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Home My WebLink AboutMiscellaneous - 93 SUGARCANE LANE 4/30/2018 (2)'N' 4 i"s A o2 gi. 2 At,' 12 • MAP # zi PARCEL # jGPPROVAL',: HAS PLAN REVIEW FEE BEEN PAID? YES NU PLAN APPROVAL: DATE DESIGNER: 0- 57-14 IV 561� PLAN DA CONDITIONS WATER WELL PERMIT WELL TESTS: Y : TOWN WELL COMMENTS: DRILLER._..._._._._.--_---..__..__..._.__..._.................... ...... .... ...- - CHEMICAL ACTERIllI B C TE 'n _II DAIE APPROVED VAIE (IPPRUVED DATE APPROVED-_____ FORM U APPROVAL: APPROVAL TO ISSUE'� YE NO DATEISSUED . ..... . ................ .......... .. CONDITIONS: FINAL APPROVAL:. NO ALL PERMITS PAID WELL CONSTRUCTION APPROVAL, ---y NU SEPTIC SYSTEM CONSTRUCTION APPROVAL" YE`' NO OTHER YES NU ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DA TE:�h.,`"f�., BY: REPT �ZEd�NSIfl4��I�Q�! i ; t :f. t.-.J:..•f • ;. #i', \ -. - ` ry�� : ,�? y . ; 1'ry, �Y-; d . y,y � ♦.T'..:. •fi A 5,,, , F ; i�i`Cn 1 Y, .w 7 r �.. )1..r - 4 �� ,e IS THE LICENS NO .INSTALLER . i OF CONSTRUCTION: NEW REPAIR STYPE . ; NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEWYE NO,, CONDITIONS OF..APPROVAL YES NO (FROM FORM U) • - ''.ISSUANCE OF DWC PERMIT - '� �' YES NO PERMIT N0. t INSTALLER:' Sys-�l'c . ,DWC I BEGIN INSPECTION ES 0: c EXCAVATION INSPECTION: NEEDED: SASSED BY :CONSTRUCTION INSPECTION:. NEEDED: IJ AS BUILT PLAN SATISFACTORY:,. YES - HJT-' r APPROVAL TO BACKFILL: DATE: BY , FINAL.GRADING APPROVAL: DATE • • � •BY APPROVAL: DATE: ZZ��/ BY t FINAL CONSTRUCTION . O 7006 F j e` +` • Lp Town of North Andover '�•'• .:,' HEALTH DEPARTMENT ,sSACM�St� CHECK #: AT LOCATI : � ,� JUa u , I r) H/O NAME: CONTRACTOR N Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment ❑ Body Art Practitioner ❑ Dumpster ❑ Food Service - Type:_ ❑ Funeral Directors ❑ Massage Establishment ❑ Massage Practice ❑ Offal (Septic) Hauler ❑ Recreational Camp ❑ Sun tanning ❑ Swimming Pool ❑ Tobacco ❑ Trash/Solid Waste Hauler ❑ Well Construction SEPTIC Systems: ❑ Septic - Soil Testing ❑ Septic - Design Approval ❑ Septic Disposal Works Construction (DWC) ❑ Septic Disposal Works Installers (DWI) ❑ Title 5 Inspector Title 5 Report ❑ Other. (Indicate) ( 0 Irz? Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary AssesE 93 Sugarcane Lane Property Address Alan Veaa Owner Owner's Name information is required for North Andover every page. City/Town Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. ICI ICI MA 08145 State Zip Code Rp I� TORO CSF NUR N HEALTH DEPAI 9/11/2014 Date of Inspection 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: Neil J. Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover Citylrown 978-475-4786 Telephone Number B. Certification MA State SI 15 License Number 01810 Zip Code 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 ❑ N aign rther Evaluation by the Local Approving Authority ' 9/11/2014 Inspect rsjture 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 .cop ies sent to the buyer, if applicable, and.the approving authority. ****This report only describes conditions at the time of inspection and ,Un. er;r he conditions of use at that time. This inspection does not address how the system will peiForm in the future under the same or different conditions of use. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 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 93 Sugarcane Lane Property Address Alan Vega Owner's Name North Andover Citylrown B. Certification (cont.) MA 08145 State Zip Code 9/11/2014 Date of Inspection 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): t5ins • 3/13 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 93 Sugarcane Lane Property Address Alan Vega Owner Owner's Name information is required for North Andover MA 08145 9/11/2014 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced • ❑ Y ❑ N ❑ ND (Explain below): ❑ 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): 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 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 93 Sugarcane Lane Property Address Alan Vega Owner's Name North Andover Cityrrown B. Certification (cont.) MA 08145 State Zip Code 9/11/2014 Date of Inspection 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 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 must be attached to this form. 3. Other: 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 Y2 day flow t5ins • 31113 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 4 of 17 ❑ ® 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 • 3/13 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 Sugarcane Lane Property Address Alan Vega Owner information is Owner's Name required for North Andover MA 08145 9/11/2014 every page. CityfTown State Zip Code Date of Inspection 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 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 • 3/13 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 Sugarcane Lane Property Address Alan Vega Owner Owner's Name information is required for North Andover MA 08145 9/11/2014 every page. Cityrrown 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: A Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): A aan t5ins • 3/13 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 93 Sugarcane Lane Property Address Alan Vega Owner Owner's Name information is required for North Andover MA 08145 9/11/2014 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 9 ( Y 9 (gp ))� Yes Detail: Sump pump? ® Yes ❑ No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o kv1Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 Sugarcane Lane Property Address Alan Vega Owner Owner's Name information is required for North Andover MA 08145 9/11/2014 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Date Pumped 2012, owner 1500 gallons Measured tank Inspect tank, tees ® Yes ❑ No Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 93 Sugarcane Lane Property Address Alan Vega Owner Owner's Name information. is. required for North Andover MA 08145 9/11/2014 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 18 years old, 6/10/1996, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 1.4 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4' PVC through floor, 3" PVC in house, No leaks visible Septic Tank (locate on site plan): Depth below grade: .4 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 certificate) ❑ Yes ❑ No Dimensions: 10'x 5'x 4' Sludge depth: 3" t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments < 93 Sugarcane Lane Property Address Alan Vega Owner Owner's Name information is required for North Andover MA 08145 9/11/2014 every page. t5ins • 3113 Cityrrown D. System Information (cont.) State Zip Code Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" Date of Inspection Scum thickness 3" 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 12" How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 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 93 Sugarcane Lane Property Address Alan Vega Owner Owners Name information is required for North Andover MA 08145 9/11/2014 every page. Citylrown State Zip Code 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.): 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 E] other (explain): 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.): " Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins - 3/13 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 Sugarcane Lane D. System Information (cont.) 9/11/2014 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 level & distribution equal. No evidence of leakage. Evidence of light carryover, pumped d -box to clean. 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.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins - 3/13 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 12 of 17 Property Address Alan Vega Owner Owner's Name information is required for North Andover MA 08145 every page. Cityrrown State Zip Code D. System Information (cont.) 9/11/2014 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 level & distribution equal. No evidence of leakage. Evidence of light carryover, pumped d -box to clean. 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.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins - 3/13 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 12 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 Sugarcane Lane Property Address Alan Vega Owner Owner's Name information is required for North Andover MA 08145 9/11/2014 every page. Cityrrown State Zip Code Date of Inspection D. System information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields 1 field 24'x 43' number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface. 1 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 • 3/13 ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts 01F UTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 Sugarcane Lane Property Address Alan Vega Owner Owner's Name information is required for North Andover MA 08145 9/11/2014 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 93 Sugarcane Lane Property Address Alan Vega Owner Owners Name information is required for North Andover MA 08145 9/11/2014 every page. Cityrrown 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 tCt 14 t5ins - 3/13 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 15 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 93 Sugarcane Lane Property Address Alan Vega Owner's Name North Andover MA 08145 9/11/2014 Citylrown 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: '4 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 5/2/1995 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Design plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: As per design plan test pit data. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 ' • \ Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 Sugarcane Lane E. Report Completeness Checklist 08145 9/11/2014 Zip Code Date of Inspection ® 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 Property Address Alan Vega Owner Owner's Name information is required for North Andover MA every page. Cityrrown State E. Report Completeness Checklist 08145 9/11/2014 Zip Code Date of Inspection ® 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 DEP has provided this form for uswby 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/ftig�htrear Left / right side of house, Left / Right side of building, Left / Right front of building, LMf uilding, Under deck Address Ua�-e_ UW1141A cityfrown state Zip code 2. System Owner. Name B. Address (if different from location) CitylTown ' State de Telephone Number Record 1. Date of Pumping 3. Type of system: ❑ Date 2. Quantity Pumped: Gallons Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes Na '5. Condition of Sy tem: I n 6. System Pumped By. Neil. Bateson Name Bateson Enterprises Inc- Company nc Company 7. Location G. S. Sig Hau t5foml4.doa- 06/03 contents were disposed: F5821 Vehicle License Number Date41, System Pumping Record • Page 1 of 1 Summary Record Card generated on 8/29/2014 10:46:34 AM by Karen Hanlon Page 1 Town of North Andover Tax Map # 210-106.A-0262-0000.0 Parcel Id 17407 93 SUGARCANE LANE VEGA, ALAN 93 SUGARCANE LANE NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 0.67 Acres FY 2015 UB-M'aitina Index Name/Address Type Loan Number Active/Inact. From Until VEGA, ALAN Payor 93 SUGARCANE LANE NORTH ANDOVER, MA 01845 UB Account'Maint. Account No Cycle Bldg Id. 17840.0 - 93 SUGARCANE LANE 3170505 03 Cycle 03 UB Services Maint. Account No. 3170505 Service Code MISCFEE ADMIN FEE WTR WATER UB Meter Maintenance Account No. 3170505 Serial No Status 40661686 a Active Date Reading 6/11/2014 214 3/11/2014 196 12/10/2013 182 9/12/2013 170 6/12/2013 121 3/13/2013 103 12/1112012 91 9/13/2012 75 6/12/2012 10 3/28/2012 0 12/12/2011 2193 MSG 9/12/2011 MSG 6/7/2011 3/8/2011 12/9/2010 9/10/2010 6/7/2010 3/9/2010 12/8/2009 9/9/2009 6/8/2009 3/13/2009 12/9/2008 9/8/2008 6/6/2008 3%7/2008 12/11/2007 Occupant Name Active/Inactive Last Billing Date 7/8/2014 Active Rate Charge Multiplier/Users 0.635/8 7.82 1/ 01 ALL METER SIZE 68.40 /1 Location Brand Type Size YTD Cons ERT HH b Badger w Water 0.630.63 214 Code Consumption Posted Date Variance a Actual 18 7/16/2014 27% a Actual 14 4/11/2014 14% a Actual 12 1/17/2014 -75% a Actual 49 10/15/2013 169% a Actual 18 7/24/2013 52% a Actual 12 4/22/2013 -27% a Actual 16 1/9/2013 -74% a Actual 65 10/15/2012 431% a Actual 10 7/16/2012 0% n New Meter 0 4/14/2012 0% m Manual estimate 20 1/17/2012 -77% 2173 m Manual estimate 91 10/13/2011 374% 2082 a Actual 18 7/20/2011 10% 2064 a Actual 16 4/13/2011 8% 2048 aActual 15 1/12/2011 -83% 2033 a Actual 91 10/15/2010 311% 1942 a Actual 21 7/15/2010 18% 1921 a Actual 18 4/14/2010 11% 1903 a Actual 16 1/12/2010 -21% 1887 a Actual 21 10/15/2009 79% 1866 a Actual 11 7/20/2009 -30% 1855 a Actual 17 4/29/2009 -24% 1838 aActual 22 1/20/2009 -45% 1816 a Actual 41 10/10/2008 231% 1775 a Actual 12 7/16/2008 -28% 1763 aActual 16 4/11/2008 -6% 1747 aActual 19 1/22/2008 -77% ..-.... • .<p. - :.,,. �..r. '�+,Y�r9 wnr s..:,. ..:. „l -r1 r . - a.r � �:� a+x - - ,Ayer .. .t a.• COMMONWEALTH OF MMSACHU9ETTS FgECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS fJ DEPARTMENT ;OF EIWfRONMENTAL PROTECTION .wa. mss.: TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:.413 So&-02.cAjc 1--p')L Mo rZn_4 A- ,J D 000L /t^ i4 Owner's Name: tit; t-Aw Owner's Address: Q`2, I.-AAJ lV o2�c1� tkAv 0 o e2, ,-0 A Date of Inspection: Name of Inspector: (please print) L O--,C-c-o Company Name: /Vgw i m&t-A&)o N(,WC I (R1a 6 Mailing Address: (--o ; ic>,iw? N V 2-t' A yoo , A4 A Telephone Number: .43-78- (::,PG- ) ? (z$ 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 15340 of Title 5 (310 CMR 15.000).. The system: 'Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails 'Inspector's Signature: Date: ja1ojo.o << The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or bEP) 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 Od copies sent to the buyer, if appiicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future-underthfesane`or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT ' SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM - PART A CERTIFICATION (continued) ROPERTY ADDRESS: 93 Sugarcane Lane North Andover, MA OWNER: Lisa Laidlaw i DATE OF INSPECTION: 10/30/00 Inspection Summary: Check' A,B,C,D or E / ALWAYS complete all of Section D ' W50 em Passes:have not found any information which indicates that any of the failure criteria described in 310 CMR r in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System Conditionally Passes: ne or more system components as described in the "Conditional Pass" section need to a replaced or repaired. system, upon completion of the replacement or repair, as approved by the Bo of Health, will pass. Answer yes, no or not ermined (Y,N,ND) in the for the following statemept's. If "not determined" please explain. The septic tank is metal an ver 20 years old* or the. septic tank(WIhether metal or not) is structurally unsound, exhibits substantial infiltrate or exfiltration or tank failurejs(imminent. System will pass inspection if the existing tank is replaced with a complyin eptic tank as approvedby the Board of Health. .*A metal septic tank will pass inspection if u ' structurally,so#d, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old available, ND explain: Observation of sewage backup or break t or high sta ' Water level in the distribution box due to broken or ,obstructed pipe(s) or due to a broken, settled uneven dist6uti , box. System will pass inspection if (with 'approval of Board of Health): i b en pipe(s) are replaced bstruction is removed distribution box is leveled or replaced ND explain: The system r uired pumping more than 4 times a year due to broken or obstructed e(s). The,system will pass inspection if ith approval of t$e Board of Health): broken pipe(s) are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 Page 3 of 1:1 L, 4 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' `3 PART A CERTIFICATION (continued) ROPERTY ADDRESS: 93 Sugarcane Lane North Andover; MA g :. OWNER:' Lisa Laidlaw DATE OF INSPECTION: 10/30/00 ' C. Further Evaluation Is Required by the Board of Health: r �y Conditions exist which require further evaluation by the Board of Health in order to determine if the system s failingtool t public health; safety or the environment Sll pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the sot functioning in a manner which will protect public health, safety and the environment: ool or privy is within 50 feet of a surface water or privy is within 50 feet of a bordering vegetated wetlan r /asalt marsh 2. System will fail unless th Board of health (and Pubyc"Water Supplier, if any) determines that the system is functioning in a mann that protects the pu ic health, safety and environment: _ The system has a septic tank soil absorp on system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a s ace ter supply. i i The system has. a septic tank and S an the SAS is within a Zone 1 of a public water supply. The system has a septic tank AS and the S is within 50 feet of a private water supply well. The system ha's a septic and SAS and the SAS i ess than 100 feet but 50 feet or nloreSrom a private water supply, well**. ethod used to determine dis e "This system passes i e; well water analysis, performed ata DE ertified laboratory, for coliform bacteria and volatile' rgamc compounds indicates that the well is free pollution from thm facility and the;presence of onia nitrogen and nitrate nitrogen is equal,to or less th 5 ppm, 0'to vided that no other failure criteria triggered. A copy of the analysis must be attached io this fo r 3. Ot r: , Title 5 Inspection Form 6/15/2000 3 Page 4 Of 11 OFFICIAL INSPECTION FORM — NOT, FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPbSAL SYSTEM INSPECTION FORM ' FART A CERTIFICATION (continued) ROPERTY ADDRESS: 93 Sugarcaue:Lane North Andover, MA OWNER: Lisa Laidlaw DATE OF INSPECTION: 10/30/00 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 _ N' 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 %z day flow y/ 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 is less than 100 feet but 50 feet privy greater than from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates .that the well is free from pollution from that facility and the presence of ammonia . nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure Criteria are triggered. A copy of the Analysis must be attached to this form.] NO: (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,.therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems To a considered a' large system the system must serve a facility with a design flow of 10,000 gpd to B,600. gpd. You must ' icate either "yes" or ` no',to each of the following: (The following 'terra apply to large systems in addition to the criteria a e) yes no the system is within 0 feet of a surface water supply _ the system is within 200 feet o to a surface drinking water suppl}+ the system is located in a ogen sensiti ea (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of public w r supply well If you have answere " es" to any question in Section E the system ' considered a significant threat, or answered "yes" in Sectio above the large system has failed. The owner or oper of any large system considered a significan eat under Section E or failed under Section D shall upgrade the m in accordance with 310 CMR 15.3 . e system owner should contact the appropriate regional office of the Dep ent. Title 5 Inspection Form 6/15/2000 4 • '. a 'a-. , .i rwa,'�r.;,w^,+•,�•'p,"•, .PF"^�:'�7°� u'L:4"ll�� Page S of 11 Ki , OF'ICIA.L INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS' SUBSUUACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM •t 1 ' PART B CHECKLIST 1 PROPERTY ADDRESS: 93 Sugarcane Lane ! i North Andover, MA xr; OWNER: Lisa Laidlaw r.' DATE OF INSPECTION: 10/30/00 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 V"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) f _ Was the facility or dwelling inspected for signs of sewage back up ? Ve"_ 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 bafflos 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 p size and location of the Soil Absorption System (SAS) on the Site has been determined based on: i Yes no V 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 appropcimation of distance is unacceptable) [3 10 CMR 15302(3)(b)] Title 5 Imnection Form 6/15/2000 5 77 t • "�,. 7',,21 I_ �, fir£, »t r r r rt,a9 .�%+,kplrp,•yrt`• d age 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLVNTARY ASSESSMENTS SUBSURFACE §aEWAGE DISPOSAL-SYSTEM;INSPECi'ION FOPM PART C 'OYSTEM INFORMATION 'ROPERTY ADDRESS: 93 Sugarcane Lane North Andover,: MA i OWNER: Lisa Laidlaw i :! DATE OF INSPECTION: 10/30/00 rLVW CONDMONS RESIDENTIAL Number of bedrooms (design): H Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): i . D 2 foo G Number of current residents:_ L x3 Does residence have a garbage grinder (yes or no): %-\el'J Is laundry on a separate sewage system (yes or no):/1/_0 [if yes separate inspection required] Laundry system inspected (yes or no): Seasonal use: (yes or no): � jl Q Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or no): A10'. Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: _ Design flow (based on 310 CMR 15.203): Rvd Basis of design flow (seats/orsonS/sg8,etc.): Grease trap present (yes or no): I'ndu'strial waste holding tank present (yes or no): Non -sanitary waste discharged to the Title 5 system (yes or no): _ Water meter readings, if available: East date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping'Records Source of information:; o nj ► Vt S Was system pumped as part of the inspection (yes or no): If yes, volume pumped: Gallons — How was quantity pumped determined? F Reason for pumping: rr c r.r TYPE OF SYSTEM r Septic tank, distribution box, soil absorption system Single cesspool _ Overflow cesspool r _ Privy 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: .57 S Were sewage odors detected when arriving at the site (yes or no): A10 Title 5 Inspection Form 6/15/2000 6 ^ • r -. f Y ri+•«rr xr < c .r. - i .a� y v ,YY�'7'li.,r F a .__ z} t u r+ u f .Fa y$ par rIt f Pat ge'?of 11+� y:. OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE, DISPOS`A.L SYSTEM:INSP'ECTION FORM ' PART C t . SYSTEM INFORMATION (continued) 'ROPERTY ADDRESS: 93 Sugarcane Lane ; North Andover, MA , OWNER: Lisa Laidlaw DATE OF INSPECTION: 10/30/00 r� •'a BUILDING SEWER (locate on site plan) Depth below grade Materials of construction: _cast iron 40 PVC other (explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): ��7� �iaOL(L ��o�2r /VE>1 U�l[3LI✓� SEPTIC TANK: _ (locate on site plan) Depth below grade: I- Material of construction: ✓concrete _metal _fiberglass _polyethylene —other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) Dimensions: 15-12 o G -q L -Lo N `5. Sludge depth: Ve 1� Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: L 1! Distance from top of scum to top of outlet tee or baffle: ia. Distance from bottom of scum' bottom of outlet tee or baffle: 5 , How were dimensions determined: n� IE -c,_, ,Z L S11L Comments (on pumping recommendations, inlet and outlet -tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): C TAIY. 1ti G-v�a c�N n ) aV� AJ GREASE TRAP: &Alocate onsite plan) ;; t Depth below grade: _ Material of construction: _concrete _metal _fiberglass_polyethylene _other (explain): - Dimensions:' Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to 'bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Title 5 Insnection Form 6/15/7000 7 -,,page 8 of 11 7 `fit OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE -DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) tOPEkTY ADDRESS: 93 Sugarcane Lane North Andover, MA )WNER: Lisa Laidlaw )ATE OF INSPECTION: 10130100 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: —concrete —metal fiberglass polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: (if present must be opened)(locate on . site plan) Depth of liquid level above outlet invert: 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.): ODA I Aj (>V C 012 VI k I't Q AJ /Vo z -f V) _0 FN C -C C> I 04 tzizN a, V, AAO t_4Ewv_t (kj 6,-z- C> Lzr7 PUMP CHAMMER-" (locate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): 43 14mments (note condition of pump chamber condition of pumps a(%d' appurtenances, etc.): Title 5 Inspection Form 6/15/2000 8 771 Page 9 of 11 OFFICIAL INSPECTION FOI.M — NOT FOR VOLUNTARY ASSESSMENTS :SUBSURFACE SjEWAGEDISPOSAL SYSTEM INSPECTION FORM il PART C SYSTEM INFORMATION (continued) tOPERTY ADDRESS: 93 Sugarcane Lane North Andover, MA )WNER: Lisa Laidlaw )ATE OF INSPECTION: 10/30/00 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: leaching chambers, number: leaching galleries, number: leaching trenches, number, length: -Ieaching fields, number, dimensions: overflow cesspool, number: innovative/alternative system Typelpame of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetationi' etc.): CESSPOOLS: NA(cesspool must be pumped as part of inspection)(locate on site plan) r Number and configuration: Depth — top of liquid to inlet invert Depth of solids Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yps or no): Comments (pt� condition of soil, s'igns of hydraulic failure, level of ponding,po4dition of vcgetatio r'etc. ii PRIVY: WA(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.): Title 5 Inspection Form 6/15/2000 9 yY �. r '`,ir'?��C..:r, �`. y':. �;a�arw r G � •__-, ;...�ha•.r�rd%�6F!w.�. L y h ,• (3F,Y y r Page 10 of 11 s' ' OFFICIAL INSPECTION FORM — NOT FOR vrOLUNTARY ASSESSMENTS` SUBSURFACE SEWAGR DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION (continued) ROPERTY ADDRESS: 93 Sugarcane Lane North Andover, MA OWNER: Lisa Laidlaw DATE OF INSPECTION: 10/30/00 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. 3?� Title 5 insnection Form 6/15/2000 10 3a' w.at k. Page 11 off 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' i PART C SYSTEM INFORMATION (continued) ,OPERTY ADDRESS: 93 Sugarcane Lane North Andover, MA )WNER: L!sa Laidlaw )ATE OF INSPECTION: 10/30/00 SITE EXAM ; Slope Surface water e Check cellar Aj�.) 5 � Shallow wells Mone, Estimated depth to ground water _2t' feet Please indicate (check) all methods used to determine the high ground water elevation: _j_ Obtained from system design plans on record - If checked, date of design plan reviewed: Observed siteabu ' ( thng property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: p m. Checked with local excavators, installers- (attach documentation k/ Accessed USGS database -explain: You must describe how you established the high ground water elevation: u S G-5 1/--3 Title 5 Inspection Form 6/15/2000 11 rCone onwe Ith of Massachusetts Massachusetts System Pumping Record System Owner System Location aD S 0 �- ls-\-� CaAAq Date of Pumping: Cesspool: No T ves Quantity Pumped: / b^2�4e�allons Septic Tank: No Yes=.J System Pumped by: 04fciott a&nh4i4ed License # Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: 'APR 2 61998 i SEPTIC AND CERTIFIED PLOT PLAN LOCATED IN NORTH ANDOVER, MASS. SCALE:1 "=40' DATE:6/10/96 Scott L. Giles R.P.L.S. 50 Deer Meadow Road North Andover, Mass. W Z vu1l119fX - IJu. U" INTO BOX =130.56 OUT OF BOX =130.40 END PIPES .=130.10-130.12 I CERTIFY THAT OFFSETS SHOWN ARE FOR THE USE N of THE OFFSETS OF THE BUILDING INSPECTOR ONLY SHOWN COMPLY AND SUCH USE IS FOR THE WITH THE ZONING BY LAWS OF DETERMINATION OF ZONING CONFORMITY OR NON-CONFORMITYs�STia 19t�TZ H NORTH ANDOVER WHEN CONSTRUCTED. t �ri0s. WHEN CONSTRUCTED C No................ _....... THE COMMONWEALTH OF MASSACHUS BOARD OF. HEALTF 701J Al 41fiV 7-14 /.LXJAA Applirtttiun fur 19iipouttl Workii Tomitrnrtion f rrmit Application is hereby made for a Permit to. Construct (u -j or Repair ( ) an Individual Sewage Disposal System at: ...............5 4 ..111.E ht .................... _........... ......1 ..4_ LE WN QA -XS L ation . Address or t No. ps�_ T :..rr ..LAI ................................... ... c� � N .�r� �:�.. :. �.. �, �o u .._..... Owner Address ..............•--..................................a.........................--•..........._................................................. ..ddre............................................. Installer X Address Type Building No. of Bedrooms..............�T:...... ............Ex Expansion Attic e Lot...._�°il..�.��D.....Sq. feet YP g Siz Dwelling — •••.. P ( ) Garbage Grinder ( ) Other — Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures .............................................................................._.......................:........ Design Flow ............ t . .................gallons per person per dal. Total daily flow .................!E�iaQ.................gallons. Septic Tank --Liquid capactty.L$bQgalIons Length.10.Width.A..... ..... Diamet'er.... .......... Dth...�..... .. Disposal 'I=f"a4 er...FlE.�.... Width ......50....... Total,.Length..... 37:".:... Total leaching area ... i IQ.. ...... sq. ft: Seepage Pit No ..................... Diameter.................... Depth below inlet .................... Total. leaching area .................sq. ft. Other Distribution box (V� Dosing tank .( ) Percolation Test Results Performed by ... GRlit�/Ad'�S/til.r..Kl.�..!!Sl.,.... Date..f L6�87 9�/S'18i 6/1�Q3 Test Pit No. I ..... 4 ....... minutes per inch Depth of Test Pit ..... .g...... Depth to ground water --- 4.8 -H -6T.4) 0.1tr .� Test Pit No. 2.... .Z......minutes per inch Depth of Test Pit........? Depth to ground water ...!i8.... .................•--.....I---•-------•........_.._........:...........-.---.--.......... Description of Soil....Z.tS.:Y-4A....S-1_iiaLY...141Y-PY.J.4).AM.1...CIH.SSLV.��..t[.K.M..-.FillA.. ....1�✓.1.L79........... _..................................i4!kG.v(,.HCL....jlbN+ 4 ........................................ .......... ................................................................ .......................... .............--...............................................,e.--•--....................................---....................................................... Nature of Repairs or Alterations — Answer when applicable............................................................................................... .......................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed... ................. ........................•-...•-•-••---........------........--•-.. ......................... _ Date Application Approved By................•--.......---•-•--•---.............••.............._. ......---........................................ Date Application Disapproved for the follozi,ing reasons: ................................................................................................................ ..........................................................................•--•-•......_...................-------•----..............----.............---•------......................................... Due PermitNo .................................................... _._ . Issued ................................. ::.................. _ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...... OF ........ . ...................................... Trrtifirtttae of Tomplittnrae THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed by......... ................................................................. ) or Repaired ( ..............................................................:.......................a...................... Installer a has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No ......................................... dated ............................. I..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...----••--...--•-•...........•-----•-----------•---•---.......-•--•-•.......... Inspector .................................. THE COMMONWEALTH OF MASSACHUSETTS No......................... BOARD OF HEALTH OF. _ Riwuuttl Vurbi Tumitrnrtinn Prrmit FRE ................ Permission is hereby granted ............... to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo.......................••---•...._..._.._...•......••----................-•-••......._..........._.._............••.._.................••....••--••'-..................._......_.._._... Street as shown on the application for Disposal Works Construction Permit No ..... :..... .......... Dated .......................................... '! 1...................................................................................... DATE.............................................................................•. Board of Health FORM 1255 A. M. SULKIN. INC__ BOSTON SEPTIC AND CERTIFIED PLOT PLAN LOCATED IN NORTH ANDOVER, MASS. SCALE: 1"=40' DATE -6/10796 Scott L. Giles R. P. L. S; 50 Deer Meadow: Road North Andover, Mass., TABLE OF ELEV. OUT OF HSE:=131.60 INTO TANK =131.11 OUT TANK =130.94 INTO BOX =130.5 OUT OF BOX =130.40 END PIPES =130.10-130.12 CERTIFY THAT OFFSETS. SHOWN ARE FOR THE USE 01 Of THE OFFSETS OF THE BUILDING INSPECTOR ONLY SHOWN COMPLY AND SUCH USE IS FOR THE WITH THE ZONING DETERMINATION OF ZONING BY LAWS OF CONFORMITY OR NON -CONFORMITY: NORTH ANDOVER WHEN CONSTRUCTED. ;:.. b At;U,NQ WHEN CONSTRUCTED 1E P M\ N a� � a v Cb'a \ v w M y Qi U vLvi oa ra-i G 0 C � � F-1 \ W Qi W w° cn o W° U w o C4 w a° C V :r1 cc O C U O y C O z �.d C v .Q t o ei. a: :off • E a (%j L o: �coo d^: S CD � o y E c - Q � � a� o :oo c v� E L c ca cc a 1 CD m 3 y cm CD GCn ) n y d m �E� R CD o rimcm a-- -a Q rm c C� C CJ y O L cm, •� o v C 0 cm �_ CD CD O CL = m :m�CD N ~ ) CS O y == C Z °C .E V CD rn tm O C.0 a CD = c c Q N o21 m '� :r, o co O _ CL, W 0 o i � O O V z CD CL o y v � o am o .c ca 0 co •LA Co E c CD 0 CD CL +� L o� o L CLI) o CC o d C CMQ y = � o CIO V c a� o c. V COD s CQ d COD - is .a O :W^ 1�1 C/ z .Q Z o � O Q � � o Cl) C/O tJ Q W 0 o i � O O V z CD CL o y v � o am o .c ca 0 co •LA Co E c CD 0 CD CL +� L o� o L CLI) o CC o d C CMQ y = � o CIO V c a� o c. V COD s CQ d COD - is Form No. 3 Town of North Andover, Massachusetts BOARD OF HEALTH 19 M MORTH . 3rOe't��ac oe'�.yOO�. f A DISPOSAL WORKS CONSTRUCTION PERMIT �SSNCMUS� TELEPHONE Applicant ADDRESS NAME Tr Site Location or Repair ( ) an Individual Soil Absorption to Construct Permission is hereby granted ( rovat S.S. No. e Disposal System as shown on the Design App Sewa g CHAIRMAN, BOARD OF HEALTH D.W.C. No. Fee FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: �• Coa wG V /X01 et PC, - CdPY0 Phone c5d"L-23�d LOCATION: Assessor's Map Number 104'4 Parcel Subdivision y Street Sus 04Z c~x- St. Number ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Date Approved Conservation Administrator Date Rejected Comments Date Approved Town Planner Date Rejected Comments Food Inspectto.or�--Health a Septic Inspector -Health Comments Public Works - sewer/water connections - driveway permit Fire Department Date Approved Date Rejected j Date Approved Date Rejected Received by Building Inspector Date water -F b)e Septic Comp a nce, Inc E. Paul Cardone, Soil Evaluator June 17, 1999 Sandra Starr, Health Agent North Andover Board of Health 27 Charles Street North Andover, MA 01845 Re: Sanitary Disposal System Inspection 93 Sugarcane Lane - Alexander Crosett Dear Ms Starr: In accordance with the Commonwealth of Massachusetts, Department of Environmental Protection, State Environmental Code (Title V), 310 CMR 15.301, paragraph 7, please find attached a "Subsurface Sewage Disposal System Inspection Form" for your records. If you have any questions regarding this report or any of its contents please do not hesitate to contact this office. We thank you, in advance, for your continued cooperation in these matters. Very truly yours, SEPTIC COMPLIANCE, INC. Paul Cardone Certified Septic Inspector Attachment PC/JMP title 5crosett.wps • TITLE 5 SYSTEM INSPECTORS • D.E.P. SOIL EVALUATORS • 447 Boston St., Topsfield, MA 01983 371/2 Baremeadow St., Methuen, MA 01844 Tel (978) 887-8586 Fax (978) 887-3480 (978) 681-0726 ARGEO PAUL CELLUCCI Governor Septic Compliance, Inc. F. Paul Cardone, Soil Evaluator COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENviRoNMENTAL AFFAIRS DEPARTm&NT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292.5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address:93 Sugaracne Ln. No. Andover, Ma. 01845 Date of Inspection:June 10, 1999 Name of inspector: (Please Print) Paul Cardone TRUDY COXE Secretary DAVID B. STRUHS Commissioner Name of Owner: Alexander Crosett Address of Owner:Same I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Septic Compliance, Inc. Mailing Address: 447 Boston St. Topsfield, Ma. 01883 Telephone Number: (978)887-8586 or (978)681-0726 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes XX Conditionally Passes Needs Fu �nby1 Approving Authority Fails 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 thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the System owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS • TITLE 5 SYSTEM INSPECTORS • D.E.P. SOIL EVALUATORS • 447 Boston St., Topsfield, MA 01983 Tel (978)887-8586 Fax (978) 887-3480 Revised 9/2/98 Page I of II 37!/2 Baremeadow St. , Methuen, MA 01844 (978) 681-0726 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 ARGEO PAUL CELLUCCI Governor TRUDY COXE Secretary DAVID B. STRUHS Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 93 Sugarcane Ln. NO. Andover, Ma. 01845 Name of Owner :Alexander Crosett Address of Owner: Same Date of Inspection: June 10, 1999 Name of Inspector: (Please Print) Paul Cardone I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Mailing Address: 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 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: XX Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority F' inspector's Signature• Date.G 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 Environmenta Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page 1 of 1 l SUBSURFACE SEWAGE DISPOSAL SYSTEM (INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of inspection: 93 Sugarcane Ln. No. Andover, Ma. 01845 Alexander Crosett 6-10-99 INSPECTION SUMMARY: check A, B, C, or D. A. SYSTEM PASSES: XX I have not found any information which indicates that any of the failure conditions described in 310 CMR 16.303 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 four times -a year -due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 93 Sugarcane Ln. No. Andover, Ma. 01845 Owner: Alexander Crosett Date of Inspection: June 10, 1999 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. WILL PROJECT THE PUBLIC HEALTH. AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetlend or a sale marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF ANY) DETERMINES THAT THE SYSTEM 1S FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not Valid). 3) OTHER revised 9/2/98 page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 93 Sugarcane Ln. No. Andover, Ma. 01845 Owner: Date of Inspection: Alexander Crosett 6-10-99 D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of -sewage into facility or system component -due to an overloaded clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the 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 then 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 servos 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 an, the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system -is -within 200 feet of a tributary to a surface drinking water supply - the system is located in a nitrogen sensitive area (interim Wellhead Protection Area ; IWPA) or a mapped Zone 11 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. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Daft at Inspection: 93 Sugercane Ln. No. Andover, Me. 01845 Alexander Crosett 6-10-99 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. Yes None of system components have at least two weeks and has been flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ _Proposed— As built plans have been obtained and examined. Note if they are not available with WA Yes The facility or dwelling was inspected for signs of sewage back-up. Yes The system does not receive non -sanitary or industrial waste flow. Yes The site was inspected for signs of breakout. Yes All system components, excluding the Soil Absorption System, have been located on the site. Yes 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: Yes Existing information. For example, Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)) Yes The facility owner land occupants, if different owner) were provided information on the proper maintenance f Subsurface Disposal Systems. revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:93 Sugarcane Ln. No. Andover, Ma. 01845 Owner. -Alexander Crosett Date of Inspection:6-10-99 FLOW CONDITIONS RESIDENTIAL: Design flow:_ 165 g.p,d. /bedroom. Number of bedrooms (design): 4 Number of bedrooms (actual): 4 Total DESIGN flow 660 Number of current residents: 4 Garbage grinder (yes or no): Yes Laundry (separate system) (yes or no): No If Yes, separate inspection required Laundry system inspected (yes or no): Seasonal use (yes or no):No Water meter readings, if available (last two year's usage (gpd): Sump Pump (yes or no): No Last date of occupancy: occupied COMMERCILA / INDUSTRIAL: Type of establishment: Design flow: qpd ( Based on 15-203) Basis of design flow Grease trap present: (yes or no) Industrial Waste Holding Tank present: (yes or no)_ Non -sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Lest date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: According to owner tank was pumped April 1999 System pumped as part of inspection: (yes or no) No If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM XX 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 APPROXIMATE AGE of all components, date installed (if known) and source of information: _House and ststem are both three years of age. Sewage odors detected when arriving at the site: (yes or no) No Page 6 of 11 SURFACE SEWAGE DISPOSAL SYSTEM INSPEC71ON FORM PART C SYSTEM INFORMATION (continued) idover, Ma. 01845 �VC _ other (explain) :eakage, etc. _Fiberglass _Polyethylene _other (explain) .rtificate of Compliance (Yes/No) baffle: 38" e: 6" or baffle: 6" outlet toes or -baffles, depth of liquid level in relation to outlet invert, structural integrity, pumped once a year, tees were in very -good Gond liquid levels were good structural integrity was good no evidence of —Fiberglass—Polyethylene other (explain) e: - or baffle: cutlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, Revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 93 Sugarcane Ln. No. Andover, Ma. 01945 Owner: Alexander Crosett Date of Inspection: June 10, 1999 SOIL ABSORPTION SYSTEM (SAS):XX (locate on site plan, if possible; excavation not required, location may be approximated by non -intrusive methods) If not located, explain: Type: leaching pits, number:__ leaching chambers, number: leaching galleries, number: leaching trenches, number, length: leaching fields, number, dimensions: 1 field 30' wide 37' lona 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.) nomral none none no grassy side yard area. CESSPOOLS: N/A (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 consbuction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of pending, condition of vegetation, etc.) PRIVY: NIA (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.) SEPTIC AND CERTIFIED PLOT PLAN LOCATED IN NORTH? ANDOVER, MASS. SCALE.1 "=40' LOT 3 248.50 N� N I i it 111 LOT 4 I' ' II ,, r�0 • � T 29,136 S.F. o -,-56 5, 210.66 LOT 5 TABLE OF ELEV. OUT OF HSE.=131.60 INTO TANK =131.11 OUT TANK =130.94 INTO BOX =130.56 OUT OF BOX =130.40 END PIPES =130.10-130.12 I CERTIFY THAT THE OFFSETS SHOWN COMPLY WITH THE ZONING BY LAWS OF NORTH ANDOVER WHEN CONSTRUCTED OFFSETS SHOWN ARE FOR THE USE OF THE BUILDING INSPECTOR ONLY AND SUCH USE IS FOR THE DETERMINATION OF ZONING CONFORMITY OR NON -CONFORMITY WHEN CONSTRUCTED. W t P ,J OFFSETS SHOWN ARE FOR THE USE OF THE BUILDING INSPECTOR ONLY AND SUCH USE IS FOR THE DETERMINATION OF ZONING CONFORMITY OR NON -CONFORMITY WHEN CONSTRUCTED. W t P revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:93 Sugarcane Ln. No. Andover, Ma. 01845 Owner:Alexander Crosett Date of Inspection:June 10, 1999 NRCS Report name i U C �' o /- /- �`�,; moi[ e, Soil Type C 6 elO Typical groundwater r — YP �P� to USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate SITE EXAM Slope20G g "/�j`► Surface water None Check Cellar Dry (finished bsmt) Shallow wells No Estimated Depth to Groundwater 4' Feet Please indicate all the methods used to determine High Groundwater Elevation: X Obtained from Design Plans on record X Observed Site (Abutting property, observation hole, basement sump etc.) X Determined from local conditions Checked with local Board of health Checked FEMA Maps X Checked pumping records Checked local excavators, installers Deep X Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) This is a relatively new system, all liquid levels were good , dry basement, perc and deeps done on 5-2-95. f ,.orrrM ti w F ,-T ACHUSEtj Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 2 DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant e A 1 j 31k,- UAUX -_ Test No. Site Location % -C 4 /1 Reference Plans and Specs ENGINEER 0 Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. D/ Fee Go L CHAIRMAN, BOARD OF HEALTH Site System Permit No. q q TOWN OF NORTH ANDOVER - SYSTEM PUMPING RECORD DATE: 94 SYSTEM 0 NER & ADDRESS Al/I SYSTEM LOCATION (example: left front of house) OCT - 3 ?001 DATE OF PUMPING: —�/—RAb 1 QUANTITY PUMPED ,[r0 6GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINEIII OF NORTH ANDO" -,i/ - __ZEMERGENCY P BOARD OF HFi 7 N OBSERVATIONS: GOOD CONDITION ✓ FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: -)aV COMMENTS: CONTENTS TRANSFERRED TO: y S+ �rd Memo To: Andover Septic From:Sandra Starr, Health Director CC: Sue Contarino, File Date: 10/5/01 Re: Pump record for 93 Sugarcane Lane The attached record is being returned because it is incomplete. Please fill in the missing information and return it to our office. I am also sending some new blank forms for you to copy, because we noticed some of your forms are copying very dark and are hard to read. Thank you for your cooperation. B=l;vvm�3 OF 4liRTH AN00;4R P-OAPD Qu HEALT-3 Agra__..._. ..-._ ..�. o.. .. 1 0 Page 1 Applican Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 1 APPLICATION FOR SITE TESTING/INSPECTION Site Location Engineer ` �'�Ju S`Cd/VL� s:�� `►— �_ .0 NAME ADDRESS y TELEPHONE Test/Inspection Date and Time CHAIRMAN, BOARD OF HEALTH Fee l `Zig .� Test No. S.S. Permit No. �� D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts Form No. 1 V40RTH BOARD OF HEALTH 6q"°-I�1'il,ft'�u 1 i? 19 OL O 1 V APPLICATION FOR SITE TESTING/INSPECTION Applicant— NAME ADDRESS TELEPHONE Site Location (X) n n _i, Engineer J.rLJ—�4 1 (t.,^v;, .xl xk—k-A ,r'° NAME ADDRESS r ` TELEPHONE Test/Inspection Date and Time r Fee , .) CHAIRMAN, BOARD OF HEALTH Test No. �• (,, S.S. Permit No. 79� D.W.C. No. C.C. Date Plbg. Permit No. �L\ Commonwealth of Massachusetts AM City/Town of System Pumping Record NOV 12 cQ�Z Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 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, Leftight rear of hous , eft /right side of house, Left / Right side of building, Left / Right front of building, a Ight rear of building, Under deck Address Cityrrown State 2. System Owner: V�& Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ Zip Code State t / 'rO,s`Z'Code Telephone Number, Date 2. Quantity Pumped: Gallons Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of,�tem: ,U_ I � 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company contents were disposed: 9 Lowell Waste Water F5821 Vehicle License Number t5form4.doc• 06103 System Pumping Record • Page 1 of 1