Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Miscellaneous - 95 LIBERTY STREET 4/30/2018 (2)
PUBLIC HEALTH DEPAI Town of North Ando Community Development D CERTIFICATE OF COMPLIANCE As of: 6/25/13 This is to certify that the individual subsurface disposal system has been installed in accordance with the provisions of Title 5 of the State Environmental Code: Repair of D -Box By: Todd Bateson At: 95 Liberty Street Map 090B Lot 0058 callorth Andover, MA 01845 of t i s i4)s te`tall not 1. be construed as a guarantee that the system will function satisfactorily. Michele Grant ` Public Health Age 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 fax 978.688.8476 Web www.townofnorthandover.com PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 6/25/13 This is to certify that the individual subsurface disposal system has been installed in accordance with the provisions of Title 5 of the State Environmental Code: Repair of D -Box By: Todd Bateson At: 95 Liberty Street Map 090B Lot 0058 North Andover, MA 01845 of tks 44ate-stall not be construed as a guarantee that the system will function satisfactorily. Michele Grant Public Health Age 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com • � SETTLED j��' �n„ x Fi CCPV PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE . As of: 6/25/13 This is to certify that the individual subsurface disposal system has been installed in, accordance with the provisions of Title 5 of the State Environmental Code: Repair of D -Box By: Todd Bateson At: 95 Liberty Street Map 090B Lot 0058 �� North Andover, MA 01845 e of Gs cer #cate-s as a guarantee that the system will all not be construed M � Y function satisfactorily. Michele Grant Public Health 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com _ 4 North Andover Health Department (ommunity Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 95 Liberty Street MAP: 090B LOT: 58 INSTALLER: Todd Bateson DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: D -BOX 6/4/13 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 ❑ Watertightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port i Comments: PUMP CHAMBER Comments: CONTROL PANEL Comments: DISTRIBUTION -BOX Comments: ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged 1500 gallon Pump Chamber installed H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Watertightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement X Installed on stable stone base X H-20 D -Box X Inlet tee (if pumped or >0.08'/foot) X Hydraulic cement around inlet & outlets X Observed even distribution X Speed levelers provided (not required) Commonwealth of Massachusetts Map -Block -Lot 090.80058 BOARD OF HEALTH Permit NNo ------------- North Andover - BHP -2013-0734 ------------------ ---- P.I. FEE F. 1. $125.00 -------------- -------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd Bateson ----------------------------------------------------------------------------------------------------- to (Repair) an Individual Sewage Disposal System. b— 60 at No 95 LIBERTY STREET as shown on the application for Disposal Works Construction Permit No. BHP -2013-073 e r. ---------------------------- Pr - inte - d On: May -29-2013 BOARD OF HEALTH Commonwealth of Massachusetts Map -Block -Lot 090.60058 BOARD OF HEALTH ----------------- North Andover CERTIFI TE OF CO/ P IANCE r S IS TO CERTIFY hat th Individual Sewage/Disposal stem (Repair) byVninstalled ateson ----------------------------------------------- -------------------- ------------------------------------------ ----- --------------------- Installer atBERT STREhain acco dan with the provisions o TITLE of the State Environmental Code as described in the application for Disposal r s Construction Permit B -2013-073Dated ----------------------------------------------------------------- Printed On: May -29-2013 BOARD OF HEALTH •ys�"° Commonwealth of Massachusetts Map -Block -Lot 090.80058 ----------------------- BOARD OF HEALTH Permit No North Andover BHP -2013-0734 FEE k $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted ToddBateson Q�� ___ - - - - ---- -- to (Repair) an Individual Sewage Disposal System. EOCOPY at No - -95--LIBERTY--STREET -------------------------------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP -2013-073 Dated �11-1-5 -------------------------------- Printed On: May -29-2013 ----------------------------- BOARD OF HEALTH Of NO oTM � : • 0 f • 9 Town of North Andover HEALTH DEPARTMEP SACNUSt CHECK #:J D TE: LOCATION: `.; H/ O NAME: r CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal ❑ Body Art Establishment ❑ Body Art Practitioner ❑ Dumpster ❑ Food Service - Type.- 0 ype:❑ Funeral Directors ❑ Massage Establishment ❑ Massage Practice ❑ Offal (Septic) Hauler ❑ Recreational Camp ❑ Sun tanning ❑ Swimming Pool ❑ Tobacco ❑ Trash/Solid Waste Hauler ❑ Well Construction SEPTIC Systems: ❑ Septic - Soil Testing ❑ Septic - Design Approval Septic Disposal Works Construction (DWC) ❑ Septic Disposal Works Installers (DWI) ❑ Title 5Inspector ❑ Title 5 Report 6505 ❑ Other: (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer i r a NooTN,a Application for Septic Disposal System 5_t:9- 1.3 TODAY'S DATE nConstruction Permit - TOWN OF �' * ORTH ANDOVER MA 01845 $ 250.00 –Full Repair ••'��' $125.00 - Component ��SSwCMUSE4 Important: Application is hereby made fora permit to: When filling out Construct a new on-site sewage disposal system* forms on the computer, use only the tab key ❑ Repair or replace an existing on-site sewage disposal system* to move your �4I( pair or replace an existing system component – What? �aep A be- b—&X cursor - do not use the return key. A. Facility Information - - RECEIVED r� Address or Lot # — 9 2013 Cityfrown D V -0-m— TOWN OF NORTH ANDOVER 2.- *TYPE OF SEPTIC SYSTEM*: HEALTH DEPARTMENT ❑ Pumpavity (choose one) ***If nijmp system, attach copy of electrical permit to application*** onventional System (pipe and stone system) ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certificationFnE> ��# m. ❑Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenanceent) ❑_ Pressure Dosed (D -Box Present) S.A.S. AY 2 9 2013 OF NORTH ANDOVER 2. Owner Information /L LTH DEPARTMENT Wh S LC (r --- Name 7,S Address (if different from above) N� Ado City/Town State Zip Code Telephone Number 3. Installer Information n 6�RtsES Name Name of Co any ' 1 I ARGILLA ROAD J I / A*- -• /1. ANDOVER -W: n1 au Address City/Town State Zip Code Telephone Number (Cell Phone # if possible please) 4. Desiqr Name Address City/Town Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 i NTHS AP -at! Disposal �ystem s— 9 — 1 3 3r .:�� • �;• e� ., ....�.� TODAY'S GATE 40 A Construction •Permit ' TOWN -6F * •ORTH ANDOVER, MA 01845 $.2$0.00 - Full Repair 4,•'•,��"•ttc'� a $125.00,- Component JTACNUS PAGE 2 OF 2 A, Facility. Information continued.... 5. Type* of Buildin e'sidential Dwelling or[]Commercial B. Agreement The undersigned agrees to.ensure the construction and maintenance of the afore -described on-site sewage disposal system In accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andove and not to place the system In operation until a Certificate of Compliance has been Issu is Board of Health. Name Date Application r • yed By: (Board of Health Representative) NameDate � Application DisappVed the following reasons:" For Office Use Only: L . Fee Attached? Yes `' No 2. PtojectMariager Obligation Form Attached Yes• No • 3.: &M -P item? Ifso� 4. FoundadOnAs Built.? (hew construction •ronly): (Same scale as approved plan) A Floor Plans? (hew construction only): No 0P!6V6n'for•9)(spotal SysteriY:0onstrncfI0b Penntt 6 Page 2 of 2 SEP'xIC SY.STEM.INSTALL�ER PROJECT MANAGEMENT nBLIGATIONS &r the construction for the septic system .fot.the propetty at: As tlie.North Aadover.licenseil Installer X1,5 .L•-`%.�� . s� For pians by (Address of septic system) 1 Relative to the -application of �D A ('�S°O✓ (in'staller's name) And dated Dated S_ a I — l 3 o s ate With revisioi I understand the following oliligations for management of -this project: or L As the installer, I a' .obligated to obtain. all permits ,and Board of Health approved plans d— to performing any work on a site. I must have the anproved�ilans and the permit on site when any work is being _done. 2. As the installer,•I must•call for any and all'inspe'ctions: 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 • b e' applicable. .` As the installer, I atn' required to. have .the necessary work cgmpleted prior to the .applicable inspectioris as t indicated below:- I.iittdef rand that re ieshn� spection without comt;letion of the items in. accordant .. _ _.1� _ _ - .. _. y. _ dFe A•/1h..LT_.... t_- 1e... e.� ...•.�..e1• Win. an r� �n• v eo=aav a, Bo'tto'mbf'Bed�-Generall, this is the frst. 1` : ins ection unless.there is a-retainin wall, which should•be dt�ne<iYrst: T1ie uistall Musttequest die inspect orl but sloesnot have to be presetit: b. Final Constiuctori.Inspectiori — Engineer must first :do theif iixspecton for elevations; ties, 'etc. As-� of verbal OK (or a -mail -to: healtl deiit(cl) ownofnorthandover.com): from the engineer mast be subniitEed•to ..the Board-of'Realth, aftex:,w u insthner,cails 'for•an inspection time. Installer must be present for d*.inspection, 17ith a pump .system, a31' electrical •work;must be ready and- able to cause pump.to work arid:alartn'.to fun�tton. . c. Findl Gfade —Installer must request inspection wheai OR •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 :rr'»rple exeavation) and '1 am required to complete the.' stallation of the systemidentified in ft attached application for. installation: T futtl` h reasons for denial ion of•myieense•to operate m the Tow-n.ol North Andover si —cant fines Io all liersons involved are also ssi6le. 5.. As the.instiller,:I understand that:I rnu§t'#�e on-site during the.perfosmance of the .following construction.' steps: a: Detcmiinad= that.tbeproper elevation of excatration has been reached, b. Inspection ofthe`sand and starie -to be used, c. Finalinspection by Board of ffealth staffor consultant. d. Installation., of tank, D -Box pipes, stone, vent, primp chamber, retaining wall and other. COffibonents. G. Undersigned Licensed Septic.Installer: (Nitne, � hnt... i w jqoday's Dtie) . 4 r�/l7 Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer MOR7N - Of 6491 �.�oo 3: •. o # �_ —.' P Town of North Andover HEALTH DEPARTMENT CNUSE4 CHECK #: DATE: y 12) LOCATION: H/ O NAME: CONTRACTOR NA : _ . I I 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 $ ❑ TrashlSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector ?-� Title 5 Report $ $ ❑ Other. (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer 6491 ORTH_ Town of North Andover HEALTH DEPARTMENT SACMUS� .. f'j CHECK #: D I 1 DATE: LOCATION: -k� I (-hA H/O NAME: I� CONTRACTOR NAM Y5 k lle/ -h [l-- 1 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 $ ❑ TrashlSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ �❑ Title 5Inspector Title 5 Report $ ? ❑ Other. (Indicate) $ Health Agent 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. V`Rt� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Liberty Street Property Address Craig Wheeler Owner's Name North Andover City/Town MA 01845 April 16, 2013 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. A. General Information Inspector: Michael Graham Name of Inspector Wind River Environmental Company Name 163 Western Ave Company Address Gloucester City/Town (978) 282-7315 Telephone Number B. Certification MA State 13560 License Number 01930 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 ❑ ❑ Needs Further Evaluation by the Local Approving Authority 5, - April 16, 2013 Inspector's Signature Date ails RECEIVE® MAY 0 0 2013 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • M 3 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Y I Commonwealth of Massachusetts w Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Liberty Street Property Address Craig Wheeler Owner Owner's Name information is required for every North Andover page. CityfTown B. Certification (cont.) MA 01845 April 16, 2013 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. Comments: B) System Conditionally Passes: ® One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old` or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Liberty Street Property Address Craig Wheeler Owner Owner's Name information is North Andover MA 01845 Aril 16, 2013 required for every p page. City/Town 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): D -box is corroded. There is leakage around lines, in and out. ❑ 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 - 3/13 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 ' 95 Liberty Street Property Address Craig Wheeler Owner Owner's Name information is required for every Northover AndMA 01845 April 16, 2013 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "" This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 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 Liberty Street Property Address Craig Wheeler Owner's Name North Andover City/Town B. Certification (cont.) Yes No MA 01845 April 16, 2013 State Zip Code Date of Inspection ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone 11 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 - 3113 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 Liberty Street Property Address Craig Wheeler Owner Owner's Name information is required for every Northover AndMA 01845 April 16, 2013 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided,by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 t5ins - 3/13 Title 5 Official Inspection Form* Subsurface Sewage Disposal System - Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Liberty Street Property Address Craig Wheeler Owner Owner's Name information is required for every North Andover MA 01845 April 16, 2013 page. CityfTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Well 9 ( Y 9 (gP ))� Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes ® No Current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Liberty Street Property Address Craig Wheeler Owner Owner's Name information is North Andover MA 01845 Aril 16, 2013 required for every p page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Date Source of information: Wind River Environmental and the owner. Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Pump truck. Reason for pumping: To check structural integrity. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 95 Liberty Street Property Address Craig Wheeler Owner Owner's Name information is required for every Northover AndMA 01845 April 16, 2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 20 feet Material of construction: ® cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: 25 feet Comments (on condition of joints, venting, evidence of leakage, etc.): The joints are good and clean. Good venting no evidence of any leakage. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal Water softner is attached to the se 1511 feet ❑ fiberglass ❑ polyethylene ❑ other (explain) tem causinq corrosion on outlet side of tank. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10.611 x 5.811 x 5.811 Sludge depth: 13" t5ins • 3113 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 95 Liberty Street Property Address Craig Wheeler Owner Owner's Name information is required for every Northover AndMA 01845 April 16, 2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) t5ins • 3/13 Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 31" 1" 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 17 How were dimensions determined? Sludge judge, rod and ruler. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Service system annually. The inelt and outlet T's are in good condition, the tank is structurally sound. Liauid level is at 0" to outlet. Invert has no evidence of anv leakaoe. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Liberty Street Property Address Craig Wheeler Owner Owner's Name information is required for every Northover p AndMA 01845 April 16, 2013 page. CityFrown 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: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): i * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Liberty Street Property Address Craig Wheeler Owner Owner's Name information is North Andover MA 01845 Aril 16, 2013 required for every p page. City/Town 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.): D -box is 23" below grade. The D -box is level, distribution to outlets is equal. Moderate to heavy carryover to SAS. Evidence of leakage around all outlets. D -box is corroded and requires replacement. 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Liberty Street _ Property Address Craig Wheeler Owner Owner's Name information is required for every North Andover MA 01845 April 16, 2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields 1 @ 20'x 40' 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.): The soil is good, clean and dry. There are no signs of hydraulic failure. Normal vegetation. SAS under lawn. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins • 113 Title 5 Official Inspection FormSubsurface Sewage Disposal System • Page 13 of 17 s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Liberty Street Property Address Craig Wheeler Owner Owner's Name information is required for every North Andover MA 01845 April 16, 2013 page. 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 - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 P Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e 95 Liberty Street Property Address Craig Wheeler Owner Owner's Name information is North Andover MA_ 01845 Aril 16, 2013 required for every _ p page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below I—I u drawing attached separately t5ins • 3/13 Title 50ffidal Inspect Form: Subsurface Sewage Disposal System -Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments / 95 Liberty Street Property Address Craig Wheeler Owner Owner's Name information is required for every Northover AndMA 01845 April 16, 2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 6'feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 1989 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Deep observation hole by Christian Eng. dated 3/18/1988. System designed 4' above mottles observed at a depth of 60". From 1989 plans, also previous Title 5 from 9/16/05. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins' 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Liberty Street Property Address Craig Wheeler Owner Owner's Name information is North Andover MA 01845 Aril 16, 2013 required for every p page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 �L\ Commonwealth of Massachusetts RECEIVED City/Town of MAY 14 2013 _ System Pumping Record NORTH ANDD �MFNORTH ANDOVER Form 4 HEALTH DEPARTMENT y DEP has provided this form fqr use.by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility information Important: When filling out 1. System Location: forms on the computer, use only the tab key Address 6%�f to move your _ _.—...1.. �/�1�" 1J cursor - do not State Zip Code use the return City own key. 2 System Owner: r Name _ . �° Address (if different frorl'r location) -- - -- Slate Zip Code CiiylTown Telephone Number B. Pumping Record / _ (�- Pumped: / 1. - Date of Pumping Date 2. Quantity Gallons 3. Type of system: ❑ Cesspool(s) Septic.Tank ❑ Tight Tank ❑ Grease Trap El Other (describe)i - - - - 4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of Sysm: 6. System Pumped ByLn , /1 - - - -- -" Vehicle License Number Name Company 7. Location where contents were disposed: Signature of Hauier Signature of Receiving Facility - — - - 40 01, Date - wE Date 15form4.doc• 03106 System Pumping Record • Page 1 of 1 , 1 CL LL y N li D, a �v m m 0 m m H 3 A O 3 n O m m .a O z Commonwealth of Massachusetts City/Town of NORTH ANDOVER, MASSACHUSETTS System Pumping Record Form 4 N Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. _LQ_ return DEP has provided this form for use by local Boards of Health - be submitted to the local Board of Health or other approvih4 a A. Facility Information 1. System Location: City/Town 2. System Owner: a I--�`�-- tAg_ q I'L Name G 1__1 Address (if different from location) City/Town APR 0 4 TOWN OF NORTH HEALLTH DEPARTMOER ENT AA - State Zip Code sta Zip Code T phone Number B. Pumping Record 1. Date of Pumping Date , a� 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s)[]�e`ptic Tank ❑ Tight Tank ❑ Other (describe): — 4. Effluent Tee Or present? es ❑ No 5. Condition of System: 6. System Pumped By: IM 111 ti Name ! Company 7. Location where contents were disposed: Signature of Hul r ` http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect Record must If yes, was it cleaned? ❑ Yes ❑ No 8(4a'7 — — Vehicle License Number — — -� G -� Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 NEW ENGLAND ENGINEERING SERVICES INC September 20, 2005 Ms. Susan Sawyer North Andover Board of Health 400 Osgood Street North Andover, MA 01845 RE: TITLE V REPORT: RE: 95 Liberty Street North Andover, MA Dear Ms. Sawyer: Enclosed is a copy of the Title V report for the above referenced property. The system PASSED our inspection. If there are any questions please call me at my office, 686-1768. Sincerely, C�G- enjamin C. Osgoo ,r. Certified Title 5 Inspector 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 I of 11� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 95 Liberty Street North Andover, MA 01845 RECEIVED Owner's Name: Laureen & John Federico Owner's Address: 95 Liberty Street North Andover, MA 01845 SEP 2 2 2005 Date of Inspection: 9/16/05 TOWN OF NORTH ANDOVER Name of Inspector: (please print) Benjamin C. Osgood, Jr. Certified Title 5 ispectorLTH DEPARTMENT Company Name: New England Engineering Services Inc. Mailing Address: 60 Beechwood Drive North Andover, MA 01845 Telephone Number: 978-686-1768 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 the on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15340 of Title 5 (310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: (io cs The system inspection 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 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. 2of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 95 Liberty Street North Andover, MA 01845 Owner's Name: Laureen & John Federico Date of Inspection: 9/16/05 Inspection Summary: Check A, B, C, D or E/ALWAYS complete all of Section D A. System Passes: ES 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: O One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: 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 explain: 3of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 95 Liberty Street North Andover, MA 01845 Owner's Name: Laureen & John Federico Date of Inspection: 9/16/05 C. Further Evaluation is Required by the Board of Health: NO 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 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 (SAS) Soil Absorption System and the (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 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 organize 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 5ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 4of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 95 Liberty Street North Andover, MA 01845 Owner's Name: Laureen & John Federico Date of Inspection: 9/16/05 D. System 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 y _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overload or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overload or clogged SAS or cesspool X Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow c 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. — Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply c 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. F 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 nitrogen is equal to or less than 5ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) 40 (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. You ftrust indicate either "yes" or W' to each of the following: (The followm teria apply to large systems in addition to the criteria above) Yes No The system is within 4OO Leet of a surface drinking water The system is within 200 feet of a tributary to a 5ur�ftc–e drinking water supply The system is located in a nitro ensitive ar terim Wellhead Protection Area – IWPA) or a mapped Zone II of a public water suppl If you answered "yes" to uestion in Section E the system is considered a sign ific eat, or answered "yes" in Section D above the large system h ed. The owner or operator of any large system considered a significan eat under Section E or failed under Section D s upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 5of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 95 Liberty Street North Andover, MA 01845 Owner's Name: Laureen & John Federico Date of Inspection: 9/16/05 Check if the following have been done. You must indicate "ves" or "no" as to each of the following: Yes No ,c 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 ? X Have large volumes of water been introduced to the system recently or as part of an inspection ? Were as built plans of the system obtained and examined? (If they were not available note as N/A) �C Was the facility or dwelling inspected for signs of sewage back up ? c� Was the site inspected for sign of break out? X Were all system components, excluding the SAS, located on site? _ (L Were all 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? X_ Was the facility owner ( and occupants if difference from owner) provided with information on the proper maintenance of the 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. _ 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)] 6of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 95 Liberty Street North Andover, MA 01845 Owner's Name: Laureen & John Federico Date of Inspection: 9/16/05 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design)__H_Number of bedrooms (actual): �{ DESIGN flow based in 310 CMR 15.203 ( for example: 110 gpd x 4 of bedrooms): 60o t' Number of current residents:_ Does residence have a garbage grinder (yes or no): AI Q Is laundry on a separate sewage system (yes or no):)LJ 0 [if yes separate inspection required] Laundry system inspected ( yes or no): Seasonal use: (yes or no): /V O . Water meter readings, if available (last 2 years usage (gpd): w e L-lr Sump Pump (yes or no): Al y . Last date of occupancy Gv r r P✓aT COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgft, 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: P R 1 L— OS 1 G R (Dw Aj9- Was system pumped as part of the inspection (yes or no): /u 0 If yes, volume pumped: gallons — How was quantity pumped determined? Reason for numnine: TYPE OF SYSTEM Septic tank, distribution box, soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank Attached a copy of the DEP approval Other (describe): Approximate age of all components, date installed (if known) and source of information: 13 Ij I L:—\ i N 1 I S R i> erg d+s — 5, , H -- Were sewage odors detected wen arriving at the site (yes or no): A) 0 7of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 95 Liberty Street North Andover, MA 01845 Owner's Name: Laureen & John Federico Date of Inspection: 9/t6/05 BUILDING SEWER (locate on site plan) Depth below grader Materials of construction:-2s.—cast iron 40 PVC other (explain) Distance from private water supply well or suction line: 3 0 ` -►" Comments (on condition of joints, venting, evidence of leakage, etc_): F% PE I -s 0 K co "'I> 1 -no ,u I ra BA5 riot rNT SEPTIC TANK: (locate on site plan) Depth below grade: 16' 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: t.Soo cTA�� SNS Sludge depth: 410. Distance from top of sludge to bottom of outlet tee or baffle: iF 1t 007(-6-1-r6t �t ssr�r G _ Scum thickness: —1 " Distance from top of scum to top of outlet tee or baffle: 4 Distance from bottom of scum to bottom of outlet tee or baffle 4, How were dimensions determined: A^ As,ja STic.k Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): ilort, cgt-)Ceel-F t»Tt-E i TcCC iwesst vCr_ RE-PLRCEv if -s PA✓L i OF lnjSPc?C i7pN REC- AA ENQ fLiS C -C25 !?ie l-,"T-tu-en TQ) to 6 of &%, ,ADS c>ti J+1,- 0Pr"n11�vr;-s. GREASE TRAP:jUA- (locate on site plan) Depth below grade: Materials 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 sludge 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. 8of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 95 Liberty Street North Andover, MA 01845 Owner's Name: Laureen & John Federico Date of Inspection: 9/16/05 TIGHT OR HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Materials of construction: concrete metal fiberglass polyethylene other (explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: D Comments ( note if box is level and distribution to outlets equal, any evidnence of solids carryover, any evidence of leakage into or out of box, etc.): BDX IM pi< con,jS> ST%Zt90NN .9L_ No EJB cuCl 6 Wa5ft"Cle ins �.2 a.s sC>tint C,42RNOoL-a- r 2`=� BEL -01) U214INr _ PUMP CHAMBER:/? 1 A- (locate on sire 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.): 9of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 95 Liberty Street North Andover, MA 01845 Owner's Name: Laureen & John Federico Date of Inspection: 9/16/05 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 in length 1 leaching fields, number, dimensions: overflow cesspool, number: innovative/altemative system Type/name of technology: Comments ( note condition of soil, signs of hydraulic failure. Level of ponding, damp soil, condition of vegetation, etc) o-aFr4 01= FIELD 4-0014S ti0RneAL. n. r,jiD'NCo 90"V%,N (.- D14^A- P -CO iL-, o [Z Uh1vSv A L I: E(7-ETr4-'70A.) CESSPOOLS: N ( r- (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.): PRIVY: Aj 14 -(locate on site plan) Material of construction: Dimensions: Depth of solids Comments (note condition of soil signs of hydraulic failure, level of ponding, condition of vegetation, etc. 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 95 Liberty Street North Andover, MA 01845 Owner's Name: Laureen & John Federico Date of Inspection: 9/16/05 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 whcrc public water supply enters the building. >- PO;K TA,v k .PI-%-% iqj C E-5 JA 45, z j)1, 20.5 uk g,o &3.� ,�x H It z 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 95 Liberty Street North Andover, MA 01845 Owner's Name: Laureen & John Federico Date of Inspection: 9/16/05 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained 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 excavator, installers — (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: 5 s—s" o e S,C ^1E0 -1-7'LCs oi3sew- Ea r4T f� D 4138 or Co`. Wealth Department utin SCz — Forwarded 6y (Pamela Please return after review. Thank Yom F �_ �Vi Date: Re stg�" 5 c mo o2'#A ➢ Susan: ➢ Michele ➢ Debbie Health Calendar Updated? ❑ Yes ❑ No ❑ n/a RETURN TO PAMELA ❑ File: ❑ Dispose NOTE: Form 4 -- System Pumping Record Commonwealth of Massachusetss Massachusetts System Pumpina Record System Owner Zucr-o Kim 9's Liborty St kl(Dzth Andovrir, M -A, 0184,,, 6, 2, 5 - -, Type: Ell ------ Routine Cesspool: NoYes Date of Pumping: IC3 System Pumped By: Wind River Environmental, UC Contomts transferred to: Contents Disposed at: Daft: LJISJ03 Condition of SysteWother Comments in Location MAY 5 Primary Home 95 Ut�erty St MA, 01�4�j 97 8 —685-5477 ,,11cco Kin Septic tank: KID Yes M71 Quantity Pumped:):�C)o Gallons Permit #: M Dep Approved Form - 12/07/95 0 WELL USE Department of Environmental Management/Division of Water Resources WATER WELL, COMPLETION REPORT WELL LOCATION n ,i AddressLlberty Lane Lot 42 V Other Water -bearing Zones 1) From To City/Town n. Andover. MA 01810 a. X. Method Drilled Rot a Tr�T� v G.S. Gmadrangle Map -- 21 From To Grid Location ^�3ry Owner '4r. Mark COnSerya ► -�.t L/ / �, •r . Address POB 92 N. Andover. Y1A Length Diameter UNCONSOLIDATED WELL Water -bearing Materials Type steer 61 STATIC WATER LEVEL Feet below land surface - 25 WELL USE CONSOLIDATED WELL r Domestic Q Public'❑ Industrial ❑ ,i Type of Water -bearing. Rock V Other Water -bearing Zones 1) From To , Method Drilled Rot a Tr�T� v -- 21 From To Date Drilled 4 / 7 / R R 3) From To 4) From / To CASING 611 26 Depth to Bedrock r Length Diameter UNCONSOLIDATED WELL Water -bearing Materials Type steer STATIC WATER LEVEL Feet below land surface - 25 Sand: fine ❑ medium ❑ coarse ❑ Date measured 9/88$ Gravel fine[] medium[] coarse❑ Screen: GRAVEL PACK WELL Yes ❑ No slot length from to Split Screen (or 2nd screen) Slot At lenqth from to_ WATER QUALITY TESTS.MADE Chemical ❑ Biological ❑ Depth To Bedrock PUMP TEST 4 Drawdown feet after pumping days hours at GPM. How measured air ComioreSA6cdery feet after hours. LOG of FORMATIONS COMMENTS: (On Kell or water) Materials From To o DRILLER Firm1.;k1 1 1 i n.s4nd Scans, Tn . Address 269 Prnetor Hili 'En 1d City. Tin t 1 i c_ TIN n Q n 4 Q Registration No. P n ,� c v r BOARD OF HEALTH COPY L/ 2SM•10-85•807101 a COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIRCATION property Address;.. Address of Owner Date of Inspection: 1� VVV Name of Inspector: 1 em a D approved system inspector purse Section 15.340 of Title 5 (310 CMR 15.000) Company Name: �. IlAainy Address: Talep)tone Number: *L CERTIFICATION STATEMENT I certify that 1. have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of h p the time of inspection. p tion. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: !L//Passes '.. T Conditionally Passes a _ Needs her Eva[ on By the Local Approving Authority _ Fa[is Inspector's Signature: Date: The System Inspector shall bmi*1s spection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of completing this Inspection If the d system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to he appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. f' NOTESAND COMMENTS I , w', , revised, 9-/2/9B Page lefll SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) <-*oparlyAddress: q5 Uiber+1 Wit', 14, fljctoutf' m� oi errrN5 Own: 1alec� . 4 Deft of kumpection: 5 (I Lej.b U WSPECTION SUMMARY: Ch9c;IW B, C, or I> A ' SY PASSES;. I have not found any Information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS; A B SYSTEM CONDITIONALLY PASSES: One or mores stem components a Y s described din the "Conditional Pass" ss section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes: no, or not determined (Y. N, or NO). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pips(s) + or due to -a broken, settled or uneven distribution box. The system will pass inspection if (with it approval of the Bo `r Health), PP Board of ,� •,. ea th).. broken pips(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed 1 *Note: THE TITLE 5 INSPECTION IS NOT AGUARANTEE/WARRANTY OF THE FUTURE FUNCTION OF j SEPTIC SYSTEM.FUNCTIONTHE— I� revised' 9/2/98 Page :or>t j: t; { SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: R5 Libeiri-4 3t, N.. Ar Ao0cc, mA 01T45, Owner: .,, pate of Inspection; . 5 j l lAl o o C.. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system.is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMR 15.30311)(b) THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 1, 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 AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 fest of a surface water supply or o tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well Is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address qsLi bar T11 Owners l ec f :' Data of 4tspecbon, 5 f )e l o o D.. ` SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yas No _ Backup of sewage into facility or system component due to an 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 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. F Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. -T- _ Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less -then 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes , . No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply .� �. the system is located in a nitrogen sensitive area (interim -Wellhead Protection Area =1WPA) ora mapped Zone 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. ski} i; g;f revised,. '9/2/98 Page 4of11 i 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART 6 CHECKLIST PropertyPropertyAddress: 95 Li ber+LA 3�, et A no j e -r, rn /� 01 TL45 Owner: b>60 ekj Date at inspection; 5 1 UA 0 6 Check If the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No. Pumping Information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks ks and the system has been,Teceiving,,,we I, al flow rates during that period. Large volumes of water have not been introduced into the system em recent IV or as part of this As built plans have been obt.ained and examined. Note if they are not available with N/A. The facility or dwelling was inspected.for signs of sewage back-up. The system does not, receive non -sanitary or industrial waste flow. The site was inspected for signs of breakout. 6—/ All. system components, excluding the Soil Absorption System, have been located on the site. 'The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles of toes, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION --Property Address:,►s 1—i r1 d a very Owner:�d Pau of inspection: 0 a RESIDENTIAL: FLOW CONDITIONS ;-Design flow4j�9P__g.p,d./bedroom. 'Number of bedrooms (design) Number of bedrooms factual) Total DESIGN flow Number of current r eidents: Garba9e grinder (yes or no):, Laundry (separate system) lyes or no)-A-K; if yes; &operate inspection required Laundry system inspected (yes or no) Soasonal use (yes or no) 1w /y Water motor readings, if available (last two year's usage Igpd): td ee- Sump Pump (yes or no):JQ Last date of occupancy;o� . COMMERCIALIINDUSTRIAL- Type of establishment:_ Design flow: a`�_ ('Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title b system: (yes or no)_ Water meter readings, if available: Last date of occupancy: ,, OTHER: (Describe) '.est date of oc@Npancy: GENERAL INFORMATION PUMPING RECORDS and source of information: . � .. o✓ 19 Syste pump d as part of inspection: (yes or no),_ If yes, volume pumped: gallons Reason for pumping: TYKW SYSTEM Septic tank/distribution box/soil absorption system -. Single cesspool Overflow cesspool. Privy Shared system (yes or no) (if yes, attach Previous inspection records, if any; i I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other ' .. APPROXIMATE AGE of all components, date installed (if known) and source of information: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) � Address: `I 7LLiber-,4 St, til And�oL)e.r, MA als�l5 Date of Inspection: t „ ; BUILDING SEWER: :(locate on site, plan) Depth below grade:, t ' Material of construction: cast Iron 40 PVC _other (explain) Distance from private water supply well or suction line IUD -4- Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:_ (locate on site ;Ian)... Depth below grader Materiel of construction: Vancrete metal ,_Fiberglass _Polyethylene _other(explain) If tank is metal, list age — Is age confirmed by Certificate.of Compliance _ (Yes/No) Dimensions: ! ! S" Sludge depth:' Distance from top otsludge to bottom of outlet tee or baffle:.= Scum thickness:_ Distance from top of scum to top of outlet toe or baffle;,�_ Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were 'a determined: :&4f a Comments . (recommendation for pumping, c ndi ' n f inlet andel utlet tees or baffl evidence of leakage, etc.) bow% 4A.AA--t, depth of liquid level in relation to outlet invert, structural integrity, GREASE TRAP: (locate on site pla 1 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 tae or baffle: Date of last pumping: T_ Comments:• . . (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level )n relation to outlet invert, structural integrity, evidence of leakage, etc.) f- =D revised 9/2/98 Page 7orlt r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) c `' 'i operty Address: SPS 1_1 be-r4� St. N. �}:nrto,)f r, YYI R 01 Sq owner: �]al e,� Dae of ktspecoort: S,� l lel 0 0 } TIGHT OR HOLDING TANK -.4 (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade: Material of construction: _concrete metal _Fiberglass _Polyethylene _otherlexplain) Dimensions- Capacity,.- imensions•Capacity, gallons Design flow:gallons/day Alarm present.: Alarm level; Alarm in working order: Yes No Data of previous pumping: Comment;: (condition of inlet tea; condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate onsite plan) depth of liqui0evel above outlet invert: Comments:' (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)-,//, 'I'Lo AVSa IiA4 IF PUMP CHAMBER•. (locate on site plan) l Pumps in'working order: (Yes or No) J. Alarms In working order (Yes or No) Comment$: .(nota condition of pump chamber, condition of pumps and appurtenances, etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: a;b{ert� S 4 . N, {{al to s er, Y� t fl o i �S t{ 5 Date of Inspection: 5 (l lx1 b o SOIL ABSORPTION SYSTEM (SAS) (locate on site plan. If possible; excavation not required, location may be approximated by non -intrusive methods) If not located, explain: Type _ t „ .leaching pits, number: Isaching chambers, number: leaching 'galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions:-2% overflow cesspool, number Alternative system: Name of Technology: Comments .(note condition of soil, signs of hydraulic failure, level ofigorjing, dai?p soil, cpndition of,vegetation, etc.) (locate; on site elfin) Number and configuration: Depth -top of 4quid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: Inflow (cesspool must be pumped as part of inspection) i Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY; (.locate on its plan) Materiels of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) LOIS 43.899 S.F,. • ansnNc r LOT 3. 381.60' ANK \ OQSTING D—BOX LOT 6A $ ye�q,, � dpi 38.ri� 25 1p 293.50' EXISTING FNDN. TF -219.44 115.5' 6,-_ .•o Well ACCESS EASLT.y _� I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Progeny Address: �1'S.1-i bar +� g"t N. And over, M R p I v 4 b Deft of hspwtion: s I iel D U NRCS Report name i Well • LOT 3 381.60' � Lij 46.0' LOT --9 EXISTING FNDN. 43,899 S.F. EXISTING TANK TF=219.44 0 (� N� EXISTING D—BOX, acs LOT 6A oo. e�eltr l� 115.5' t1+' 3e9j16'—��Well 1 45 ACCESS EASUT}CIO 293.50' LOT 1 Well 0 DRAM ELEVATION TO TOP OF PIPE DWELLING: -- TANK —TANK IN: 216.45 TANK OUT: 216.20 D— BOX IN: 216.05 D—BOX OUT: A 215.80 B 215.80 C 215.80 D 215.80 END OF DISTRIBUTION LINE: A 215.46 B 215.50 C 215.50 D 215.54 "THIS IS TO CERTIFY THAT I HAVE INSPECTED THE CONSTRUCTION OF THE SAID DISPOSAL SYSTEM LOCATED AT LOT 2, LIBER, ST., NORTH ANDOVER, MA. THE G S ARE AS SPECIFIED IN THE PLANS AN ; SP FICATIONS DATED 7/20/88 BY �J. OSATI." AS BUILT SEWAGE DISPOSAL, SYSTEM PLAN IN NORTH ANDOVER, MA. AS PREPARED FOR MARK CONSERVA SCALE 1"=80' DATE APRIL 1989 MARCHIONDA & ASSOC., INC. ENGINEERING AND PLANNING CONSULTANTS 80 MAPLE STREET R. F.D. 16 STONEHAM, MASS. 02180 MANCHESTER, NH 03103 (617) 438-6121 (603) 434-8725 Permit # BOARD OF HEALTH Town of _North Andover,Mass. Date" APPLICATION FOR WELL & PUMP PERMIT Application is hereby made for permit to drill a well (-). made to install ( ) a pump system. Location: Add -Tess Owner Well Contractor Pump Contractor �fi Application.is .-Lot #- _TAd d r e s S el. 76 - 3 WELL CONTRACTOR (To xe completed at time of pump test) r Well used for J�C_ Type of Well L�� Diameter of Well Size of. Casing � If � 2 Depth of Bed Rock Depth casing into Bed Rock 07,/ Was Seal Tested? Yes (-) No (_) Date. of Testing IF— 7" Depth o£ Wil - Well Ended in W.ha-t- Material Depth to Water_ l Delivers _Gals -Per Min. for 4 hours Drawdown a 0 feet after pumping- hours- a t _ 7 GPM P Q! s Date of Completi gnature Wel Cont ctor `� .. .r, J. J... J. J. J. J: i; J, .V J. c•_ J, .•. L..y y i� i; i. i. n i. n i. i. i. .. r .. .. i. .. .. ...... .: is PUMP INSTALLER (To be. filled i.n.before i.nstal.lation) Size & Name Pump 3 � Pump Type Used _ _- Water Pump Delivers -9 GPM Size of Tank Pipe Material Used in Well: Cast Iron (_) Galvanized (_) Plastic Well Pit (_) or Pitless .Adapter Was sleeve used to protect pipe? Yes ) NO( -).Type or Name Well Sea i Date 'r�4►�r�rit►MiE�M�4►M�'e►4i4�`t�4�htia�M►M�Mti1r�4t'rtiY�r►4ti4�k�'r►M�'r►M�r�Y�4+4i`rti4ti4�'r�'r�'ri4ti'r 5;,F -1V, ,1a U*,'13tirY?,f)P ri;nc�iF,�r , �,�4tkdfd��45ivde'!r Date Water analysis repor-t submitted to Board of lreal'th Date release given to owner of record & Bldg. Insp Health Inspector ,o ' North Andover Test Sodium Iron Manganese Coliform Ph Hardness ( QR� OF, H64L.I -1 LOT Z �pu C4Iv I KINlJ1� p CJ WEU Pc��1 D�So �ivc1� ,�, �• Fl,�v DWTI� �I SAPPRpV�p G(��D(T�O�JS Dw� scf��� c SYSTEM i � SiA LZ,,Q"j'io�J F12�),,j �-tvtJS,� TO PA S51-1 F/O)L ,01FROOED uiJTC -5.-2'7_ Av)iT(oPAL Ips j�'S (IS- Q^'y) DI S/, Pt7KOv6p DA ► C N5%iOI�G( ►�CASa NS FML APPS INN APP) W (JG 6u i�►o�, /� 1 ��� ������U�������^�� The Water -' `~-'-- ~~~~~~`~^~~~~~^^~~~~ ofMASSACHUSETTS, INC.- P.O. Box NC.-P.O.Box 687 ° Leominster, Massachusetts 01453 (508)534-1444 ° ��B-0094 (in Mass) Name : Skilling & Sons Inc Sample Location : Mark Conserver Address : 269 Proctor Hill Road Lot 2 Liberty Street N. Andover Ma City : Hollis Sampled By : Skillings & Sons W -53 State : Nh Zip Code : O3049 Invoice Number : 12122 Date : Sep 15, 1988 WATER QUALITY TEST RESULTS { P }Primary Standard { S } Secondary Standard TEST RESULTS LIMITS Coliform Bacteria It. P } 0/100 4/100 ml Fecal Bacteria { P } NT 0/1O0 ml Standard Plate Count NT 200/100 ml Arsenic { P } NT 0-0.05 mg/l � Sodium { S } 14.80 0-250 mg/l � Copper { S } ND 0-1 mg/l � Iron { S } 0.06 0-0.3 mg/l � � Lead { P } NT 0-0.05 mg/l Manganese { S } ND 0-0.05 mg/l Magnesium 4.40 0-200 mg/l Calcium 33.60 0-20O mg/l Alkalinity { S } 76.00 NO LIMIT Chlorine ND 0-0.05 mg/l Chloride { S } 0.10 0-250 mg/l � Hardness 90.00 0-160 mg/l � Nitrate { P } ND 0-10 mg/l Corrosiveness { S } (.-1'ORR NO LIMIT � Sulfate { S } ND 0-250 mg/l � Total Solids { S } 83.50 0-500 mg/l PH { S } 7.50 6.578.5 Conductivity 167.00 0-550 Color { S } 1.00 0-15 cu Dissolved Oxygen 8.40 0-15 mg/l Odor { S } ND 0-3 TON Turbidity { P } 1.60 0-5 NTU Comments : NT - Not tested ND - Below level of detection for this parameter For those items tested, this sample meets the following EPA criteria for drinking water. { X } Primary { X } Secondary { } >Neither Date : Sep 19, 1980 Reported By : Eric J. Koslowski FORM U - IAT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section****************** APPLICANT: C VrI4 A 671 cal, ( 6 Phone b F. 0 z 3 LOCATION: Assessor's Map Number Parcel Subdivision Street Lots) St. Number C, i - ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Conservation Administrator Comments Town Planner Comments Food Inspector --Health Septic Inspector -Health Comments Public Works - sewer/water connections - driveway permit Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Date Approved / Date Rejected Fire Department Received by Building Inspector Date TOWN F NORTH ANDOVFk U rr SYS PUMPING RBCC)pj. SYSTEM OWNER dt AnDRBSS Fa-er Gi J OV. /uC/pv�.� SYST Lp�.AT7QN VAll OF PVMMNQ;_ 1 113°"._QUA,NTiTY PUMPED,_ ._ VOSPOOL: NO !. Y.gS 50Puc I'uik: NU Y ES NA rUKE OF SERVICE; KUU'rINE:,✓ RECD{�'ED UkSSBRVA'PIUNS; MAY 0 6 2005 000D CONDITIONPULL'N (,COVER TOWN of:LTHNOK DEPVo ARTM OVER H$AVY OREA$8 _! BAPPLBS IN PLACL, HE ROOTS --'FLOODED _ LEACI'MELD RUNBA(:K . BXCS.Ssive SOLIDS FLOODED SOLID CARAYOYER,_, OTKER EXPLAIN Sy1tom Pun"d by _. ? ,..... G.. c. ., .. a017�&l17a. "UMMLNTS. CUN rum's rKANsf'ERR L) I'U Commonwealth of Massachusetts ,.bZE iVED City/Town of NORTH ANDOVER DEC p 4 2009 _ulSystem Pumping Kecord Form 4 PARTMENT ER +F, .1 DE DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out 1. System Location: forms on the computer, useonly the tab key Address �a to move your cursor - do not City/Town State Zip Code use the return key. 2. System Owner: Name Address (if different from location) -- -- City/Town State Telephone Number Zip Code B. Pumping Record D ^3lC71_ 2 QuantityPumped: 1. Date of Pumping Date p Gallons 3. Type of system: ❑ Cesspool(s) E4 eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of SystWn: 6. System Pumped By: Name {� ---- Company 7. Location where contents were disposed: If yes, was it cleaned? ❑ Yes ❑ No 'eol�,-eM2 r� - — Vehicle License Number Signature of Hauler Date Signature of Receiving Facility Date G.L.S.D. t5form4.doc• 03106 System Pumping Record • Page 1 of 1 ,fN, Commonwealth of Massachusetts City/Town of System Pumping Record NORTH ANDOVER Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. RECEIVED Important: When filling out forms on the computer, use only the tab key to mote your cursor - do not use the return key. Fn& A. Facility Information 1 System Location: 9 Address ISI©���n A�cl avLl CityfTown 2. System Owner: Name Address (if different from location) h`t:1�� TOWN Of NWITH ANDOVER HEALTH DEPARTMENT _ MA State ©I�Lo, Zip Code City/Town�~7 ----- — State Zip Code Telephone Number_ B. Pumping Record 3 � � r ------------ 1. Date of Pumping Da(e 2. Quantity Pumped: P Gallons 3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): --------- --- -- —-------- -- — — 4. Effluent Tee Filter present? ❑ Yes VNo If yes, was it cleaned? ❑ Yes /No 5. Conditionof System: Good 6. System Pumped By: -71,3677j Name Vehicle License Number ----& _� ��'i%G� Env if O'ilw t✓t' Company 7. Location where contents were disposed: Jpgwich Signature of Hauler — DatePswich G f"14 4_ s Signature of Receiving Facility Date "� ,z,x) t5form4.doc• 03106 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping Record NORTH ANDOVE .4 Form 4 RECEIVED OCT 1Qz ti TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When Tilling out 1. System Location: forms on the R computer, use only the tab key Address to move your Q Code cursor - do not Slate P use the return key. Z System Owner: Name �+* Address {if different from tocationj "� --- - ___ ._._ _. -- - -• State p Zip Code CityiTown /, �Q Telephone Number B. Pumping Record / 2. QuantityPumped: /l ...... 1. Date of Pumping Date Gallons 3. Type of system: ❑ Cesspool(s) E is Tank [] Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No if yes, was it cleaned? , ❑ Yes ❑ No 5. Condition of System'. �Q 6. System Pumped By: r �I ' __ - - Name ✓� �-- __ --- _ Vehicle Licens Number 0 � r Company 7. Location where contents were disposed: G.L. S.D. bate Signature of Hauler ----------- _-_ Date......--- Signature of Receiving 3 acifity t5form4.doc• 03106 System Pumping Record • Page t of t