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Home My WebLink AboutMiscellaneous - 960 JOHNSON STREET 4/30/2018FA l Commonwealth" of Massachusetts City/Town of +FED IV w° System Pumping Record [APR ��at1 M SV Form 4 TOWN OF NORTH ANDOVT R DEP has provided this form for use by local Boards of Health. Other form it A information must be substantially the same as that provided here. Before sing is 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 front of house, right front of house, left side of house, right side of house, Left rear of house, right rear of house, left side of building, right rear of building, under deck. 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): Date Cesspool(s) 4. Effluent Tee Filter present? ❑ Yes 0_90 5. Condi 'oj�fSystem: C 6. System Pumped By: Neil J. Bateson Name Bateson Enterprises Inc. Company 7. Locationvi(here contents were disposed: S. State, , /� 3� p Code C.J Telephone Number — 2. Quantity Pumped: Septic Tank Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No S�I�"3 F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 M RECEIVED SEP 2 8 2009 ITOv� w .-- F�..,n i n ANDOVER I L FjL, FH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left side of house, Right side of house, Left front of ouse, Right front of house, Left rear of house, Right rear of house. Address 6'7® City/Town State 2. System Owner: n Name Address (if different from location) Cityrrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ A4Zip Code State � , e —J4v� _/7 Telep one Number Quantity Pumped Date Cesspool(s) Septic Tank Gallons ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes J2 No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: V-\ f;)-7 `6�✓� � (��/� , 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: .L. Lowell Waste Water e -'—m ;iA _ &3 () CA�� C11, Vehicle License Number F5821 Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. rIA 1�1 Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 REGEIV La, JUN 0 9 2008 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Address`7 O City/Town 2. System Owner. Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ v V - [IV. State I Zip Code StateiCode �JCo Telephone Number Date v� 2. Quantity Pumped Cesspool(s) Septic Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes J�No 5. Conditi`on�>ofl�Sys�� i Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No SO t 1 C4: --S- 6. Systemm � Name C Vehicle License Number Company 6 7. Location 7,17 t7., re 11 Date � -') -<D<�- t5form4.doc- 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping Record 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. . A. Facility Information Important: When fining out 1. System Location- forms ocationforms the computer, use only the tab key Address 6 to move your � /� cursor - do not �J P, A�� use thereturn Cityrrown State Zip Code key. 2. System Owner. ofi�C�� Name Address (if different from Location) Cityfrown State Telephone Number B. Pumping Re6ord q 1. Date.of Pumping �2.Pumped.. DateQuantity Gallons .3. Type of system: [] Cesspool(s) Septic Tank- ❑ Tight Tank ❑ Other(descnbe)` 4. Effluent Tee Filter present? ❑ Yes Ld" No If yes, was it cleaned? ❑Yes ` ❑ No 5. Condition of System - SJ/ 6: System Pumped By` --� :'Nam > Vehicle License Number Company .. 7. Location here contents wer isposed: Commonwe Ith of Massachusetts Massachusetts System Pumping Record System Owner �ocCo ccs Date of Pumping: (—:30-99 Cesspool: No L� Yes U System Location S4 - Quantity Pumped Septic Tank: No IJ System Pumped by: Fatejea Sit&M,47aa License # Contents transferrred to : Greater Lawrence Sanitary District Date: _ Inspector: gallons Yes L� B. Certification 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 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 RECEIVED Commonwealth of Massachusetts Title 5 Official Inspection Forme z4 203 Subsurface Sewage Disposal System Form - Not for Voluntary Assessme ttOWN OF NORTH OVER HEALTH DEPA NT GSM 960 Johnson St Property Address Rick Gauthier Owner Owner's Name information is required for North Andover Ma 01845 3/25/2013 every page. 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. Important: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your Dean Dynan cursor - do not use the return Name of Inspector key. Company Name rQ 2 Suntaug Street Company Address Lynnfield Ma 01940 Ram City/Town State Zip Code 508-726-9935 S112837 Telephone Number License Number B. Certification 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 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 3/13 Title 5 Official 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 960 Johnson St Property Address Rick Gauthier Owner Owner's Name information is required for North Andover Ma 01845 3/25/2 every page. City/Town State Zip Code Date of 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: single family three bedroom dwelling system in working order 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 013 Inspection 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: single family three bedroom dwelling system in working order 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 • 3/13 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 G M 960 Johnson St Property Address Rick Gauthier Owner Owner's Name information is required for North Andover Ma 01845 3/25/2013 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Commonwealth of Massachusetts u - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M ,960 Johnson St Property Address Rick Gauthier Owner Owner's Name nformation is required for North Andover Ma 01845 3/25/2013 for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ i Liquid depth in cesspool is less than 6" below invert or available volume is less than Y day flow t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 ❑ 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 Y 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 wM 960 Johnson St Property Address Rick Gauthier Owner Owner's Name information is required for North Andover Ma 01845 3/25/2013 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 • 3/13 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 ;M 960 Johnson St Property Address Rick Gauthier Owner Owner's Name information is required for North Andover Ma 01845 every page. City/Town State Zip Code C. Checklist 3/25/2013 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 - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 960 Johnson St G„M SVBy`Ow Property Address Rick Gauthier Owner Owner's Name information is required for North Andover Ma 01845 3/25/2013 every page. City/Town State Zip Code Date of Inspection D. System Information Description: 3 bedroom single family dwelling 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: house has been vacant no useful water records on file 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 Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts H w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 960 Johnson St Property Address Rick Gauthier Owner information is required for every page. Owner's Name North Andover Cityrrown D. System Information (cont.) Last date of occupancy/use: Other (describe below): State Zip Code 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 Board of Health gallons Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool 3/25/2013 Date of Inspection ❑ Yes ® No ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 960 Johnson St Property Address Rick Gauthier Owner Owner's Name information is required for North Andover Ma 01845 3/25/2013 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1974 as oer file at BOH Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 12"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.): building sewer in good condition no evidence of leakaqe Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 1500 gallon concrete tank 12" feet ❑ Yes ® No ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: L 10'6" X W UX H 5'.5" Sludge depth: 4" t5ins • 3/13 Title 5 Official Inspection Forth: 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 ;M 960 Johnson St Property Address Rick Gauthier Owner Owner's Name information is required for North Andover every page. City/Town D. System Information (cont.) State Zip Code Septic Tank (cont.) 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 3/25/2013 Date of Inspection 28" 0 - 1" 6" 24" How were dimensions determined? infield with measure stick and tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic tank should be pumped every 2 to 4 years depending on number of occupants and usage Septic tank is in working order inlet and outlet have concrete baffle Liquid is at bottom of pipe on outlet line with separation from inlet and outlet Septic tank in good / fair condition / there is no evidence of leakeage into or out of tank/ Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 N Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 960 Johnson St Property Address Rick Gauthier Owner Owner's Name information is required for North Andover Ma 01845 3/25/2013 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 Desi n Flow g 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 960 Johnson St Property Address Rick Gauthier Owner Owner's Name information is required for North Andover Ma 01845 3/25/2013 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert liquid is at bottom of outlet lines 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.): 16 X16 concrete d box is in working order, D box is 22" from grade / d box is level with equal distribution to outlets / little solids carryover d box sump fairly clean / no evidence of leakaqe into or out of box 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 • 3/13 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 960 Johnson St Property Address Rick Gauthier Owner Owner's Name information is required for North Andover every page. City/Town Ma State 01845 3/25/2013 Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 3 shallow pits ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ 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.): SAS in working condition / soils in good condition / no evidence of breakout / located in grass area with consistant vegetation of like colors / no ponding located on slope / Pipe locator was inserted into outlet lines on d box and found no obstructions and located all pits 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 • 3113 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 �M 960 Johnson St Property Address Rick Gauthier Owner Owner's Name information is required for North Andover Ma 01845 3/25/2013 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Owner information is required for every page. 0 l 'V 6.0 9q �l Ap 3 ? 6P X7' V� X10 5�- (3P 3J�l t5ins • 3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 960 Johnson St Property Address Rick Gauthier Owner's Name North Andover Ma 01845 3/25/2013 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 ❑ drawing attached separately C0``ttT6� SfJ J Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M , •'�r 960 Johnson St Property Address Rick Gauthier Owner Owners Name information is required for North Andover Ma 01845 3/25/2013 every page. Cityfrown 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: 90" no water as per plan on file w /BOH 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: 1974 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: Checked file and plans at local board of health 90" no water in 1974 dwelling is on sloping lot more than 30' drop shallow pits approx 4'6" from grade Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 960 Johnson St Property Address Rick Gauthier Owner Owner's Name information is required for North Andover Ma 01845 3/25/2013 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 y-' Town of North Andover Office of the Conservation Department Community Development and Services Division Alison McKay Conservation Associate May 5, 2003 Mr. John Marocco 960 Johnson Street North Andover, MA 01845 27 Charles Street North Andover, Massachusetts 01845 RE: Information for Conservation's Permit Application Process Dear Mr. Marocco: Telephone (978) 688-9530 Fax (978) 688-9542 Included with this letter are several documents, which will aid in the Conservation filing process for the proposed work discussed at our on site meeting on May 5, 2003. Specifically, a -list flf local wetland Consultants/Engineers/Surveyors to contact for the proposed work, the Conservation Commission's Meeting Schedule and associated deadlines, and the application checklist for a Notice. of.Intent filing for your information (this will be included with your final application). Please feel free to contact me if you have further questions in this regard. Sincerely, Alison McKay Conservation Asso iate BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNTiv'G 688-9535 �1 i u 44 0 ti \ i (Ij � x ,i ti i 14, (�1,Z tv 0 ti i RM O 9 13 IN r I .n A.. O 4 91 r `r' r r � r V ct r 4 cr -4 i6o JoFwsoej 5 r 5