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HomeMy WebLinkAboutMiscellaneous - 951 FOREST STREET 4/30/2018N J P -to 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. IL 0 �;Aj I •4: Commonwealth of Massachusetts �`�eQ Title 5 Official Inspection Form ,6-c Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Jv�`' C PN�O�EEZ 951 Forest Street .,taOFN�EPPR�M��� Property Address Kevin Patterson Owner's Name North Andover Cityrrown Ma 01845 State Zip Code 5-10-17 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: John DiVincenzo v)J6 Name of Inspector J and S Development Corp / Stewarts Septic Service Company Name 58 South Kimball St Company Address Bradford MA 01835 Cityfrown State Zip Code 978-372-7471 s113386 Telephone Number B. Certification License Number 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 ❑ deeds Further Evaluation by the Local Approving Authority ature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of alth or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. 'This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. 'S} Commonwealth of Massachusetts �® Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessment�1%Q► 951 Forest Street SOA Property Address Kevin Patterson Owner's Name North Andover Ma 01845 5-10-17 Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Distribution box was replaced B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc - rev. 6/16 Title 5 Official inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 PUBLIC HEALTH DEPARTMENT Town of North Andover Community and Economic Development Division CERTIFICATE OF COMPLIANCE As of May 25, 2017 a This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: D -Box Repair By: John Divincenzo At: 951 Forest Street Map 105.D Lot 12 Noon over, MA 01845 this certi at s 1j not b ued as a guarantee that the system will function satisfactorily. Mikhek Grant Public Health Agent 120 Main St., North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web www.northandoverma.gov 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. Commonwealth of Massachusetts Title 5 Official Inspection Fdfin A�� Subsurface Sewage Disposal System Form - Not for Volunt ents�D�pP� 951 Forest Street Property Address Kevin Patterson Owner's Name North Andover City/Town Ma 01845 5-10-1 State Zip Code Date of 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 I nspector: John DiVincenzo Name of Inspector J and S Development Corp / Stewarts Septic Service Company Name 58 South Kimball St Company Address Bradford City/Town 978-372-7471 Telephone Number B. Certification MA State s113386 License Number 01835 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 1141 1--- 2 i -d►d-0 Signature Date Th¢ system inspector shairsubmit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 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_1 Forest Street Property Address Kevin Patterson Owner's Name North Andover _Ma _ 01845 5_-10-17 Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 951 Forest Street Property Address Kevin Patterson _ Owner Owner's Name information is required for every North Andover Ma 01845 5-10-17 -- page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): Distribution box leakaoe around the outlet inverts ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 951 Forest Street Property Address Kevin Patterson Owner's Name North Andover City/Town B. Certification (cont.) _Ma 01845 State Zip Code 5-10017 Date of Inspection 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well'. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than ''Y2 day flow t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 951 Forest Street Property Address Kevin Patterson Owner Owner's Name information is North Andover Ma 01845 5-10-17 required for 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.doc • rev. 6/16 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1 .y, 951 Forest Street Property Address Kevin Patterson Owner Owner's Name information is required for every North Andover page. City/Town C. Checklist Ma _ 01845 5-10-17 State Zip Code Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts -- W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 951 Forest Street_ Property Address Kevin Patterson Owner Owner's Name information is required for every North Andover page. City/Town 010 D. System Information Description: Number of current residents: Ma 01845 State Zip Code 5-10-17 Date of Inspection Does residence have a garbage grinder? Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) 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: Gallons per day (gpd) ❑ Yes ® No occupied Date ❑ 4 ❑ No ❑ Yes ❑ Yes ® No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ® No ❑ Yes ® No occupied Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 951 Forest Street Property Address Kevin Patterson _ Owner Owner's Name information is required for every North Andover Ma 01845 5-10-17 — - - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other (describe below): Pumping Records: Source of information: General Information Stewart's Septic Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: 1500 gallons Site guage on truck To inspect the tank ® Yes ❑ No Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy Shared system (yes o no if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 951 Forest Street Property Address Kevin Patterson Owner Owner's Name information is required for every North Andover page. City/Town 5-10-17 State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 18"feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): - ❑ Yes ® No Distance from private water supply well or suction line: 100' to tank 120 to field feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 10 -6x5 -8X5" 12" 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) Dimensions: - -- Sludge depth: ❑ Yes ❑ No t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts --- W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 951 Forest Street Property Address Kevin Patterson Owner Owner's Name information is required for every North Andover Ma 01845 5-10-17 page. CitylTown 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 19" How were dimensions determined? Tape measure sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Both baffles are good and no leakage t5ins.doc • rev. 6/16 Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: -- - - - Scum thickness - ---- Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: - ----- - - Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 951 Forest Street Property Address Kevin Patterson _ Owner Owner's Name information is ruired for every North Andover Ma 01845 5-10-17 eq page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: ---- ----- Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: --------------- Capacity: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: Date of last pumping: Date Comments (condition of alarm and float switches, etc.): --------------------- ❑ Yes ❑ No * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 951 Forest Street _ Property Address Kevin Patterson Owner Owner's Name information is required for every North Andover page. City/Town State Zip Code 5-10-17 Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 - -- Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box needs replacing, leakage around the outlet inverts. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 951 Forest Street D. System Information (cont.) Type: State 01845 5-10-17 _ Zip Code Date of Inspection ❑ leaching pits Property Address ❑ leaching chambers Kevin_ Patterson Owner Owner's Name information is North Andover required for every number, dimensions: page. Cityrrown D. System Information (cont.) Type: State 01845 5-10-17 _ Zip Code Date of Inspection ❑ leaching pits number: ❑ leaching chambers number: - - ❑ leaching galleries number: ® leaching trenches number, length: 3-46'_ ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: - --- - Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No hydraulic failure, no ponding and no damp soils Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration ----- Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction — Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts - - W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °951 Forest Street Property Address Kevin Patterson Owner Owner's Name information is required for every North Andover page. City/Town Ma 01845 5-10-17 State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: - Dimensions --- - Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 951 Forest Street Property Address Kevin Patterson Owner Owner's Name information is required for every North Andover _ Ma 01845 5-10-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand -sketch in the area below ® drawing attached separately t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 4.� 1 U Commonwealth of Massachusetts -- w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 951 Forest Street Property Address Kevin Patterson Owner Owner's Name information is required for every North Andover Ma 01845 5-10-17 _ page. 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: feet _ Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 4-7-84 _ Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Pulled file ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Taken from plans on file at the board of health. Water elevation 103.0; bottom of bed at 107.0 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 951 Forest Street Property Address Kevin Patterson 01845 Zip Code Owner Owner's Name information is North Andover Ma required for every page. City/Town State E. Report Completeness Checklist 5-10-17 Date of Inspection ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 NORT L •{ 'f.0 3?�r • OL r r Town of North Andover `'••,,,,, ..,' HEALTH DEPARTMENT CINU CHECK #: �t/j DATE: 51A �-0/7 LOCATION: 9 5/ zco—%,54 Sir' H/O NAME: `!21/i /) Pte. l' tl ,501 CONTRACTOR NAME:70Aa �i1%i/? e,a Type of Permit or License: (Check box) $ ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector . ), 'o /1 oll $ � Title 5 Report c � ! 5 $50- ❑ Other. (Indicate) $ Healent Initials White - Applicant Yellow - Health Pink - Treasurer J AND S DEVELOPMENT CORPORATION 16197 North Andover Health Department Community and Economic Development Division DECEIVED MAY 2 5 2017 TOWN, DEPARTMORTH ENTER ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 951 Forest Street MAP: 105.D LOT: 12 INSTALLER: John Divincenzo, Stewarts/J&S Development DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: SEPTIC TANK ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROLPANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION -BOX ® Installed on stable stone base ® H-20 D -Box ❑ Inlet tee (if pumped or >0.08'/foot) ® Hydraulic cement around inlet & outlets ® Observed even distribution ® Speed levelers provided (not required) ® Schedule 40 PVC Pipe Comments: D -Box Repair 5/25/2017 Added risers SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder / concrete / timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel -less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = FINAL GRADE ❑ Loamed ❑ Seeded ❑ Cover per plan Comments: DOCUMENTS NEEDED ❑ Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer ❑ As -Built Plan SYSTEM ELEVATIONS SKETCH PLAN ROD AS -BLT INVERT ELEVATION ELEV DESIGN INVERT ELEV Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 TOP Lateral 1 INVERT Lateral 2 TOP Lateral 2 INVERT Lateral 3 TOP Lateral 3 INVERT Lateral 4 TOP Lateral 4 INVERT Lateral 5 TOP Lateral 5 INVERT Lateral 6 TOP Lateral 6 INVERT Top of Chamber Bottom of Bed/Chamber SKETCH PLAN 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 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 North Andover Health Department (ommunity and Economic Development Division RECEIVED MAY 2 5 2017 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 951 Forest Street MAP: 105.D LOT: 12 INSTALLER: John Divincenzo, Stewarts/J&S Development DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS f L)`r)�� TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: SEPTIC TANK ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROLPANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION -BOX Installed on stable stone base -20 D -Box ❑ Inlet tee (if pumped or >0.08'/foot) ydraulic cement around inlet & outlets Observed even distribution peed levelers provided (not required) Schedule 40 PVC Pipe Comments: SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder / concrete / timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel -less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = FINAL GRADE ❑ Loamed ❑ Seeded ❑ Cover per plan Comments: DOCUMENTS NEEDED ❑ Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer ❑ As -Built Plan BM = HR= HI = SYSTEM ELEVATIONS ROD AS -BLT INVERT DESIGN INVERT ELEVATION ELEV ELEV Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 TOP Lateral 1 INVERT Lateral 2 TOP Lateral 2 INVERT Lateral 3 TOP Lateral 3 INVERT Lateral 4 TOP Lateral 4 INVERT Lateral 5 TOP Lateral 5 INVERT Lateral 6 TOP Lateral 6 INVERT Top of Chamber Bottom of Bed/Chamber SKETCH PLAN CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback 1 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 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 1 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 L.4 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. te6 retie RECEIVED Application for Septic Disposal System Construction Permit —TOWN OF TODAY'S D✓ir'_ �_ L� NDOVER NORTH ANDOVER, MA 01845 $ ;500 M�` MENT Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system* ❑ Repair or replace an existing on-site sewage disposal system* � �ir or replace an existing system component — What? U ` S�1% A. Facility Information ._ Address or 2.- *TYPE OF SEPPC SYSTEM*: ➢ ❑ Pump Gravity (choose one) ***If pump system, attach copy of electrical permit to application*** ➢ ❑ Conventional System (pipe and stone system) ➢ ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.) ➢ ❑ Pressure Distribution S.A.S. (No D -Box) / ➢ ❑ Pressure Dosed (D -Box Present) S.A.S. ✓/ ➢ ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES = (no further info. needed) NO = (installer must specify brand of filter before DWC issuance) 2. What is the Make? What is the Model. Address (if different from ove) AJD Xvlt4y)�­e' J'h O��Y6r City/Town State Zip Code �1-2y' •39'7 Email address Telephone Number 3. Installer Information 1\13 -me Name of Company 6� so v�,�,6� c i s r Address City/Town State Zip Code 1112 or- e7 Telephone Number (Cell Phone # if possible please) 4. Designer Information Name Name of Company Address City/Town State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit - Page 1 of 2 • ���° •. Application for Septic Disposal System * } • , TODAY'S DATE Construction Permit -TOWN OF NORTH ANDOVER MA 01845$350.00 - Full Repair $175.00 - Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: Residential Dwelling or ❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Envi o mental Code, as well as the Local Subsurface Disposal Regulations for the Town of Nord,jndotler.�nders that until a final Certificate of Compliance has been issued by thi B and f W , t installed system is not approved. aA -..1 Date Appli n Ap o By: (Board of Health Representative) `[ ZZ Nam Date Appli ation/Isapproved for the following reasons: For Office Use Only: 1. Fee Attached? Yes No 2. Project Manager Obligation Form Attached.P Yes No 3. Pump S sy tem? If so, Attach coy of Electrical Permit Yes No Applicantreceived copy of "Electrical Inspection Notes for Septic Systems" Yes No Handout? 4. Reviewed approval letter, all paperwork received? Yes No 5. Foundation As -Built? (new construction only): Yes No (Same scale as approved plan) 6. Floor Plans? (new construction only): Yes No Application for Disposal System Construction Permit • Page 2 of 2 •Of YV' •. O Town of North Andover HEALTH DEPARTMENT SACHU`+E CHECK #: 6/9 DATE: LOCATION: 9,5- / ,�o% a H/0 NAME: /4t, / /e/17.0 /-) CONTRACTOR NAME: -tt, l.(J/, /- �S Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing + ( $ ❑ Septic - Design Approval $ Septic Disposal Works Construction (DWC) x $�-" ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) $ fl�R Hea gent Initials White - Applicant Yellow - Health Pink - Treasurer r Commonwealth of Massachusetts Map -Block -Lot 105.D0012 BOARD OF HEALTH /---------- Ul y(� � Permit No North Andover p.� ( (((,,,��� BHP -2017-0433 / H 01 -- 3 P.I. FEE F.I. $175.00 tt----------------------- DISPOSAL WORKS CONSTRUCTIO ERMIT Permission is hereby granted J_& S Development_Corporation --------- to (Construct) an Individual Sewage Disposal System. at No 951 FOREST STREET as shown on the application for Disposal Works Construction Permit No. BHP -20177043 Dated --May-22-,-20-1-7 - - ---------- -. - --------- Issued On: May -22-2017 BOARD OF HEALTH •°f . Commonwealth of Massachusetts Map -Block -Lot • 105.D0012 BOARD OF HEALTH --------------- --- North Andover IFICATE OF COMPLIA THIS IS TO CERTIFY, Tha Individual Sewa osal System (Construct) b J &_S_Develo ment Co_ oration F Y . P rP-------------------------- Installer at No 951 FOREST ST has been installed ' cordance with the provisions of TITLE 5 of the State Environmental as described in the applicatio isposal Works Construction Permit No. BHP -2017-043 Dated --May 22,_201 -------- -------------------------- Printed On: May -22-2017 ----- - ------------------------------------------ - BOARD OF HEALTH Commonwealth of Massachusetts Map -Block -Lot • 105.D0012 BOARD OF HEALTH ----- Pe o North Andover HP -2017-0433 ----------------------- FEE $175.00 DISPOSAL WORKS CON U ON PERMIT Permission is hereby granted J_& S_ Development Co -- ion ___� to (Construct) an Individual Sewage Disposal System. J at No 951 FOREST STREET as shown on the application for Dis Works Construction Permit No. BHP -20177043 Dated—May-22 17 Issued On: May -22-2 ------- -- ------------------- ------------------- -- BOARD OF HEALTH u r Commonwealth of Massachusetts Map -Block -Lot •� 105.D0012 ------------------- BOARD OF HEALTH Permit No BHP -2017-0433 North Andover-------------- P.I.FEE F.I. - $175.00 DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted J_& S Development_Corporation _ -- to (Construct) an Individual Sewage Disposal System. at No 951 FOREST STREET ---------- -------------------------------- - - - as shown on the application for Disposal Works Construction Permit No. BHP -2017-043 Dated May -22.2017 ---- ---------------------------------------------- Issued On: May -22-2017 BOARD OF HEALTH • Commonwealth of Massachusetts Map -Block -Lot 105.D0012 BOARD OF HEALTH ----------------------- North Andover CERTIFICATE OF COMPLIANCE THIS IS TO CERTIFY, That the Individual Sewage Disposal System (Construct) by J & S Development Corporation • Tnetallar at No 951 FOREST STREET - ------ - -- _ -------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. BHP -2017-043 Dated May 22,_ 2017 ----------------------- - 1 Printed On: May -22-2017 BOARD OF HEALTH -- -- -I • - - ---------- -- Commonwealth of Massachusetts Map -Block -Lot 105.D0012 BOARD OF HEALTH -------------- Permit No North Andover BHP -e017-0433 FEE $175.00 ------------ DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted J Development Corporation- --------------------- -- - - --------------------------- J & S 1 to (Construct) an Individual Sewage Disposal System. at No 951 FOREST STREET as shown on the application for Disposal Works Construction Permit No. BHP -2017-043 Dated May 22, 2017 ------------- --------- ---- ---------------------------------------------- Issued On: May -22-2017 BOARD OF HEALTH PUBLIC HEALTH DEPARTMENT Community & Economic Development TOWN OF NORTH ANDOVER SEPTIC DISPOSAL SYSTEM — INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System ( ) constructed; (�ired; By: t3o ,& K) L_ li (Print Name) Ge-A✓2-6 Located at: 16W _Gr�iL`1- %` 1'1 l r7g l OL J L '5T_ 'Cj{MZ 1"`rJ )'net - (Installation Address) Was installed in conformance with the North Andover Board of Health approved plan, originally dated and last revised on with a design flow of gallons per day. The materials used were in conformance with those specified on the approved plan; the system was installed in accordance with the provisions of 310. CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on the As -built which has been submitted to the Board of Health. Bottom of Bed Inspection Date: Engineer Representative (Signature) And — Print Name Final Construction Inspection Date: Engineer Representative (Signature) And — Print Installer: J&, �� rZ Y 1' �(Signature) Date: Engineer: (Signature) Date: And — Print Name And — Print Name 120 Main Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web http://www.northandoverma.gov SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the prope,t)F k�G��ti �,.`CH Dtk'At�T�t�T (address of septic system) �� / Relative to the application of �J p l --) L., A ✓ j oCPM2-g-) (Installer's name) Dated _671d a212 o ay s ate For plans by And dated With revisions dated I understand the following obligations for management of this project: (Engineer) (Original ate (Last revised date) 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner, contractor, project manager, or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection}without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or M companT. a. Bottom of Bed — Generally, this is the first (VS inspection unless there is a retaining wall, which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection — Engineer must first do their inspection for elevations, ties, etc. As -built of verbal OK (or e-mail to: healthdept@northandoverma.gov) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system, all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade — Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation) and I am required to complete the installation of the system identifiedin the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board ofHealth staff or consultant. d. Installation of tank, D -Box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer, I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: -�v 1 d )A) C ,PAY20 (Name — Print /e— iRne A r O C) 7 O O N Ov-0 0'00 O N (D Q ({D O w X p l CD n O oq wn N m O X m CD N X m m T 0w o�� aa00 X 0 C (P D (D a ; _ (D N N N (D n .. N (p 3 C) N .. 0 MDD z-'Om� GONr 2 Z ,ZOmm D m cn Cn z 0 �ZZ N) W� �� Dww mxwm=mw-a N N X w C (D O_ O U) G D X N, Ad7 aDO D. 00 �-'67 0 M -I�� A n CO 3 x�sw"'wa � OG7 0•ppv Wd o °o m (n mm< m=Z m •n A . CD N (n D1 N 3'� �3N 3 3 T —_ N N y v D �D' r N N X .. u m z w m -n n O m ;0 c N 9 . w 0 -n i A oT �-n W o o To 0 m o CD =p CDCK O Z rn rn T W U( n 0 p CL -n ]' m =• 0o z n3 cot �w D� 2 T D� D(o N �a 3 .c — D m CD m -i co O Cf C() 0 DG�� N �� � Z A Tn A O O O w N O 00 00 cn (0W A O 0) 0 N 0 Z D>>0 0 E mmm> 4 N co==o O� 0 N 7 N .— Cnf_n(� DZ 3 w3 F5' ` nGi w co nGi C a D m _ C)m�� o oW - C N c m N O rt (p N x(D co 00 oCD ocl)h ��_�NM r T ��v0 A(31 Oo ;u �C] Q - DN n C) wCD CD mw DCD O N N (D N C s (Dz C7 Z1xW O ZJ N N CD = C) oo w N Ul O Q� C v N O O O NN — -00 v m m C ��ao G)v C CO Ct O o n * dna m m (D m (0(0�0 OD o� 'm CL 0 o� DC7 U CD ° lammm CI)o0D �D N 03 03 m z CL CL m y 0 v 0. � � -A Cl) �Cl) z— -n C A(0 Z 00 OD � � wC A w C/) O m ; o z dy/ z A O I \ CD DSO a, rr0 o -n u, nn Z CLO ;i o, —O -0 n<rn X 3 (n N O m v o ,cm 0 ` o ic o c w . 3 0 3 0 :fU) a0 (� 0� nO N w WWW o'3 + wwGl Cil oO z N �o o 1. �., m (� p1Z CD 000—o 000006 o� o J C) (D fY •#. 7 7 (n j n a (7 � m m � n ww cn u, N cc O 0 N A r O C) 7 O O N Ov-0 0'00 O N (D Q ({D O w X p l CD n O oq wn N m O X m CD N X m m 101 HIGH STREET, PO BOX 40, NORWICH, CT 06360 FOUNDED 1840 INSURANCE COMPANIES (860) 887-3553 — TOLL FREE 1-800-962-0800 / 1-800-243-4080 — FAX (860) 886-8270 / (860) 887-2898 www.nlcinsurance.com March 12, 2015 Inspector of Buildings 1600 Osgood Street North Andover, MA 01845 RE: Insured: Kevin Patterson Property Address: 951 Forest Street Company Policy Number: H5206945 Date of Loss: 03/10/15 Claim Number: C52566 Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1,000.00 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Sec 3B is appropriate, please direct it to the attention of the writer and include reference to the captioned insured, location, policy number, date of loss, and claim number. On this date, copies of this notice have been sent by first class mail to the municipal officials named above at the address shown. Sincerely, NLC Insurance Companies ' V �--�-j--- Y U`p UL s tr r Commonwealth of Massachusetts SES 13 2010 City/Town of NORTH ANDOVER MAS OVER System Pumping Record "T Form 4 DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving authority. Important: Men filling out forms on the computer, use only the tab key to move your cursor - do not use the return � tt� A.. Facility Information 1. 2. System QNkner._ _ , ; , , Address (if different from location) City/Town State Zip Code Telephone Number B. Pumping Record rr�� 1. Date of Pumping pa V 2. Quantity Pumped 3.., Type of system: ❑ Cesspool(s) ( Septic Tank --E] Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: 6. ystem Pumped By: e t Company fit �cQ 7. l Gallons ❑ Tight Tank If yes,.was it cleaned? ❑ Yes ❑ No Vehicle License Number http:/Avww.mass.gov/depAvater/approval&tt5forms.htm#inspect t5form4.doa O6103 n, System Pumping Record • Page 1 of 1 b v 0 a : m m ►1 W P. Q 0rt a N 3 P. N n w � N . a m a ►u r+• rt cn O O O �• C cn U) aal n m h a0 3 K w a 0 a In Fn rt :3 N rt �C • a rt m �rt n G a a 0 rtrt rt N O H O � • •m �rt a (\� to n 0� n � a o m. %D U) b m i� a m En m a rt m rt z pz m th hi 'c7 0 n 4 (40 tri 9 f F' U1tri H .+ to O •O rt . n tt9i (A F' a r0t :�i�• aIfs,, � 0 m .. ' , t to En fn `ro m � a n mw am �> U! F-+ d N N 0 i N N a � ►0fi 0 En ;, a — - *AQ II /Mv e //o - ///. // /n/✓, /,i/ T. Al A,- -//a. e3 /M✓ Ov'r rv,,vk - //O, G9 /NV /.I (f O -8ov - //0, 37 \ 1A.1V OV7 P 4> -BOY -//o. /% /.vV O 7' - //� • 7 C 3� /•v ✓ BG Al 7z6A& Al - //O . /4 //V✓ eVO TeEML.. - /09.9e, et--/) /NV EMD 7-,e e NL /+/ - /09.94 �� 2 /'v V. ENv TRE'vcs/ - /09.94 e03, �v. JL I AS- BU/C T sue-sv,e"wee D/s/pc s4L sysrEM /�,� / AV / V • 14OV069 OF Zo r .17 wle Pik ift DiPRETE • MARCHIONDA & ASSOCIATES INC. AW ENGINEERING A PLANNING CONSULTANTS 185 New Boston Street R.F.D. #3 Woburn, Massachusetts 01801 Manchester, New Hampshire 03103 (617) 938.1037 (603) 434-8725 Of 4AORT h �h • Town of North Andover HEALTH DEPARTMENT ,SSACHUStt 1EDATE;, )CATION: /O NAME: DNTRACTOR NAME: tpe of Permit or License: (Check box) Animal Body Art Establishment Body Art Practitioner Dumpster Food Service - Type: I Funeral Directors I Massage Establishment ] Massage Practice ] Offal (Septic) Hauler I Recreational Camp 7 Sun tanning 7 Swimming Pool 7 Tobacco Trash/Solid Waste Hauler :3 Well Construction SEPTICS stems: ❑ Septic - Soil Testing ❑ Septic - Design Approval ❑ Septic Disposal Works Construction (DWC) ❑ Septic Disposal Works Installers (DWI) ❑ Title 5 Inspector ATitle 5 Report Ya ❑ Other: (Indicate) S-, - ( t�) .. Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. II� ✓V Commonwealth of Massachusetts Title 5 Official Inspection Form';,, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 951 Forest St Property Address Kevin Sweeney Owner's Name North Andover MA 01845 12/10/2013 City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: JAN IN 14 Warren Pearce Jr. Name of Inspector I HEA1 Pearce Construction Company Name 196 Park St Company Address North Reading MA City/Town State 978-664-5264 S11959 Telephone Number License Number B. Certification 01864 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. 1 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 R Re:::�k Inspector's Signature / -�k — 1 Co - DiD I 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 • 3113 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System - Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 951 Forest St Property Address Kevin Sweeney Owner Owner's Name information is required for North Andover MA 01845 12/10/2013 every page_ Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D t5ins - 3113 A) System Passes: 56/1'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 exMtration 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): 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 951 Forest St Property Address Kevin Sweeney Owner's Name North Andover MA 01845 12/10/2013 City/Town B. Certification (cont.) State Zip Code Date of Inspection ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1- System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 15ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Insp Subsurface Sewage Disposal System Form M 951 Forest St 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 ❑ 211" Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ on 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 '/2 day flow t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System . Page 4 of 17 ection Form - Not for Voluntary Assessments Property Address Kevin Sweeney Owner Owners Name information is required for North Andover MA 01845 12/10/2013 every page. Cityrrown 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 ❑ 211" Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ on 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 '/2 day flow t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System . Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y 951 Forest St Property Address Kevin Sweeney Owner Owner's Name information is required for North Andover MA 01845 12/10/2013 every page. Cityrrown 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. ❑ p Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Pr 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. ❑ 2' 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 5 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 951 Forest St Property Address Kevin Sweeney Owner's Name North Andover MA 01845 12/10/2013 Cityrrown C. Checklist State Zip Code Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ® Were as built plans of the system obtained and examined? (if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? 19 ❑ Were all system components, excluding the SAS, located on site? 59 ❑ 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: 1 ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 t,\_ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 951 Forest St Property Address Kevin Sweeney Owner Owner's Name information is North Andover MA 01845 12/10/2013 required for State Zi Code Date of Inspection every page. City/Town P P D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 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: Gallons per day (gpd) ❑ Yes ® No current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 3113 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 7 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 951 Forest St Property Address Kevin Sweeney Owner Owner's Name information is North Andover MA 01845 12/10/2013 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other (describe below): General Information Pumping Records: Source of information: Pumped 3 years ago by Stewarts Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: gallons ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 951 Forest St Property Address Kevin Sweeney Owner's Name North Andover MA 01845 12/10/2013 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Installed 1984 t; — X�- G Lt A s Bu i Ls 1 Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: 70W- ►'/ • % S�. feet feet Comments (on condition of joints, venting, evidence of leakage, etc.): All OK inside Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal If tank is metal, list age: ❑ fiberglass 12" feet ❑ polyethylene ❑ other (explain) years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'6"x5'8"x5' Deep Sludge depth: 5" t5ins - 3113 Title 5 Official Inspeclion 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 951 Forest St Property Address Kevin Sweeney Owner Owner's Name information is required for North Andover MA 01845 12/10/2013 every page. Cityfrown 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 27 <1" Scum thickness Distance from top of scum to top of outlet tee or baffle 51- Distance "Distance from bottom of scum to bottom of outlet tee or baffle 19" How were dimensions determined? tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees are in place. Liquid level is proper. Tank appears in good shape Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page W of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 951 Forest St Property Address Kevin Sweeney Owner Owner's Name information is required for North Andover MA 01845 12/10/2013 every page. cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass Dimensions: Capacity: Design Flow: Alarm present: Alarm level: Date of last pumping: gallons ❑ polyethylene ❑ other (explain): gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins . 3/13 Title 5 Official Inspection Forth: 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 951 Forest St Property Address Kevin Sweeney Owner's Name North Andover MA 01845 CitylTown State Zip Code D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 12/10/2013 Date of Inspection 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 appears level. Distribution is equal. D -Box is in fair shape Some solids Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins - 3113 Title 6 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspec Subsurface Sewage Disposal System Form - 951 Forest St Property Address Kevin Sweeney Owner Owner's Name information is required for North Andover every page. C4rrown D. System Information (cont.) Type: Elleaching pits ❑ leaching chambers Elleaching galleries ® leaching trenches ❑ leaching fields ❑ overflow cesspool ❑ innovative/altemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No 'av(l,i Ar- Slf)tg QF jkJ0 ';(JA{ I ,/ 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 - 3t13 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 13 of 17 tion Form Not for Voluntary Assessments MA 01845 12/10/2013 State Zip Code Date of Inspection number: number number: �L1 number, length: number, dimensions: number. Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No 'av(l,i Ar- Slf)tg QF jkJ0 ';(JA{ I ,/ 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 - 3t13 Title 5 Official Inspection Forth: 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 951 Forest St Property Address Kevin Sweeney Owner's Name North Andover MA 01845 12/10/2013 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 • 3113 rifle 5 Official inspection Forth: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 951 Forest St Property Address Kevin Sweeney Owner Owner's Name information is required for North Andover MA 01845 12110/2013 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand -sketch in the area below Dg drawing attached separately t5ms • 3113 Title 5 Offiaal Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 Commonwealth of Massachusetts _ Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 951 Forest St Property Address Kevin Sweeney Owner Owner's Name information is required for North Andover MA 01845 12/10/2013 every page. 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: 10 feet feet Please indicate all methods used to determine the high ground water elevation: J4 W ►Z/ 0 Obtained from system design plans on record If checked, date of design plan reviewed: 1984 Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: Checked with local excavators, installers - (attach documentation) Accessed USGS database - explain: You must describe how you established the high ground water elevation: Site slopes down to an elevation well below bottom of system NoLk'b-0-1A 1=i,,cyv#== DG-9tr& PLR �'�wk t t 9th A9 1-2 L:-' CRt'k-T' .�A-Tk.oN ID6L6-b . r , l��y Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3)13 Title 5 Official Inspection Form: Subsurface Sewage Dispose) System - Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 951 Forest St rroperry Aaaress Kevin Sweeney Owner Owner's Name information fn is North Andover required for MA 01845 12/10/2013 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist [N Inspection Summary: A, B, C, D, or E checked j Inspection Summary D (System Failure Criteria Applicable to All Systems) completed System Information — Estimated depth to high groundwater (K Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 17 of 17 /.vv & /40 - ///. // IA/V, /a/ rW A11G - //O. e.3 /N✓ Ovr r*V&- //o. G9 /,VV /a/ d 0-800 - /i0, 37 ivv ovrdoo-B'vr-/io,/P/ (°E/) /A/Y ovr " " - /io , v (02 ) /A/V oU7' /io. y (t 3) /.vV B6 ti 7Z644AI - 110,14 /ivv E,aD 74'EN4.41 - jo9.9L (#/ /NV EA40 TQE a/L %w - aa9.94 (*' 2 ) /'Vv. E'vv 7VE.,v4W - /09.94AC/-✓3� 170 066-/4' �C ©OMA AS- BU/C 7" /V OF Lor .7 fay w DiPRETE • MARCHIONDA & ASSOCIATES INC. ENGINEERING A PLANNING CONSULTANTS 185 New Boston Street R.F.D. #3 Woburn, Massachusetts 01801 Manchester, New Hampshire 03103 (617) 938.1037 (603) 434.8725 -OWN ur hax i l� NUl- v SEP - 7 2005 unik 0�2(o�C�.� JYS'T-sm PUMPINU Poi^,joF ,.c )YS r61►f O%VNER & ADD RZ EP Svsv --`.`r__�` Sl'ST'M C& A9, &&�) DATE OF PVMFiNq uo�OS QUAN71TY P W 144 rUKb UN 9�'RYIC`�: xUV'flNc ursyaR YA GOOD CUNOI rloN K&1VY BAY)"I-88 IN fGQiQ'j'3 L EitiCKF181.. Q K UN 8 A �.' ►, BXCUSIVS SOLIDS FLOODED SOLID CA RRYp YER.. -"fER EXPLAIN y , 4m F`wTt}s,c �l b y vlrlNl' {ll.lNyl�KKU ri 0 M to M C rt o o n v 0 A � 3 o a D o a' � I o JO 2 I � n 7 rr � a 3 vat 3' �C� p u rt � 7 � ) S C 1 'a r O 1 i iA <D i O v 0 r� c 3 c� rt a 0 0 l i 0 M to M Board of Health North An ver Haas. l ' OK C1__.111 M 1 SEPTIC SISTEH INSTAI•I,ATICK CHECK LIST LOT'` 7 ���✓ / CJ AVATI Ob FAIL 7-5.94 1. Distance Tot a. Wetlands b. Drains c.. Well 2. Water Line Location 3. No PPC Pipe �. Septic Tank a. _Tees -_Length k To Clean Out Covers b. Cement Pipe to Tank- On Both Sides of Tank 5. Distribution Box a. Covers k Box - No Cracks b. All Lines Flowing Equal Amounts c. No Back Flow 6. • Leach Field or Trench a. Dimensions b. Stone Depth c: Capped lids d. Clean Double Washed Stone 7. Leach Pits a. Dimensions b. Stone Depth c. Splash Pads d. Tees e. Cer, mt Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. No Garbage Disposal 9. -T nxal Grading Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System c. Location with Regard -to Pere Test d. Elevations e. Water Table 55 7�Z Board of Health Nazti::.ndo�-er,24a.sa APPROM Provided;' '/T/�t r SUBSURFACE DISPOSAL DFMGN CHECK LISP LOT` DISAPPRUM DAT$ Reasons: Title V Reg 2.5 FAIL CE The submitted .plan :gust show as a Mn__? � M: a) the lot to be served-area,ciimenaione lot,abntters b location and log deep observation holes -distance to ties location and results percolation tests -distance to ties d design calculations & calculations shoving required leaching area e) location and dimensions of system -including reserve area S) existing and proposed contours g) location any wet areas thin 100' of sewage disposal system or disclaimer -check wetlands mapping a disposal (h) surface and subsurface drains within 100' of scrag system or disci a__ in -`3r (i) location any drain -age easements Idthin 100' of serge disposal system or disclair-er-P arming: Board files (j) know sources of cater supply within 200' of stege disporal a _ ---- system or disclainer (k) �eation -ef any proposed �-el]_to serelot=100 from leaching fail' (1) location of jater lines on property -101 from lezehing- facii� : --- (m) location of benchmark _ (n)' drive6-4r _= -- _-- (o) garbage -disposals (p) no PVC to be used in construction - tic l i e s anY (q) profile of -system-e1 ecatione of basement, plumb, -P P ., eP distribution box inlets and outlets, distribution field piping and _ ' Other elevations -= (r) maxi :am ground later elevation in area se -►.age disposal sj stem (s) plan must be prepared by a Professional Elgineer-or other professional. _authorized by lax to prepare suet plans Reg 6 - Septic Tanks (a) capacities-i50� of f1o�;, _ter table, tees, depth of tees, access, pumping (b) cleanout � ool (c) 1.0' from cellar k -all or in.ground s - ng P (d) 25+ from subsurface resins 1 Reg 10.2 Reg 10.4 Distribution lyes (a) slope greater than 0.08 b) sum r. �D11R st WELL& PUMP CO. RT. 28 WINDHAM, N.H. 03087 [603] 898-4232 • [617] 887-5888 ELM SQUARE BLDRS TEL. NO. I ELM SO ANDOVER MA 01810 LOT NUMBER OR SAM- F'LE LOCATION: LOT 7 WATER TEST RESULTS 4 AF'R 84 HARDNESS 68.4 (0--_50 REC STANDARD) IRON _ (0—.3 ? REC STANDARD) MANGANESE C) ( i r—, 0)0 REC v F A N D A R D } HYDROGEN SULFIDE 0 (0—.01 REC STANDARD) F'h (ACIDITY) 6.5 (b.5--7.5 REC STANDARD) TURBIDITY G (0-2)C; REC STANDARD) CHLORIDES ^i (0-150 REC STANDARD) CUL I TORN BACTERIA 0 (0 REQUIRED STANDARD) ###Q•iC•#-#•k •� #T i�•I'.•iF?E#3F•t; ##3E #######3c#######3E##•Yr•k•#-1F3Eic •k #i'—•�•#if•#•#• CHARGE I- OR CHEMICAL °.. BACTERIA TEST #* $25.00 ABOVE TESTS MEET REQUIRED STANDARDS AND LASED ON THESE, (MATER IS SAFE FOR HOUSEHOLD USE AND HUMAN CONSUMF'TION. THERE ARE OTI--IER LI -SS COMMON MINERALS WHICH CAN AFFECT QUALITY OF WATER. - Pumps • Submersible • Jet • Centrifugal • Cellar • Sewage Tanks Filters • Softener • Iron • Ch. rcoal ti� .Ual�zer • Cartrid ;e Water Testing Pump Parts Motor Controls Nater Suft; ncr Sal Resin Cleaner Rust & Stain Ramo, Potassium Permanganate Plastic Pipe & Fittir La% n Watering S)'Si�'mS Nater Heaters • Solar • Heat Pump • Electric • Energy Saving -- -Wells • Drilled • Driven • pug • Gravel Chemical Feeders Tank Alarms & Controls Hoist Service Portable Pump Pu' Emergency Service Goulds Aermotor Jacuzzi Red Jacket Fairbanks Morse Wayne Aquatron Well -X -Trot f rj Lot No ?north Andover, :,:ass. Street No -- P1 and a,;ner �IJ) !.. ___ .- T,oc/Subdiv. - -- -- - -- - - - - - - - ,-�- - --- -- -. Tnvestigator - /44 ----- Observer-___- SOIL Pno' ,ILE DATFS_ 2 . F1 ev 3 . k l ev 4. El ev _ — ,. -- - -- - - -- l o -- - — o --- ---- — 1 Ptlots e: --�-- 2 2 _ 2 --- - - 2 -- - - - 3 5' r i-o - 1 o 0 7-1 pit 2 0 _44- �- Drop of 6"-';' 3e l tit, «.. f,r",tk(-;r WELL DATABASE ADDRESS: CI 1 F� h AGE OF WELL: �110A WELL DRILLER: WELL PERMIT 7: ? WELL LOCATION: 7 7 _..WELL PERMIT DATE: DEPTH OWELL: Xv TYPE OF WELL: a.. DRILLED b. DUG C. TJ-NlQi owN TYPE. OF WATER BEARING ROCK: � WATER ANALYSIS DATE_ �' HIGH MANGANESE: Y N� iONTAMINANTS:HIGHIRON: Y O ICIER Y N � r WELL DA'. ADDRESS: l 7 6 AGE OF WELL: WELL DRILLS : WELL PERINfIT r: WELL LOCATI WELL PERMIT DATE: DEPTH 0 TYPE OF WELL: a.. DRILLED b. DUG c. L -+-KNOWN TYPE OF WATER BEARING ROCK: - y WATER ANALYSIS DATE: HIGH MANGANESE: Y N HIGH IRON: Y N OTHER CONTAMINANTS: Y N .::':';'gh•'.;7i'2':���f�t1�G�::!%1 C�`a�tv:�':jt:: �. 1.. 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