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roperty Record Card
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Location: 95 PENNI LANE
Owner Name: KON, YIN THIAM
MAC, YEN LE
Owner Address: 95 PENNI LANE
City: NORTH ANDOVER State: MA Zip: 01845
Neighborhood: 7 - 7 Land Area: 1.00 acres
Use Code: 101-SNGL-FAM-RES Total Finished Area: 2776 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 538,400 538,400
Building Value: 312,800 312,800
Land Value: 225,600 225,600
Market Land Value: 225,600
Chapter Land Value: 11
http://csc-ma.us/PROPAPP/display.do?linkld=1896684&town=NandoverPubAcc 5/17/2012
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Date. .0.7. 15-7.kA ......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .... . . . ......................................................
t 1-% - Z
.... ...........
has permission to perform U ..........
wiring in the building of................ . ....................................................
......... q
...... Andover, at .........�..I.
................ North. over, ass
*
Fee... ....... Lic. No. ............. . .. .. ......... .. ..... ...
ELECTRICAL INSPECTOR SPECTOR
Check #
I .
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the
C X
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall -be limited as to the time of ongoing construction activity, and may be.deemed-bythe Inspector_of_Wires abandoned.and.invalidafhe.—_.
or she has determined that the authorized work has not.comme_nced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entitystated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chanter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long -tern economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 208 and extending'through August 15, 2012.
❑ Mule 8 — Permit/Date Closed:***Note: Reapply for new permit -
0 Permit Extension Act — Permit/Date Closed:
IN Commonwealth of Massachusetts
Department of Fire Services
,a BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. ! 0 2-2-
Occupancy and Fee Checked
[Rev. 1/071 (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code ( C), 127 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date:
City or Town of: NORTH ANDOVER To the Inspecto of 'res:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) 95_pp,, o \Ane
Owner or Tenant YetN m(k C- Telephone No.
Owner's Address :nmr_
Is this permit in conjunction wip a building permit? Yes ❑ No 91 (Check Appropriate Box)
Purpose of Building Utility Authorization No. /J IA
Existing Service 2-06 Amps 120 LJ6Volts Overhead ❑ Undgrd ® No. of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Completion of the following table may be waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ In-E]
rnd. rnd.
o mergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pum
Totals
Number
To ns
J.KW
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water KW
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value o Ele trical Work: 360,00 (When required by municipal policy.)
Work to Start: 211S 1\\ Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE CO E AGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the
licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned
certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE MI BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties of perjury, that the information on this application is true and completes
FIRM NAME: \ LIC. NO.: b,I v I
Licensee: M11y1e1e% Y rA p\A1 Signature LIC. NO.:
(If applicable, enter "exempt" in the lice nu�l,�r line.) Bus. Tel. No.:
Address: 2 S�v� S 1`1CVSGS Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required
by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's
Owner/Agent PERMIT FEE: $ 35
Signature Telephone No.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
ky 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Y r '/ o 116
Address: o S Au 0 6
City/State/Zip: �U Phone #: �V IJ2 3 96 T ff
A/You an employer? Check the appropriate box:
DJ4am a employer with ( 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
❑ I am a sole proprietor or partner- listed on the attached sheet. +
ship and have no employees These sub -contractors have
working for me in any capacity. workers' comp. insurance.
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their
❑ I am a homeowner doing all work right of exemption per MGL
myself. [No workers' comp. c. 152, §1(4), and we have no
insurance required.] t employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.0 Other
*Any applicant that checks box # I must also fill out the section below showing their workers' compensation policy information.
fi Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: On- ( ,
Policy # or Self -ins. Lic. #: W��S P Z 3 3S Expiration Date: �6 —�611
Job Site Address: 5Pco) �A ne City/State/Zip: AM, &A0 Imle—
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido hereb certify and r the pains and penalties of perjury that the information provided abov1 is tru and correct.
Sienature:il r)atP• �/ �S �j l
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone #:
if
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
1)ATI :;
�YSTEM OWNER & ADDRESS
9s cru 9e�
1clo-14wle)cl�
SYSTEM LOCATION
(example: left front of house)
i c�
DATE OF PUMPING: QUANTITY PUMPED dw GALLONS
C_4'SS1)00L: NO u YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
"Y"TEM PUMPED BY:
CO11NIENTS:
C:O'NTE'.'N'I'S TRANSFERRED T0:
HULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
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1 31) 414in.Cf 9rEWARTIS IMVIC TALC SB WCE
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978-372.•7471
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MP e !/ 1060
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TO:
FROM:
NORTH ANDOVER, MASS aZ' Z /-7 19 7J -
BOARD OF HEALTH
DESIGN ENGINEER Re: Soil Absorption Sewage
System Inspection
This is to certify that I have inspected the construction of the said disposal system at
Z-0-7- /3 7 E1V.,V /9AIC- North Andover, Mass.
SITE LOCATION
The grades and construction are as specified in my plans and specifications dated
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UANTITY ('UMn Za
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C. i':»I'UUL ANO YES.
1UWNER
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SEPTIC TANK: NO
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YES
NAtUKE O.F.SERVI. CE;. ROUTINE.
EMERGENCY
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��il>�RYr1TIONS: ► ,.,
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UUOp"C�Nll11:.ION :.
F'ULL:TU'COYC-k.
FIGAY•;Y A$ 13`:.;;—
:-BAFFLES IN PLACl?
:BUOYS "'
LEACHFICLD RUNDACCK:..
GXCESSIY ".SO1�1DS..
' FLOO.DED`..
SOLLU: CARRYOYR
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CUNI NI R'NTS,
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UN �5 TRA N T C,1Zl E p TO.
tl/
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
' DEPARTMENT OF ENVIRONMENTAL PROTECTION
i,
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: JzLqV1V
8LO—k 14 2 2 03
Owner's Name: ,Z e ,, u
Owner's Address: N� '
Date of Inspection: /A _ 3 j a Z
Name of Inspector: (pl e print t l ( (C
Company Name:T-t'"
Mailing Address: V 08'Z
e, CAA_ iN 4
Telephone Number: S:4 -)0a-)(,
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 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: Date: /6 -I Z— C, 3
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 d Comments
je L),) 64kr
.****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 Insnectinn T=nrrn ocit snnnn __„_ r
Page 2 of 11.
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 7 fivN
C
Owner: e w(,) "7,K -u ST'
Date of Inspection: icy— ,2 o
Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D
A. System Passes:
1, I have not found any information which indicates that anv 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.
B. Systeiq Conditionally Passes:
One or fficp system components as described in the "Conditional Pass" on need to be replaced or
repaired. The syste upon completion of the replacement or reZasapd by the Board of Health, will pass.
Answer yes, no or not determine ,N,ND) in the for th ments. If "not determined" please
explain.
The septic tank is metal and over 20yeah • r the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfil on tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying sept' tank as ap ved by the Board of Health.
•A metal septic tank will pass inspection if ' is structurally so not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 ye old is available.
ND explain:
Observation of sew a backup or break out or high static water level in the ' 'bution box due to broken or
obstructed pipe(s) or du o a broken, settled or uneven distribution box. System will p inspection if (with
approval of Board of ealth):
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
ND plain:
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 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
-PART A
CERTIFICATION (continued)
Property Address: 9S eti,k`j I _.e
/� we -
Owner• hL'Wt%
Date of Inspection: 1a, - Z/ —
C. FuN1,11er Evaluation is Required by the Board of Health: /
Lon ions exist which require further evaluation by the;Boardof Heal order to determine if the system
is failing to pro public health, safety or the environment1. System will p unless Board of Health determines idance with 310 CMR IS-M(1)(b) that the
system is not fun oning in a manner which will proslic health, safety and the environment:
_ Cesspool or privy ""§tithin 50 feet of a surface
_ Cesspool or privy is whhin 50 feet of a bordevl
2. System will fail unless the Board of ealth ( a
system is functioning in a manner that rotects the
vegetated wetland or, a salt marsh
Water Supplier, if any) determines that the
health, safety and environment:
_ The system*has a septic tank d soil absorption system AS) and the SAS is within 100 feet of a
surface water supply or tributary o a surface water supply.
_ The system has a septic and SAS and the SAS is within a Zo 1 of a public water supply.
The system has a sep ' tank and SAS and the SAS is within 50 feet of a rivate water supply well.
_ The system has a s uc tank and SAS and the SAS is less than 100 feet but 50 or more from a
private water supply w 1••. Method used to determine distance
"This system passe if the well water analysis, performed at a DEP certified laboratory, for liform
bacteria and volatil organic compounds indicates that the well is free from pollution from that aciliry and
the presence of monis nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria triggered. A copy of the analysis must be attached to this form.
3.
Page 4 of I I
R
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSM. EN`TS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: S eN,,% / /`/JN
Owner: LQ.W 1.3 i 2L" S- i
Date of Inspection:lo — Z/ --U'S
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following for all inspections:
Yes No
0 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
J( Liquid depth in cesspool is less than 6" below invert or available volume is less than''/_ day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped .
Any portion of the SAS, cesspool or privy is below high ground water elevation..
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ 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 SO feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
(Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
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 Sof I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:�1'11 ti. , 4N L�
)� �� �v.
Owner: ew tS
Date of Inspection: / o - 2 -O
Check if the following have been done. You must indicate `wes" or "no" as to each of the followins:
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 ?
o—_ Were the septic tank manholes uncovered, opened. and the interior of the tank inspected for the condition
the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge Q p 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 {DSAS) on the site has been determined based on:
Yes . no
Existing information. For example, a plan at the Board of Health.
Determined in the field (if anv 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
Property Address:�E peNn�,
Q ri cmc t
Owner: I2ul S
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): Number of bedrooms (actual)•
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):
Number of current residents: 0
Does residence have a garbage grinder (yes or no): N
Is laundry on a separate sewage system (yes or no): A/' [if yes separate inspection required]
Laundry system inspected (yes or no): AJ
Seasonal use: (yes or no): W
Water meter readings, if avai able (last 2 years usage (gpd)): /U
Sump pump (yes or no): ill
Last date of occupancy: S —63
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR 15.203)` and
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: ALT
Was system, pumped as part of the inspection (yes or no)-. &I
If yes, volume pumped: _gallons — How was quantity pumped determined?
Reason for pumping:
Ty P,
OF SYSTEM
j� 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
Were sewage odors detected when
date installed (if known) and source of i
the site (yes or 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:
Owner: 4e W i
Date of Inspection: — Z
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: 4 (low on site plan)
Depth below grade:_
Material of construction: concrete _metal _fiberglass __polyethylene
—other(explain)
If tank is metal list age: — Is age confirmed by a Certificate of Compliance (yes or no):_ (attach a copy of
certificate)
Dimensions:
Sludge depth.
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: �
Distance from top of scum to top of outlet tee or baffle: S ��
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: 'fie P
Comments (on pumping recommendationY, utlet and outlet tee or baffle condition, structural integrity, liquid levels
as _ relatgd �
to -outlet invert, evidence of leakage, etc.):
Ta ,
_ l 1. -r".- —
75 -a- (Te -
GREASE TRAP: _(locate on site plan)
J
r�t'k'T� C'/'!�s' nS
Depth below grade: _
Material of construction: concrete metal fiberglass _polvethylene other
(explain): — — — —
Dimensions:
Scum thickness:
Distance from top of scum to topof 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 AddresO f P•vry + ,+fy
Owner• kCCnY S ZZL(c S7-
Date
^Date of Inspection: /0 ^ —Z4
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: ¢allons/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: O
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover. any evidence of
ka a into or out of box, etc .)•
bf-f-%z
/J )xv��( LJ 4 6J3q tJL ✓r ✓-7e c j A+L1I I Li 1656 , . ra-1
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.):
v
Page 9 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSME?N-TS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: QauN /r¢N�
Owner:/t-o(-S
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required)
If SAS not Ipcated explain why:
Type
leaching pits. number. _
leaching chambers, number
leaching galleries, number
leaching trenches, number, length:
Zleaching fields, number, dimensions: X YQ
overflow cesspool, number.
umovativeialtemative system Type!name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil. condition of vegetation,
etc.): J
CESSPOOLS: (cesspool must be pumped as pact of inspection)(locate on site plan)
Number and configuration:
Depth — top of liquid to inlet invert:
Depth of solids laver:
Depth of scum laver:
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 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: ��"� �.8 N (L
/V G�.�• v�
Owner: 5
Date of Inspection: G4&
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.
q6
Xi
Pic
Page 11 of 11
f OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection: Q Z.(
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 2 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 properryiobservation 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 hpw you estabi' hedjlte hi h g ound water ev n: -
�x S � Q U cj --� �u�a'� ��' P,
11 -1<L �y
A) e,+ le,