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Miscellaneous - 94 WINDKIST FARM ROAD 4/30/2018 (2)
_N O w a Lot & Street Jor la Zi)i,u DKi i5 Map/Parcel G0 CONSTRUCTION APPROVAL Has plan review fee been paid: NO Permit# 91p� Plan Approval: Date: Q Approved by: Designer:/,/- Plan Date:dl Conditions: Water Supply: Town Well Well Permit: Driller: Well Tests: Chemical Date Approved Bacteria I Date Approved Bacteria II Date Approved Plumbing Sign -Off: Comments: Form "U" Approval: Date Issued Conditions: Final Approval: Wiring Sign -Off: Approval to Issue By: YES NO All Permits Paid? YES NO Well Construction Approval? YES NO Septic System Construction Approval? YES NO Certification? YES NO Other YES NO Any Variance Needed? YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: APPROVED BY: LD t3� t SEPTIC SYSTEM INSTALLATION Is Excavation Inspection: Needed: Passed: By: By: Construction Inspection: Needed: (�As Built P )Satisfactory - YES: Approval of Backfill: Date: G� Zf By- / Final Grading Approval: Date: By:�, Final Construction Approval: Dater By: Certificate of Compliance: Approval: Date: 6z L �5V-0 - 7P& --e- 'D 4/a6 Is the installer licensed? NO Type of Construction: REPS New Construction: Certified Plot Plan Review5� NO Floor Plan Review NO Conditions of Approval from Form U YES e1v Issuance of DWC permit: YES NO DWC Permit Paid? YES NO DWC Permit # Installer:7� Begin Inspection: NO Excavation Inspection: Needed: Passed: By: By: Construction Inspection: Needed: (�As Built P )Satisfactory - YES: Approval of Backfill: Date: G� Zf By- / Final Grading Approval: Date: By:�, Final Construction Approval: Dater By: Certificate of Compliance: Approval: Date: 6z L �5V-0 - 7P& --e- 'D 4/a6 North Andover Board of Assessors Public Access t ,►ORT// �,SSACHUb t� Click Seal To Return Search for Parcels Search for Sales Summary Residence Detached Structure Condo Commercial Page 1 of 1 North Andover Board of Assessors roperty Record Card Aarrat m -)IAM no n-nn47-nnnn n W-1filn ('nmmnnihT • Nnr+6 Andnvor Location: 94 WINDKIST FARM ROAD Owner Name: DEMAIO, FRANK & PAULINE Owner Address: 94 WINDKIST FARM ROAD City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 8 - 8 Land Area: 1.41 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 4081 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 925,500 985,400 Building Value: 692,400 755,300 Land Value: 233,100 230,100 Market Land Value: 233,100 Chapter Land Value: http://csc-ma.us/PROPAPP/display.do?linkld=1520492&town=NandoverPubAcc 1/4/2010 -tie 5 U c-al inspection i-o F-r- Not for Voluntary Assessments Subsurface Sewage Disposal System .Form MA/R(�y-/(�J(/( M Y• `, ���lL/ ([. TLS Inspection results must be submitted on this form or on the officiallfii f t t;� A. Certification Important When filling out 1. Property Information; Owner's Address CitylTown State Zip Code Date of Inspection Date 2. Inspector: Name of Inspector Company Name Company Address City/Town State Zip Code Telephone Number Certification -Statement: ' I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and ma intenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ,®'Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Furt4er Evaluatio by the Local Approving Authority _ Z r0 .? Inspector's Signature Date The. system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. 'This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc • 11120D4 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 1 of 16 _ Title 5 Official Inspection Form. Not for Voluntary Assessments - Subsurface Sewage Disposal System Form A. Certification (cont.) Property Address City/Town State Zip Code e Owner's Name Date of Inspection 1 A) System Passes: II 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 describegi/in the "Conditional Pass" section need to be, replaced or repairk. The system, upon coM/ Iletlon of the replacement or repair, as approved by the Board of Health, ill pass. i Answer yes; no or not det fined (Y, N, ND)n the ❑ forthe following statements, if "not determined," please explain. ❑ The seotic tank is metal a d over 2D y`ears old* or the septic tank (whether metal or not) is structurally unsound, exhib s subst tial infiltration or ex2tration ortank failure is imminent. System will pass inspection the e isting tank is replaced with a complying septictank as approved by the Board of He th. * A metal septic tank will pass ' pection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that e ank is less than 20 years old is available. ND Explain: t5insp.doc - 11/2004 Title 5 Official inspection Form: Subsurface Sewage Disposal System Paoe.2 of 16 I itic 5 Utticiai inspection. Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form _A__Certification (cant.) ! — GitjdTowra 5t3te Z�{i Code owner'sName o Date df Insoeotion ❑ Observation of sewage backup or brea • out or high static water level in the distribution box due fa broken or obstnrcted pipe(s) or due jo a broken, settled or uneven distribution box. System will pass inspection if (with approval of Bord of Health): ❑ broken pipe(s) are rep`t`aced ❑ obstruction is removed ❑ distribution box is levels or replaced ND Explain: ❑ The system required pumping more than 4,�imes 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 replacd ❑ obstruction is removed ND Explain: f C) Further Evaluation is Required by the Board of Health: r ❑ 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 orthe environment. 1. System will pass unless Boar of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is nofunctioning in a manner which will protect public health., safety and the environment: ❑ Cesspool or privy is within 50 et of a surface water El Cesspool or privy is within 50/feet of a bordering vegetated wetland or a salt marsh t5insp.doc - 11120D4 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 3 of 16 W ection`or�m Title 5 Official Insp Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification P C)_ Further Evaluation is Required by the Board of Health (cont.): 2. System -will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manned that protects the public health, safety and environment: i Q The system has a septic tank and soil absorlAion 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 SAi and the SAS is within a'zone 1 of a public water supply. ❑ . The system has a supply well. ❑ The system has.a more from a private water Method used to de, ctank SAS and the SAS is within 50 feet of a private water and SAS and the SAS is less than 100 feet but 50 feet or ine�distance: "" This system passes if the well wat-' analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic c mpounds indicates that the well is free from pollution from that facility and the presence of ammon nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3, Other: t5insp.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 4 of 16 Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form . 4 - A rErtifi�.a�ion - ----P-rooerty-Aririre�c _. /"0 A�er,L0 ark n"PLIS '. to ?ipGode 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 clDgg-ed SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than'/ day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ © Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy,is within 100 feet of a surface water supply or tributary to a surface water supply. ❑. [ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.. [This system -passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form,] Yes No ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. t5insp.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 5 of 16 Title,50ffidal Inspection -Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A.. -Certification-- ( cont. L_ .. � 1//tel>ia�✓� ��� ,�� State Code Owners Name Date of Inspection 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 "yesi or "no" to each of the following, in addition to the questions in Section D. YES NO ❑ ❑ the sym is within 4 0 feet of a surface drinking water supply ❑ ❑ the syst rpt is within /00 feet of a tributary to a surface drinking water supply ❑ thesystem islocated in a nitrogen sensitive area (Intenr-n Wellhead Protection Area - IWPA) ter -a mapped Zone al of a public water supply well If you have answered "yes" to any quo tion in Section E the system is considered a significant threat, or answered "yes" in. Section D abov t Iarge system has failed. The owner or operator of any large system considered a significant thret un er Section E or failed under Section D shall upgrade the system in accordance with 310 CM}, 15.34. The system owner should contact the appropriate regional office of the Department. t5insp.doc • 11/20D4 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 6 of 16 i we o uniciai inspection i-orm Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Checklist —.-- erope.rty_Address_T__ UH8CK it t e o owing ave Been clone. You must Inoica a es or no as to each otth, to owing: YES NO NU e 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 th e interior of the tank inspected for the condition of the baffles ortees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner (and occupants if different from own er) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ Existing information. For example, a plan at the Board of Health. ©, Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] t5insp.d= • 1112004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 7of16 Title,5 Official Inspection l=oan Not for Voluntary Assessments r Subsurface Sewage Disposal System Form r M V C. System Information 1K(* Property Address State Zip Code City/Town Owner's Name Date of Inspection Number of bedrooms (actual): U Number of bedrooms (design): ( ) DESIGN flow based on 31 D CMR 15.203 (for example: 110 gpd x # of bedroc3ms): Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Sump pump? Last date of occupancy: Commerciallindustrial Flow Conditions: Type of Establi Design flow (based oRy310 CMR 15 Basis of design flow (se Grease trap present? Industrial waste holding tank prNerlt? etc.): Non -sanitary waste discharged toA\e Title 5 system? Water meter readings, if ava Last date of occupancy/use: Other (describe): t5insp.doc • 1112004 ❑ Yes 2 No ❑ Yes �2 No ❑ Yes 2 No ❑ Yes P No .0 ❑ Yes Za' No Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Date Title 5 Official Inspection "Form: Subsurface Sewage Disposal system Pace 6 of 11 Tale 5 Official inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M V• `•V G. System Informafion (cont ) Dr n h AAA ,12n,6 r-,cr ____w_ 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: Type of System: gallons Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy E -Yes ❑ 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 system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): Approximate age of all components, date installed (f known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes �J—No t5insp.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 9 of 16 Titles official Inspection., Form Not for Voluntary Assessments r Subsurface Sewage Disposal System Form C System Information (cont.) Property Address --- ,,, _,ft CitylTown State Zip Code Material of construction: ❑ other (explain): ❑ cast iron R'40 PVC Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence -of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: Material of construction: 2rGoncrete ❑ metal []'fiberglass 4 feet ❑ polyethylene ❑ other (explain) If tank is metal, fist age: years Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ❑ No certificate) - Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle ,T - scum thickness `,o Distance from top of scum to top of outlet tee or baffle rf Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? t5insp.doc • 1112004 Title 5 Official Inspection Form: subsurface Sewage Disposal System Page ID of 1E Otle 5 Uicial Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C Sysfem_fnfonnation_LLo.ntr) ---- ---- --- Property.Address--- -- -- - — —�- - ---- rrt�rJTOuun State - _-.....,�..•� ��,, r-,..r,..y .u� + n +,uc+uv.7, 11M,1 a11u WUucl LUU Ui 00111G 1UIIUIuUrt JLIUULIICH—ffi idly, iiqu4d- Ieveis-a-s-r-dated-te-�autt ver-�,-av+denae-ef-ieak-age et -c : e s Y C Al" C�' L C >��! (� AWC ir r a e Grease Trap (locate on site plan): Depth below grade: feet Material of constructio ❑ concrete ❑ etal ❑ fiberglass ❑ polyethylene El other (explain): -Dimensions: Scum thickness Distance from top of scum to t p of outlet tee or baffle Distance from bottom of scu t bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping reMrrme dations, inlet and outlet tee or baffle conditi on, structural integrity, liquid levels as related to outlet inv` evidence of leakage, etc.): Tight or Holding. Tank (tank ust e pumped at time of inspection) (locate onsite plan): Depth below grade: Material of construction: ❑ concrete ❑ me I: ❑ fiberglass ❑ polyethylene y ❑ other (explain): t5insp.doc • 1112004 Title 5 Official Inspection Form: subsurface Sewage Disposal System Page 11 of 16 y�..,.\ V4tllll llveerr v..a•..•. .�. .���--^ W Title ficial Inspection Form - Not for, Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) - _ ....Property Address .. _.... _ .... _ :...--- _.. Zi Code` �Vnwn State b _ 0 owner's Name..., _ Dae of Inspection ig cT H -61 -mg an l Dimensions: Capacity: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ No Alarm in working order. Date of last pumping'. Date Comments (condition of alarm an float witches, etc.): ❑ Yes ❑ No Distribution Sox (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.): Pump Chamber (locate on site Pumps in working order. Alarms in working order. ❑ Yes ❑ No ❑ Yes ❑ No tsinsp.doc • 11120D4 Title s official inspection Form: Subsurface Sewage Disposal System Page 12 of 1( M I it[e 5 Uttici2�1 inspection �o� Not for Voluntary Assessments Subsurface Sewage Disposal System Form M v C. System Informationj-cm- tj _... .._ ... Property Address ... ... . r*B.m9d e Owner's Name— ---Date nf.1.n comments (note condltign of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate onsite plan, excavation not required): If SAS not located, explain why: C1',, / Type: ❑ leaching pits ❑ leaching chambers ❑ leaching galleries ❑ leaching trenches Ee' leaching fields ❑ overflow cesspool ❑ innovative/alternative system Type/name of technology: number: number: number. number, length: number, dimensions: 0�`xs� number. Comments (note condition of soil, signs of hydraulic failure, level of ponding, Cl amp soil, condition of vegetation, etc.): /y / ,%% , t5insp.doc • 1112004 Title 5 Official Inspection Form: Subsurface Sewage Disposal system Page 13 of 16 z �\ Title 5 Official Inspection l=oan - Not for Voluntary Assessments v° Subsurface Sewage Disposal System Form C. System Information (cont.) _ p� 1ti1� c✓�� f ,min /�'� --- Property Address Cit [Town o c✓ State Zi Code Owner's Name Date of inspectionCeSSPooIST1DeSS_ - r - Number and configuration Depth — top of liquid to inlet invert Depth of solids layer f Depth of scum layer Dimensions of cesspool Materials of construction Indication. of groundwater inflow ❑ Yes ❑ No Comments (note condition. of soil, s' ns 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, sig etc.): t5insp.doc • 1112DD4 ulic failure, level of ponding, condition of vegetation, Title 5 Official inspection Form: Subsurface Sewage Disposal System Page 14 of 16 ins,peGtIon i ' Not for Voluntary Assessments. Subsurface Sewage Disposal System Form V Cw.,SaC5�E17.L�!]�D�r']�1o11�cQnt Property _Address-- 1 ..-- - ---------- .--------- J _ _ - =-- -- -- - -_- _.. t�winr'C llama DntP f InqhRrfin Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at-least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. t5insp.doc • II/2oD4 � 31 �o °� EPe " 0 Title 5 Official Inspection Form: Subsurface_ Sewage Disposal System Page 15 of 16 Titl.e 5 Officiai,maps .tion Form Not for Voluntary Assessmnts SubsurfaczLSewap Disposal System Form Vey`' C Svsiem Inf®rmaion (cont.) — Property Address z .._...._ _._.__._... _...._ c+�}a Z!D Code Mire, Slope a Surface water 120lLe Check cellar Shallow wells n Estimated depth to ground water: / Please indicate all methods used to determine the high ground water elevatio n;. j- Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain; ' ❑ Checked with local excavators, Jnstallers. - (attach documentatio n) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: t5insp.doc • 11120D4 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Paoe 16 of 1E OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 94 Windkist Farm Road N Andover, MA 01845 Owner's Name: Wayne Poe Bate of Inspection: 6/4/02 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. X80)( PT.�,t. .x, .�• c .-. , rig \\. %• 20 2t •: 'v. ` ,,:i '\'l 0 10, 23'--- TOP M. i — 257.Ole ' °. 1500 OALLOO SEPTIC' TANK RESERVE i i . �'r X91 -Ix -f. AREA TP97—t2— P'' 10 ' A L) �kl MORTf� O?t •.r •..� ppw Town of North Andover M+�'•�;, ;o .• HEALTH DEPARTMENT �SSAcNus CHECK #: / / DATE- `3 /D 10, LOCATION: H/O NAME: _ CONTRACTOR NAME: Tyne 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 Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title -5 Inspector $�� CY Title 5 Report $ Q ❑ Other. (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer �i�� 5 C3'`1�1�! il�SpeCt0lil'� ECS E Not for Voluntary Assessments'��m�i/.�//�� Subsurface Sewage Disposal System Form MAR p ' M Inspection results must be .submitted on this form or on the official (M -M §1�800: i rb.un Tmsi'nal-rmt=be-MteTeth - A. Certification Important, When filling out 1 Property Information: --mom nn computer, use onlv the tab ke Property Address Owner's Address - City(Fown Date of Inspection: 2. Inspector: %Ir }e/ �yCr State Zip Code Date Name of Inspector �% .S Company Rame 'eye Company Address/ 07 City/Town state Zip Code Z%E f9/7F61,op Telephone Number , Certification -Statement: I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: P'Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Furt r Evaluatio.R by the Local Approving Authority a 0� Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 god or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc • 1112004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 1 of 16 VV111111U11VVGQI.C11 Vt IYI GiJaul+l ltJ.7 tr caJ Title 5 Official Inspectionform Not for Voluntary Assessments Subsurface Sewage Disposal System Form � M V A. Certification (cont.) Property Address City/Town State Zip code t5insp.doc • 11/2004 1 Owner's Name Date of inspection A) System Passes: 21have 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: YIiIU B) System Conditionally Passes: ❑ one or more system components as describe 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, ill pass. Answer yes; no or not dete ined (Y, N, ND) n the ❑ forthe following statements. If "not determined," please explain. ❑ The septic tank is metal a d over 20 11ears old* or the septic tank (whether metal or not) is structurally unsound, exhib s substa tial infiltration or exfiltration or tank failure is imminent. System will pass inspection the a isting tank is replaced with a complying septic tank as approved by the Board of He th. * A metal septic tank will pass ' pection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that he ank is less than 20 years old is available. ND Explain: Title 5 Official Inspection Form: Subsurface Sewage Disposal System. - Page. 2 ystem.•Page.2 of 15- i M -Title 5 official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form _A_Certification (nco -) - -- ----._Property-Address-------- ------ ---.—.------ – -- ❑ Observation of sewage backup or brea out or high static water level in the distribution box due to, broken or obstructed pipe(s) or due o a broken, settled or uneven distribution box. System will pass inspection if (with approval of Bo, rd of Health): ❑ broken pipe(s) are rep aced ❑ obstruction is removed ❑ distribution box is levele or replaced ND Explain: ❑ The system required pumping system will pass inspection if (wi ❑ broken pipe(s) are repla ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Bc ❑ Conditions exist which require further evalu the system is failing to protect public health 1. System will pass unless Boar\ of He 15.303(1)(b) that the system is no funcf'ti safety and the environment: ❑ Cesspool or privy is within 50 ❑ Cesspool or privy is within 5V t5insp.doc • 11120D4 mes a year due to broken or obstructed pipe(s). The of the Board of Health): -ard of Health: ati n by the Board of Health in order to determine if safety or the environment. filth determines in accordance with 310 CMR oning in a manner which will protect public health., of a surface water of a bordering vegetated wetlan d or a salt marsh Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 3 of 16 Title 5 official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form V A. Certification cant.) •-----------..P.rope.rty_.Ad C)_ Further Evaluation is Required by the Board of Health (coni.): 2. System -will fail unless the Board of Health (and Pub�ic Water Supplier, if any) determines that the system is functioning in a mann that protects the public health, safety and environment: ❑ The system has a septic tank and soil absor Ion 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 tan/ndSAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has\aaptic tanand the SAS is within 50 feet of a private water supply well. ❑ The system has a septi tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water sup well". Method used to detE$mine`pistance: This system passes if the well wat analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic c mpounds indicates that the well is free from pollution from that facility and the presence of ammon nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteri are triggered. A copy of the analysis must be attached to this form. 3. Other: t5insp.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 4 of 16 N Title 5 Ut ictal Inspection Fora Not for Voluntary Assessments Subsurface Sewage Disposal System Form _A,-Gertifi.cati_on Lcflnt_) ------P-roperty-Address ----• ----------- / o"P w l - ^'ty/Town n � State ��pOode D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ a Backup of sewage into facility or system component due to overloaded or clDgged SAS or cesspool ❑ E Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow ❑ © Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ © Any portion of the SAS, cesspool or privy is below high g round 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. ❑ Q Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Fq 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 systerro_passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.]. Yes No ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. t5insp.doc.• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 5 of 16 VVIIIIIIv(IVV +a.114v1 ..���^�••------- _ I Title 5 Official Inspectio.9 'Form - Not for Voluntary Assessments Subsurface Sewage Disposal System Form a ' A Certification (cont) Cod owners Name Date of Inspection 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 '1 l ❑ ❑ the sys�em is within 4 0 feet of a surface drinking water supply ❑ ❑ the systel\ is within 00 feet of a tributary to a surface drinking water supply the system is ocat d in a nitrogen sensitive area (Interim Wellhead Protection ❑ 0 Area - IWPA) r-amapped Zone :II of a public water supply well If you have answered "yes" to any que tion in Section E the system is consid ered a significant threat, or answered "yes" in. Section D abov t` large system has failed. The owner or operator of any large system considered a significant thre t unV er Section E or failed under Section D shall upgrade the system in accordance with 310 CM 15.3 4. The system owner should contact the appropriate regional office of the Department. t5insp.doc • 11120D4 Title 5 official inspection Form: Subsurface Sewage Disposal System Page 6 of 16 _i ie uTTICiai inspection i-orm Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M V B. Checklist-.;'., ProDerty Address UneCK It e following nave been done. You must indicate es or no as to each of the following:_ YES NO Lj ❑ 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? Z ❑ Has the system received normal flows in the previous two week.period? ■ NAMEN all ■1 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 own er) 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 pian at the Board of Health. ©, El Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] t5insp.doc • 1112004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 7 of 16 W Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form Owner's Name Date of Inspection Industrial waste holding tank Non -sanitary waste discharged toft Title 5 system? Water meter readings, if Last date of occupancy/use: other (describe): Date ❑ Yes Number of bedrooms (design): — V Number of bedrooms (actual): --- DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedroc3ms):�- Yes Number of current residents: No Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? [if yes separate inspection required) ❑ Yes No Laundry system inspected? ❑ Yes No Seasonal use? ❑ -Yes No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? . ❑ Yes ®' No Last date of occupancy: Date Commercial/industrial Flow Conditions: �� fl Type of Establiss ent: Design flow (based o 310 CMR 15.203;): Gallons per day (gpd) Basis of design flow (sea /persons/9 ft., etc.): Grease trap present? El Yes ❑ No Industrial waste holding tank Non -sanitary waste discharged toft Title 5 system? Water meter readings, if Last date of occupancy/use: other (describe): Date ❑ Yes ❑ No ❑ Yes ❑ No t5insp.doc • 11120D4 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 8 of 11 Title 5 official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M V • ,Y C. System information (cont.)_ eJ roperty-.Address — ---------------_-- —=------------ - ---- -----. 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: Type of System: 1.J 0 gallons ( Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy E -Yes ❑ No ❑ Shared system (yes or no) (If yes, attach previous inspection records, if any) ❑ Innovative/Aitemative 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: Were sewage odors detected when arriving at the site? ❑ Yes �j—No t5insp.doc • 1112004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 9 of 16 �.._----- oo.\ -title 5 official Inspection Form - Not for Voluntary Assessments _ Subsurface Sewage Disposal System Form C System Information (cont.) Property Address State 1 11 Zip Code Owner's Name Date of Inspection Depth below grade: feet Material of construction: ❑ cast iron 2'40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence -of leakage, etc.): Septic Tank (locate on site plan): !1 Depth below grade: feet _ Material of construction: 2'Soncrete ❑ metal ❑ fiberglass ❑ polyethylen e ❑ other (explain) If tank is metal, list age: - years Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ yes ❑ No certificate) Dimensions: ��. Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle r} �J Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? t5insp.doc • 1112004 Tale 5 official Inspection Form: Subsurface Sewage Disposal System Page 10 of 1 f _ ove 5 utticial Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C -System J1 of a m.atiD n (wont. ) -----.—.._.---- --- Property Address----- —,:. — --- -- - -- - — - - ---- �,itjR/�owa �dh��//.� �O�nn,o �i�'�iQy �lu� 1%�.. //�� eb.G�CI _ . �{k f�nnr✓�n�/ ..C.Q6 �� /,%If E� J // /,�7.¢ yr .r �� i/C,�l/1'4' tom' (� � h !�!i / 4r !�L/1� Lf �' i% � !✓ r Grease Trap (locate on site plan): Depth below grade: feet Material of constructio ❑ concrete �%etal ❑fiberglass ❑polyethylene ❑other (explain): -Dimensions: Scum thickness Distance from top of scum to t Distance from bottom of scum) 1 Date of last pumping: Comments (on pumping recom liquid levels as related to outlet of outlet tee or baffle bottom of outlet tee or baffle Date ,` dations, inlet and outlet tee or baffle conditi on, structural integrity, evidence of leakage, etc.): Tight or Holding Tank (taXustpumped at time of inspection) (locate onsite plan): Depth below grade:. Material of construction: [I concrete Elme❑ fiberglass ❑ polyethylene ❑ other (explain): t5insp.doc • 11120o4 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 11 of 16 (a+�\ t�v{•e�l��vstvveee�c.�i .,� �e�c,.,.......,.......____ _ M W Title ficial Inspection Fora -Not for Voluntary Assessments Subsurface Sewage Disposal System Form n Information (cont. C( _...... __ Property Address itvrrnwn State Zip Code G 0 0 ewn is Name.., Dae of Inspection Igit oar FlolPing I an Dimensions: Capacity: Design Flow: Alarm present: Alarm level: Date of last pumping: Comments (condition of alarm anp float gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date 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 oroutofpbox, /etc.): Pump Chamber (locate on site Pumps in working order: Alarms in working order: ❑ Yes ❑ No ❑ Yes ❑ No t5insp.doc • 1112004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 12 of 11 J Iitie 5 Utticiai inspection corm a Not for Voluntary Assessments Subsurface Sewage Disposal System Form V y C Sy-stlem_fnformation (-c-an Prooerty Address .. .. __ ..... ... _ . .... 4140WFt � Owner's Name Date. of..J. Rection-- --- Comments (note condition of pump chamber, condition of pumps.and appurtenances, etc.): Soil Absorption System (SAS) (locate onsite plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits ❑ leaching chambers ❑ leaching galleries ❑ leaching trenches D? leaching fields ❑ overflow cesspool ❑ innovative/alternative system Type/name of technology: number: number: number: number, length: number, dimensions number: z0-oxy-. Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): I 1 / 1 i7 e jI — /? J , - t5insp.doc • 1112004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 13 of 16 Title 5 Official In'spectionForm Not for Voluntary Assessmerits Subsurface Sewage Disposal System Form C. System information (cont.) Property Address h HvlTnum M A state ,_ Zip Code , ��1G//Cfinda- owner's Name Date of inspection -- -m-trst 5e paMM-as-paTT-v-Msp0L-1 I) k -- Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication. of groundwater inflow ❑ Yes ❑ No Comments (note condition. of soil, s'gns 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, si etc.): t5insp.doc • 1112004 hydraulic failure, level of ponding, condition of vegetation, Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 14 of 16 r Me 5 Official Inspection Form Not for Voluntary �Assessments. R Subsurface Sewage Disposal System Form V C fDn3ation (sQnt Property _Address_ rt BVJfi ei to �p-Gade fh�enPr'c lamg t-18i'P f tncnecfio� Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to of -least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. G hyo t5insp.doc • 11/2004 0 Title 5 Official Inspection Form: Subsurface_ Sewage Disposal System Page 15 of 16 Title 5-Officiai iForm Not for Voluntary Assessments - • ' Jwyw Subsurface..Sewap Disposal System Form ` C system information (cont.) -- Property Address .. _... _...._ �t'i. tP Zip Code r e . Slope e� Surface water %Joie Check cellar Shallow wells .n Estimated depth to ground water: / Please indicate all methods used to determine the high ground water elevation, Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting praperty(observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain; ❑ Checked with local excavators, installers - (attach documentatio n) ❑ Accessed USGS database - explain: You must describe how -'you established the high ground water elevation: t5insp.doC • 11/204 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 16 of 1E OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 94Windkist Faroe- Road N Andover, MA 01845 Owner's Name: Wayne Poe Date of inspection: 6/4/02 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal systeku 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. +4,5, x .ice' rp MW �'. �� Wit:• :! PT ia 20? pie G r 2t 10' 213 ST AfG FOUWW RIM MP D. 257.71 1500 GALLON SEPTIC' TANK ra RESER VE I REl4 TPP T Pq; I,? f 10 5-u k -e � '�-o, ct" �Ge ,mac' G� c Parc RECEIVED MAR 10 2009 ITOHMN TH DEPARTMENT ANDOVER 1 ENCS .6 io e .J a e Adll''. r, f jJ* / ,(/ 4,/01 AAe- �'� 1 i�� �l i �+' � 1�, � .7 � y� 0 _j FORM 11 - SOIL EVALUATORgeFOR M Date: 1� 9 No. - Commonwealth of Massachusetts NOr4 � jf� , Massachusetts Soil Suitabili Asses • • Smen rOl. on-site Sewage Dim osal a _,3 • Dater �7 � /............. Performed By: .... c. fa� ' ...................... .......... Witnessed By:.,�,G'?'1�(,Y�t........Y.......:.. `. a.k-a. ?S oWKr : N:tee, c01D Y� k-� 441110 -e 4ev Add -L -nd I d �y lu rh®: Location Address a �//`z s J / I Loc [ . Telephorc I k/D %/7 /4a,(. &4 O /1?YJ '0 AJo. jeyZ-1 New construction 3 Repair El Office Review Published Soil Survey Available: No Yes Std 1Cf Publication Scale Year Published ����� ��� Drainage Class Well dra"N-. Soil Limitations Surf"icial Geologic Report Available: No ,Yes ❑ P Wit- ion Scale - A.,9 P6 c. Soil Map Unit1. u Year Published ................ Geologic Material (Map Unit) Y.� W // ..................................................... Landform ................... El............... Flood Insurance Rate Map: U Yes Above 500 year flood boundary No �,�/ ❑ Within 500 year flood boundary No 2 I es Within 100 year flood boundary No es ❑ Wetland Area: unit) ............. National Wetland Inventory Map (map Wetlands Conservancy Program Map (map unit) Current Water Resource Conditions (USGS): Month Range :Above Normal []Normal ❑Bel``•/ Normal ❑ Other References Reviewed: DEP APPROVED FOIN - 12107195 FORM 11 - SOIL EVALUATOR FORA Page _'of 3 Location Address or Lot I4,41�i✓1C�!(l.S �Gi/vim �00G On-site Review Deep Hole Numbjr —IA' _f Date: .>/1f, Time: Location (identify on site plan) Land Use .. Slope (%) Surface Stones Weather Vegetation - - Landform . Position on landscape (sketch on the back) Distances from: Open Water Body feet Drainage way feet Possible Wet Area feet Property Line feet Drinking Water Well feet Other DEEP OBSERVATION HOLE _OG' Other Depth from Soil Horizon Soil Texture Soil Color Soil Bould Surface (inches) I I (USDA) I (Munsell) Mottling (Structure, Stones G avel)ers, Consistency, 0/0' !Q ! 03 ,SYS/( 92&11 130 v&IOERS c, FES t PROPOSED .� ! / Parent Material, (geologic) DepthtoBedrock: .-- Depth to Groundwater: Standing Water in the Hole: • ''—�' Weeping from Pit Face: Estimated Seasonal High Ground Water: CV DEP APPROVED FORM - 11107/95 • jr FUR31 11 - S 0 1 L L� ALL:L r U t,UKIM Page 3 of 3 Location Address or Lot No. fQsfPll Determination for Seasonal Hioh Water Tanl Method Used: Depth observed standing in observation hole inches inches i-1 Depth weeping from side of observation hole Depth to soil mottles 2-(0 inches Ground water aaJustment feet Reading Date Index well level index Well Number _........... g .. . Adjusted around water level _ Adjustment actor J Depth of NO aturally ccurring ?envious Material Does at least four feet of naturallosedoccurring- forthe soil absorption material systeexist m? in all areas observed throughout the area pry* If not, what is the depth of naturally occurring pervious material? .i-rt�ficatlon certify that on /� ` (date) I have passed the soil evaluator examinavor approved by the Department a� Environmental Protection ning, expertise above experaenc� was performed by me consistent with the required described in 310 CMR 1 x.017. 1� G Date/�2i7 Signature iiDEP APPROVED FORA - 1:107195 FORM 11 - SOIL EVALUATOR FORM Page ''of 3 Location Address or Lot NOAQ l5'OA ��i� �vc� On-site Review Deep Hole Number 19 Date: g/Z�Time: Weather Location (identify on site plan) Land Use .. Slope M) Surface Stones Vegetation Landform -- Position on landscape (sketch on the back) Distances from: Open Water Body feet Drainage way feet Possible Wet Area feet Property Line feet Drinking Water Well feet Other DEEP OBSERVATION HOLE "—OG� Depth from Soil Horizon Soil Texture Surface (Inches) (USDA) Soil Color Soil Other (Munsell) Mottling (Structure, Stones, Boulders. Consistence, °i rave 6 - 3 Alp k Y� 3 -- Za l L3;v r t rr t SPOSAL AFU77 � Parent Material- (geologic) 7-14j--DepihtoBedrock: 4d Depthto Groundwater: Standing Water in the Hole: %%Q weeping from Pit Face:'/ Estimated Seasonal High Ground Water: j DEP APPROVED FORTE • 12/07/95 FORM II - SOIL L� aL�:�ivt: rutu�i Page 3 of 3 Location Address or Lot No./01 etermination for Seasonal High 'W -FP 3 9 Method UsecL Depth observed standing in observation hole ... I_; Depth weeping from side of observation hole Depth to soil mottles %R inches Ground- water adjustment fejt r inches inches Reading Date Index well level Index Well Number ............ g . Adjustment factor .... _ ...... Adjusted around water level Deoth o; Naturally Occurring Pervious Material al exist Does at least four feet of naturoallosed for the y occurring- soilabsorption ervious risystem? m all. areas observed throughout the area proposed If not, what is the depth of naturally occurring pervious material? Certilicatlon M I certify that on /.f � (date) I have passed the soil evaluator examination approved by the Department of 'EnvironmentalePr�odte wining expertise and exp riand that the above enci was performed by me consistent with t q described in 310 CMR .017. Signature D ate i 7 DEP APPROVED FOR -%1 - 12/07195 FORM 12 - PERCOLATION TEST Location Address or Lot No. /A G�� 10vd COMMONWEALTH OF MASSACHUSETTS lVD. Massachusetts Percolation Test* Date: 5//2_1,7 Time:,. 8421 Observation Hole # P!) Depth of Perc Start Pre-soak a.aZ 9"13 End Pre-soak Time at 12" Time at 9" Time at 6" 10,''(747 Time (9"-6") .5,-') Rate Min./Inch * Minimum of 1 Dercolatlon test must bo p r fcr.mad in both the primary area AND reserve area. Site Passed 2111" Site Failed ❑ .....................................................................................................................................-_._....._........... Performed By: `� v2 /ZCL Witnessed By: Susi Comments: DEP APPROVED FORM - 12/07/95 f NORT1/ 011"16 4, 0 3j�r •' 0 o I. w a ssACHUStt _ Town of North Andover, Massachusetts . BOARD OF HEALTH Form No. 2 1 vq 19-1 z DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant Test No_9l0 6 Site Location Z07— Reference DTReference Plans and SpecsT/i9�tJS,c% 1� �� /Q7 --ENGINEER DESIGN DATE _Permission is granted -for an- individual soil absorption sewage disposal system -to be installed in accordancewith regulations of Board of Health-.- -- - , cH IRMAN, BOARD OF HEALTH Fee �'�D� .Site System Permit No. �WN Yy I O APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: ,3--/D —,9Z? CURRENT INSTALLER'S LICENSE# LOCATION: A z- � /� Gc�,:Jo114 t L LICENSED INSTALLER: S SIGNATURE: TELEPHONE# CHECK ONE: REPAIR: ._._NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. Administrative Use Only $75.00 Fee Attached? Yes No Foundation As -Built? Yes✓ No Floor Plans? Yes No Approval Date: G 1L �`r53. N QQO�. SNd1d 1001A, 5 7:msm5��\NOH �NI�dJd00 �, F9 SW�d� ,�SI`�QNIM - ��Ic�� U -11 D%V\. .4� 86 /4Z /I ;ava I:a-"Z I ,101 a 4 �x•.4 ��a�ll ..0•.B �.a,ti I ..4-.5 r (V J I O I I I SII I 13 51 I O � I � I I I Q II I iv I Z I 6p ] I L----------- (V �---------J , 4 �o (V � � 1.91/6b-�9 �L SBI t am QN b � T - nb-�4Z 14-411 ,a,Zl W04 W"MO bona av eland (V 4 � 4 I I Q iv 6p (V nb-�4Z 14-411 ,a,Zl W04 W"MO bona av eland --A& (V 4 � 4 Q iv 6p (V (V �o (V � --A& � :liar,a�va dIdOOH QQO L'A9 NMiUba Nd1d d001J QNOD1S lea S�1/VD�I �NI� �O d�Q'i1�1�1 9614 /I, I10� I IIU /I Im Zi;01 SWd� �SIIQNIM auu lea o� c M N 4 4 P (V ao(V T N 3 ?------------ \ �6 r� 0 � Y _O I I � / 4 (V ao(V T \ 3 ?------------ �,O��b ..6.4Z X h RM MAIII, I I m ll01-.b4 I[4-Ic T \ 3 ?------------ \ �6 r� 0 � _O I I / %------------ N N d � � O - � fDYM /qA � - � N M � ��Z- z11ti1 �o- L— �JT , 5-zI o �,O��b ..6.4Z X h RM MAIII, I I m ll01-.b4 I[4-Ic \ 3 ?------------ \ �6 YN � I I / %------------ �,O��b ..6.4Z X h RM MAIII, I I m ll01-.b4 I[4-Ic Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES WILLIAM J. SCOTT Director March 4, 1998 Mr. Philip Christiansen Christiansen & Sergi 160 Summer St. Haverhill, MA 01830 Re: Lot 12 Windkist N. Andover, MA 01845 Dear Phil: 30 School Street North Andover, Massachusetts 01845 This is to inform you that the proposed plans for the site referenced above have been approved. If you have any questions, please do not hesitate to call the Board of Health Office at the number below. Sincerely, Sandra Starr, R.S. Health Administrator S S/rel cc: Barina Realty Trust File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 NORTH ANDOVER BOARD OF HEALTH DESIGN REVIEW REPORT DATE 81W9 FEE: (06d PERMIT ## DATE RECEIVED 7 APPLICANT 'BQRIN�� 7ZCry 7Te MAP PARCEL ADDRESS 'Ta ��°L � /oAJh Tib �X/� �Z� LOT ## 1c�'% STREET ## ENG.�fiWSO-/,AIS,,!5� STREET LUl/U�,�15i �M ENGINEER'S ADD. %wl O 5z;,p Ntzz aG-'ell lez PLAN DATE Z C%l ,7 REV. DATE CONDITIONS OF APPROVAL APPROVED REASONS FOR DISAPPROVAL: t 1-1 , No Bc,oc%l 17>A el-, &)/1/-) 7� DISAPPROVED N S,64 ez, � ..�. -�/�e� � �' /�� r � DG r�C 2 /� `• �- 3 �- CEJ J' ©/'' �ZG�S�,eUlo- /�! l5s/.v� - l /j/• /�, o'Z . A`;� ' GLQ 1ZE�j Cj.O4- necc� L i o 7. Z&1961/ ,q,���� m� ,�- a40 (6)J --P/M&-N516A)5 G,G 7--/E66 --j-:::�,/ Tti /01 00 � a19-6 li , 4 A-)67- C11A1U6<!=-F6 O,) -vaT CAlAA)6672 d ,U 9.0/(/)) C517 -6-- s Ecr-ro�• Z71p g LOCATION SEPTIC PLAN SUBMITTALS r iZ 1( NEW PLANS: YES $60.00/Plan REVISED PLANS '`r YP�S DATE: $25.00 an / Z --�—' DESIGN ENGINEER.- When NGINEER: When the submission is all in place, route to the Health Secretary 2. /� &)IIU D el,5 r OF / / 91,06 Ak 116e-,J//('G b/,!�v% Q-0 02/Gs 7 /GG ///6'f7'�,e H4� tee. R Z- J �zZ . /9,�J�1ST�' ccs j `t • � /�GJC'�` fit) ��L.C�D� `t''L�iC.1� ''"`" �� 5 pry,ez-;r FORM U - VERIFICATION FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: ��/UCL��/5 j //� ZL 6 - Phone LOCATION: Assessor's Map Number 6� Parcel 31�;/, Subdivision l �K%S ��2�'/ Lot (s) Street _L'�/Z%��� J`- St. Number ********************** Official RECOMMENDATI NS WN AGENTS: Conservation Administrator Comments 14, wn Pla e Comments Food Inspector -Health Septic Inspector -Health Comments Use Only************************ Date Approved Data Rejected Date Approved Date,Rejected Date Approved Date Rejected Date Approved Date Rejected �/19� Public Works - sewer/water connections - driveway Fire Department permit Received by Building Inspector' Date i%— Town of North Andover, Massachusetts Form No. 3 3? qp BOARD OF HEALTH o ' ' t / p 41�ao ,se�.....ap r 19 L p . 9 DISPOSAL WORKS CONSTRUCTION PERMIT �,SSICHUSEt Applicant (/31 - NAME 1NAME ADDR 5 _ � TELEPHONE Site Location — ', ! ! Permission is hereby granted to Construct �Xor Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. 9 4L It Fee Zs -'CH7ZIRMAN, BOARD OF HEA D.W.C. No. w+c. h iY .. ���?• < ..:,.. _-. a;>$Sifitir(�Rr, M+ r, .�.d i - ., , . _ .. K yr , 1 Form No. 4 Town of North Andover, Massachusetts BOARD OF HEALTH - June 24 19 98 CERTIFICATE OF COMPLIANCE - - This is to certify that the Individual Soil Absorption Sewage Disposal System construc-ted (X) or repaired ( ) William Sa er-i^j,. — by INSTALLER at Lot 12 Wi�ndkist Road, N. Andover, MA SITE LOCATION has been installed in accordance with Board of Health Regulations as described in the Design Approval Site System Permit No. 966 dated Feb 11 1998 The issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. i T- I r i k i' :i i l� a< E: r M -199E 6:5AAM V 5083723960 APG F RD 1 YM $ARRFTT HOt.1ES 976 682 2397 TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM 1;�1STALLATION CERT CATION The nndersigmgd hereby certify the: the Sewage Disposal System (�jl constructed: ( `,repaired; �* r f located as was installed iu confo=x=with the North Andover board of Aealth approved plan, System Design Permit A ji, Ldaoed ��1 / 9 � , with an Wmved design flow of � gallons per day. The mataidWIEW were in contformanCe wvt those specified on the approved PIM: theSYS=was installed it Ccordanee with the provisions of 310 CMR 15.000, Title 5 and local re$uisdoaa, and the anal grading agrees Subscaatially *ith the approved plan. All work is Aceurttely represented on the As -bulk which her bear submitted to the Board of Health. iastalier, Dcap E P02 P. Date: 31 -2Z -f6 �- .3s '� APR 3 0 o p/* -7. J,S FA L,fU JUIV TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTCM INSTALLATION CEXf1flCAII0N The mdcrsiped hereby T*,that the Sewage Disposal System ()() constructed; ( ) repaired; was installed in confb=mce with the North Audom Board of Health approved plan, System Design Permit # dated? -7. with an a�ppmvad do p flow of gS1 M pa day. The materials were is coofornUm with those specified on tho approved " plan; the system wasinstailed is accordwmc with the provisions of 310 CMR 15.000. Title S and — • local r Tdmoas, and the Saai grading agrees substantially with the approved pins. All work is - ... 'accurately reprcmutcd oa the As -built which has been submittod to the Board of Health. Installa Dmign . .. .....6 . Date: Dato: Gr— 94 Windkist Farm Road, North Andover, MA Commonwealth of Massachusetts Town of North Andover System Pumping Record System Owner & Address: DeMaio 94 Windkist Farm Road North Andover, MA Date of Pumping: August 24, 2007 Type of System: Septic tank Location of System: Right side Gallons Pumped: 1500 System Pumped By: John Zanni Pumping Co. LLC P.O. Box 4 Reading, MA 01867 License #: BHP -2006-0670 FiEG iVED SEP 2 2007 TOWNOF NUK HEZTI GEP Contents Transferred to: Greater Lawrence Sanitary District Date: August 24, 2007 Pumping Technician: BL This is proprietary and confidential information that may be used only by the Board of Health for regulatory purposes y r TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 94 Windkist Farm Road N Andover, MA 01845 Owner's Name: Wayne Poe Date of Inspection: 6/4/02 Name of Inspector: Erie Lenardson Company Name: Statewide Environmental Services, inc. Mailing Address: 2750 Harkney Hill Rd. Coventry, RI 02816 Telephone Number. (401) 392-6906 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: x Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature:A, o&AwA vw Date:6/4102 The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 34 days of completing this inspection. H the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. PART A CERTMCATION (continued) Property Address: 94 Windkist Farm Road N Andover, MA 01845 Owner's Name: Wayne Poe Date of Inspection: 6/4/02 Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. system Passes: —x I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicted below. Comments: It. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the T 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 Be" xA metal septic tank will pass inspection if it is stiucturully sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass Inspection if (with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND =plain OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 94 Windkist Farm Road N Andover, MA 01845 Owner's Name: Wayne Poe Dated Inspection: 6/4/02 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(l)(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 witign 50 feet of a bordering vegetated wetland or a salt marsh 2L 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 bealth, 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 i 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 fat but 50 feet or more from a private water supply well**. Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that. no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other. ,OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 94 Windkist Farm Road N Andover, MA 01945 Owner's Name: Wayne Poe Date of hispection: 614!02 D. System Failure Criteria applicable to all systems: You most indicate "yes" or "no" to each of the following for all inspections: Yes No x Backup of sewage into facility or system component due to overloaded or clogged SAS or rssspool x Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool x_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool x Liquid depth in cesspool is less than 6" below invert or available volume is less than %s day flow x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped x Any portion of the SAS, cesspool or privy is below high ground water elevation. x Any portion of cesspool: or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ x Any portion of a cesspool or privy is within a Zone l of a public well. _ x Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ —x Any portion of a cesspool or privy is less than 100 feel but greater than 50 fret 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 % 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 1000 gpd to 15,000 gpd. You must indicate either "yes" or `Ino" to each of the foiiow'ing: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply T _ 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 D 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 CN R 15,304. The system owner should contact the appropriate regional office of the Department. OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 94 Windkist Farm Road N Andover, MA 01845 Owner's Name: Wayne Poe Date of Inspection: 6/4/02 Check if the following have been done. You most indicate "yes" or "no" as to each of the following _ Yes No x_ _ Pumping information was provided by the owner, occupant, or Board of Health x_ Were any of the system components pumped out in the previous two weeks ? x _ Has the system received normal flows in the previous two week period ? x Have Large volumes of water been introduced to the system recently or as part of this inspection x_ Were as built plans of the system obtained and examined? (If they were not available note as N/A) x_ — Was the facility or dwelling inspected for signs of sewage back up ? X_ _ Was the site inspected for signs of break out ? x _ Were all system components, excluding the SAS, located on site ? x _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the bathes or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? _x_ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no x _ Existing information. For example, a plan at the Board of Health. _ _x Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unocceptab le)1310 CM R 15.302(3)(b)) M OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM PH ORMATION (continued) Property Address: 94 Windkist Farm Road N Andover, MA 01845 Owner's Name: Wayne Poe Date of inspection: 6/4/02 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 5' feet Please indicate (check) all methods used to determine the high ground water elevation: _x Obtained from system design plans on record - If checked, date of design plan reviewed: 92' Observed site (abutting property/observation hole within 130 feet of SAS) Checked with local Board of Health -explain: Checked with local excavators, installers- (attach documentation) !Accessed USGS database -explain: You must describe how you established the high ground water elevation: Plans on recd at BOH 11 -OFFICIAL INSPECTION FORM – NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PARTC SYSTEM INFORMATION Property Address: 94 Windkist Farm Road N Andover, MA 01845 Owner's Name: Wayne Poe Date of Inspection: 614102 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): 4 Number of bedrooms (actuals 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # ofbedrooms): 440 Number of current residents: 4 Does residence have a garbage grinder (yes or no): no Is laundry on a separate sewage system. (yes or no): no [if yes separate inspection required] Laundry system inspected (yes or no): n/a Seasonal use: (yes or no): no Water meter readings, if available (last 2 years usage (gpd)): 310 gpd Sump pump (yes or no): no Last date of occupancy: current COMMERCIA ANDUSTRIAL Type of establishment. Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sq%et0: 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 ofoceupancy/use: OTHER (descnU): GENERAL RNORMATION Pumping Records Source of information: asbuilt 199$ Was system pumped as pact of the inspection (yes or no): no If yes, volume pumped: __ptlons --How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM x_ Septic tank, distribution box, soil absorption system Single cesspool Overflow cesspool Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the currant operation and maintenance contract (to be obtained from system owner) Tight tank _ Attach a copy of the DEP approval Other (describe): Approximate age of an components, date installed (if known) and source of information: asbuilt 1998 Were sewage odors detected when arriving at the site (yes or no): no OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 94 Windkist Farm Road N Andover, MA 01845 Owner's Name: Wayne Poe Date of Inspection: 6/4/02 ' BUILDING SEWER (locate on site plan) Depth below grade: 26" Materials of construction: _test iron x-40 PVC other (exPlain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): Tight joints no evidence of leakage SEPTIC TANK: , (locate on site plan) Depth below grade: 20" Material of construction _x_concrete metal fiberglass _polyethylene _other(explain) if tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ _ (attach a copy of certificate) Dimensions: 1500 gallons Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle- 29" .Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 16" How were dimensions determined: in the field Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Wet/outlet me in good condition and functioning properly. Septic tank shows no evidence of leakage and appears GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: concrete _ metal „fiberglass _polyethylene other (expo): 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.): OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 94 Windkist Farm Road N Andover, MA 01845 Owner's Name: Wayne Poe Date of Inspection: 6/4/02 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: oallons Design Flow•allons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of lastpumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: rx (if present must be opened)Qocate 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 is level and distribution of flow equal. No evidence of solid carryover or leakage into or out of D -box. PUMPCHAMBER: (locate on site pian) Pumps in working order (yes or no): Alarms in working order (yes orno): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 94 Windkist Farm Road N Andover, MA 01845 owner's Name: Wayne Poe Daft sf Inspection: 6/4/02 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- -x— leaching fields, number, dimensions: 1 45' x 20' overflow cesspool, number: _ innovative/alternative system Typetname of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc. No signs of ponding or hydraulic failure. System on the surface is functioning properly. Ager examining tank, D -box and surrounding area the system appears to be fimetiomag properly CESSPOOLS: (cesspool must be pumped as part of inspectionXlocate on site plan) Number and configuration: Depth — top of liquid to inlet invert: Depth of solids layer: Depth of scum layer. Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs ofhydraulic 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.):