HomeMy WebLinkAboutMiscellaneous - 95 CAMPBELL ROAD 4/30/2018 (2)r
Commonwealth of Massachusetts G,v�Q
Title 5 Official Inspection Form R� 10pl
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
95 Campbell Road
Property Address
Michael Rice
Owner Owner's Name
information is
required for every North Andover Ma 01845
page. City/Town State Zip Code
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
ICS
ji
fA 10
F�n�&
OF c1�RpP�.�MEN
7-26-17
Date of Inspection
Inspection results -must be submitted on this form. Inspection forms may not be alt red in any
way. Please see completeness checklist at the end of the form.
A. General Information
1. Inspector:
John DiVincenzo
Name of Inspector
J Ad S Development Corp / Stewarts Septic Service
Company Name
58 South Kimball St
Company Address
Bradford MA 01835
City/Town
978-372-7471
Telephone Number
B. Certification
State
s113386
License Number
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
❑ Ne ds Further valuation by the Local Approving Authority
Inso or's Signature Date
Th� 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 has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17
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Cor`nmonWealth of Massachusetts
Title 5 Official Inspection Form
I. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
i
95 Campbell Road
Property Address
Michael Rice
Owner Owner's Name
information is North Andover
required for every
page. Cityrrown
B. Certification (cont.)
Ma 01845 7-26-17
State Zip Code 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.
Col?hments:
4
The distribution box was replaced
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.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17
North Andover Health Department
(ommunity and Economic Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 95 Campbell Road MAP: 106.13 LOT: 0038
INSTALLER: John Divincenzo — Stewart's Septic
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
D -Box — 8/15/2017 Michele Grant
INSPECTIONS
TANK INSPECTION:
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
Comments:
SEPTIC TANK
❑ Contractor reports any changes to design plan
❑Existing septic tank properly abandoned
❑ Internal plumbing all to one building sewer
❑ Topography not appreciably altered
❑ Building sewer in continuous grade, on
compacted firm base
❑ Cleanouts per plan
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ 1500 gallon tank has been installed
H-10 loading
❑ Monolithic tank construction
0 Water tightness of tank has been achieved by
OF r1O R T/1 qti
SSA C H VSE
PUBLIC HEALTH DEPARTMENT
Town of North Andover
Community and Economic Development Division
CERTIFICATE OF
COMPLIANCE
As of: August 15, 2017
This is to certify that the individual subsurface disposal system received a
SATISFACTORY INSPECTION of the:
D -Box Repair
On -Site Sewage Disposal System
By: John DiVincenzo, Stewart's Septic
At: 95 Campbell Road
Map 106.B Lot 38
North Andover, MA 01845
suance of this certi scat Xa4t be construed as a guarantee that the system will function satisfactorily.
Michele Grant
Public Health Agent
120 Main St., North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.9542 Web www.northandoverma.gov
Commonwealth of Massachusetts Map -Block -Lot
106.B0038
BOARD OF HEALTC Permit No
North Andover " ` BHP -2017-0518
PJ. FEE
F.I.
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted STEW--SEPTSEPTIC
---------------------------------------------------------------------------------------------------
to (Construct) an Individual Sewage Disposal System. 9 � Jx �_t pk c e rAe4 t &A "Ik
at No 95 CAMPBELL ROAD
----------------------------------------------------------------------------------------------------------------- ------------------------------------
as shown on the application for Disposal Works Construction Permit No. BHP -2017- ted
------------------------%-------------------------------------
Issued On: Jul -31-2017 BOARD OF HEALTH
' ,x�.� • Application for Septic Disposal System
Construction Permit —TOWN OF
NORTH ANDOVER, MA 01845
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
rerun
TODAY'S DATE
$350.00 - Full Repair
$175.00 - Component
Application is hereby made for a permit to:
❑ Construct a new on-site sewage disposal system*
❑ R it or replace an existing on-site sewage disposal system* Go
Repair or replace an existing system component– What? L —. V
A. Facility In ormatioA
( 0,19 •nab R .1 / 12 fi( ���� . �Ncp,
Address or Lot #
City/Town
2.- *TYPE OF SEP C SYSTEM*:
➢ ❑ Pump YGravity (choose one)
***If pump stem, attach copy of electrical permit to application***
➢ Lfj Conventional System (pipe and stone system)
➢ ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.)
➢ ❑ Pressure Distribution S.A.S. (No D -Box)
- ➢ - -❑-Pressure Dosed-(D=Box Present)-S.A.S .___ - - -- - - - .
➢ ❑ Does the system require an effluent filter? Yes No
If yes, does plan specify make and model of filter? YES = (no further info. needed)
NO = (installer must specify brand of filter before DWC issuance)
What is the Make? What is the Model.
2. Owner Inton
Name
Address (if different
City/To n
Email address
3.
State + Zip Code
Telephone Number
g
City/Town
4. Designer Information
Name
Address
City/Town
State
up uuue
Telephone Number (Cell Phone # if possible please)
Name of Company
State
Zip Code
Telephone Number (Best # to Reach)
Application for Disposal System Construction Permit • Page 1 of 2
t '
• �a Application for Septic Disposal System
TODAY'S DATE I
Construction Permit -TOWN OF
$350.00 - Full Repair
NORTH ANDOVER, MA 01845 $175.00 - Component
PAGE 2 OF 2
A. Facility Information continued....
5. Type of Building: esidential Dwelling or ❑Commercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore -described
on-site sewage sal system in accordance with the provisions of Title 5 of the
Nnvir n ent I , as 11 as the Local Subsurface Disposal Regulations for the Town of
No do r u der and that until a final Certificate of Compliance has been issued by
thi B rd It , e installed system is not approved.
l/
e Date
Applic n Appr9oard of Health Representativ1'3
a ( 7
NaXeV ZDate
Applicat(on Disapproved for the following reasons:
For Office Use Only: /
v
1. Fee Attached? Yes J No
2. Project Manager Obligation Form Attached? Yes No
3. Pump Ssy tem? If so, Attach copy ofElectrical Permit
Applicant received copy of
"ElectticalInspection Notes for Septic Systems"
Handout?
4. Reviewed approvalletter, all paperwork received.
Missing..
5. Foundation As -Built? (new construction only).
(Same scale as approved plan)
Yes No
Yes No
Yes No
Yes No
G. Floor Plans? (new construction only): Yes No
Application for Disposal System Construction Permit • Page 2 of 2
RECEIVED
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIQ3§3 -12017
As the North ndover licensed installer for e construction for the septic system for the proN�ORTHANDOVER
HFAN DEPARTMENT
(Address of septic system) For plans by
? r (Engineer)
Relative to the application of
(Installer's name) And dated
Dated
o ay s dateT
With revisions dated
I understand the following obligations for management of this project:
(Original ate
(Last revised date)
1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to
performing any work on a site. I must have the approved plans and the permit on site when any work is
being done.
2. As the installer, I must call for any and all inspections. If homeowner, contractor, project manager, or any
other person not associated with my company schedules an inspection and the system is not ready, then
item three shall be applicable.
3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as
indicated below. I understand that requesting an insnection. without completion of the items in accordance
with Tide 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or
my company
a. Bottom of Bed — Generally, this is the first (1'� inspection unless there is a retaining wall, which
should be done first. The installer must request the inspection but does not have to be present.
b. Final Construction Inspection — Engineer must first do their inspection for elevations, ties, etc.
As -built of verbal OK (or e-mail to: healthdept@northandoverma.gov) from the engineer must be
submitted to the Board of Health, after which installer calls for an inspection time. Installer must be
present for this inspection. Witl-k a pump system, all electrical work must be ready and able to cause
pump to work and alarm to function.
c. Final Grade — Installer must request inspection when all grading is complete. Installer does not
have to be on-site.
4. As the installer, I understand that only I may perform the work (other than simple excavation) and I am required
to complete the installation of the system identified in the attached application forinstallation. I further
understand that work done by others unlicensed to install septic systems in North Andover can constitute
reasons for denial of the system and/or revocation or suspension of my license to overate in the Town of
North Andover, significant fines to all persons involved are also possible.
5. As the installer, I understand that I must be on-site during the performance of the following construction
steps:
a. Determination that the proper elevation of the excavation has been reached.
b. Inspection of the sand and stone to be used.
c. Final inspection by Board ofHealth staff or consultant.
d. Installation of tank, D -Box, pipes, stone, vent, pump chamber, retaining wall and other
components.
6.
me of this obligation.
Undersigned censed Septic Installer: (To y's te)
?Name — Pant am — rgne
❑ Other: (Indicate) $
Hea ent Initials
White - Applicant Yellow - Health Pink - Treasurer
Gq MO �Tk 1M
.7969
. O
Town of North Andover
.,,,o ..�' HEALTH DEPARTMENT
SAC S
CHECK #: 60 DATE: 3
LOCATION: 95 G /r k `%
d
H/O NAME: /!% ce
CONTRACTOR NAME:
V1, &Q-0
.
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
$
f SEPTIC Systems:
❑ Septic - Soil Testing
$
❑ Septic - Design Approval lee
$
Septic Disposal Works Construction (DWC)
J
s/7.5 -"
❑ Septic Disposal Works Installers (DWI)
$
❑ Title 5 Inspector
$
❑ Title 5 Report
$
❑ Other: (Indicate) $
Hea ent Initials
White - Applicant Yellow - Health Pink - Treasurer
Owner
information is
required for every
page.
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
14,
Coinmonwealth of Massachusetts
Title 5 Official Inspection FormRECEIVED
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments AUG 14 2017
95 Campbell Road MWUOFNORTHANDOVIA
ficklaunpok MEW
Property Address
Michael Rice
Owner's Name
.North Andover Ma 01845 7-26-17
City/Town State Zip Code 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. I ' I
A. General Information
Inspector:
John DiVincenzo
Name of Inspector
J acid S Development Corp / Stewarts Septic Service
Company Name
58 South Kimball St
Company Address
Bradford MA 01835
City/town
978-372-7471
telephone Number
B. Certification
State
s113386
License Number
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
❑ ds rthi
In tor's Signature
® Conditionally Passes ❑ Fails
uation by the Local Approving Authority
Date
g-110 -1-)
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 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 aut#iority.
'*"*This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins.doc • rev. 6/16 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
95 Campbell Road
Property Address
Michael Rice
Owner's Name
North Andover Ma 01845 7-26-17
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
® One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
l5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
95 Campbell Road
Property Address
Michael Rice
Owner's Name
North Andover Ma 01845 7-26-17
Citylrown 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
❑ Y
❑ N
❑
ND (Explain below):
❑
obstruction is removed
❑ 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.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 95 Campbell Road
Property Address
Michael Rice
Owner Owner's Name
information is
required for every North Andover Ma 01845
page. City/Town State Zip Code
B. Certification (cont.)
7-26-17
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: 85'
*'' 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.doc • rev. 6/16
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 95 Campbell Road
Property Address
Michael Rice
Owner Owner's Name
tiis
reequirequired ffor every North Andover Ma 01845 7-26-17
o
page. City/Town 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 a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the
questions in Section D.
Yes
No
❑
❑
the system is within 400 feet of a surface drinking water supply
❑
❑
the system is within 200 feet of a tributary to a surface drinking water supply
❑
i
the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area — IWPA) or a mapped Zone II of a public water supply well
❑ ® The 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.doc • rev. 6/16 Title 5 Official 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
95 Campbell Road
Property Address
Michael Rice
Owner Owner's Name
information is
required for every North Andover
page. City/Town
C. Checklist
Ma 01845
State Zip Code
7-26-17
Date of Inspection
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
® ❑
Pumping information was provided by the owner, occupant, or Board of Health
❑ ®
Were any of the system components pumped out in the previous two weeks?
® ❑
Has the system received normal flows in the previous two week period?
❑ ®
Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑
Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑
Was the facility or dwelling inspected for signs of sewage back up?
® ❑
Was the site inspected for signs of break out?
® ❑
Were all system components, excluding the SAS, located on site?
® ❑
Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑
Was the facility owner (and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑
Existing information. For example, a plan at the Board of Health.
® ❑
Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):
t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 95 Campbell Road
Property Address
Michael Rice
Owner Owner's Name
information is
required for every North Andover
page. City/Town
Ma 01845
State Zip Code
7-26-17
Date of Inspection
D. System Information
Yes
❑
No
❑
Description:
❑
No
❑
Yes
❑
No
Number of current residents:
5
Does residence have a garbage grinder?
❑
Yes
®
No
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.)
❑
Yes
®
No
Laundry system inspected?
❑
Yes
❑
No
Seasonal use?
❑
Yes
®
No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump?
❑
Yes
®
No
Last date of occupancy:
occupied
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?
Industrial waste holding tank present?
Non -sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
❑
Yes
❑
No
❑
Yes
❑
No
❑
Yes
❑
No
t5ins.doc • rev. 6/16 The 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
95 Campbell Road
Property Address.
Michael Rice
Owner Owner's Name
information is
required for every North Andover
page. City/Town
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
State Zip Code
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:
Date
Stewarts Septic
1000
gallons
Site guage on truck
To insDect the tank
7-26-17
Date of Inspection
® Yes ❑ No
® 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.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 95 Campbell Road
Property Address
Michael Rice
Owner Owner's Name
information is
required for every North Andover
page. CitylTown
Ma 01845 7-26-17
State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1980
Were sewage odors detected when arriving at the site?
Building Sewer (locate on site plan):
Depth below grade: 16"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.):
❑ Yes ® No
Septic Tank (locate on site plan):
Depth below grade: 2,.
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)
Dimensions:
Sludge depth:
❑ Yes ❑ No
t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 95 Campbell Road
Property Address
Michael Rice
Owner Owner's Name
information is
required for every North Andover
page. Citylrown
D. System Information (cont.)
Septic Tank (cont.)
Ma 01845
State Zip Code
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
7-26-17
Date of Inspection
29"
1"
6"
Distance from bottom of scum to bottom of outlet tee or baffle 14"—
How were dimensions determined? Tape measure sludge judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Liquid level is good. Both tees are good and there is no leakage.
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
Dimensions:
Scum thickness
feet
❑ fiberglass ❑ polyethylene ❑ other (explain):
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
t5ins.doc • rev. 6/16
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
wM 95 Campbell Road
Property Address
Michael Rice
Owner Owner's Name
information is
required for every North Andover
page. City/Town
Ma 01845 7-26-17
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 ❑ other (explain):
Dimensions:
Capacity:
Design Flow:
gallons
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.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
95 Campbell Road
Property Address
Michael Rice
Owner Owner's Name
information is
required for every North Andover
page. Citylrown
Ma 01845 7-26-17
State Zip Code Date of Inspection
D. System Information (cont.)
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.):
Distribution box needs replacing. It is coroaded around the outlet inverts.
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.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
95 Campbell Road
Property Address
Michael Rice
Owner Owner's Name
information is
required for every North Andover Ma 01845 7-26-17
page. City/Town 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
1-20x35
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.):
No hydraulic failure, no ponding and no damp soils.
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.doc - rev. 6/16
❑ Yes ❑ No
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 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
95 Campbell Road
Property Address
Michael Rice
Owner's Name
North Andover Ma 01845 7-26-17
City/Town 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.doc • rev. 6/16 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
95 Campbell Road
Property Address
Michael Rice
Owner
Owner's Name
information is
required for every
North Andover Ma 01845
page.
City/Town State Zip Code
7-26-17
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
t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B ; <
SYSTEM INFORMATION continued
SKETCH OF 'SEWAGE •DISPOSAL SYSTEM:
-include ties at least two permanent references landmarks or benchmarks.;':;,;:.,
locat_ep all wells within 100'
v v A -
C4
�7
� f
DEPTH TO GROUNDWATER I
depth to groundwater
TJu 41,
:method of determination or approximation:
C
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 95 Campbell Road
Property Address
Michael Rice
Owner Owner's Name
information is
required for every North Andover
page. City/Town
D. System Information (cont.)
Site Exam:
®
Check Slope
❑
Surface water
®
Check cellar
❑
Shallow wells
Estimated de th to hi In round water•
Ma 01845
State Zip Code
21
7-26-17
Date of Inspection
V g g feet
Please indicate all methods used to determine the high ground water elevation:
�1
Obtained from system design plans on record
If checked, date of design plan reviewed. Title 5
Date
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
Pulled file
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Taken from Title 5 on file. Slope on property. No sump pump in the basement.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
95 Campbell Road
Property Address
Michael Rice
Owner Owner's Name
information is
required for every North Andover
page. Cityfrown
Ma 01845
State Zip Code
E. Report Completeness Checklist
7-26-17
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.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17
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SUBSURFACE SEWAGE DISPOSAL SYSTEM I
Address of property CG�^^'Y-' ,
Owner s r name Y '' 1 -en m k,(,
Date of Inspection
ART A
CHECKLIST
MAY � 5
CTION FO 1.
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of`
Health.
V None of the system components have been pumped for at least two weeks'
and the system has been receiving normal flow rates during that
period. Large volumes of water have not been introduced into the
system recently or as part of this inspection.
As built plans have been obtained and examined. Note if they are not
available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
The site was inspected for signs of breakout.
All system components, excluding the SAS, have been located on the
site.
-The septic tank manholes were uncovered, opened, and the interior of
the septic tank was inspected for condition of baffles or tees,
material of construction, dimensions, depth of liquid, depth of
sludge, depth of scum.
The size and location of the SAS on the site has been determined based
on existing information or approximated. by non -intrusive methods.
The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
e T i
Y .
9_
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued a<:
SEPTIC TANK:
(locate on site plan)
depth belowgrade•
material of construction: concrete metal FRP other(explain)
dimensions:__
sludge depth
distance from top of sludge to bottom of outlet tee or baffle
scum thickness
distance from top of scum to top of outlet tee or baffle
-fj distance from bottom of scum to bottom of outlet tee or baffle
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, recommendations for repairs, etc.)
DISTRIBUTION BOX:2
(locate on site plan)
depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solidscarryover,
ev�igen e of leA-
into or out of --box, recomme�pdation jor repairs, etc. )
J ,! nk D .�,-1 UPI _,0U_424 A IAI C -f -A U0 Q nv&J l n , . /� n i . 6 ��
PUMP CHAMBER:
(locate on site plan)
pumps in.working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs,etc.)
�t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties at least two permanent references landmarks or benchmarks`;'
;;1,
locate all wells within 100'
Sc
ana,q�) K.ec
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of .Inspectoro cy • C�ci C
Company Name ��(,�C coo
Company Address 4D4 4 etk -v�Dj./ WK.
Certification Statement
I Certify that I have personally inspected the sewage disposal system at::,:
this address and that the information reported is true, accurate and
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
yeo
ance of on-site sewage disposal systems.
ne:
have not found any.information which indicates that the system fails
to adequately protect public health or the environment as defined in
310 CMR 15.303. Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and
the environment as defied in 310 CMR 15.303. The basis for this
determination is provi d in t AILURE CRITERIA section of this
form.
Inspector's Signature
Date
Original to system owner
Copies to: a pw ` fed a4,�o �jC,,66 i
Buyer (if applicable)
Approving authority
4F
J�
LETTER OF TRANSMITTAL
North Andover Health Department of NO oTh
400,0 od Street .Z• e`t ��' 46' 640
North Andover, MA 01845 - -'
978.688.9540 - Phone
978.688.8476 - Fax a •
•pA c«.acc"I
wwncs `?•
healthdentntownofnorthandover.com - E-mail ED
www.townofnorthandover.com - WebsitePage of �� ss^CHus�i
TO: -
DATE:
COMPANY:
FROM: Pamela DelleChiaie, Health Dept. Assistant
Phone: %�� �• �P� /
Fax:
SIGNED:
We are sendin ou: OCopyofLetter OPlans /7 Other all in below)
iL nese are transmitted as cnec crbelow:
OApproved as Noted equested OAs Required OResubmit copies for approval
OFor approval OFor Review and comment OFor Your Use OSubmit copies for dist.
REMARKS:
SCJUr
COPY TO:
COPY TO:
SIGNED:
COPY TO:
i
ACTIVITY REPORT
TIME
08/01/2005 10:40
NAME
HEALTH
FAX
9786888476
TEL
9786888476
SER.#
000B4J120960
NO.
DATE
TIME
FAX NO./NAME
DURATION
PAGE{S}
RESULT
COMMENT
#020
07/25
15:21
89789753925
40
01
OK
TX ECM
#022
07/25
15:24
819786851099
52
03
OK
TX ECM
0023
07/26
12:35
819784096122
24
02
OK
TX ECM
07/26
13:09
9786238359
16
01
OK
RX ECM
07/26
15:18
9783276563
25
02
OK
RX ECM
#025
07/26
16:20
89786851099
42
02
OK
TX ECM
#024
07/26
16:25
89786861768
00
00
BUSY
TX
07/27
12:43
15
01
OK
RX ECM
07/27
14:12
57
02
OK
RX ECM
07/27
15:13
9786850249
12
01
OK
RX ECM
07/27
15:16
617 252 6899
02:17
05
OK
RX
#026
07/28
13:03
819789880038
08:07
21
OK
TX ECM
07/29
09:48
9783276563
26
02
OK
RX ECM
#029
07/29
12:17
819784091269
48
03
OK
TX
07/29
15:03
781 383 0108
35
01
OK
RX ECM
#030
07/29
16:35
89786851099
01:06
03
OK
TX ECM
08/01
08:43
19
01
OK
RX ECM
#032
08/01
10:37
816177901392 /
01:31
08
OK
TX ECM
#033
08/01
10:39
816177901392 ,/
45
04
OK
TX ECM
BUSY: BUSY/NO RESPONSE
NG POOR LINE CONDITION / OUT OF MEMORY
CV COVERPAGE
POL POLLING
RET RETRIEVAL
PC PC -FAX
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:
JV 46r�,A=Ple
�(
Owner's Name: ' -t
Owner's Address:
Date of Inspection: P�,� • C73
Name of Inspector: (please printQM1C�
Company Name: �►;-.C�rS _Sc� c^. c S�rY c�
Mailing Address:
di
Telephone Number: q 1 7�4 7(
2 \�
CERTIFICATION STATEMENT °
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector^pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: I/'� l "Date: _ �' 0 5�
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or
DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****This report only describes conditions at the time ®f 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.
Title 5 Inspection Form 6/15/2000
page I
Page 2 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
0.6perty Address: a
Owner:
Date of Inspection: `i
Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D
A. System Passes:
Y,
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: /T•
One or more system components as described int he "Conditional Pass" section need to be replaced or
repaired: The system, upon completion of the replacerift r repair, as approved by the Board of Health, will pass.
ti
Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please
explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
brokea_pil*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):
ND explain:
broken pipe(s) are replaced
obstruction is removed -
2
Page 3 of 11
0
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address
Owner
Date of Inspection: q
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 weiland or a salt marsh
2. System will fail unless the Boar
,"f Health (and Public Water Supplier, if any) determines that the
system is functioning in a manner that protects the public health, safety and environment:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be.attached to this form.
3. Other:.
3
Page 4 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address C -.Q
Owner• �`
Date of Inspection:NL�
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 '/z 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
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.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
r1 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.]
17 u (Yes/No) The system fails.' I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gPd . . � - _ 1 ...._
You must indicate either "yes" or "no" to.each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
— _ the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
_ 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 systern 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.
4
Page 5 of 11 - =
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property AddressMA440 It
44 Andcwf-
Owner (' C
Date of Inspection: I - 3 n" -C'
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes
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:
Yes' no
Existing inforiiiation. 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) [3 10 CMR 15.302(3)(b)]
S
Page 7 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Addres . �
Owner' { t QG
Date of Inspection: '9-a-0—ca
BUILDING SEWER (locate on site plan)
Depth below grade: S v
Materials of construction: leEast iron 40 PVC other (explain):
Distance from private water supply well or suction line:
Comments (on condition of joints, venting, evidence of leakage, etc.):
f �
SEPTIC TANK: _ (locate on site plan)
�1
Depth below grade: j
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: Sr
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: 3
Scum thickness: / ,, // Jq
Distance from top of scum to top of outlet tee or baffle: C�
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: Q,A/ 5'/ rc
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
GREASE TRAP: _(locate on site plan)
Depth below,.grade:
Material of construction: concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
7
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address.
Owner•ji
Date of nspection: Ci — 34r'C1�
FLOW CONDITIONS
RESIDENTIAL/I
Number of bedrooms (design): Number of bedrooms (actual):
DESIGN flow based on 310 CMR 5.203 (for example: 110 gpd x # of bedrooms):
Number of current residents: _4,�- �/
Does residence have a garbage grinder (yes or no): Yes c No T v ' 1 � `' ��� /3
Is laundry on a separate sewage system (yes or no): J4% [if yes separate inspection required]
Laundry system inspected (yes or no): _
Seasonal us'e: (yes or no):
Water meter readings, if available (last 2 years usage (gpd)): u/ '
Sump pump (yes or no): NO
Last date of occupancy:_7 � F'C
COMMERCIALANDUSTRIAL
Type of establishment: //
Design flow (based on 310 CMR 15.203): gpd
Basis of design flow (seats/persons/sqft,etc.):
Grease trap present (yes or no): _
Industrial waste holding tank present (yes or no): _
Non -sanitary waste discharged to the Title 5 system (yes or no): _
Water meter readings, if available:
Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: If 194 C /f ,e7t
Was system pumped as part of the inspection (yes or no):' i
If yes, volume pumped:/ ,:Y— gallons -- How was quantity pumped determined?
Reason for pumping: r
TYP ^'OF SYSTEM
_ Septic tank, distribution boX, soil absoipti(m system
_ Single cesspool
Overflow cesspool
— ivy
_ 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:
S
Were sewage odors detected when arriving at the site (yes or no): A0
Az
Page 8 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Addres _ CQf
Owner �'i, s b
c-oicrl
Date of Inspection:
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):
4
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.):
CC
DISTRIBUTION BOX: Y -P. if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 'r-4 t14?
Comments (note if box is level and distributiion to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
W x Leovs-2)/ s 'T )e i R u r/ u �� . f ��sv � f 'j am to r J-1 5T/
PUMP CHAMBER: (locate on site plan)
Pumps in working order (yes or no):
Alarms in working order (yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
N SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Addr`esss::q el 11
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS)/- J— (locate on site plan, excavation not required)
If SAS not located explain why:
Type -
leaching
pe leaching pits, number: _
leaching chambers, number:
leaching galleries, number:
leaching trenches, number, length:
::.Ifeaching fields, number, dimensions: t„/ 1111 f'.3 —70,A `fi
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.):
AU
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth — top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow (yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
c
J4.
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.):
9
Page 10 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
r
PART C
SYSTEM INFORMATION (continued)
Property Address: pa
Owner,�j�i—t'
1'
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
f 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.
l
10
r V
r
r.
Page 11 of 11
0
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owneka�26 40 --
Date of Inspection: ci— .3O — QR
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
`? t
Estimated depth to ground water feet ,
Please indicate (check) all methods used to determine the high ground water elevation:
Abtained from system design plans on record - If checked, date of design plan reviewed:
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain:
Checked.with local excavators, installers- (attach documentation)
Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
/lip �Pay
11
ISE
North Andover
Waw TratniAnE Pim
420 Gmt Pond Road
North Andover, MA 01845
The following are the results of the tests performed on your well water sample_
TestsPerformed:
Total Coliform Bacteria/E. coli
Date: 2/26/04
Lab ID: B8136
Location- Greg Strileckis
95 Campbell Rd.
North Andover, MA 01845
Results:
Total Coliform Bacteria/E.coli: Negative/Negative
If you have any further questions please call us at (978) 688 -9574 -
Sincerely,
gJ4.4
David Kalisz
Senior Water Quality Analyst
North Andover Water Treatment Plant
Mass Cert. # for Bacteria - MA 21054
ZO 39Vd dIM 83AOGNV ON gtS68898t6e t7O:t7T t700Z/Z-Z/Z0
AMERICAN ENVIR ONMENTAL REPORT NUMBER: AA5 9 065.....-'..
LABORATORIES, INCORPORATED
- LAB ID #: MA076 -
- ANALYTICAL RESULTS -
PARAMETE
--------------------
:TEST::::
MDL ;
METHOT
.:DATE:
Dichlorodifluoromethane
ND
UG/L
04/12/95
0.5
EPA
524.2
Chloromethane
ND
UG/L
04/12/95
0.5
EPA
524.2
Vinyl Chloride
ND
UG/L
04/12/95
0.5
EPA
524.2
Bromomethane
ND
UG/L
04/12/95
0.5
EPA
524.2
Chloroethane
ND
UG/L
04/12/95
0.5
EPA
524.2
Trichlorofluoromethane
ND
UG/L
04/12/95
0.5
EPA
524.2
1,1-Dichloroethene
ND
UG/L
04/12/95 -
0.5
EPA
524.2
Methylene Chloride
ND
UG/L
04/12/95
0.5
EPA
524.2
Trans-1,2-Dichloroethene
ND
UG/L
04/12/95
0.5
EPA
524.2
1,1-Dichloroethane
ND
UG/L
04/12/95
0.5
EPA
524.2
2,2-Dichloropropane
ND
UG/L
04/12/95
0.5
EPA
524.2
Cis-1,2-Dichloroethene
ND
UG/L
04/12/95
0.5
EPA
524.2
Chloroform (THM)
ND
UG/L
04/12/95
0.5
EPA
524.2
Bromochloromethane
ND
UG/L
04/12/95
0.5
EPA
524.2
1,1,1 -Trichloroethane
ND
-UG/L
04/12/95
0.5
EPA
524.2
1,1-Dichloropropene
ND
UG/L
04/12/95
0.5
EPA
524.2
Carbon Tetrachloride
ND
UG/L
04/12/95
0.5
EPA
524.2
Benzene
ND
UG/L
04/12/95
0.5
EPA
524.2
1,2-Dichloroethane
ND
UG/L
04/3.2/95
0.5
EPA
524.2
Trichloroethene
ND
UG/L
04/12/95
0.5
EPA
524.2
1,2-Dichloropropane
ND
UG/L
04/12/95
0.5
EPA
524.2
Bromodichloromethane (THM)
ND
UG/L
04/12/95
0.5
EPA
524.2
Dibromomethane
ND
UG/L
04/12/95
0.5
EPA
524.2
Cis-1,3-Dichloropropene
ND
UG/L
04/12/95
0.5
EPA
524.2
Toluene
ND
UG/L
04/12/95
0.5
EPA
524.2
Trans-1,3-Dichloropropene
ND
UG/L
04/12/95
0.5
EPA
524.2
1,1,2 -Trichloroethane
ND
UG/L
04/12/95
0.5
EPA
524.2
1,3-Dichloropropane
ND
UG/L
04/12/95
0.5
EPA
524.2
Tetrachloroethene
ND
UG/L
04/12/95
0.5
EPA
524.2
Dibromochloromethane (THM)
ND
UG/L
04/12/95
0.5
EPA
524.2
1,2-Dibromoethane
ND
UG/L
04/12/95
0.5
EPA
524.2
Chlorobenzene
ND
UG/L
04/12/95
0.5
EPA
524.2
1,1,1,2 -Tetrachloroethane
ND
UG/L
04/12/95
0.5
EPA
524.2
60 Elm Hill Avenue, Leominster, Massachusetts 01453
(508) 534-1444 e 1 (800) 522-0094 • Fax: (508) 537-6252
Pl-co p....1, Q
_c
4 AMERICAN ENVIRONMENTAL
LABORATORIES, INCORPORATED
LAB ID #: MA076 -
PARAMETER
AMMONIA
- ANALYTICAL RESULTS -
RESULT :UOM . TEST ;DATE: MDL ---METHOD.
ND MG/L 04/12/95 0:01 SM # 417B
ANALYZED BY: (Q )
REVIEWED BY: ( )
These results apply only to the actual sample as tested. The integrity of results is dependent upon the quality of the
sampling technique and subsequent handling. Actual detection limits are the above reported MDL's multiplied by
dilution factors, if any. American Environmental Laboratories, Inc. shall not be held liable for any interpretation of
analytical results.
60 Elm Hill A venue, Leominster, Massachusetts 01453
• - Exceeds EPA Guidelines 508 534-1444 ° 1 c400 ° ND - Not Detected
MDL- Method Detection Limit ) ( ) 522-0094 Fax: (508) 537-6252 UOM - Unit of Measure
n ....... p,,,,.._r., OT%
AMERICAN ENVIRONMENTAL
•.` LABORATORIES, INCORPORATED
PARAMETER '
Ethylbenzene
Total Xylenes
Styrene
Bromoform (THM)
Isopropylbenzene
1,1,2,2 -Tetrachloroethane
1,2,3-Trichloropropane
Bromobenzene
N-Propylbenzene
2-Chlorotoluene
1,3,5-Trimethylbenzene
4-Chlorotoluene
Tert-Butylbenzene
112,4-Trimethylbenzene
sec-Butylbenzene
4-Isopropyltoluene
1,3 -Dichlorobenzene
1,4 -Dichlorobenzene
N-Butylbenzene
112 -Dichlorobenzene
1,2-Dibromo-3-Chloropropane
1,2,4-Trichlorobenzene
Hexachlorobutadiene
Napthalene
1,2,3-Trichlorobenzene
DILUTION FACTOR: NONE
PERCENT SURROGATE RECOVERY:
4-Bromofluorobenzene
1,2 -Dichlorobenzene D-4
REPORT NUMBER:AA59065
RESULT
UOM-
TEST DATE
MDL
METHOD
ND
ND
UG/L
04/12/95
0.5
EPA 524.2
ND
UG/L
04/12/95
0.5
EPA 524.2
ND
UG/L
04/12/95
0.5
EPA 524.2
ND
UG/L
04/12/95
0.5
EPA 524.2
ND
.UG/L
04/12/95
0.5
EPA 524.2
ND
UG/L
04/12/95
0.5
EPA 524.2
ND
UG/L
04/12/95
0.5
EPA 524.2
ND
UG/L
04/12/95
0.5
EPA 524.2
ND
UG/L
04/12/95
0.5
EPA 524.2
ND
UG/L
04/12/95
0.5
EPA 524.2
ND
UG/L
04/12/95
0.5
EPA 524.2
ND
UG/L
Q4/12/95
0.5
EPA 524.2
ND
UG/L
04/12/95
0.5
EPA 524.2
ND
UG/L
04/12/95
0.5
EPA 524.2
ND
UG/L
04/12/95
0.5
EPA 524.2
ND
UG/L
04/12/95
0.5
EPA 524.2
ND
UG/L
04/12/95
0.5
EPA 524.2
ND
UG/L
UG/L
04/12/95
0.5
EPA 524.2
ND
UG/L
04/12/95
0.5
EPA 524.2
ND
UG/L-
04/12/95
0.5
EPA 524.2
ND
UG/L
04/12/95
1.0
EPA 524.2
ND
UG/L
04/12/95
0.5
EPA 524.2
ND
UG/LEPA
04/12/95
0.5
524.2
ND
UG/L
04/12/95
0.5
EPA 524.2
04/12/95
0.5
EPA 524.2
102%
96%
ANALYZED BY: (1
REVIEWED BY: j
These results apply only to the actual sample as tested. The integrity of results is de pendent u
sampling technique and subsequent handling. Actual detection limits are the abovepreendent upon
the
quality
by
the
dilution factors, . any, American Environmental Laboratories, Inc. shall not be held liable for any interpretation of
analytical results.
Exc
60 Elm Hill Avenue, Leominster, Massachusetts 01453
)L - Method Detection Limit (508) 534-1444 • 1 (800
) 522.0094 , Fax.• (508) 537-6252 ND -Not Detected
TlA%4 TT. -
AMERICAN ENVIRONMENTAL E.:::... REPORT .NUMBEI
LABORATORIES, INCORPORATED PAGE 1 of 1
- LAB ID #: MA076 -
1
ANALYZED BY: (Q )
REVIEWED BY: ( )
60 Elm Hill Avenue, Leominster, Massachusetts 01453
MCL- ds Maxim m Contaminant
508 534-1444 • 1 800 522-0094 • Fax: 508 537-6252
MCL -Maximum Coataminaat Level � � � � � � MDL•Method Detection Limit
Please Recycle
x . AMERICAN ENVIRONMENTAL REPORT NUMBER: AA59 065
LABORATORIES, INCORPORATED
LAB ID #: MA076 -
- ANALYTICAL RESULTS -
PARAMETER RESULTUOMj TEST..DATE: MDL METHOD
NITRATE 0.24 MG/L 04/17/95 0.02 EPA 335.2
SUBCONTRACTED: M—PA009
ANALYZED BY: (Y—
REVIEWED
Y )
REVIEWED BY: Q )
These results apply only to the actual sample as tested. The integrity of results is dependent upon the quality of the
sampling technique and subsequent handling. Actual detection limits are the above reported MDL's multiplied by
dilution factors, if any. American Environmental Laboratories, Inc. shall not be held liable for any interpretation of
analytical results.
60 Elm H;11 Avenue Leomi t M h tt 01453
, nS er, QSS"L uSe S ^ -Subcontracted Analysis
• - Exceeds EPA Guidelines (508) 534-1444 • 1 (800) 522-0094 • Fax: (508) 537-6252 ND - Not Detected
MDL- Method Detection Limit UOM - Unit of Measure
Please Recvcle
.���/
Date....
0 TOWN OF NORTH ANDOVER
0
PERMIT FOR WIRING
S CHUS
This certifies that ............ ... ....... ........... . .. ......... ............................
has permission to perform . ........ . ...
wiring in 0Sbuilding of . .... ... . . .. ....... ..... .... 1.6& . ...........
�l
at . ............. .North Andover, Mass.
Fee...
................. Lic. No/!?'3.............................................................
ELEcrRICAL INSPEC-MR
Check #
5206
I
9
i
Ll
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
�j S
Permit No.
Occupancy and Fee Checked "
[Rev. 11/991 leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYP ALL INFORMATION) Date: l D -G 4-1
City or Town of: %1/ To the Inspector of Wires:
By this application the undersigned gives not' 'f his`or er i tention to perform the electrical work described below.
Location (Street & Number) 9 1/l ��/� AW
Owner or Tenant tn0//jam S j /// ti/ /j/�Q Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes [I No
Purpose of Building Utility
Existing Service Amps / Volts Overhead ❑
New Service Amps / Volts Overhead ❑
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
WEARr WA
(Check Appropriate Box)
.uthorization No.
Undgrd ❑ No. of Meters
Undgrd ❑ No. of Meters
Cmmnletinn nfthe follnwino table may he waived by the In.cnertor of Wires
No. of Recessed Fixtures
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Lighting Outlets
No. of Hot Tubs
Generators KVA
No. of Lighting Fixtures
Swimming Pool Above E]In- d. ❑
rnd. rn
o. omergencyig ting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
I No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
Number
I Tons
JKW
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local Municipal ❑ Other
No. of Dryers
Heating AppliancesKW
Security Systems:
No. of Devices orE4ivalent
No. of Water Kms,
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail i(desired, or as required big the Inspector of 'Vires.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coy rage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
(Expiration Date)
Estimated_ Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I certify, under theains and penalties ofperJ*upL that the information on this a plication is true and complete. ��
FIRM NAME . "A/," LIC. NO.: / SO ppOC 12
Licensee: [ _ 14
(If applicable, enter
Address f
OWNER'S NSU
required by law.
Owner/Agent
Signature
/��oS f'1 A2U U e2 Signature LIC. NO.;�SCQ 000 7asf
exempt " in the licen a number 1" e.) I Bus. Tel. No.
e H / Alt. Tel. No.:
RANCE WAIVER: I am aware that the Likensee eoes not have the liability insurance coverage normally
By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's aeent.
Telephone No. I PERJV1IT FEE:
DOVER MASSACHUSETTc
;j
v11 1.,
gp
0EP.hoa ptoldad jhIj lot (.9 to, X60
00 4':dmlllod`!o the local 8carc: cr oj r�
FacilityInfo rrlro kion
• 1 vvvN OF NORTH ANDOVER
008 UOn; HEALTH DEPARTMENT
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.Commonwealth of Massachusetts
:.City/Town.'b NORTH ANDOVER, MASSACHUSETTS
' System_' Pumping Record
�. Form 4
DEP has provided this form for use by local Boards of Heal h. The�ys'te�riP,umping ecord mu!
be submitted to the local Board of Health or other approvin authority.
A. Facility Information
Important: TOWN OF NORTH ANDOVER
When filling out 1,' System Location:* HEALTH DEPARTMENT
forms on the ..
computer, use
only the tab key Address /� / -'—__..__.-__�____•_- _. _
to move your
cursor - do not
use the return City/Town
key. --'- -
'
Zip Code
2. •System Owner:
Name - -- - --- -_
Address (if different from location)
City/Town-'!-'-- State ----_- Tip Code -
�- a---'-= -
Telephone Number
.1
B. Pumping Record -
1.
Dale of Pumping Date a -- 2. Quantity Pumped:
Gall ns
3. Type of system: ❑ Cesspool(s) Septic Tank
F_) Tight Tank
❑ Other (describe):
A. Effluent Tee Filter present? ❑ Yes ❑ No
r
5. Condition of System:
umped By:
If yes, was it cleaned? ❑ Yes ❑ No
N
ame } Vehicle License Number — - -
Company
7. _.: Location where contents were disposed: J
Aw
Si ature of Hau Date - ---- — - "- -
http://www.ma'ss gov/dep/water% proyals/t5forms.htm#inspect
0
15form4.doc- 06/03
System Pumping Record • Page 1 of i
TOWN OF NORTH ANDOVER'S
SYSTEM PUMPING RECORb�(
� 2p03 1�
DATE IP
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
DATE OF PUMPING . 164 -D/- 6T3 QUANTITY PUMPED aycj
CESSPOOL NO__LZ/YES SEPTIC TANK NO YES
NATURE OF SERVICE: ROUTINE i/ EMRGENCY
OBSERVATIONS:
GOOD CONDITION
FULL TO COVER
HEAVY GREASE
BAFFLES IN LACE
ROOTS
LEACHFIELD RUNBACK
EXCESSIVE SOLIDS
FLOODED
SOLID CARRYOVER
OTHER EXPLAIN
SYSTEM PUMPED BY
r
COMMENTS:
CONTENTS TRANSFERRED TO
Page I of 1
DelleChiaie, Pamela
From: Griffin, Heidi
Sent: Monday, February 02, 2004 11:45 AM
To: DelleChiaie, Pamela
Subject: homeowner request
Hi Pam:
Please call Christine Rice at 978-979-2820, she is inquiring about 95 Campbell Street, and would like to know if
there is an approved septic plan on this location. She would like to purchase the property.
Thanks,
Heidi Griffin
Community Development & Services Director
27 Charles Street
North Andover, MA 01845
(978) 688-9531
(978) 688-9542 fax
2/2/2004