow.
N required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped: none
N Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
N/A Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water
supply.
N/A Any portion of a cesspool or privy is within a Zone I of a private water supply well.
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well.
N/A 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:
The following criteria apply to a large system in addition to the criteria above.
N/A The design flow of system is 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:
N The system is within 400 feet of a surface drinking water supply
N The system is within 200 feet of a tributary to a surface drinking water supply
N The system is located in a nitrogen sensitive area (Interim Wellhead Area (IWPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment
program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the DEP for further information.
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART B - CHECKLIST
Property Address: 91 Fuller Road, North Andover, MA
Owner's Name Elliott Mandell
Date of Inspection 3/10/97
Check if the following have been done:
✓ Pumping information was requested of the owner, occupant and Board of Health.
✓ None of the system components have been pumped for at least two weeks and the system has been receiving
normal flow rates during that period. Large volumes of water have not been introduced into the system
recently or as part of this inspection.
✓ As built plans have been obtained and examined. Note they are not available with N/A.
✓ The facility or dwelling was inspected for signs of breakout.
✓ All system components, excluding the SAS, 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 SAS on the site has been determined based on existing information or
approximated by non -intrusive methods.
✓ The facility owner (and occupants, if different from owner) were provided with information on the proper
maintenance of SSDS.
PART C - SYSTEM INFORMATION
FLOW CONDITIONS
RESIDENTIAL:
Design Flow: 440 gallons
Number of bedrooms: 4
Current residents: 2
Garbage grinder: no
Laundry connected to system: yes
Seasonal use: no
Water meter readings, if available: 62,200 cu.ft. 1996 and 1996
Last date of occupancy: current
COMMERCIAL/INDUSTRIAL:
Type of Establishment:
N/A
Design Flow:
N/A
Grease trap present:
N/A
Industrial waste holding tank
N/A
Non -sanitary waste discharged
the Title 5 system
N/A
Water meter readings, if available:
N/A
Last date of occupancy:
N/A
OTHER:
Describe: N/A
Last date of occupancy: N/A
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 91 Fuller Road, North Andover, MA
Owner's Name Elliott Mandell
Date of Inspection 3/10/97
GENERAL INFORMATION
PUMPING RECORDS and source of information:
last pumping: five to six years according owner
System pumped as part of inspection: no (pumped following inspection)
if yes, volume pumped: N/A gallons
Reason for pumping: N/A
TYPE OF SYSTEM
✓ Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
NO Shared system (yes or no - if yes, attach previous inspection records, if any)
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information:
House was constructed in 1980. "As built" plans were available, but position of d -box was not shown.
Sewage odors detected when arriving at the site NO
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 6"-8"
material of construction: ✓ concrete metal FRP other (explain)
Dimensions: rectangular - 1,500 gallons
< 1" sludge depth
39" distance from top of sludge to bottom of outlet tee or baffle
< 1 " scum thickness
7" distance from top of scum to top of outlet tee or baffle
17" distance from bottom of scum to bottom of outlet tee or baffle
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, recommendations for repairs, etc.)
Tank was watertight and functioning properly.
Property Address:
Owner's Name
Date of Inspection
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
GENERAL INFORMATION (continued)
91 Fuller Road, North Andover, MA
Elliott Mandell
3/10/97
GREASE TRAP: N/A (locate on site plan)
Depth below grade:
material of construction: concrete metal FRP other (explain)
Dimensions:
scum thickness
distance from top of scum to top of outlet tee or baffle
distance from bottom of scum to bottom of outlet tee or baffle
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, recommendations for repairs, etc.)
N/A
TIGHT OR HOLDING TANK: N/A (locate on site plan)
Depth below grade:
material of construction: concrete metal FRP other (explain)
Dimensions:
Capacity: gallons per day
Design Flow: gallons per day
Alarm level:
Comments: (condition of inlet tee, condition of alarm and float switches, etc.)
N/A
DISTRIBUTION BOX: ✓ (locate on site plan)
0" depth of liquid above outlet invert
Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box,
recommendation for repairs, etc.)
Box was watertight and functioning properly. Little evidence of solids carryover. Depth below surface to top of cover was 12. "
PUMP CHAMBER: N/A (locate on site plan)
N/A pumps in working order, yes or no
Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,
etc.)
N/A
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
GENERAL INFORMATION (continued)
Property Address: 91 Fuller Road, North Andover, MA
Owner's Name Elliott Mandell
Date of Inspection 3/10/97
SOIL ABSORPTION SYSTEM (SAS): ✓ (locate on site plan, if possible; excavation not required, but may be
approximated by non -intrusive methods)
If not determined to be present, explain: not applicable
Type
leaching pits and number
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool, number
N/A
N/A
N/A
N/A
five lines, about 900 square feet
N/A
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
recommendations for maintenance, repairs, etc.)
Soils over leaching area were good, no evidence of breakout.
CESSPOOLS: N/A (locate on site plan)
number and configuration
N/A
depth -top of liquid to inlet invert
N/A
depth of solids layer
N/A
depth of scum layer
N/A
dimensions of cesspool
N/A
materials of construction
N/A
indication of groundwater inflow (cesspool
must be pumped as part of inspection)
N/A
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
recommendations for maintenance or repairs, etc.)
not applicable
PRIVY: N/A (locate on site plan)
materials of construction N/A
dimensions N/A
depth of solids N/A
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
recommendations for maintenance or repairs, etc.)
not applicable
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
GENERAL INFORMATION (continued)
Property Address: 91 Fuller Road, North Andover, MA
Owner's Name Elliott Mandell
Date of Inspection 3/10/97
SKETCH OF SEWAGE DISPOSAL SYSTEM:
indicate at least two permanent references, landmarks, or benchmarks
locate all wells within 100' N/A
2 s7t` y
D
we llih9'
� 8
ler. c4,; ,y
Secy
Zol
ys i
1500 9g110h
SPpflc tank
D - 6cX
SEPTIC TANK TIES: A
to
Inlet
(I)
4114"
B
to Inlet
2210"
A
to
Center
(C)
45110"
B
to Center
19'0"
A
to
Outlet
(0)
50'6"
B
to Outlet
1616"
D -BOX TIES: C
to
Box
591011
D
to Box
321011
NOTE: System is in the front yard.
DEPTH TO GROUNDWATER
4' depth to groundwater (below bottom of SAS)
method of determination or approximation:
Four (4) feet separation from groundwater per septic design plan
TOWN OF A). &Jo\,Lr
SYSTEM PUMPING RECO
DATE: 6- 2 L Q 5
SYSTEM OWNER & ADDRESS
(�
qtc���
SEP - 7 2005
TOWN OF NORTH ANDOVER
HEALTH DEPARTVENT
SYSTEM LOCATION
(example: left front of house)
r if ;0 k k 6 \'ts -f--
DATE OF PUMPING: (` 91- Q S QUANTITY PUMPED: 0 GALLONS
CESSPOOL: NO J YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAEN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.D V Lowell Waste
PETER F. REILLY
136 ANDOVER STREET
ANDOVER, MA 01810
(978) 375-3750
R`:0E 1VI-Ei"I
SEP 2 S 2005
TOWN OF NORTH ANDOVER
HZALTH Dom:-ART`:tEVT
TITLE V
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION
Property Address:
91 Fuller Road, North Andover, MA 01845
Name of Owner:
Mark and Gaylyn Reilly
Address of Owner:
same
Name of Inspector:
Peter F. Reilly
Company Name:
same
Mailing Address:
136 Andover Street, Andover, MA 01810
Telephone Number:
(978) 375-3750
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on-site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title
5 (310 CMR 15.000) The system:
✓ Passes
N/A Conditionally Passes
N/A Needs Further Evaluation By the Local Approving Authority
N/A Fails
Inspector's Signature: Date: September 21, 2005
Peter P. Reilly
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 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 a the time of inspection and under 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 (See attached Disclaimer).
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION (continued)
Property Address: 91 Fuller Road, North Andover
Owner's Name: Mark & Gaylyn Reilly
Date of Inspection: 9/21/2005
INSPECTION SUMMARY:
A. SYSTEM PASSES: Check A, B, C, D, or E / ALWAYS complete all of Section D
✓ I have not found any information which indicates that the system violates any of the failure criteria as
defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
The system met the Pass Criteria of Title V.
B. SYSTEM CONDITIONALLY PASSES:
N/A 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). Describe basis of determination in all instances. If"not determined",
explain why not)
N The septic tank is metal, and over 20 years old* or the septic tank (whether metal or not) is 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. *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 Observation of a sewage backup or breakout or high static water level 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):
N/A broken pipe(s) are replaced
N/A obstruction is removed
N/A 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):
N/A broken pipe(s) are replaced
N/A obstruction is removed
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION (continued)
Property Address: 91 Fuller Road, North Andover
Owner's Name: Mark & Gaylyn Reilly
Date of Inspection: 9/21/2005
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 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:
N/A Cesspool of privy is within 50 feet of a surface water
N/A Cesspool or privy is within 50 feet of a bordering vegetated wetland or 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:
N/A The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to
a surface water supply or tributary to a surface water supply.
N/A The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply well.
N/A The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
N/A The system has a septic tank and SAS the SAS is less than 100 feet but 50 feet or more from a
private water supply well.**Method used to determine distance N/A
This system passes if the water well water analysis, performed at a certified DEP 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. A copy of the analysis must be attached to this form.
3. Other
N/A
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION (continued)
Property Address: 91 Fuller Road, North Andover
Owner's Name: Mark & Gaylyn Reilly
Date of Inspection: 9/21/2005
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 an 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.
N/A Liquid depth in cesspool less than 6" below invert or available volume </ day flow.
No required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped: once
No Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
N/A Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water
supply.
N/A Any portion of a cesspool or privy is within a Zone I of a private water supply well.
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well.
N/A 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 laboratory, for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate
nitrogen is less than 5 ppm, provided that no other failure criteria are triggered. A copy of the
analysis must be attached to this form).
N/A The system fails. I have determined that one or more of the above failure criteria exist as defined in 310
CMR 15.303, therefore the system fails. The property owner should contact the Board of Health should be
contacted 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 a large system in addition to the criteria above)
N/A The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat
to public health and safety and the environment because one or more of the following conditions exist:
Yes No
N/A The system is within 400 feet of a surface drinking water supply
N/A The system is within 200 feet of a tributary to a surface drinking water supply
N/A The system is located in a nitrogen sensitive area (Interim Wellhead 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 such 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.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART B - CHECKLIST
Property Address: 91 Fuller Road, North Andover
Owner's Name: Mark & Gaylyn Reilly
Date of Inspection: 9/21/2005
Check if the following have been done. You must indicate either "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 flow 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 available note as N/A)
Yes Was the facility or dwelling was inspected for signs of sewage backup ?
Yes Was the site was inspected for signs of breakout ?
Yes Were all system components, excluding the SAS, located on the site ?
Yes Were the septic tank manholes uncovered, opened and the interior of the septic tank inspected
for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of
sludge, depth of scum?
Yes Was the facility owner (and occupants of if different from the owner) provided information on the
proper maintenance of subsurface sewerage 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. For example, a plan at the Board of Health. (as built)
N/A 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)].
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION
Property Address: 91 Fuller Road, North Andover
Owner's Name: Mark & Gaylyn Reilly
Date of Inspection: 9/21/2005
FLOW CONDITIONS
RESIDENTIAL:
Number of bedrooms (design):
Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203
(for example: 110 gpd x # of bedrooms:
Number of Current residents:
Does the residence have a garbage grinder (yes or no):
Is the laundry on a separate sewerage system (yes or no):
Laundry system inspected (yes or no):
Seasonal use (yes or no):
Water meter readings, if available (last 2 years usage [gpd])
Sump Pump (yes or no):
Last date of occupancy:
COMMERCIAL/INDUSTRIAL:
Type of Establishment:
Design Flow gpd (based on 15.203):
Basis of Design Flow (seats/persons/sq.ft., 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)
PUMPING RECORDS
UNK
4
UNK
4
yes
no (if yes, separate inspection required)
N/A
no
about 450 gpd
no
current
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
GENERAL INFORMATION
Source of Information: owner (in June 2005)
Was system pumped as part of inspection (yes or no): no
if yes, volume pumped (gallons): N/A
How was quantity pumped determined ? N/A
Reason for pumping: N/A
TYPE OF SYSTEM
✓ Septic tank/distribution box, soil absorption system,
Single cesspool
Overflow cesspool
Privy
NO 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 the 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: original system installed
in 1980.
Were sewerage odors detected when arriving at the site (yes of no): no
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 91 Fuller Road, North Andover
Owner's Name: Mark & Gaylyn Reilly
Date of Inspection: 9/21/2005
BUILDING SEWER: (locate on site plan)
Depth below grade: about 8"-10"
Materials of construction: cast iron ✓ 40 PVC other (explain)
Distance from private water supply well or suction line N/A
Diameter: 4"
Comments: Condition of joints, venting, evidence of leakage, etc.)
Building sewer was watertight and appeared sound at foundation.
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: about 4"-6"
Material of construction: ✓ concrete metal Fiberglass Polyethylene other (explain)
If tank is metal, list age N/A Is age confirmed by Certificate of Compliance N/A (Yes/No)
Dimensions: Rectangular- 1,500 gallons
Sludge depth: <1"
Distance from top of sludge to bottom of outlet tee or baffle: 28"
Scum thickness: <1"
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: 16"
How dimensions were determined: observation
Comments: (on pumping recommendations, of inlet and outlet tees or baffle condition, structural integrity, liquid
level as related to outlet invert, evidence of leakage, etc.)
Tank was watertight and appeared to be functioning properly. Concrete baffle in good condition.
GREASE TRAP: N/A (locate on site plan)
Depth below grade:
material of construction: concrete metal FRP other (explain)
Dimensions: N/A
Scum thickness: N/A
Distance from top of scum to top of outlet tee or baffle: N/A
Distance from bottom of scum to bottom of outlet tee or baffle: N/A
Date of Last Pumping: N/A
Comments: (on pumping recommendations, of inlet and outlet tees or baffle condition, structural integrity, liquid
level as related to outlet invert, evidence of leakage, etc.)
N/A
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 91 Fuller Road, North Andover
Owner's Name: Mark & Gaylyn Reilly
Date of Inspection: 9/21/2005
TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection) (locate on site plan)
Depth below grade:
N/A
material of construction: concrete metal
Dimensions:
Capacity:
Design Flow:
Alarm Present (yes or no):
Alarm level:
Alarm in working order (yes or no):
Date of last pumping:
Fiberglass Polyethylene other (explain)
N/A
N/A gallons
N/A gallons per day
N/A
N/A
N/A
N/A
Comments: (condition of alarm and float switches, etc.)
N/A
DISTRIBUTION BOX: ✓ (locate on site plan)
0" depth of liquid above outlet invert
Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into
or out of box, recommendation for repairs, etc.)
D -box was level. Five lines leading to SAS were accepting effluent evenly. D -box was about 12" below
surface. Little solids carryover evident.
PUMP CHAMBER: N/A (locate on site plan)
Pumps in working order (yes or no) N/A
Alarms in working order (yes or no) N/A
Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.)
not applicable
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 91 Fuller Road, North Andover
Owner's Name: Mark & Gaylyn Reilly
Date of Inspection: 9/21/2005
SOIL ABSORPTION SYSTEM (SAS): ✓ (locate on site plan, if possible; excavation not required)
If SAS not located, explain why:
Type
leaching pits, number
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
✓ leaching fields, number, dimensions
overflow cesspool, number
alternative system (name of technology)
N/A
N/A
N/A
N/A
1 field, 5 lines, about 900 square feet
N/A
N/A
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.)
Soils in area of SAS appeared normal, no signs of breakout.
CESSPOOLS: N/A (locate on site plan)
Number and configuration
N/A
Depth -top of liquid to inlet invert
N/A
Depth of solids layer
N/A
Depth of scum layer
N/A
Dimensions of cesspool
N/A
Materials of construction
N/A
Indication of groundwater inflow (cesspool
must be pumped as part of inspection)
N/A
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
recommendations for maintenance or repairs, etc.)
not applicable
PRIVY: N/A (locate on site plan)
Materials of construction
Dimensions
Depth of solids
N/A
N/A
N/A
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
recommendations for maintenance or repairs, etc.)
not applicable
n
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 91 Fuller Road, North Andover
Owner's Name: Mark & Gaylyn Reilly
Date of Inspection: 9/21/2005
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Provide a sketch of the sewerage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100'. Locate where public water supply enters the building.
0
�eql
Zti1
SEPTIC TANK TIES:
D -BOX TIES:
NOTE:
2 -- -740P11
D we 10hl
r _ g
y5-
/'rr a4 Y% I'
D - box
A to Inlet (1)
4114"
B to Inlet
2210"
A to Center (C)
45'10"
B to Center
1910"
A to Outlet (0)
5016"
B to Outlet
16'6"
A to Box
5910"
B to Box
3210"
The system is in the front yard.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 91 Fuller Road, North Andover
Owner's Name: Mark & Gaylyn Reilly
Date of Inspection: 9/21/2005
SITE EXAM
Slope flat in area of system
Surface water none observed
Check cellar dry
Shallow wells none observed
Estimated Depth to Groundwater >1" (below bottom of SAS)
Please indicate (check) all methods used to determine the high ground water elevation:
N Obtained from Design Plans on record - if checked, date of design plan reviewed: N/A
Y Observed site (abutting property, observation hole within 150 feet of SAS)
N Check with Local Board of Health - explain: information on file
Y Check local excavators, installers - (attach documentation)
N Accessed USGS Database - explain: website too complicated
You must describe how you established the high ground water elevation.*
The soils and grade changes in the area indicate no groundwater in the SAS. However, the precise
groundwater elevation cannot be determined for certain without a soil evaluation test.
*Inspector's Note: Soil Evaluation is the currently recognized method for determining
or establishing the high groundwater elevation. Since I am not a licensed or certified
soil evaluator, I am not qualified to determine or establish the high groundwater
elevation beyond the public information available, such as recent design plans of the
site or the nearby area. My estimation of the high groundwater elevation is based on
a due diligence effort to obtain all available information both on and off the site and my
experience as a certified subsurface disposal system inspector. (see attached
Disclaimer)
DISCLAIMER
This passing septic inspection under Massachusetts Title V is in no way a guaranty
or warranty of the inspected septic system. The inspection is a "snapshot in time"
and does not constitute a complete assessment of the quality or potential longevity
of the septic system. The pass/fail criteria are specific and outlined in detail in this
report. Under the limited criteria of a Title V inspection, it is impossible to determine
how long any septic system will last. The inspector made a diligent effort to certify
the septic system based on the criteria required under Title V.
Under Massachusetts Title V, soil evaluation is the accepted method of determining
the high groundwater elevation. This inspector is not a certified soil evaluator and is
therefore not qualified under Title V to determine or establish the high groundwater
elevation. The method used to estimate the high groundwater for this inspection was
based on the public records and methods of observation described on the previous
page. Groundwater levels can vary greatly from season to season, year to year and
soil evaluation is considered the most reliable method of groundwater determination
under Title V.
Peter F. Reilly
Inspector
September 21, 2005
TOWN OF
SYSTEM PUMPING RECORD' OCT 2 4 2005
DATE:
SYSTEM OWNER & ADDRESS
Z
7F �
DATE OF PUMPING:
SYSTEM LOCATION
(example: left front of house)
(a-1 ��/QUANTITY PUMPED:
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
EMERGENCY
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste
GALLONS
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4 oCT 2 32008
4'f _ 5 By`vo
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
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
kkey.
-lam
1. System Location: Left front, left rear, left side of hous . Right front right rear, right sid of ouse.
Address C
City/Town
2. System Owner:
Name
Address (if different from location)
V--Uas
f
Zip Code
Cityrrown State Zi Code
�1::& c r
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: Q Cesspool(s) A — pptic Tank Tight Tank
Other (describe):
4. Effluent Tee Filter present? Ej Yes 9—tq—o— If yes, was it cleaned? Yes No
5. Conditi n of Syste
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio ere contents were disposed:
S. Lowell Waste Water
PianaPureof u r Da e
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