HomeMy WebLinkAboutMiscellaneous - 96 SUGARCANE LANE 4/30/2018 (2)l
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;:. STREET: -
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. • �ONSTRUCTIQN�A __RO _... L,- `"'
HAS PLAN REVIEW FEE .BEEN PAID? YES
NO
PLAN APPROVAL: DATE S BY T _
DESIGNER: PLAN DATE;_ e! �
CONDITIONS
WATER SUPPLY: WN WELL
WELL PERMIT
WELL TESTS:
COMMENTS:
DRI LLE R._...—_ -,-_-
CHEMICAL
BACTERI
BACTERIA II
DA1 E AI='PRUVED
Ufa I E (IFT)RUVEU
DA 1P ROVEll__�_.____.__
FORM U APPROVAL: APPROVAL I'D ISSUE" YES NU
DATE ISSUED // BY /J
CONDITIONS:
FINAL APPROVAL:
ALL PERMITS PAID YES NO
WELL CONSTRUCTION APPROVAL YES NO
SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO
OTHER YES NO
ANY VARIANCE NEEDED
FINAL BOARD OF HEALTH APPROVAL:
YES NO
DATE• BY•
Commonwealth of Massachusetts RECEIVED
UqCity/Town ofJUL 2 2 Eo13
System Pumping RecordTOWNForm 4 OF NORTH ANDOVER
11 HEALTH DEPARTMENT
DEP has provided this form for user by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location' eft' Righ o�fron
, Left / Right rear of house, Left / right side of house, Left /
Right side of buil Ing, Left / Righilding, Left / Right rear of building, Under deck
Address
Cityrrown State Zip Code
2. System Owner:
Name
Address (if different from location)
CitylTown State �e
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
3. Type of system: ❑ Cesspool(s) DISeptic Tank
l� v
Gallons
❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes Ld No If yes, was it cleaned? ❑ Yes ❑ No
5. Condeyste LO -AJ I -,)k '� d\,
-Af5�k,�
6. System Pumped By:
Neil Bateson
Name
Bateson Entemrises Inc
Company
7. L here contents were disposed:
///GLLS-P Lowell Waste Water
t5fomt4.doc• 06/03
I
F5821
Vehicle License Number
`-? — C _ 3
Date
System Pumping Record • Page 1 of 1
pf "ORT"
4627
f 9
• Town of North Andover
,�'••,,,,• HEALTH DEPARTMENT
,SSAC MUSf� .,
CHECK #:�-� DATE:
LOCATION:��-�'/
H/O NAME:
NAME:
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) $
❑ Septic Disposal Works Installers (DWI) $
❑ Title,5 Inspector $
M—I 5 Report $
itle �
❑ Other. (Indicate) $
Health Agent Initials;
White - Applicant Yellow —Health Pink - Treasurer
Commonwealth of Massae husdrtts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessm
3 Suaarcane Lane
R15IVDJl�
JAN I 12019
TOWN OF
Property Address I MALTM DEPARTMENT
Kurt Kleinendorft
Owner Owner's Name
information is t
required for North Andover MA 01845 12/11/2009
every page. City/Town State Zip Code Date of Inspection
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
teb
rewn
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:
Neil J. Bateson
Name of Inspector
Bateson Enterprises Inc.
Company Name
111 Argilla Road
Company Address
Andover
City/Town
978-475-4786
Telephone Number
B. Certification
Ma
State
SI15
License Number
01810
Zip Code
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on 9e
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
❑ Need_sf urther Evaluation by the Local Approving Authority
12/11/2009
ln6e6for'sfSignat 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 • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
96 Sugarcane Lane
Property Address
Kurt Kleinendorft
Owner Owner's Name
information is
required for North Andover MA 01845 12/11/2009
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
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins • 09108
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17
Owner
information is
required for
every page.
t5ins • 09/08
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
96 Sugarcane Lane
Property Address
Kurt Kleinendorft
Owner's Name
North Andover MA
City[Town
B. Certification (cont.)
B) System Conditionally Passes (cont.):
01845 12/11/2009
Zip Code Date of Inspection
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if (with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
❑ Y ❑ N ❑ ND (Explain below):
❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if (with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
96 Sugarcane Lane
Property Address
Kurt Kleinendorft
Owner Owner's Name
information is
required for North Andover MA 01845 12/11/2009
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 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 facilityor 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 Y day flow
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17
Commonwealth of Massachusetts
w r Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
96 Sugarcane Lane
Property Address
Kurt Kleinendorft
Owner Owner's Name
quine d fotifor is
eNorth Andover MA 01845 12/11/2009
require
very 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.
El® 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.
El® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
El ® 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.]
i
e
❑ ® The system is a cesspool searing 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 • 09/08
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17
❑ ® The system is a cesspool searing 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 • 09/08
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M0 96 Sugarcane Lane
Property Address
Kurt Kleinendorft
Owner
information is
required for
every page.
Owner's Name
North Andover MA 01845 12/11/2009
Cityfrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
ONEFE
® ❑
® ❑
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): 600
t5ins • 09/08 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
96 Sugarcane Lane
Owner
information is
required for
every page.
Property Address
Kurt Kleinendorft
Owner's Name
North Andover MA 01845 12/11/2009
CitylTown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: .
Does residence have a garbage grinder?
Is laundry on a separate sewage system? [if yes separate inspection required]
Laundry system inspected?
Seasonaluse?
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
❑ Yes
®
No
❑ Yes
❑
No
❑ Yes
®
No
Yes
❑ Yes ® No
Current
Date
❑
Yes
❑
No
❑
Yes
❑
No
❑
Yes
❑
No
t5ins • 09/08 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
96 Sugarcane Lane
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Date
12/11/2009
Date of Inspection
Pumped two years ago owner
1500
gallons
Measured tank
Inspect tank & tees
® Yes ❑ No
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other (describe):
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17
Property Address
Kurt Kleinendorft
Owner
Owner's Name
information is
required for
North Andover MA 01845
every page.
City[Town State Zip Code
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Date
12/11/2009
Date of Inspection
Pumped two years ago owner
1500
gallons
Measured tank
Inspect tank & tees
® Yes ❑ No
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other (describe):
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 96 Sugarcane Lane
Property Address
Kurt Kleinendorft
Owner Owners Name
information is
required for North Andover MA 01845 12/11/2009
every page. Cityrrown State Zip Code Date of Inspection
t5ins - 09/08
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
13 years old, 11/25/1996, as built plan
Were sewage odors detected when arriving at the site?
Building Sewer (locate on site plan)
❑ Yes ® No
Depth below grade: 2
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other (explain):
Distance from private water supply well or suction line:
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
4"PVC to septic tank
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
® concrete ❑ metal
If tank is metal, list age:
❑ fiberglass
1
feet
❑ polyethylene ❑ other (explain)
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate)
Dimensions: 10'x 5'x 4'
Sludge depth:
2"
❑ Yes ❑ No
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
96 Sugarcane Lane
Property Address
Kurt Kleinendorft
Owner
information is
required for
every page.
t5ins • 09/08
Owners Name
North Andover MA 01845 12/11/2009
Citylrown 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
25"
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle
8"
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.):
Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage.
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass
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:
feet
❑ polyethylene ❑ other (explain):
Date
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17
Commonwealth of Massachusetts
M Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
96 Sugarcane Lane
Property Address
Kurt Kleinendorft
Owner Owner's Name
information is
required for North Andover MA 01845 12/11/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
" Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins - 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
96 Sugarcane Lane
Property Address
Kurt Kleinendorft
Owner's Name
North Andover
Cityrrown
D. System Information (cont.)
MA 01845
State Zip Code
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0
12/11/2009
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 level & distribution equal. No evidence of leakage. No evidence of carryover.
Pump Chamber (locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 96 Sugarcane Lane
Owner
information is
required for
every page.
t5ins • 09/08
Property Address
Kurt Kleinendorft
Owner's Name
North Andover MA 01845 12/11/2009
City/Town State Zip Code Date of Inspection
D. System Information (cont.) .
Type:
❑
leaching pits
number:
❑
leaching chambers
number:
❑
leaching galleries
number:
❑
leaching trenches
number, length:
®
leaching fields
number, dimensions: 1field 20' x 56'
❑
overflow cesspool
number:
❑
innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil ok. Vegetation ok. No sign of ponding to surface.
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
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17
Owner
information is
required for
every page.
t5ins • 09/08
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
96 Sugarcane Lane
Property Address
Kurt Kleinendorft
Owner's Name
North Andover MA 01845 12/11/2009
Citylrown 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.):
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 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
96 Sugarcane Lane
Property Address
Kurt Kleinendorft
Owners Name
North Andover
Citylrown
-MA 01845 12/11/2009
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
0
_ 14S
t5ins • 09/08 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 15 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
96 Sugarcane Lane
Property Address
Kurt Kleinendorft
Owner's Name
North Andover
RAA
Cityrrown State
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
01845
Zip Code
12/11/2009
Date of Inspection
Estimated depth to high ground water: '4
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: 5/2/1995
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:
As per test pit data on design plan.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins • 09/08
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17
Commonwealth of Massachusetts
_
ro Title 5 Official Inspection Form
o
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M ' 96 Sugarcane Lane
Property Address
Kurt Kleinendorft
Owner
information is
required for
every page.
Owner's Name
North Andover
Cityrrown
MA 01845
State Zip Code
12/11/2009
Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information — Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins - 09/08
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17
Summary Record Card generated on 12/11/20091:29:05 PM by Lisa Evans
Town of North Andover
Tax Map # 210-106.A-0265-0000.0
Page 1
Parcel Id 17410
96 SUGARCANE LANE
KURT KLEINENDORFT
96 SUGARCANE LANE
NORTH ANDOVER, MA 01845
Class 101 Single Family Property Type 1 Residential
Size Total 1.13 Acres
FY 2010
UB Mailina Index
Name/Address
KURT KLEINENDORFT
96 SUGARCANE LANE
NORTH ANDOVER, MA 01845
CLARK, TODD & KAREN
96 SUGARCANE LANE
NORTH ANDOVER, MA
01845
UB Account Maint,
Account No Cycle
Bldg Id. 17671.0 - 96 SUGARCANE LANE
3170341 03 Cycle 03
UB Services Maint.
Account No. 3170341
Service Code
MISCFEE ADMIN FEE
WTR WATER
UB Meter Maintenance
Account No. 3170341
Type Loan Number
Owner
Previous Customer
Active/Inact. From
Inactive 12/1/2006
Occupant Name Active/Inactive
Last Billing Date 10/7/2009
Active
Rate Charge Multiplier/Users
0.635/8 7.82 1/
01 ALL METER SIZE 241.73 /1
Serial No Status
Location
Brand
Type
33605681 a Active
ERT HH
b Badger
w Water
Date
Reading
Code
Consumption
Posted Date
9/9/2009
519
a Actual
50
10/15/2009
6/8/2009
469
a Actual
64
7/20/2009
3/13/2009
405
a Actual
28
4/29/2009
12/9/2008
377
a Actual
34
1/20/2009
9/8/2008
343
a Actual
100
10/10/2008
6/6/2008
243
a Actual
49
7/16/2008
3/7/2008
194
a Actual
21
4/11/2008
12/11/2007
173
a Actual
40
1/22/2008
9/5/2007
133
a Actual
62
10/12/2007
6/18/2007
71
a Actual
41
7/20/2007
3/14/2007
30
a Actual
30
4/16/2007
11/30/2006
0
n New Meter
0
1/19/2007
11/30/2006
1890
r Replacement
0
1/19/2007
11/30/2006
1890
f Final Bill
1
11/30/2006
9/12/2006
1889
a Actual
55
10/20/2006
Trouble Code:03
6/14/2006
1834
a Actual
33
7/10/2006
3/8/2006
1801
a Actual
19
4/17/2006
Trouble Code:03
12/21/2005
1782
a Actual
34
1/17/2006
9/20/2005
1748
a Actual
82
10/14/2005
Trouble Code:03
6/27/2005
1666
a Actual
26
7/15/2005
3/30/2005
1640
a Actual
25
4/5/2005
Size
0.63 0.63
Until
YTD Cons
325
Variance
-27%
147%
-19%
-65%
98%
123%
-41%
-47%
84%
48%
-100%
-100%
-100%
-98%
81%
36%
-33%
-62%
230%
24%
-17%
r
4
Commonwealth of Massachusetts
= City/Town of
a W° System Pumping Record
w Form 4
M
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left side of house, Right side of house, eft front of house, fight front of house,
Left rear of house, Right rear of house. Left rear of building. Right rear "building.
Address
Cityrrowh State
2. System Owner:
Name
Address (if different 1
City/Town
B. Pumping R
1. Date of Pumping
3. Type of system:
❑ Other (desch
4. Effluent Tee Filte
5. Condition of.Syst
Y) CK- &A.
location)
rd
tia-\ 1-cx�
Date
❑ Cesspool(s)
e):
present? ❑ Yes No
6. System Pumped By:
Neil Bateson
`e,v-o-� � v,
Name
Bateson Enterprises Inc
Company
7. Locatio here contents were disposed:
�.L D n /-\ Lowell Waste Water
of
State
A-) ql�-4A& 4
Zip Code
Telephone Number
— 2. Quantity Pumped
Septic Tank
Zip Code
c.s2-�
Gallons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
c CA -
F5821
Vehicle License Number
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
Town of North Andover
Health Department Date:
Location:
(Indicate Address, if Residential, or Name of B-usmeAL
Check #• �� /
Type of Permit or License: (Circle)
➢ Animal $
➢
Dumpster
$
➢
Food Service - Type:
$
➢
Funeral Directors
$
➢
Massage Establishment
$
➢
Massage Practice
$
➢
Offal (Septic) Hauler
$
➢
Recreational Camp
$
➢
SEPTIC PERMITS:
'= ❑
Septic - Soil Testing
$
❑
Septic - Design Approval
$
❑
Septic Disposal Works Construction (DWC) $
❑
Septic Disposal Works Installers (DWI)
$
`' ➢
Sun tanning
$
➢
Swimming Pool
$
➢
Tobacco
$
➢
TrashlSolid Waste Hauler
$
➢
Well Construction
$
OTHER (Indicate)
Health Agent Initials
�6 7
White - Applicant Yellow - Health Pink - Treasurer
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated
611512000. Inspection forms may not be altered in any way.
A. Certification
Important:
When filling out
1. Property Information:
forms on the
computer, use
96 Sugarcane Lane
only the tab key
Property Address
to moveLy-
amen CIa,-R —
cursor - ao not
use the return
—
Owner's Name
key.
96 Sugarcane Lane
Owner's Address
N. Andover
City/Town
Date of Inspection:
2. Inspector.
Robert Kimball
Name of Inspector
R. Kimball Excavation LLC
21 Clifton Ave
Company Address
Ma
State
07-15-06
Date
Salem NH
City/ Town state
978-375-1011
Telephone Number
01845
Zip Code
03079
Zip Code
Certification Statement:
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs urt�Evalua y he I oving Authority
Inspedo s Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
Title 5 Inspection Forms Warren N. Andover.doc - 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System -
Page 1 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
96 Sugarcane Lane
Property Address
N. Andover MA 01845
City/Town
Todd and Karren Clark
Owner's Name
State
07-15-06
Date of Inspection
Inspection urrtmary: ec or E 7 a ays comp e e all of Section D
A) System Passes:
Zip Code
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If "not
determined," please explain.
❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
Title 5 Inspection Forms Warren N. Andover.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 2 of 16
Commonwealth of Massachusetts
Elmo pq ti
Title 5 Official Inspection Form
kvNot for Voluntary Assessments
- Subsurface Sewage Disposal System Form
A. Certification (cont.)
96 Sugarcane Lane
Property Address
N. Andover MA 01845
Citylrown State Zip Code
Todd and Karren Clark
Owner's Name
n ona y POOR con
07-15-06
Date of Inspection
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if (with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if (with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
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
Title 5 Inspection Forms Warren N. Andover.doc - 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 3 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
96 Sugarcane Lane
Property Address
N. Andover MA 01845
Citylrown State Zip Code
Todd and Karren Clark
Owner's Name
07-15-06
Date of Inspection
C) Further Evaluation is Required by the Board of Health (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
coliform bacteria and volatile organic compounds indicates that the well is free from pollution from
that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached
to this form.
3. Other:
Title 5 Inspection Forms Warren N. Andover.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 4 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
96 Sugarcane Lane
Property Address
N. Andover MA 01845
City/Town State Zipcode
Todd and Karren Clark 07-15-06
Owner's Name Date of Inspection
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes No
❑ ®
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ®
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
®
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ®
Liquid depth in cesspool is less than 6" below invert or available volume is less
than % day flow
❑ ®
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 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 6 ppm, provided that no other failure criteria are triggered. A copy of
the analysis must be attached to this form.]
Yes No
❑ ® The system falls. 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.
Title 5 Inspection Forms Warren N. Andover.doc • 11/2104 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 5 of 16
Commonwealth of Massachusetts
Title.5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
96 Sugarcane Lane
Property Address
N. Andover MA 01845
Cityrrown State Zip Code
Todd and Karren Clark
Owner's Name
07-15-06
Date of Inspection
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," y
ither"yor "no" to each of the following, in addition to the
questions in Section D.
YES NO
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area — IWPA) or a mapped Zone 11 of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
Title 5 Inspection Forms Warren N. Andover.doc - 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 6 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
UIVNot for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Checklist
96 Sugarcane Lane
Property Address
N. Andover MA 01845
Cityrrown State Zip Code
Todd and Karren Clark
Owner's Name
YES NO
07-15-06
Date of Inspection
® ❑ 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(3)(b)]
Title 5 Inspection Forms Warren N. Andover.doc - 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System -
Page 7 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information
96 Sugarcane Lane
Property Address
N. Andover MA 01845
Cityrrown State Zip Code
Todd and Karren Clark 07-15-06
Owner's Name Date of Inspection
Number of bedrooms (design): 4 Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):
Number of current residents:
Does residence have a garbage grinder?
Is laundry on a separate sewage system? [if yes separate inspection required]
Laundry system inspected?
Seasonal use?
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump?
Last date of occupancy:
Commercial/Industrial Flow Conditions: 1
r
Type of Establishment: �)
/ v
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:
Last date of occupancy/use:
Other (describe):
A
AAA
5
❑
Yes
®
No
❑
Yes
®
No
®
Yes
❑
No
®
Yes
❑
No
❑ Yes ® No
ocupied
Date
Gallons per day (gpd)
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
Date
Title 5 Inspection Forms Warren N. Andover.doc • 1112004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System -
Page 8 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
96 Sugarcane Lane
Property Address
N. Andover MA 01845
City/Town State Zip Code
Todd and Karren Clark 07-15-06
Owner's Name Date of Inspection
Pumping Records:
Source of information:
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Type of System:
owner/Stewarts
gallons
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Yes ® No
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other (describe):
Approximate age of all components, date installed (if known) and source of information:
10+/ -
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Title 5 Inspection Forms Warren N. Andover.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 9 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
96 Sugarcane Lane
Property Address
N. Andover MA 01845
Cityrrown state zip code
Todd and Karren Clark 07-15-06
Owner's Name Date of Inspection
Building=Sewer�loC--�t�cu�citua-�)� -----
2'
Depth below grade:
Material of construction:
❑ cast iron ® 40 PVC ❑ other (explain):
Distance from private water supply well or suction line:
feet
city
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
❑ fiberglass
1'6"
feet
❑ polyethylene ❑ other (explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ❑ No
certificate)
Dimensions: 1500 gal
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
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
N
48"
211
1"
18"
field observation
Title 5 Inspection Forms Warren N. Andover.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 10 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
96 Sugarcane Lane
Property Address
N. Andover MA 01845
City/Town State Zip Code
Todd and Karren
Owner's Name
07-15-06
Date of Inspection
--- __ ��r1arL'1P�itS._LAt1-nl�m[�i[fc.LfAtY�mmanda�inne__inloi-�cui-n.11ct_fcn s' �-
-
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grease Trap (locate on site plan):
Depth below grade: n % feet
Material of construction: I `�
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene
❑other (explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
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: A
Material of construction. fil
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain):
Title 5 Inspection Forms Warren N. Andover.doc - 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 11 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
96 Suqarcane Lane
Property Address
N. Andover MA 01845
City/Town State Zip Code
Todd and Karren Clark 07-15-06
Owner's Name Date of Inspection
Dimensions:
Capacity:
Design Flow.
Alarm present:
Alarm level:
Date of last pumping:
gallons
gallons per day
❑ Yes ❑ No
Alarm in working order:
Date
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
N
❑ Yes ❑ No
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.):
'
Pump Chamber (locate on site plan): r� fl J 11
Pumps in working order.
Alarms in working order:
❑ Yes ❑ No
❑ Yes ❑ No
Title 5 Inspection Forms Warren N. Andover.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System -
Page 12 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
96 Sugarcane Lane
Property Address
N. Andover MA 01845
Cityrrown
Todd and Karren
Owner's Name
State
07-15-06
Date of Inspection
Zip Code
p chamber, condition OT pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑
leaching pits
❑
leaching chambers
❑
leaching galleries
❑
leaching trenches
®
leaching fields
❑
overflow cesspool
❑
innovative/alternative system
Type/name of technology:
number:
number:
number:
number, length:
number, dimensions:
number:
4/20'x56'
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Title 5 Inspection Forms Warren N. Andover.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 13 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Or
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
C. System Information (cont.)
96 Suqarcane Lane
Property Address -
N. Andover MA 01845
City/Town State Zip Code
Todd and Karren Clark 07-15-06
Owner's Name Date of Inspection
R-3= =iP 0i018 VMS93:00IIIr�yDIapIt1111p: NF1; panto1inspection) i1C7 re 6T1site i7FTti - -- -- --
Number and configuration
Depth — top of liquid to inlet invert
Depth of solids layer j'� j j
Depth of scum layer I
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow
❑ Yes ❑ 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
V
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Title 5 Inspection Forms Warren N. Andover.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 14 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
96 Sugarcane Lane
Property Address
N. Andover MA 01845
City/Town State Zip Code
Todd and Karren Clark
Owner's Name
07-15-06
Date of Inspection
bKetch Ut 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.
Title 5 Inspection Forms Warren N. Andover.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System -
Page 15 of 16
,pe
N
ti
C14 fib
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
WHOM
Not for Voluntary Assessments
�Subsurface Sewage Disposal System Form
C. System Information (cont.)
96 Sugarcane Lane
Property Address
N. Andover MA 01845
City/Town State Zip Code
Todd and Karren Clark 07-15-06
Owner's Name Date of Inspection
Slope �-a. V
Surface water tJ Q vim_
Check cellar ,
Shallow wells e_
Estimated depth to ground water. ti.k� CL 6k� -e, \ 3 (o . O q
Please indicate all methods used to determine the high ground water elevation:
►�4
101
Obtained from system design plans on record
If checked, date of design plan reviewed:
5-02-95
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:
on record
Title 5 Inspection Forms Warren N. Andover.doc - 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 16 of 16
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
renin
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The
be submitted to the local Board of Health or other approving autho
A. Facility Information
1. System Location:
Address
City/Town
2. System Owner:
Name
4 '
Address (if different from location)
City/Town
U.'rumping Record `
1. Date of Pumping v
Date
3. Type of system: ❑ Cesspool(s)
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No
Q
Condition of System:
System Pumped By:
/3W
State
RECEIVED
Pumping Record m
July - 5 2006
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Zip Code
State���_ Zip Code
Telephone Number
2. Quantity Pumped:
Mc)
Gallons .
Septic Tank ❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
Name Vehicle License Number
Company
7. Location where contents were disposed:
OL
6ure,
S gf H Date
hftp://www.mass.gov/dep/water/approvaIs/t5forms.htm#inspect
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
CERTIFIED PLOT PLAN
LOCATED IN NORTH ANDOVER, MA.
SCALE:1 "= 40' DATE: 10/25/96
Scott L- Giles R.P.L.S.
Frank S.Giles oo'
50 Deer Meadow Road HA2
North Andover, Mass.
LOT 8
V1
LOT 7 N
49,112 S.F. •
PA
SUGARCANE LANE
(CUL-DE-SAC)
R=25'
L=36.99'
L-67.13 R 50?
I CERTIFY THAT OFFSETS SHOWN AIRE FOR THE USE:
THE OFFSETS OF THE BUILDING INSPECTOR ONLY
SHOWN COMPLY AND SUCH USE IS FOR THE
WITH THE ZONINO DETERMINATION OF ZONING
BY LAWS OF CONFORMITY OR NON -CONFORMITY
NORTH ANDOVER WHEN CONSTRUCTED.
WHEN BUILT
10/25/96
SIE I
Form No. 4
Town of North Andover, Massachusetts
BOARD OF HEALTH
Feb. 10 19 97
CERTIFICATE OF COMPLIANCE
This is to certify that
the Individual Soil Absorption Sewage Disposal System constructed ( X) or repaired ( )
b Bill Sawyer
y INSTALLER
at 96 Sugarcane Lane
SITE LOCATION
has been installed in accordance with Board of Health Regulations as described in the Design
Approval Site System Permit No. 743 dated August 8 19 95
The issuance of this certificate shall not be construed as a guarantee that the system will
function satisfactorily.
BOARD OF HEALTH
., FORM - U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all -necessary approval/ permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve the
applicant and or landowner from compliance with any applicable requirements.
..............%.'.......1.1....................................................
APPLICANT �r� int f--)— -sn so n PHONE 7g 7S oc)9 l
ASSESSORS MAP NUMBER d LOT NUMBER c57 6
SUBDIVISION LOT NUMBER
STREET S U g A Q()A_A - STREET NUMBER
OFFICIAL USE ONLY
RECOMMENDATIONS OF TOWN AGENTS
... ■....,....■ ■ .............■■.....................s......■ . ■.�........■
LF-- 2 DATE APPROVED
C6kSERVAT1ON ADMINISTRATOR
DATE REJECTED
COMMENTS
DATE APPROVED
TOWN PLANNER
DATE REJECTED
coMl�-NTs
FOOD INSPECTOR -HEALTH
J SEPTIC S OR -HEALTH
CONMIENTS
PUBLIC WORKS -. SEWER / WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
COMMENTS
RECEIVED BY BUILDING INSPECTOR
DATE APPROVED
DATE REJECTED
DATE APPROVED /
DATE REJECTED
DATE APPROVED
DATE REJECTED
i
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BRADFORD ENGINEERING COMPANY, 3 WASHINGTON SQUARE, P.O. BOX 1244. HAVERHILL. MASSACHUSETTS 01831. TEL. (508) 373-2396
FAX: (508) 373-8021
REGISTERED CIVIL ENGINEERS AND LAND SURVEYORS
November 21, 1996
Colonial Development Real Estate
1049 Turnpike Street
North Andover, MA
Att: Mr. William Barrett
Re: Retaining Wall
Lot 7 - Sugarcane Lane
North Andover, MA
Mr. Barrett:
As requested by you, Peter D. Mauritz, a structural engineer with Bradford Engineering
Company has inspected the above referenced cast in place concrete retaining wall for the purpose
of verifying its structural integrity.
The attached calculations verify the section has adequate factors of safety for sliding and
overturning and that the calculated bearing pressure about the toe of the footing is just over one
ton per square foot. The section is also considered to be adequately reinforced.
I have attached an as built drawing detailing the conditions of the `*.rall as I understand them..
I hope the above information adequately addresses your concerns. Should you have any
questions or require any additional information please do not hesitate to call.
Very truly yours,
"'
Peter D. Mauritz P.E.
Structural Engineer
Bradford Engineering Company
Attachments
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Town of North Andover, Massachusetts Form No. 1
NORTHA BOARD OF HEALTH
Q SSS `Ep 16 �•1,/
y. OL —19 5
a
APPLICATION FOR SITE TESTING/INSPECTION
Applican
Site Location i,IJT �..�
Engineer NAME ADDRESS TELEPHONE
Test/Inspection Date and Time
CHAIRMAN, BOARD OF HEALTH
Fee Test No.
S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No.
Town of North Andover, Massachusetts Form No. I
NORTH BOARD OF HEALTH
ED 6 0 19
* f
��pAOA° Ew:PP .5 APPLICATION FOR SITE TESTING/INSPECTION
Applicant—AA'-A'-t'�— �Lk"X
NAME ADDRESS (`1 TELEPHONE
Site Location_ 1_!.)T
Engineer
l �/V\..���Q-�'� Q `t X� rte_
NAME ADDRESS • TELEPHONE
Test/Inspection Date and Time
"'f --S A CHAIRMAN, BOARD OF HEALTH
Fee ID, Test No. 6 Cp
S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No.
Town of North Andover, Massachusetts Fcr'n No, 3
ot*Hoarh �ti BOARD OF HEALTH
0
��Ss�cHusw'� DISPOSAL WORKS CONSTRUCTION PERMIT
Applicant
NAME ADDRESS TELEPHONE
Site Location � �. LtA-J...{,M
Permission is hereby granted to Construct ktl-- or Repair ( ) an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No. 3
CHAIRMAN, BOARD OF HEALTH
Fee �t) D.W.C. No.� ��__
FORK U - LOT RELEASE FORK
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: Co rotiy�/�s�5 �lcdL . l o �[� Phone _ c/,
LOCATION: Assessor's Map Number 0 6 Parcel %y
Subdivision % 09 -'es Lots) %
Street S'�sAa c-AryLL 9wt St. Number
************************Official Use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
Conservation Administrator
Comments
Town Planner
Comments
Food Inspector -Health
Septic Inspector -Health
Comments
Public Works - sewer/water connections
- driveway permit
Fire Department
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved �l
Date Rejected
Received by Building Inspector Date
DATE A06 - Sheet of
BOARD OF HEALTH
TOWN OF NORTH ANDOVER
SUBSURFACE DISPOSAL DESIGN REVIEW
FEES PERMIT # 3 DATE Z
�� RECEIVED_
APPLI CANT<�Ue 51' /7`/L' /r
ASSESSOR'S MAP
ADDRESS
ENGINEER C /-S
PARCEL #
LOT # 7 8,:5V&)L)
STREET . ScJGAP-C,4AJ6-
ADDRESS
PLAN DATE REVISION DATE
CONDITIONS OF APPROVAL: �f3�iUG/�/YJ/�i�/G v)//,y %d /
APPROVED
DISAPPROVED
PLAN REVIEW CHECKLIST
ADDRESS 47 7 5,�-_V&V ENGINEER
GENERAL /
3 COPIES v STAMP LOCUS NORTH ARROW 1�� SCALE
CONTOURS C/ PROFILE L✓ SECTION L BENCHMARKz SOIL &
PERCS ELEVATIONS WETS. DISCLAIMER f WELLS & WETS
WATERSHED? / /O DRIVEWAY ✓Elev) WATER LINE L-*�_ FDN DRAIN c__�
SCH40 L, --TESTS CURRENT? 50M& SOIL EVAL �, 0 'Copjy,7GG/S •:S7'1"
SEPTIC TANK
MIN 1500G(/ .17 INVERT DROP GARB. GRINDER (+200% EDF)
25' TO CELLAR C/ MANHOLE ELEV GW /# COMPS.
D -BOX
SIZE # LINES FIRST 2' LEVEL STATEMENT
INLET - OUTLET .17 ( 2" OR .17 FT) TEE REQ' D?AAa
LEACHING
MIN 660 GPD? V RESERVE AREA L,`�4' FROM PRIMARY? &- 2% SLOPE
100' TO WETLANDS `'� 100' TO WELLS L---'-41 TO S.H.GW L--' (5'>2M/IN)
35' TO FND & INTRCPTR DRAINS(- 325' TO SURFACE H2O SUPP c/
4' PERM. SOIL BELOW FACILITY Q,-' MIN 12" COVER FILL?// (we
if above natural elev; 4-8-' if below) BREAKOUT MET?L� 05 61
TRENCHES
MIN 660 gpd SLOPE (min .005 or 6"/1001) SIDEWALL DIST. 3X EFF.
W OR D (MIN 6') RESERVE BETWEEN TRENCHES? IN FILL? MUST
BE 10' MIN. 4" PEA STONE? VENT? (>3' COVER; LINES >501)
BOT + SIDE X LDNG = TOT
(L x W x #) (DxLx2x#) (G/ft2)
Copyright 0 1995 by S.L. Swrr
PITS
MIN 660 LEACHING MIN 1 (131x16') PIT MANHOLE/PIT
GW MIN 4' BELOW BOTTOM EXC 2x EFF W OR D 12"-48" STONE
BOT + SIDE x LOAD = TOTAL
(L x W x #) (2x(L+W)xD x #) (G/ft2)
CHAMBERS
MIN 660 LEACHING GW MIN 4" BELOW COVER >3 FT - VENT
MANHOLES 12"-48" STONE SPLASH PADS SLOPE .005
BED/TRENCH (Bed max. 60' X 601) MIN 13' X 16' PIT
BOT + SIDE X LOAD = TOTAL
(L x W x #) (2 x (L+W)xD x #) (G/ft2)
4114A I R
MIN 660 GPD v 900 ft2 BED " GW MIN 4' BELOW BOTTOM OF FIELD
PIPE ENDS JOINED? C,-' 4" PEA STONE? 1/ DIST LINE SLOPE .005?<<-�
>31COVER-VENT SCH 40 (j MIN 12" COVER L-1-1,
RATE 0 A) LDG (p X 660 qt4) Od X ��ji(�= TOTAL
G/ft2 REQ'D (ft2) LXW
DOSING TANKS AND PUMPS
DIMENSIONS X X = PUMP CAPACITY gpm
L W D Vol.
DISCHARGE SIZE
MANHOLES TO GRADE
inlet) HWL LWL
OP. SWITCH
Copyright C 1995 by S.L. Staff
DISCHARGE RATE DISCHARGE TIME
gpm
ALARM SEP. CIRC. GW (Min. 1' below
CHECK VALVE BLEEDER HOLE MANUAL
No....
THE COMMONWEALTH OF MASSACHUSETTS TpW6OAFlDOF
BOARD OF HEALTi--i
Q �U................. OF .... ttJo.. �1.-._ ��.V -FIZ- ---.._....... ........ _ ,0 2 2
Apphration for lliopooal Workii Tonotrurti . n
Application is hereby made for a Permit to Construct ( )O or Repair ( ) an l' '5Zwage Disposal
System at:
........................................................... ...••---...•-•----•---•••--•-..__...........----._._......._..............................-•--
CI Location - Address o t No.
Owner Address
Installer Address
Type of Building Size Lot ......
il9.e_____ai...... Sq. feet
U Dwelling —No. of Bedrooms -_-____.._ y _______________ _ _ _Expansion Attic ( ) Garbage Grinder ( )
I~ _______________ No. of ersons_____________________-______ Showers —'Cafeteria
�aOther—Type of Building _____________ p ( ) ( )
PIOther fixtures ------------------------------------------------- da ------------•--------•-------------•-------•---•-- •----•------•---•------••----•---••----•--•-
W Design Flow ____________________________________________gallons per person 'per' day. Total daily flow ......... _.__-� 0.__________________.gallons.
WSeptic Ta� iquid capacity 1590 's Length& �6 `.__._ Width.�_�._`f ��__._ Diameter________________ Depth___s
x Disposal i — No_ ____________________ Width___ s_, ...... Total Length ---- a�........ Total leaching area ..... Zl�... sq. ft.
Seepage Pit No --------------------- Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box ( Dosing to k ( ) j /'s7/ CIA115Fj
Percolation Test Results Performed by ------ .I.S�7�fll7t..�__S'�!�i4 .i2�__. Date ....... ._ -J'.._.______-.
,a� Test Pit No. i___ ______minutesperinch Depth of Test Pit#7..... l?____. Depth to ground wa erG_l_1'�Q1Z_--_.
Li, Test Pit No. 2 ..... ?........ minutes per inch Depth of Test Pie_%_____% Depth to ground water .......
................. -- -.................................r•-----•----•-•••...._._..---•-•••--•••• - -••................
.-------------------
•--•-•••-•...--
D Description of Soil-------`� Gff - =` = --•---.r _ - -ta-n -- �-�'�?
// �
t,----
-W ------•--- --------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------
VNature of Repairs or Alterations — Answer when applicable ...............................................................................................
-•----•----•---------------------------------------------------------------------------•---•---••--• -•-••---•---------------------------------------------•----....---•-----•---•--•----_-•••-•••-_--•--
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed....................................................................................... ................................
Date
ApplicationApproved By ................. ----------------------------------------•-----------------------.._...•----
Date
Application Disapproved for the following reasons- ---------------••-- ------------- ...........................
........................... ----•---••-••--------------------------••---------••---•----•----•---------------•-------------••-•• -----------•---------------------•-----••-----------•--•---------------
Date
PermitNo ......................................................... Issued ------------------ .....................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF– ..................... __ .........................................................
Tatifiratr of Tomplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System Constructed ( ) or Repaired ( )
by-------------------------------------------------------------------------------------------- InstaIlle -----• r ---------------------------------------------------•--•----------••-----••-••-•------
e
at-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ----------------------------------------- dated ---- ...................... •.....................
THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...............••---------------•--.._...---•----------------------._....__.._._ Inspector ....................................................................................
THE COM.MONVy,EALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF ...................... ................ ..............................................
No......................... FEE ........................
Diopoiial Worlo Tono#rnrtionanti
Permissionis hereby granted ......... -•-----••----••----•--•---------••• -----------•-------•---------•----••-•--•--•••--...__...--•---•-•••--•-•----•--..._...••-_-----
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
,.
Street
as shown on the application for Disposal Works Construction Permit No ----------------_--- Dated ...........................................
Board of Health
DATE--------------------------------------------------------------------------------
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
SUBSURFACE SEWAGE DISPOSAL SY611M WSPEC ioN F6iikll
PART A
CERTIFICATtON leorOwad)
N 3
Property Address:
Owner: <
Date of I ispeetian: ` C-
D. SYSTEM FAILS:
You must Indicate either "Yes" or "No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
s-
determination is identified below: The Board of Health should be contacted to deterin(ne what .will be necessary to correct the failure:
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged. SAS. orcesspool
Discharge or poriding of effluent to the surface of the ground of surface waters dues town ovetioadod or Wagged SAS or •
cesspool. N i°
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 1/2 day flow
— Required pumpinn rwartr then 4 111M ie in the loot Veer Oz due to elogfr d tip obothloted 01150411i
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation
Any portion of a cesspool or privy is within 100 feet of a surface water supply of tributary to a surface water supply
r
Any portion of a cesspool or privy Is within a Zone I ofe 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 les*Ahan 100 feet but greater than 56 feet from s private Yvater 6,00Y 4,611 with no
— a cceptable-watdi quality analysis: If the well has been analyied to 6e acceptable; attach t opy of w0 water 4nai,Vs6 for
coliform bacteria, volatile organic compounds, ammohis nitrogen and nhrate nitrogen.
E. LARGE SYSTEM FAILS:: c
You must indicate either "Yes" or "No" to each of the following: a 1 • "
The following criteria apply to large systems in addition to the criteria above z
The system serves a facility with in design flow of 10,000 god or greater (Large System) and the •system is aaignificant threafYto public
health and safety and the environment because one or more of the.followiing conditions ezisti
Yes No s
the system is within 460 feet of a surface drinking water supply
tributary t
the system is within 200 feet of a h
— y y o a surface drinking water supply.
r
the system is located in a nitrogen sansitive area (Interirh Wellhead Protection Area IWPA) ora (napped Zona ii of a public
water supply well) : t
S,
kr
The owner or operator of any such system shall upgrade the "system :in accordance with 310 'MR 15 304(21, 'Please consult the loctii tagiona)
office of the Department for further (nforjnation.
t �
r'
r e
d 4��fi yy.
revised 9!2/98 Nge4oftl:" �.
t =�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEmoti FORM
PART C
SYSTEM INFORMATION
u � i
Property Address:6
Owner:
Date of Inspection:` -- �-
r-3-ate
ijo vtii. /U-r4o,z;�4--
FLOW CONDITIONS
RESIDENTIAL:
Design flow:&I:) .g.p-d./bedroom.
_1
Number of bedrooms design): Number of bedrooms (actual):
Total DESIGN flow
Number of current residents:-
Garbage grinder (yes or no): NV
Laundry (separate system) (yes or no): �k}; If yes, separate inspection re fired
Laundry system inspectedyes or no) �(� `
Seasonal use (yes or no) - -Md f
Water readings, if available (last two year's usage (gpd):��
{ 3 f
AZ
' ` '1 r
��� / 4
meter
Sump Pump (yes or no): (V C� 1
Last date of occupancy:a,- P tin.
COMMERCIAL/INDUSTRIAL:Q
Type of establishment:
`e« '.t
S ��.\v\ t'c t - �,r�`.
v v
Design flow: apd 1 Based on 15.203)
Basis of design flow
Grease trap present: lyes 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:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of Information:
System pumped as part of inspection: (yes or no) VQ`
If yes, volume pumped: : rS-M fall ns
Reason for pumping: kYY\:-iDO-
TYPE Of WSTEM
Septic tank/distribution box/soil absorption system
Single cesspool ¢
Overflow. cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
U
GR S TRAP:Q..
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal r Fiberglass _Polyethylene other(explain)
Dimensions -
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
{
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles; depth of liquid level in relation #o outlet invert structural itttegtritti F;
evidence of leakage, etc:)
k
revised 9%x2/98 Pageyofu
i� 7 �
i
t
SUBSURFACE SEWAGE DISPOSAL SY&THN INSPECTION FORM �
PART C
SYSTEM INFORMATION (continued)
Property Address: 9 _'Skj GLCc . L-A • P rl'
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:_
Material of construction: _ concrete _metal _Fiberglass _Polyethylene other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present.
Alarm level: Alarm in working order: Yes No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: v
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and edistribufion is,equal,jevidence of solids carer; Zvi fence of leakage into or out of b ev.1
SUBSURFACE SEWA0E DISPOSAL SYSYISIII MPECYION F011M
PARR d
SYSTM WMMA13ON iemaxied)
CESSPOOLS: YY(?
(locate on site pian)
t
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 (cesspool must be pumped as part of inspection)
Comments:
a 4"
(note condition of soil, signs of hydraulic failure, level of ponding; condition of vegetation;. etc.) ,
PRIVY:
(locate on site plan)
Materials of construction: Dimensions.
F
Depth of solids:
Comments: 4
(note condition of soil, signs of hydraulic failure, level of ponding; condition of 'vegetation, etc.)-'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
�'yy SYSTEM INFORMATION
Property Address: ` I �� �C71 C-���tL-P._ L -V\, �. OA- (",- �
Owner:
Date of Inspection: LQ
-3-��
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
.1-6use
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (cawed)
J
Commonwealth of Massachusetts
P, ' "012.(� Massachusetts
stem Purnping Record
System Owner
Date of Pumping: _ 7
Cesspool: No Yes U
System Location
Quantity Pumped: gallons
Septic Tank: No U Yes �1
System Pumped by: Fctr'`ed4rt 5rl& AWded License #
Contents transferrred to : Greater Lawrence Sanitary District
.Date: _ Inspector:
DATE 7 : 6- e4l
tj
SYSTEM
�6
Vol
SYSTEM LOCATION
DATE OF PUMPING !Z--,-3a::-�.QUANTITY PUMPEDWe
CESSPOOL NO�yEs SEPTIC TANK NO YES --4"-1
NATURE OF SERVICE: RdUT�; 4�MERGENCY I I
OBSERVATIONS;
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN LACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLED CARRYOVER OTHER EXPLAIN
SYSTEM PUMPED By
COMMENTS:
CONTENTS TRANSFERRED TO
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
VIQ
I If
Fmn�A�
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Healt vc M IR m in Record must
be submitted to the local Board of Health or other approving authRi YCENE
A. Facility Information j JUL 1 7 2007
1. System Locatio
.1(0 S- _V
Address
1\3�
City/Town
2. System Owner:
�_C
TOWNORTHEPAR T N V ANDOVER
„� ry WN N OOF F I D
--D (Ay ,
State Zip Code
IL I
Name PTH � — —
C7
Address (if different from location)
City/Town StI -m – 39 (/ _ I Z� Code
//
Telephone Number
B. Pumping. Record
1. Date of Pumping Dae Z� 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) —4Septic Tank ❑ Tight Tank
❑ 'Other (describe):
4. Effluent Tee Filter present? 12LYes ❑ No If yes, was it cleaned? Yes ❑ No
5. Condition of System?: .
G
6. System Pumped By:
'8cl Ct l') 00 (o 0 4?e 6 _
Na 7,,,.,Vehicle License Number
-uS t C
Company
7. Location where contents were disposed:
I
j
[)Ll A, ` -ftl i rlxn4 ( 'AI ,i Orb s4r
Signature of Hauler
hftp://www.mass.gov/dep/water/approvals/t5forms,htm#inspect
(42 c)
Date
t5form4.doc• 06/03 . System Pumping Record • Page 1 of 1
S-\ Commonwealth of Massachusetts
_ City/Town of
System Pumping Record
Form 4
M
RECEIVED
DEC 15 2009
TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. Oth e
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information "
1. System Location: Left side of house, Right side of house, eft fron�house ight front of house,
Left rear of house, Right rear of house. Left rear of building. igng.
Address q (' S
City/Town State Zip Code
2. System Owner:
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
�D -( � -e�1y
Date
Cesspool(s)
State �C2� — 9 Lj Code
Telephone Number 1-1�
— 2. Quantity Pumped.
Septic Tank
Gallons
❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes 2 No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: ii n
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Locatjp"here contents were disposed:
Lowell Waste Water
of
F5821
Vehicle License Number
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1