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Home My WebLink AboutMiscellaneous - 95 OLYMPIC LANE 4/30/2018N i Ngrth Anddver Board of Assessors Public Access Page 1 of 1 NOR71{ I .orth Andover Board. of Assessors rOt it�eo e,ti0 _. •„ .. ♦. e Muhl roperty Record Card Parral In •')l n/I ng R_n124_1191nn n Rv•^fn11) 0--4— • 1►T. "Ik A .,.1...,.,.. Location: 95 OLYMPIC LANE Owner Name: VERMINSKI, MATTHEW VERMINSKI, MICHELLE Owner Address: 95 OLYMPIC LANE City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 7 - 7 Land Area: 1.19 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 2648 sqft Total Value: 502,800 502,800 Building Value: 275,700 275,700 Land Value: 227,100 227,100 Market Land Value: 227,100 Chapter Land Value: Sale Price: 530,000 Sale Date: 03/02/2007 Arms Length Sale Code: Y -YES -VALID Grantor: PRUDENTIAL RELOCATION Cert Doc: Book: 10653 Page: 155 http://csc-ma.us/PROPAPP/display.do?linkld=1895707&town=NandoverPubAcc 6/7/2012 0 r r; Na o N O O00 r r° O O s ci oo_ dM' co r M 0�0- m Z W Q xW T- Lo',.. a)'; N O m' '� m a CD ,. U ., C/) N ^ (1) 0) c o . UU)) 0. w0S O w „IXIt U)JQW O cWW TLf) 0 » _0 N c '0 o J LL J J c m w L:a� k� (.) 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FEE F.I. $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd B-ateson --------------------------------------------------------------------------------------------------- to (Construct) an Individual Sewage Disposal System. at No 95 OLYMPIC LANE as shown on the application for Disposal Works Construction Permit No. BHP -2012-073 Dated October 09, 2012 Issued On: Oct -09-2012 --------------------------------------------------------------- Y U ----------------------------------------------------- BOARD OF HEALTH fo Di Important, When fifiing out forms on the computer, use only the tab key to move your cursor - do not use the return key. Application Is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system* /a� of — / ) TODAY'S DATE $ 250.00 —Full Repair $125.00 - Component gReair or replace an existing on-site sewage disposal system* air or replace an existing system component— What? 711'V1( 0 �c A. Facility Information Q5 Address or Lot # r+ Cityrrown 2: *TYPE OF SEPTIC SYSTEM*: I� T�r.c;: �F ^ it Q Pump ravity (choose one) i ***If pump system, attach copy of electrical permit to application**�'a--- 5406'nventional System (pipe and stone system) ❑ Infiltrator or Blodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D -Box Present) S.A.S. 2. Owner Information Rte_ t.2/f9 V4 6,14 /C_ t' Name Address (if different from above) CWrown State Zip Code Telephone Number 3. Installer Information Name Address AJ— Cilyfrown 4. Desioner Information OWN CN I LRPRISES, INC. 111 ARGILLA ROAD State' Zip Code 1'`%8' fitx✓ — a7U.Dr Telephone Number (Cell Phone # ff possible please) WJ 1 i raw► /t° e(d c e4w&K .t acv- � ► Name Name of Company Address mylrown state Zip Code _ a�g15-35-66 Telephone Number (Best # to Reach) AppUaatkM for i)isposal System Construction Permit • Page 1 of 2 y I , . '� SEPTIC SYSTEM. INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed Installer for the construction forthe septic system -for.the property at (Address of septic system) Relative to the.application of (in'staller's name) Dated /0 41— / )— o s ate For plans by G It t a o►�,4{ �'L cn/�lQ !(Engineer) Aad dated�— nOlial date). With revisions dated (Last revised date) I understand the following obligations for management of this project: 1. As the installer, I am .obligated to obtain. aII permits and Board of Health approved plans' prior to :performing any work on a site. I must have theapproved owed plans and the hermit on site when anv work is b"eing done. 2. As the installer,.I must call for any and alinspecdons. 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. 3.4 As 'th installer, I atm required to. have .the necessary work completed priof ito the applicable inspections as indicated below. I ugderstand thatre uestinp inspection, without comnletion,of the items in. accordant _.rr.__a�L ii_Y:1_ls_.....c.....«e�,;l*;:,:A eO. F*iP•hPt'nolPvietl aoa.instme..and/o rnv eompany: a.. td4om sof Bed Generally, this is the first (1"): inspection unl-twthere is a `retaining wall, which should be do 0<&st. The`installer must xo.quost the inspection but does -hot have to be present. . b. Final Constrticton.Inspecdon — Engineer must first; do thein inspection for elevations; ties, etc. As -built of verbal OK (or a -mail to: healtl delitOtownofnorthandoveroc!RLn from the engineer must be submitted -to .the.Board-ofHealth., after.�vhichinstaller.calls for an inspection time. Installer must be present for this. inspection. With a pump system, all electrical wciprk;must be ready and able to cause purap to vrork arid,alarm'.to function. . c. Final Gtade installer must request inspection when . grading is complete.: Installer does not have to be -on-site. 4. As -the installer,' I understand that only I Itayperform the .work (other than :r)Vle excavation) and I am required to complete the -installation of the system identified in the attached application: for installation: '.I further �RAITfP� AYP AC/\ }1ACC1��P lY VLLLl 1111b1V'Y L 1 llllll..0.11.. ... � . •' 5...As the:installer, ;T understand that :I must'be onsite during the performance .of the following construction. steps: a. Detem:ination -1hat.theproperelevatlon of the excatw on has been reached. A Inspection ofthebsand and stone to be used. c. Final inspection by Board ofHealth staff or consultant. d. Installation., oftank, D -Box; pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer. I understand that I: atm solely responsible for the installation .of the systern as per the Undersigned licensed Septic. Installer. (Today's Date) Application for Septic Disposal System (Construction Permit - TOWN OF H PAGE 2 OF 2 5 A. Facility Information continued.... S. Type of Building: ❑Residential Dwelling or []Commercial B. Agreement TODAY'S DATE $ 250.00 - Full Repair $125.00 - Component 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 Andover, and not to place the system in operation until a Certificate of Compliance has been issued this Board of Health. J Name Date116 — Cie A, j1. /& — /Y / pplipfadon Approve y: (Board of Health Representative) Na a Date plication Disappro�theg reasons: For Office Use Only: L Fee Attached. Yes No 2. Project Manager Obligation Form Attached. Yes No 3. Pump System? Ifso, Attach copy ofElectrical Permit Yes No 4. Foundation As -Built? (new construction ronly): Yes No (Same scale as approved plan) 5. Floor Plans? (new construction only): Yes No Application for Disposal System Construction Permit • Page 2 of 2 TOWN OF NORTH ANDOVER NGRTh Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 1600 OSGOOD STREET; Building 2-36 NORTH ANDOVER, MASSACHUSETTS 01845 �,SSACHUS t Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 95 Olympic Lane MAP: 106B INSTALLER: Todd Bateson DESIGNER: Merrimack Engineering/Bill Dufresne PLAN DATE: 7/26/12 BOH APPROVAL DATE ON PLAN: 7/30/12 INSPECTIONS TANK INSPECTION/D BOX/PIPE INSPECTION 10/24/12 DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: SEPTIC TANK LOT: 138 X Existing septic tank properly abandoned ❑Internal plumbing all to one building sewer ❑Topography not appreciably altered X Bottom of tank hole has 6" stone base (12") X Weep hole plugged X 1500 gallon tank has been installed H-10 loading Monolithic construction X Water tightness of tank has been achieved (Visual or Vacuum Test or Water held for 24hrs) ❑ Inlet tee installed, centered under access port X Outlet tee (gas baffle or effluent filter) installed, centered under access port X 24" inch cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present X Hydraulic cement around inlet & outlet Wastewater System Documentation — Feb 2006 Page 1 of 6 TOWN OF NORTH ANDOVER NORT1i ct ? y!. , e Office of COMMUNITY DEVELOPMENT AND SERVICES s '- `' HEALTH DEPARTMENT F y1 p 1600 OSGOOD STREET; Building 2-36 ` NORTH ANDOVER, MASSACHUSETTS 01845 ^GNUS Susan Y. Sawyer, REHS/RS 978.688.9540 —Phone Public Health Director 978.688.8476 — FAX Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ Combo Tank installed. Size: ❑ 1000 gallon Pump Chamber installed H-10 loading Monolithic 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 ❑ 24" inch cover to within 6" of final grade installed over pump access port ❑ Water tightness of tank has been achieved Visual testing ❑ Hydraulic cement -around inlet & outlet Comments: ADVANCED TREATMENT TECHNOLOGY ❑ Type of treatment device: Comments: ❑ Installed per manufacturers requirements ❑ All components working in accordance with manufacturer's requirements Wastewater System Documentation — Feb 2006 Page 2 of 6 TOWN OF NORTH ANDOVER NORTH Ot Office of COMMUNITY DEVELOPMENT AND SERVICES a ��° '• HEALTH DEPARTMENT p 1600 OSGOOD STREET; Building 2-36 "► ^,. �,r NORTH ANDOVER, MASSACHUSETTS 01845 �'�s ""T a<� Cr. Sgs HU Susan Y. Sawyer, REHS/RS 978.688.9540 —Phone Public Health Director 978.688.8476 — FAX Alt -16D X Installed on stable stone base ❑ Inlet tee (if pumped or >0.08'/foot) X Hydraulic cement around inlet & outlets X Observed even distribution X Speed levelers provided (not required) Comments: SOIL ABSORPTION SYSTEM 11 Comments: Bottom of SAS excavated down to soil layer, as provided on plan Size of SAS excavated as per plan Title 5 sand installed, if specified on plan 3/4-1 Y2" double washed stone installed 1/8-1/2" (peastone) double washed stone installed Laterals installed and ends connected to header Laterals vented if impervious material above Orifices @ 5 & 7 o'clock positions Gravel -less disposal systems: type, number and location as per plan Elevations of laterals installed as on approved plan 40 Mil HDPE barrier installed Retaining wall (boulder / concrete / timber/ block) Final cover as per plan Wastewater System Documentation — Feb 2006 Page 3 of 6 TOWN OF NORTH ANDOVER TN Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT y t 1600 OSGOOD STREET; Building 2-36 * NORTH ANDOVER, MASSACHUSETTS 01845 "Ss"„CHU t� Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX PRESSURE DISTRIBUTION ❑ -- inch manifold ❑ laterals installed with end sweeps Comments: CONTROLPANEL Comments: size: material: ❑ Squirt test ft in height ❑ Equal distribution to all laterals ❑ orifice size inch as per plan ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: ❑ Rated for exterior if placed outside Wastewater System Documentation — Feb 2006 Page 4 of 6 TOWN OF NORTH ANDOVERct NORTp Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT ❑ 1600 OSGOOD STREET; Building 2-36► 10 -- NORTH ANDOVER, MASSACHUSETTS 01845 �'Ss";CHU t� Susan Y. Sawyer, REHS/RS 978.688.9540 —Phone Public Health Director 978.688.8476 — FAX CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Wastewater System Documentation — Feb 2006 Page 5 of 6 Tank SAS Sewer ❑ Property line 10 10 -- ❑ Cellar wall 10 20 -- ❑ Inground pool 10 20 -- ❑ Slab foundation 10 10 -- ❑ Deck, on footings, etc 5 10 -- ❑ Waterline 10 10 101 ❑ Private drinking well 75 1002 50 ❑ Irrigation well 75 100 ❑ Surface Water 25 50 ❑ Bordering Vegetated Wetland , Salt Marsh, Inland / Coastal Banka 75 100 ❑ Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ❑ Trib. to surface water supply 325 325 ❑ Public well 400 400 ❑ Interim Wellhead Prot. Area ❑ Reservoirs 400 400 ❑ Drains (wat. supply/trib.) 50 100 ❑ Drains (intercept g.w.) 25 50 ❑ Drains (Other) Foundation 10 (5) 20 (10) ❑ Drywells 20 25 ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Wastewater System Documentation — Feb 2006 Page 5 of 6 TOWN OF NORTH ANDOVER f NORTH Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT '. 1600 OSGOOD STREET• Building 2-36 NORTH ANDOVER, MASSACHUSETTS 01845 �,SSACHUs ` Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX SYSTEM ELEVATIONS Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 HIGH Lateral 1 LOW Lateral 2 HIGH Lateral 2 LOW Lateral 3 HIGH Lateral 3 LOW Lateral 4 HIGH Lateral 4 LOW Lateral 5 HIGH Lateral 5 LOW INVERT ON DESIGN PLAN FIELD INVERT ELEV. Wastewater System Documentation — Feb 2006 Page 6 of 6 Blackburn, Lisa From: Grant, Michele Sent: Tuesday, October 23, 2012 2:13 PM To: Blackburn, Lisa Subject: 95 Olympic Lane Hi Lisa, FYI ...... I have an inspection for a pipe/D-Box at 95 Olympic Lane tomorrow morning at 10:30am0. Michele E. Grant Public Health Agent Town of North Andover 1600 Osgood St I Suite 2035 North Andover, MA 01845 Phone 978.688.9540 Fax 978.688.8476 Email merant(@townofnorthandover.com Web www.TownofNorthAndover.com Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more information please refer to: http://www.sec.state.ma.us/pre/oreidx.htm. Please consider the environment before printing this email. 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. rL W Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Olympic Lane Property Address Matthew & Michelle Verminski Owner's Name North Andover City/Town MA 01845 June 16, 2012 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 1. Inspector: Peter F. Reilly Name of Inspector Peter F. Reilly Company Name 136 Andover Street Company Address Andover City/Town 978-375-3750 Telephone Number B. Certification State S11955 License Number ANDOVER 01810 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority June 16, 2012 Ins ctor's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 11110 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 Olympic Lane Property Address Matthew & Michelle Verminski Owner's Name North Andover MA 01845 June 16, 2012 CityrFown 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: ® 1 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 • 11110 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 Olympic Lane Property Address Matthew & Michelle Verminski Owner's Name North Andover City/Town B. Certification (cont.) B) System Conditionally Passes (cont.): MA n1RdF oiaic f -1p l.uuC June 16, 2012 Date of Inspection ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Olympic Lane Property Address Matthew & Michelle Verminski Owner's Name North Andover MA 01845 June 16, 2012 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 % day flow t5ins - 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 95 Olympic Lane Property Address Matthew & Michelle Verminski Owner Owner's Name information is required for North Andover MA 01845 June 16, 2012 every 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 ❑ ❑ 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts ro Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments CGM sa�'°95 Olympic Lane Owner information is required for every page. Property Address Matthew& Michelle Verminski Owner's Name North Andover MA 01845 June 16, 2012 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: A Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 gpd t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Olympic Lane Owner information is required for every page. Property Address Matthew & Michelle Verminski Owner's Name North Andover MA 01845 June 16, 2012 Cityfrown State Zip Code Date of Inspection D. System Information Description: 1,000 gallon septic tank / d -box / SAS (field). Original system installed in 1979. Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): 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: ❑ Yes ® No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ® No 150-200 gpd avg. ❑ Yes ® No current Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 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: owner (last pumped 4/12/2012) gallons Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Yes ® No ❑ 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Olympic Lane Property Address Matthew & Michelle Verminski Owner Owner's Name information is required for North Andover MA 01845 June 16 2012 , every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: currently occupiedDate Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: owner (last pumped 4/12/2012) gallons Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Yes ® No ❑ 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 95 Olympic Lane Owner information is required for every page. Property Address Matthew & Michelle Verminski Owner's Name North Andover City/Town D. System Information (cont.) State Zip Code June 16, 2012 Date of Inspection Approximate age of all components, date installed (if known) and source of information: original system installed.in 1979. Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: ® cast iron El 40 PVC El other (explain): Distance from rivate water su I well or sucfon n Ii ❑ Yes ® No 10" - 12" feet N/A p pp ye' feet Comments (on condition of joints, venting, evidence of leakage, etc.): Building sewer was watertight and appeared sound at the foundation. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: rectangular approx. 6' x 8' x 4' Sludge depth: <11, t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 95 Olympic Lane Property Address Matthew & Michelle Verminski Owner Owner's Name information is required for North Andover MA 01845 June 16, 2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness <1" Distance from top of scum to top of outlet tee or baffle 5.. Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? measurement Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was watertight and appears to be functioning properly. t5ins - 11110 Grease Trap (locate on site plan): Depth below grade: N/Afeet 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: Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 95 Olympic Lane GSM Property Address Matthew & Michelle Verminski Owner information is required for every page. Owner's Name North Andover City/Town State Zip Code June 16, 2012 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. N/A 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.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 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 Olympic Lane Property Address Matthew & Michelle Verminski Owner's Name North Andover City/Town D. System Information (cont.) RAA 0 L LC 01845 June 16, 2012 Zip Code Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert — 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Four lines leading to SAS were accepting effluent fairly evenly. Minimal solids carryover evident. The box cover was about 10"-12" below the surface. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins - 11/10 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 Olympic Lane M SBy`e Property Address Matthew & Michelle Verminski Owner Owner's Name information is _North Andover MA 01845 June 16 2012 required for , every page. CityT 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 number, dimensions: 1 -20'x45' ❑ 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.): Soils in the area of the SAS appeared normal, no signs of breakout. SAS dimensions based on information from 1979 "as -built" plan on file at BOH. It is noted that the system is 33 years old and observations made at the time of inspection provide no indication as to how the system will perform in the future. 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 • 11/10 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 Olympic Lane Property Address Matthew & Michelle Verminski Owner's Name North Andover MA 01845 June 16, 2012 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17 Commonwealth of Massachusetts �I ffle 5 Official Inspection Form ill Ti Subsurface Sewage Disposal System Form Not for Voluntary Assessments 95 Olympic Lane Property Address Matthew & Michelle Verminski OwnerQwner's Name information is required for North Andover MA 01845 _qpe 16,201?.__ every page, Girylrowrt state Zip Code Date of Jnspe(�tion 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 bti Ilding. Check one of the boxes below: hand -sketch, in the area below drawing attached separately FRONT App. YARD Water HOUSE 13,11 PORCH/ DECK TANK'; REAR 0 YARD SAS D- A to Inlet: 31'6" i Box A to Outlet: 37'0" A to D -Box: 68'0" B to Inlet: 29'0" B to Outlet: 29'6" B to D -Box: 60'6" y. - T r 5 CM-i:iPIrTvaec:�n Po"- 13jrwmgm Sewage rmposa� I ,, iXstsr: -Nagia it, of 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 Olympic Lane Property Address Matthew & Michelle Verminski Owner's Name North Andover MA 01845 June 16, 2012 City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 4' below bottom of SAS feet Please indicate all methods used to determine the high ground water elevation: // /1 /1 Obtained from system design plans on record If checked, date of design plan reviewed: 1979 Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health explain: information on file. ® Checked with local excavators, installers - (attach documentation) ® Accessed USGS database - explain: USGS data not specific to site. You must describe how you established the high ground water elevation: 1979 design plan indicates separation of 4' at that time. However, the precise ground water elevation cannot be determined for certain without a soil evaluation test. NOTE: Soil evaulation is the recognized method for determining or establishing the high groundwater elevation. Since I am not a licensed or certified soil evaulator, I am not qualified to determine or establish the high groundwater elevation beyond the public information available, such as recent design plans of the site or the nearby area. My estimation of the high groundwater elevation is based on a due diligence effort to obtain all available information both on and off the site and my experience as a certified septic system inspector. (see attached Discliamer) Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts • N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 95 Olympic Lane Property Address Matthew & Michelle Verminski Owner Owner's Name information is required for North Andover MA 01845 June 16 2012 every 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 - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 . 1 s DISCLAIMER This passing septic inspection under Massachusetts Title V is in no way a guaranty or warranty of the inspected septic system. The inspection is a "snapshot in time" and does not constitute a complete assessment of the quality or potential longevity of the septic system. The pass/fail criteria are specific and outlined in detail in this report. Under the limited criteria of a Title V inspection, it is impossible to determine how long any septic system will last. The inspector made a diligent effort to certify the septic system based on the criteria required under Title V. Under Massachusetts Title V, soil evaluation is the accepted method of determining the high groundwater elevation. This inspector is not a certified soil evaluator and is therefore not qualified under Title V to determine or establish the high groundwater elevation. The method used to estimate the high groundwater for this inspection was based on the public records and methods of observation described on the previous page. Groundwater levels can vary greatly from season to season, year to year and soil evaluation is considered the most reliable method of groundwater determination under Title V. O7 Peter F. Reilly Inspector June 16, 2012 North Andover Health Department (ommunity Development Division August 14, 2012 Michelle Verminski 95 Olympic Lane North Andover, MA 01845 RE. Re: Subsurface Sewase Disposal System Plan for 95 Olympic Lane, N. Andover Dear Ms. Verminski, The North Andover Board of Health has completed the review of the design for the relocation of the septic tank dated July 26, 2012 submitted on your behalf by Merrimack Engineering Services. The design has been approved. This approval is also subject to the following conditions: If site conditions are found in the field to be different from those indicated on the design plan and/or soil evaluation, the originally issued Disposal System Construction Permit is void, installation shall stop, and the applicant shall reapply for a new Disposal Systems Construction Permit (3 10 CMR 15.020(l)). It is the responsibility of the applicant and/or the applicant's septic system designer, septic system installer or other representative to ensure that all other state and municipal requirements are met. These may include review by the Conservation Commission, Zoning Board, Planning Board, Building Inspector, Plumbing Inspector and/or Electrical Inspector. The issuance of a Disposal System Construction Permit shall not construe and/or imply compliance with any of the aforementioned requirements. Your effort to provide a properly functioning septic system for your dwelling is greatly appreciated. The Health Department may be reached at 978-688-9540 with any questions you might have. 7blic awyer, REHS/RS alth Director cc: Vladimir Nemchenok, PE File Attach: List of local licensed septic installers Page 1 of 1 North Andover Health Department, 1600 Osgood Street, Building 20, Suite 2-36, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 Grant, Michele From: DelleChiaie, Pamela Sent: Monday, June 11, 2012 9:03 AM To: Sawyer, Susan; Grant, Michele Subject: FW: FW: I.R. - 95 Olympic Lane, North Andover - Health Dept. File Hello, This is for either of you .... whoever is available to meet with the contractor or homeowner ........ can one of you call Michelle Verminski and go over this with her? Please see below. Thanks. —p From: Michelle Verminski[mailto:michelle(a)verminski.com] Sent: Saturday, June 09, 2012 1:53 PM To: DelleChiaie, Pamela Subject: Re: FW: I.R. - 95 Olympic Lane, North Andover - Health Dept. File Thank you for sending the document. Our contractor will be submitting the paperwork for a permit next week for a renovation on the kitchen, which will be taking over the existing deck. He believes the septic tank is only 7 feet verses the 10 feet that is shows on the plans. Would it be possible for me to meet with someone to see if we will need to apply for a variance? Is there a form online that I should have him fill out? ThankYou for Your assistance. ✓/ � ��"Q 'Q `" ` "�%�i� �� (L/ Michelle Verminski 11l/, v4Lwl�� 95 Olytn is Lane 6 978-208-8711 l� On 6/8/2012 12:24 PM, DelleChiaie, Pamela wrote: I noticed I had mchelle instead of michelle. O Here you go. From: DelleChiaie, Pamela Sent: Thursday, June 07, 2012 4:39 PM To: 'mchelle(d)verminski.com' Subject: I.R. - 95 Olympic Lane, North Andover - Health Dept. File To: Michelle Verminski 978.208.8711 O -SL d_ I�di Attached is your scanned Health Dept. file as you requested. Please call the office with any questions. Pamela DelleChiaie Health Department Town of North Andover 1600 Osgood Street I Bldg. 20 1 Suite 2-36 North Andover, MA 01845 Phone 978.688.9540 Fax 978.688.8476 Email Pdellechiaie@townofnorthandover.com Web www.TownofNorthAndover.com FORM U - LAT 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: Phone LOCATION: Assessor's Map Number Parcel Subdivision Lot(s) Streeter y/►`I%�,� �1 /�St. Number - ************************official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: V/ Date Approved Conservation Administrator Date Rejected Comments Town Planner Comments /Food Inspector -Health Sep is Inspector -Health Comments a Public Works - sewer/water connections - driveway permit Fire Department Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Received by Building Inspector Date Board of HeRlth Nqrth AndoverpMass. DAT OK /1/ SEPTIC SYSTEM INSTALLATION %;HHCK LIST LOT # TSAPMOM DATE EXC. ®aspns�r 40 '•�, Distance Tot / a. Wetlands b. Drains c. Well '� , �,n , 2, Water Line Location 3. No PPC Pipe 4. Septic Tank a. Tees - Length & To Clean out Covers b. Cement Pipe to Tank - on Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Equal Amounts c. No Bach Flow 6. .Leach Field or Trench a. Dimensions b. Stone -Depth o. Capped Ends d. Clean Double Washed Stone 7. Leach Pits a. Dimensi s b. Stone epth c . Sp sh Pads d. s e. Cement Pipe to Pit - Both Sides f , Clean Double Washed Stone 8. No Garbage Disposal 9. liinal Grading Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System c. Location with Hegard_to Pere Test d. Elevations e: Water Table PPROVED DWPE PROVIDED 11 Titl1' 5 Reg. 2.5 IT Reg. 6 'ail �OARD OF HEALTH 33 DISAPPROVED DATE TIME REASON y - 0 The'`submitted plan must show as a ma.t r�; vl?- A' . r. served (area dimensions, `�� a� (a) the lot t o b eri�. (Planning Board -files) `� tance- location and log of deep observation hal_ to ties (c)l location and results of percolation tes -s-- ,/� to ties required (d) design calculations & calculations showing leaching areay resery (e) --location and dimensions of system .(including, _area) Sf existing and proposed contours .- /� g� location of any wet areas within 100' of the sewage disposal system or- disclaimer -(check wetlands mappi (})- surface and subsurface drains within 100' of sewage / disposal system or disclaimer (i) location of any drainage easements within 100' of sewage disposal system or disclaimer (planning boax �,. files) . known-.- sou -rtes. of -.water supply within 200' of seiragE disposal_ -system- or, disclaimer.. 10C location of any proposed well -to serve the lot from leaching facility) ( ) location of 1Jater lines on property (10' from. leaci facilities) m location of benchmark driveways garbage disposers q�-y'"-ino PVC is to be used in construction a profile of the system (elevations of basement, p pipe septic tank, distribution box inlets and outl distribution.field piping and any other elevations (r) maximum ground .water elevation in area of sewage d system (s) plan must be prepared by a Professional Engineer c other professional authorized by law to prepare su plans peptic Tanks (a _ Capacities - 150% of floe:, water table, tees, dept of tees, access, pumping, - Cleanout �c� 10''from cellar wall or inground swimming pool d 25' from subsurface drains stribution Foxes a Slope greater than 0.08 b Sump Leaching Leaching pits are Pref. ed where the installation is possible a Calculations of leaching area (minimum 500 S.F.) b Spacifn'g C Sri'ace drainage 2% di -'pver material e 2 ,f2°s¢" Spin 1;kec C -I L aching Fields �1 Imo a. RiGreater than 20 minutes/inch .15 Area (minimum..900 S.F.) , Construction of field j d Surface drainage 2% (e 20' from cellar wall or inground swimming pool Leaching Trenches ations f a Calcul �" leaching area (min. 500 S.F.) b Spacing (4�ft. min. 6 'ft. with reserve between): c Dimensio � ' (d Construction. (e Stone (f vx rface drainage 2% 4Downhill Sl owe,, f a Slope - be shown' by/x ��50= �to to be shown Pumfl a (a). Appro al (b Stan --by power j � S a bd a_ v .,c- A IlIvestivator O bsecvez'�.. _ 6 T PROFILES-DATE z, Elev.._.. �--- Elev. 3, Elev. 4'Elev. 2 Ties to Test Pits 2 3 3 3 -- ---- W.w 5 - _ 5 -- --- _ 5 -- 6 -__ — 6 — - ---- 6 ---- 7 7 7 __- 8' 8 8 -__ 10 - 10 10 - �i;c�hmazk _Loci a t i on __.Datum_ Percolation Tests-Date i_ t 141.)nbnr 4 2 — _3 S L t Satu_r _ -itlon ,off o f 3 , � ._ T �_ rn � . --._. �_� �✓ _-------- _ Op of ns rop — - tes& S'r._etcl, on Sack --- — COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL DEPARTMENT OF ENVIRONMENTAL RECEIVE ) �1t o�, AUG 2 2 2006 TOWNOF NORTH ANDOVER CH DEPARTMENT TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 95 Olympic Lane North Andover,Ma.01845 Owner's Name: Frank Rauschen Owner's Address: SAME Date of Inspection: 7 f 17 Z 0 6 Name of Inspector: (please print) Brian S . Murphy Company Name: B&D Septic Inspections Mailing Address: P.O. Box 47 Hull,Ma.02045 Telephone Number: ( 7 81 ) 2 9 0— 9 9 4 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: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature:(_ Date: Z 0 b 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 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. • Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 95 Olympic Ln . N.Andover,Ma. Owner: Frank Rauschen Date of Inspection: 7 / 17/06 Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are 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. 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: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 95 Olympic Ln. N.Andover,Ma. Owner: Frank Rauschen Date of Inspection: 7/17/06 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 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 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: Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 95 Olympic Ln . N.Andover,Ma. Owner: Frank Rauschen Date of Inspection: 7 / 17 / 0 6 D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool x Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or X clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow g 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. X Any portion of a cesspool or privy is within a Zone 1 of a public well. -J_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. -_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] NO (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either "yes" or "no" to each of the following: (The following criteria apply to 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 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. Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 95 Olympic Ln . N.Andover,Ma. Owner: Frank Rauschen Date of Inspection: 7/ 1 7/( 6 Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No X _ Pumping information was provided by the owner, occupant, or Board of Health X Were any of the system components pumped out in the previous two weeks ' X _ Has the system received normal flows in the previous two week period X Have large volumes of water been introduced to the system recently or as part of this inspection X _ Were as built plans of the system obtained and examined? (If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up r X _ Was the site inspected for signs of break out .' X _ Were all system components, excluding the SAS, located on site .' X _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the 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 different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no X _ Existing information. For example, a plan at the Board of Health. 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)] Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PropertyAddress: 95 Olympic Ln . �N.An over, a. Owner: Frank Rauschen Date of Inspection: 7/17/06 FLOW CONDITIONS RESIDENTIAL 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): 4 x 150=600 gpd. Number of current residents: 4 Does residence have a garbage grinder (yes or no): no Is laundry on a separate sewage system (yes or no): UQ [if yes separate inspection required] Laundry system inspected (yes or no): _ Seasonal use: (yes or no): no Water meter readings, if available (last 2 years usage (gpd)): appx . 257 gd. Sump pump (yes or no):1j Last date of occupancy: p r e s e n t COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): avd Basis of design flow (seats/persons/sgtetc.): 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: last pumped 8/05 homeowner Was system pumped as part of the inspection (yes or no): n o If yes, volume pumped: _gallons -- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank, distribution box, soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the 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: 25+ yrs. installed 7/79 local BOH records. Were sewage odors detected when arriving at the site (yes or no): no Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 95 Olympic Ln . N.Andover,Ma. Owner: Frank Rauschen Date of Inspection: 7 / 17/06 BUILDING SEWER (locate on site plan) Depth below grade: 16 " Materials of construction: _cast iron _40 PVC _other (explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: JL(locate on site plan) Depth below grade: 12 " 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: 8 ' x5 ' x4 ' 1000 gal. Sludge depth: 1 " Distance from top of sludge to bottom of outlet tee or baffle: 3 3 " Scum thickness: 2 11 Distance from top of scum to top of outlet tee or baffle: 5 �� Distance from bottom of scum to bottom of outlet tee or bale: How were dimensions determined: i n f i e l d Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank and inlet baffle in good condition,outlet baffle in fair condition,liquid levelwith ou a an appea s sound of leaxage. 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.): Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 95 Olympic Ln . N.An over, a. Owner: Frank Rauschen Date of Inspection: 7/17/06 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: X (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 in fair condition,box shows signs of deterioration, liquid level distribution equal,no signs of carryover or leakage. 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.): Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 95 Olympic Ln . N.Andover,Ma. Owner: Frank Rauschen Date of Inspection: 7/17/06 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: leaching trenches, number, length: X leaching fields, number, dimensions: 1 @ 2 0 ' x4 5 ' overflow cesspool, number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil conditions normal,no signs of hydraulic failure,vegetation normal. 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.): 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.): Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 95 Olympic Ln. N.Andover,Ma. Owner: Frank Rauschen Date of Inspection: 7 / 17 / 0 6 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A-1=31'6" D A-2=37' A-3=68' R B-1=29' B-2=29'6" I B-3=60'6" V 95 OLYMPIC LANE A 1 2 3 ED Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 95 Olympic Ln . N.Andover,Ma. Owner: Frank gauschen Date of Inspection: 7/17/06 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 4 feet Please indicate (check) all methods used to determine the high ground water elevation: X Obtained from system design plans on record - If checked, date of design plan reviewed: 5 / 7 9 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: Groundwater determined from design plan on record @ local BOH, design plan shows water bottom o -system EN 103-00 Class Size Total FY Summary Record Card generated on 7/17/2006 8:57:59 AM by Elaine Barclay Town of ,North Andover Tax'Map # 210-106.8-0138-0000.0 95 OLYMPIC LANE FRANK RAUSCHEN 95 OLYMPIC LANE NORTH ANDOVER, MA 01845 101 Single Family Property Type 1.19 Acres 2006 UB Mailing Index Name/Address Type Loan Number FRANK RAUSCHEN Owner 95 OLYMPIC LANE NORTH ANDOVER, MA 01845 Active/Inact. From PROBST, HARRY Previous Customer Inactive 95 OLYMPIC LANE N. ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Bldg Id. 17504.0 - 95 OLYMPIC LANE Last Billing Date 7/5/2006 3170174 03 Cycle 03 UB Services Maint. METE METE w Water Service Code Posted Date Rate MISCFEE ADMIN FEE 11 0.636/8 WTR WATER 1/17/2006 01 ALL METER SIZE UB Meter Maintenance 12 Serial No Status Location 29821513 a Active 1/14/2005 ERT HH Date Reading Code 6/14/2006 163 a Actual 3/8/2006 122 a Actual 12/22/2005 111 a Actual 9/21/2005 92 a Actual 6/27/2005 32 a Actual 3/9/2005 20 a Actual 12/13/2004 20 m Manual estimate 11/15/2004 0 n New Meter 11/15/2004 5469 r Replacement 11/15/2004 5469 f Final Bill 9/16/2004 5459 a Actual Trouble Code:03 6/22/2004 5381 a Actual Trouble Code:03 4/15/2004 5362 a Actual Trouble Code:03 12/12/2003 5337 n New Meter 11/19/2004 Active/Inactive Active Charge Multiplier/Users 7.82 1 / 176.16 /1 Brand Type METE METE w Water Consumption Posted Date 41 7/10/2006 11 4/17/2006 19 1/17/2006 60 10/14/2005 12 7/15/2005 4/5/2005 20 1/14/2005 0 1/14/2005 0 1/14/2005 10 11/15/2004 78 10/8/2004 19 7/30/2004 25 5/17/2004 0 12/12/2003 Size 0.63 0.63 Page 1 1 Residential Until YTD Cons Variance 189% -30% -70% 540% -100% -100% -100% -100% -82% 225% 40% 0% 0% 1 R4 - COMMONWEALTH OF MASSACHUSETTS OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENT NOV - 12004 1 j TOWN OF NORTH ANDOVER HEALTH DEPARTMENT TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A t CERTIFICATION Property Address: 7:5-- o zq&4D ,7 �t/D2ih/ i4 DOS Owner's Name: PAOJS7- Owner's Address: Date of Inspection: /DIST y Name of Inspector: (please print) ,91Z 144/ M0-47—*5-le Company Name: % )CAM l ,I. V/AO,,e4lA16 Matt; Mailing Address: $ WAESTaAJ.S'%' TEO Telephone Number: 97Sr-74, s- 0S 7ec, �r CERTIFICATION STATEMENT �� , I certify that I have personally inspected the sewage disposalsys'tern �at this address -and, t a the inform o`r ported 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: a Date: The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments 5Y57'5fvj 21 48ov6 i_ 5Hw7— kIiTH 2 MSN/11/, 50.z4S 1✓17-+1 26-' BUFrfR- To 1 -?VV A-rrr-O-,c /vo,zTH AnipovF_,- 13e)l-f 7�a.s// 97 7 . A S � v11-7- /?&,,4lv A cc ua,4TZ. ****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. Title 5 Inspection Form 6/15/2000 page I � e2 f11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS -SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ► CER'T'IFICATION (continued) Property Address: n PR o ° ` Owner: Date of Inspection: Inspection Summary:. Check A,B,C,D or E / ALWAYS complete all of Section D� A. System Passes: (/ 1 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. :f 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. Answer yes, no or not determined (Y,N,ND) in the for the s fo lowg s ai emeh lfrno detcrmifi,ed",l ase explain. �. `"� } lel 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: 3 PQ3of11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 4,,5- /0 LliP_ 11:b,- t 1 Am Owner: Pit n a5 ITi Date of Inspection: 7 �fiy 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. a� 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(I)(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 k f _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 publihealth, safety and environment The system has a septic tank and soil absorption;system-( AS) and the SAS is within 100 feet,of a 7" 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: (. v 49— ver K' /7ft/CeL,e-/ J l Owner: / i Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes No —>D �ackup of sewage into facility or system component due to over)oadedtor-clg gpd tSAS or cesspool Discharge or ponding of effluent to the surface of the ground surface wate due to an overloaded or clogged SAS or cesspool "' o _✓ Static liquid level in the distribution box above outlet, invert. due to an overloaded or clogged SAS or esspool -',�-✓ ` �I,iquid depth in cesspool is less below invert or available/volume is less than'/, day flow Required pumping more than 4°times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ J 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 I of a public well. ,Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. IThis system passes if the well water analysis, performed at a DEP certified labor'Wry, 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.] A)O (Y/No) he system fails. I have .determined that one or more of the above failure criteria exist as cribed 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 sy em the system m16t serve a facility with 'a design flow of 10,000 gpd to 15,000 gpd. _ You must indicate either "yes" or "no" to each of the folt6wing: p 7.r (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" i — 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 I1 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. . 4 :' 4 :Page 5 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: .L_ a id Lone. ot�l `v A�ot�u� Owner: /?20,9,5 Date of Inspection: /p _r/0 Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes N�o/ Y 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? 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 information. For example, a plan, at the Board of Health. li 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)] 5 ^, Page 6ofII OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: /��/ (//'�w�ys1e /UOf �In lY�t/rCLA-2i'' Owner: 14G" Date of Inspection: /0 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: l 10 gpd x # of bedrooms): ti's Number of current residents:-• Does residence have a garbage grinder (yes or no): Al Is laundry on a separate sewage system (yes; pr no):—�//[if yes separate inspection required] Laundry system inspected (ye or no): /11 f] Seasonal use: (yes or no):, Water meter readings, if available last 2 ears usage d t ± ( Y g (gpd)): Sump pump (yes or no): __L1% Last date of occupancy: C. Re gol rj CO.MMERCIAL/INDUSTRIAL 111 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): _ r 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 60w— it/C9 C 5 kzAATS Was system. pumped as part of the inspection (yes o no): If yes, volume pumped: /000 gallons -- How was quantity pumped determined? A4 Reason for pumping: _;C,� s��c., >�• TYPE OF SYSTEM �ptic 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 _ Attach a copy of the DEP approval Other (describe): Approximate age of all components, date installed (if known) and source of information: .2 5 - Were Were sewage odors detected when arriving. at the site (yes or no): 6 . Tage 7 of 11. OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: /012 -Us T` Date of Inspection: D / S BUILDING SEWER (locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC - other (explain):. Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: _ (locate onsite plan). n Depth below grade: / O 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 r certificate) Dimensions: Ti'/)/ C 1 G AEe-. -,4AJ6 Lz5 Cc4jC Sludge depth: !2-" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 3' Distance from top of scum to top of outlet tee or baffle: Distance from bottom:of scum to bottom of outlet tee or baffle: How were dimensions determined: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 14AI tI4114e ,0y1nP1AUG 7-e 42o Ts=Cg- 6AeL.,A-)1) wM D;g- A N b is vc 7'c� uti1) F-iZS Tri N� GREASE TRAP: _(locate on site plan)�i Depth below grade: ! /7"' Material of construction: _concrete metal fiberglass polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet teeor 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 8 of I 1 y e OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ?z 0 H/ G 1 ti Owner: A 6 " 7 - Date Date of Inspection: / D 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: i gallons Design Flow: gallons/day 1 h. 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:Zif resent must be o ened locate on site lanP P )( plan) Depth of liquid level above outlet invert: Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): 1A] l ; ,v�erLA L ,� cr,Nt7T/vn/ RI-A7-/1/ Tv � 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.): t 8 Pageof 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: f y" O% h t a i c_ r(1y✓ � � f7w c✓Gv-e r Owner: P.9D.g S 7— Date Date of Inspection: 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: E leaching trenches, number, length: Zleaching fields, number, dimensions: z.o u y S' S /in -e s 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.): CESSPOOLS: 4(cesspool must be pumped as part of inspect ion)(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.): 9 d 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 R Page 40 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM"INFORMATION (continued) Property Address: D /�_L44c— dens. -e.✓' Owner: p,�d 50v Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. je1w. Comm '�►1lv brer�! t w'uswev C.0is w tae A?0 TT6M OR (,Srfow 9ra�le.� W Qf4, �roand tisx•-�e�r 7- M"K /II -r- TclG ra-4e— . 'Pd ge 11 of 11 k OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION. (continued) Property Address: 91 to%y A e. jc, a Owner: /3,5 Date of Inspection: /b /S o SITE EXAM Slope Surface water 4/00 1 Check cellar�S Shallow. wells NQ Estimated depth to ground water 3 feet Please indicate (check) all methods used to determine the high ground water elevation: Vee0obtuained from system design plans on record - If checked, date of design plan reviewed: 7 Z57 ? --+Observed site(abutting roe /observation hole within 15.0 feet of SAS) Checked with local Board of Health -explain: t"Pvi r Checked.with local excavators, installers- (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: A-5 . PAS=t/ ) � I >�l S� r�7 iG L TaE�iG •l,� pt_'A iV i 11 f -N �V - L.E. N/AT i O 1Ny PIPE QUI OF HSE N I A . T C:� INV_ PIPE INTO D ESOX { OC�L INV. nee LiT_D- psnx U,IV EN lQ DP Pt 9E; f L )1 f AS 5UILT 5Ygo-'T �M INJ pp ,lCn 4 _ � 12A -r E-=, 7 FRANK GC-7E"L,NA•SA550Ctg'T'ES F- [--= -�tIT'ECTS *4 s t ZS,N DvrA e->. A N