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Miscellaneous - 970 JOHNSON STREET 4/30/2018
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Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Commonwealth of Massachusetts �O Title 5 Official Inspection Form u Subsurface Sewage Disposal System Form -Not for Voluntary Assessmen �a 970 Johnson Street Property Address Myles Costello Owner's Name North Andover MA 01845 11-29-2017 Citylrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information Inspector: DEC 18 2017 Neil James Bateson TOWN OF NORTH ANDOVER Name of Inspector HEALTH DEPARTMENT Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover City/Town 978-475-4786 Telephone Number B. Certification MA 01810 State Zip Code SI -15 License Number I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs F rther Evaluation by the Local Approving Authority -,z J"j 11-29-2017 Insp ct 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 has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc • rev. 6116 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 970 Johnson Street Property Address Myles Costello Owner Owner's Name information is required for every North Andover MA 01845 11-29-2017 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: ® 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: After permit from B.O.H., install new outlet tee with gas baffle in septic tank, new outlet cover, new outlet pipe to d -box & new d -box with riser, inspection from B.O.H., septic system now passes Title 5 inspection. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 12/6/2017 • Resized952017112995125535.jpg q 10 __.J vh f �� https:/Imail.google.com/mail/u/O/#inbox/l 602c3203c6fc35a?p rojector=l 1/1 12/6/2017 s Resized952017112995125602.jpg hftps://mail.google.com/mail/u/O/#inbox/l 602c32dacdOeaae?projector-1 1 /1 12/6/2017 v Resized952017112995125630.jpg n n C - y https://mail.google.com/mail/u/0/#inbox/1602c33218b42ed2?projector-1 1/1 z �0�2 4 br Commonwealth of Massachusetts J BOARD OF HEALTH North Andover P.I. FI Map -Block -Lot 107.AO098 - ---------------------- PennitNo BHP -2017-1099 FEE ------------------ DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Bateson Ent -1 ------- - -- ------------------------------------------------------- to (Construct) an Individual Sewage Disposal System. at No 970 JOHNSON STREET------------------- --------------------------------------------------- ---- --- - ------ ove 2017 ------ -- -- as shown on the application for Disposal Works Construction Permit No. -BHP-2-01-7- at ed ------------------------ I ---------- ---------------------------- Issued On: Nov -16-2017 BOARD OF HEALTH ------------------------------------- Commonwealth of Massachusetts Map -Block -Lot 107.AO098 BOARD OF HEALTH -- -------------------- Permit No North Andover BHP -2017-1099 -- -------------------- FEE ---------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Bateson -Ent ------------------------------------------------------ ------------------------------- to (Construct) an Individual Sewage Disposal System. Guy&� at No 970 JOHNSON STREET ----------------------------- -- ------- -------- --- - -------- -- --- ---- ----------- --- -- as shown - on - the - application - for Disposal Works Construction -P-en-n-it- No. BHP -2017-1 ---- 7---1 ----- Dated ove 017 ------------ -------- ------------- --- ----------- - --- --- -------------------- Issued On: Nov -16-201- 7 ------------------------------------------------- OF HEALTH Application for S. _0 Disposal System //_ A - / 7 TODAY'S DATE Construction : PeiyOt —TOWN OF NORTH ANDOVER MA 01845 $ 250:00- Full Repair 31 $125.00 - Component _Application is hereby made for a permit to: Construct a new on-site sewage disposal system* ❑ Repair. or replace an existing on-site sewage disposal system* _ Okepair or replace an existing system component —What? 0 4-f l. -f l `1'-0- A D— Ito}C A. Facility Information. q� �y �� / / /� � d Lw 50,E S/- RECiEIVED. Address or Lot # F I 7 Ap CityfTown TOWN OF NORTH ANDOVER 2: *TYPE OF SEPTIC SYSTEM*: HEALTH DEPARTMENT ➢ [] Pump cavity (choose one) ' If pump system, attach copy of electrical permit to application**` Conventional System (pipe and stone system) ➢ ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install_ this type of system.) ➢ ❑ Pressure Distribution S.A.S. (No D -Box) ➢ ❑ Pressure Dosed (D -Box Present) S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No /fyes, does plan specify make and model of filter? YES = (no further info. needed) 'NO = (installer must specify brand of (iter before DWC issuance) What is the Make? Whatis thcModaV 2. Owner Information Mame �/ �f i / f o Address (if different �from above CityfTown State Zip Code 27S'/tea--/3� y Telephone Number 3. Installer Information I3ATMOON ENTERPRISES, INC. Name Name of C'mpanyANDOVER, MA 01310 Address �f Cityrrown, 4. Desi _gner''Infoation Name Address Cityrrown A1011 - ,:::21S110 S1/D State Zip Code Telephone Number (Cell Phone #itpossible please) Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit . Page 1 of 2 ll -IL. --17 - • T•ODAYS DATE $:250.00 T Full Repair $'125:00;- Component PAGE 20F2. A. Fac.iliiy Information continued.,.. 5. Type'of Bui_ ldin4: esidential,Dwelling or QGommercial B. Agreement The underslgned agrees to ensure the construction and maintenance of the afore -described on-slte sewage disposal system,in accordance with he provisions of Title 3 of the Envlro»mental Code, as well as the Local Subsurface Disposal Regulatlons for the Town of Norfh Andover, and not to place he system fn operation until a Certlflcate of Compllshce has been I by this Board of Health. `7 Name Date Application Approved By: (Board of Health Representative) Name Date Application Disapproved. for the following reasons:" For Office Use Only: Fee Attached? Yes No 2.. ProlectArartager Ob1i tion Foy Attached?1! — Yes No 3.; ama Svstem? Ifso) AttachcQFp�pF.I��mcal Pumrt; �'es : No� 4. Fouadato»As:Bur'!x?(new consfruction•ronl}r); (Same scale as appro ed lan 5. F1oorPlans? (hew construction, only). �1pp((catldn'-for,01905a1. $.ysteryt:Oonstrgetiuri Permtt Rsoe 2 dr ♦ { SFP'k`IG`•S.Y3'i'T�+I•�N$?1�1�'�I�OjBaC�!' iV�A�ti�:�rE1�+I'��(313LiGA"�'I�YhfS As fi*Nqtffi Andover•iio metlaa� frsF #fid tc' qn► f 'th aeptia a�te�pa fort th'e'Pt4�sexiga� o (Ad4ctls etsq* s gw4 -Act Am bs ReUtW to thupp of � A (-e--v X1 {i�ait s aAma Abd dAtiod Diced '//— /L_ — l °7 d i A ��i lZ4�t�01 I nadetatAsid the Wowing obligations fort tms9=cnt oftia ptqecC 1. As thefaster I =.obligated io abWs r2pewits tad•B.bx d of ea th ,tpp=Mod l sp= to �petg anp:tQcit3c ala R e 3. As 9ie ia�d .I itis call mry and il*q=di= �i£2� ' Q aaian not e�rtted with � Q��=wgo l or uny p ' mY P �'an kVix dm snd the Mtein is notsreAdp Bien Item bc�2tq>�pCd iviedIi�taWt• et ;,«-: 23 • ,1� •-�=�' . t�ir �.�1"�•�poa-�thet+a � �,utai�ig •tom, p�hiclr 4 104 mea -not bm to be pmibza : • . t6kverbs Oifi"(ar e-maii iaatap Z.for tom' etc. • ' �ba ftibiaittied•trs �hc-8o�itd dfHea�t, a�xt: .•kwamAxum tha etigfaeea est • _ bep� iFoi�eii �'pectiPst. eupae. 'Iiaitalie= iu�t •fWQtk st beready ad able to . - •eauaep.to�►or3r sici is _ , ,.. • ' . hava #o bean{site.� ��pltt14sm1%t dace trot 4. A - e fmstAliez' I ted that aalp I~ sp g �eri8c'� r a�+r �) I dei gtiired COM plete ins� tOnOfthe spAtrt��ir##Ii�'��`� tioa felmmufrNrlr»�sl•��t{si.� w•t.�.�1:.�5,.�.....rt..a..:...:- �_t�ts_____ �- _ Jf .. thtfaEdEt� Y tlhttL�L�2ttvd •ob;iia tie vezfozmgnCtf t CpIIgan s: De#�rnla� t thirt.drep dm dad dfiL- ekarnwaftl f Impedidaff arftkcl pmad Dad a4a lv he uwaL _. �•�'ia�l��aa�ua#oahpBoaniatr�e�iltfr�lrrffarc+aae�. . d .fit lls aft�aalr, - e�ng , mug vent p='P cftx&zw' jtx� svrrllsati other a. Und�d'�cetued 3aptic.I� : (iP , i• . Ot 'NOR7.,M0 V U / b FO � 9 Town of North Andover HEALTH DEPARTMENT ,sS�CMU`+�t / / CHECK #: 16 50 DATE: LOCATION:'? 7 O MLam ST H/O NAME: /'X/% S Co S Ve.11O _ CONTRACTOR NAME: CY y6aL -e_aon 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 lr $ L, 'CJ SEPTIC Systems: �J ❑ Septic - Soil Testing A'� i $ ❑ Septic -Design Approval `Q/� $ x5 Septic Disposal Works Construction (DWC) $ /7 ` ❑ Septic Disposal Works Installers (DWI) $_ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other: (Indicate) $ He gent Initials White - Applicant Yellow - Health Pink - Treasurer PUBLIC HEALTH DEPARTMENT Town of North Andover Community and Economic Development Division CERTIFICATE OF COMPLIANCE As of: December 6, 2017 oho This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: D -Box, Outlet Tee & Pipe Repair of On -Site Sewage Disposal System By: Todd Bateson — Bateson Enterprises, Inc. At: 970 Johnson Street Map 107.A Lot 98 Nort Andover, MA 01845 this certKicate,:11 no be construed as a guarantee that the system will function satisfactorily. Michele E. Grant oG Public Health Inspector 120 Main St., North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web www.northandoverma.gov NORTy qti N� o p GP 5 ��SSA (,ills North Andover Health Department Community and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 970 Johnson Street MAP: 107.A LOT: 98 INSTALLER: Bateson DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: D -box, outlet tee and pipe SITE CONDITIONS Comments: SEPTIC TANK ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Watertightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROLPANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION -BOX ® Installed on stable stone base ® H-20 D -Box ❑ Inlet tee (if pumped or >0.08'/foot) ® Hydraulic cement around inlet & outlets ❑ Observed even distribution ® Speed levelers provided (not required) ® Schedule 40 PVC Pipe Comments: 12/6/2017 — pictures sent to Michele Grant SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder / concrete / timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel -less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = FINAL GRADE ❑ Loamed ❑ Seeded ❑ Cover per plan Comments: DOCUMENTS NEEDED ❑ Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer ❑ As -Built Plan SYSTEM ELEVATIONS ROD AS -BLT INVERT DESIGN INVERT ELEVATION ELEV ELEV Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 TOP Lateral 1 INVERT Lateral 2 TOP Lateral 2 INVERT Lateral 3 TOP Lateral 3 INVERT Lateral 4 TOP Lateral 4 INVERT Lateral 5 TOP Lateral 5 INVERT Lateral 6 TOP Lateral 6 INVERT Top of Chamber Bottom of Bed/Chamber SKETCH PLAN 4 CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- ® Waterline 10 10 101 ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh, Inland / Coastal Banka 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib. to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot. Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 ® Drains (Other) Foundation 10 (5) 20 (10) ® Drywells 20 25 ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws :SII Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Commonwealth of Massachusetts RECEIVEW Title 5 Official Inspection Form cgllV 1 42017 Subsurface Sewage Disposal System Form - Not for Voluntary Assessmen%WN OF NORTH ANDOVIR 970 Johnson Street HEALTH DEPARTMENT Property Address Myles Costello Owners Name North Andover City/Town MA 01845 11-2-2017 State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered inn way. Please see completeness checklist at the end of the form. A. General Information 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 SI -15 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 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 ❑ e s Fu er Evaluation by the Local Approving Authority 11-2-2017 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 has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc - rev. 6/16 Tdtle 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 of 17 =_A_ Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 970 Johnson Street Property Address Myles Costello Owner's Name North Andover Cityrrown B. Certification (cont.) MA 01845 State Zip Code 11-2-2017 Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ® N ❑ ND (Explain below): l5ins.doc • rev. 6116 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 970 Johnson Street Property Address Myles Costello Owner Owner's Name information is required for every North Andover MA 01845 page. Citylrown State Zip Code B. Certification (cont.) 11-2-2017 Date of Inspection ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below): ❑ Y ® N ❑ ND (Explain below): ❑ 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.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 970 Johnson Street Property Address Myles Costello Owner's Name North Andover MA 01845 11-2-2017 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: Outlet cover, outlet tee, d -box needs to be replaced and riser install on d -box. D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 970 Johnson Street Property Address Myles Costello Owner Owner's Name information is required for every North Andover MA 01845 11-2-2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 970 Johnson Street 11-2-2017 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? ® ❑ Property Address Myles Costello Owner Owner's Name information is required for every North Andover MA 01845 page. Citylrown State Zip Code ® ❑ C. Checklist 11-2-2017 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): N/A Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): N/A t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 970 Johnson Street Property Address Myles Costello Owner Owner's Name information is required for every North Andover MA 01845 11-2-2017 page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 r-It 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)): Yes Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins.doc - rev. 6116 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 ,.•�''r 970 Johnson Street Property Address Myles Costello Owner Owner's Name information is required for every North Andover MA 01845 11-2-2017 page. Cityfrown State Zip Code Date of Inspection 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 Pumped 2017, owner gallons Type of System: ® 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 970 Johnson Street Property Address Myles Costello Owner Owners Name information is North Andover MA 01845 11-2-2017 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Oriainal system. owner Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 2' feet Material of construction: ® cast iron ❑ 40 PVCCopper ® other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" cast iron through floor, 3" Copper in house, no leaks visible Septic Tank (locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 7'x 5'x 4' Sludge depth: a ❑ Yes ❑ No t5ins.doc - rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 970 Johnson Street Property Address Myles Costello Owner Owner's Name information is North Andover MA required for every page. Citylrown State D. System Information (cont.) t5ins.doc • rev. 6/16 01845 11-2-2017 Zip Code Date of Inspection Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 33' Scum thickness 0 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 15" 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.): Inlet baffle ok. Outlet tee badly corroded, needs to be replaced. Outlet cover broken, needs to be replaced, Depth of liquid at outlet invert, no evidence of leakge. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 970 Johnson Street Property Address Myles Costello Owner Owner's Name information is required for every North Andover MA 01845 11-2-2017 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass Dimensions: Capacity: Design Flow: Alarm present: Alarm level: gallons ❑ polyethylene ❑ other (explain): gallons per day ❑ Yes ❑ No 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.doc • rev. 6/16 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 970 Johnson Street Property Address Myles Costello Owner's Name North Andover MA 01845 11-2-2017 Cityfrown D. System Information (cont.) State Zip Code Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert -1 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 badly corroded needs to be replaced, Evidence of leakage. Evidence of carryover. D -box needs riser 3' deep. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc • rev. 6116 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 970 Johnson Street Property Address Myles Costello Owner Owner's Name information is North Andover MA 01845 11-2-2017 required for every page. Cityrrown 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: ❑ overflow cesspool number: ❑ innovative/alternative system 4 trenches 35' long 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 t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •�''� 970 Johnson Street Property Address Myles Costello Owner Owner's Name information is required for every North Andover MA 01845 11-2-2017 page. 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.): t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 970 Johnson Street State Zip Code 11-2-2017 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 6 0<c --,Se- tL� C_ e3 t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Property Address Myles Costello Owner Owner's Name information is North Andover required for every page. Cityrrown State Zip Code 11-2-2017 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 6 0<c --,Se- tL� C_ e3 t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 6 Powers Road Property Address Mike Reilly Owner Owner's Name information is Andover MA 01810 10-12-2017 required for every page. Cityrrown 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: 1.5 to 3. 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: 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: Essex Countv Soil Map You must describe how you established the high ground water elevation: Essex County Soil Map, Sheet #36, woodbridge Soil, Water 1.5 to 3. Deep. No Sump pump in cellar,and trenches 15' deep. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc - rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 970 Johnson Street Myles Costello Owner Owner's Name information is North Andover required for every page. Citylrown MA 01845 11-2-2017 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.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Summary Record Card generated on 10/18/2017 2:55:54 PM by Karen Hanlon Town of North Andover Tax Map # 210-107.A-0098-0000.0 Parcel Id 17923 970 JOHNSON STREET COSTELLO, MYLES J. 970 JOHNSON STREET N. ANDOVER, MA 01845 Page 1 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.16 Acres FY 2018 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until COSTELLO, MYLES J. Payor 970 JOHNSON STREET N. ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 14310.0 - 970 JOHNSON STREET Last Billing Date 9/12/2017 2100308 02 Cycle 02 Active UB Services Maint. Account No. 2100308 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 53.20 /1 UB Meter Maintenance Account No. 2100308 Serial No Status Location Brand Type Size YTD Cons 16336179 a Active ERT METE METE w Water 0.63 0.63 612 Date Reading Code Consumption Posted Date Variance 8/2/2017 1235 a Actual 14 9/20/2017 -3% 5/2/2017 1221 a Actual 11 6/26/2017 -13% 2/21/2017 1210 aActual 20 3/14/2017 -9% 11/2/2016 1190 aActual 18 12/19/2016 6% 8/3/2016 1172 a Actual 17 9/21/2016' /21 /201613%a : 5/4/2016 1155 aActual 15 6/21/2016 2% 2/3/2016 1140 a Actual 15 3/28/2016 -10% 11/2/2015 1125 aActual 16 12/30/2015 3% 8/5/2015 1109 a Actual 16 9/14/2015 13% 5/5/2015 1093 a Actual 14 6/22/2015 -21% 2/3/2015 1079 a Actual 18 3/20/2015 -6% 11/3/2014 1061 aActual 19 12/15/2014 9% 8/4/2014 1042 aActual 17 9/11/2014 17% 5/7/2014 1025 a Actual 15 6/12/2014 -8% 2/4/2014 1010 a Actual 17 3/17/2014 14% 10/31/2013 993 aActual 14 12/20/2013 -10% 8/2/2013 979 a Actual 16 9/18/2013 -3% 5/1/2013 963 aActual 15 6/18/2013 14% 2/5/2013 948 a Actual 15 3/13/2013 -6% 10/31/2012 933 a Actual 14 12/13/2012 -1% 8/7/2012 919 a Actual 16 9/26/2012 1 % 5/3/2012 903 a Actual 15 6/20/2012 -4% 2/2/2012 888 a Actual 16 3/14/2012 -8% 11/1/2011 872 aActual 17 12/15/2011 12% 8/2/2011 855 a Actual 15 9/14/2011 -4% 5/4/2011 840 a Actual 15 6/13/2011 -10% 2/7/2011 825 a Actual 19 3/15/2011 3% 11/1/2010 806 aActual 17 12/13/2010 -10% 8/3/2010 789 a Actual 19 9/13/2010 12% f NORTH , 8093 o,�y� i= •`� .. 0 9 Town of North Andover HEALTH DEPARTMENT ,SS�CNUSE� CHECK #: /6V DATE: /- /5,70/% LOCATION: ?o X10 /lO nSO4 Sl H/O NAME:0 CONTRACTOR NAME: z6a A30,0 &16 . 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 x 5 Inspector Title 5 Reporte,, j )a;a5 $ $ ❑ Other. (Indicate) $ Hed'IthAgent Initials White - Applicant Yellow - Health Pink - Treasurer Was Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protecti Wllllam F. Weld G"Mm Argeo Paul Celluccl U. coomor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION C � Property Addreaa c170/L/�q n! j C'Y1 S i• G C , a 66 0 �J Date of Inspection: /I — i 3 — / & (If different) Name of Inspector. L"! i I I I pt'v9, 4i J,-,QCompany Name, Address and Telephone Number. / p �V' rudy Cox@ �n David or Struts commb,io,,.r CERTIFICATION STATEMENT ' ,5 C '�- (4 ) L' 6 7 (C' C 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes _ Needs Further Evaluation By the LyAppg Authority FailsInspector's Signatn� 2(iA44,JzDate:The System Inspector shall submit a copy of this inspectionApproving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES.. I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. BI SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passel inspection. Indicate ye@, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined', explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a yonforming septic tank as approved by the Board of Health. (revised 11/03/95) One Winter Street a Boston, Massachusetts 02108 0 FAX (617) 556-1049 a Telephone (617) 292.5500 s3 vm,led or. Recycled Vapor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner. Date of Inspection: B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(*) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health): broken pipe(*) are replaced obstruction is removed distribution box is levelled or replaced The system requited pumping more than four timee a year due to broken or obstructed pipe(*). The system will pass inspection if (with approval of the Board of Health): broken pipe(*) are replaced obstruction is removed CJ 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM 19 NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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. 3) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM I9 FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic uuA and soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well L free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen L equal to or less than 5 ppm. 3) OTHER (revised 11/03/95) f' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) �f ,q Property Address: S °7 �0 Ll N 5 d11 S I ,. / V C%Z 1 (, Owner. Q r3 7-{11 d Date of Inspectlow o D) SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. — Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding cf effluent to the aur.'ace 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 leas than 1/2 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 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 or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. — Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. EJ LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 7 (G. //� YJ �+f Sct � ✓�J C',L / 7/� Owner. �� I� S �<STc//o Date of Inspection: Check if the following have been done: v"Pumping information was requested of the owner, occupant, and Board of Health. _ Noone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ✓A/�As built plans have been obtained and examined. Note if they are not available with N/A. ✓The facility or dwelling was inspected for signs of sewage back-up. L- ' e system does not receive non -sanitary or industrial waste flow The site was inspected for signs of breakout. system components, excluding the Soil Absorption System, have been located on the site. septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non -intrusive methods. 1, P @ facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub - Surface Disposal System. (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address , �,6 `1e� 1i S C'>, j / �,� / ► C Ate. Owner. 1y2 ('c,57 -.e Date of Inapeotion: - 5 .,, REstDENTIAI,; FLOW CONDITIONS Design flow: gallons Number of bedrooms: 3 Number of current residents: a� Garbagegrinder (yes or no): Laundry connected to system or no): Seasonal use (yes or no): Water meter readings, if available: /1I t' hc"L- Last date of occupancy: l �Ali.lj COMM ERC IAL /INDUS TRIAL: Type of establishment: Design flow:----gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no) Non -sanitary waste discharged to the Title 5 system: (yes or no) Water meter reading@, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of System pumped as part of ijv ion: (yes or no) If yes, volume pumped: 5.,� 0 (yes Reason for pumping t- k - TYPE 0 YSTEM Septic UuWdistribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) -A (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: / Owner. Date of Inspection: SEPTIC TANK:✓ (locate on site pian) Depth below grade: Material of construction: Aconcrete _metal _FRP —other(explain) Dimensions sludge depth: y " t Distance from top of sludge to bottom of outlet tee or baffle: ti Scum thicimess: c4 t� Distance from top of scum to top of outlet tee or battle: L Distance from bottom of scwn to bottom of outlet tee or battle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relati n to outlet invert, stz; evidence of leakage, etcJ L u rot m e"i 46! )y �'4 ate_ _ b �, GREASE TRAP._ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scum thickneas: D4tince from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 2U Jct n/v5r-,'1 Date % U of lnspeotlon: S / TIGHT OR HOLDING TANK_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal —FRP _other(expiain) Dimensions: Capacity: ¢allons Design flow: gallons/day Alarm level: Comments: (condition of Inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: ' Comments: (notei[ level an ibutioi; is equal, Tevidence of solids 11 PUMP CHAMBER_ (locate on site plan) Pumps In working order -(yes or no) a of leakage into or out of box, etc.) S.Z.! -7'C: k t /y''' % Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �jSYSTEM INFORMATION (contln ed) Property Addresm ` �t AJ 5- M t / Owner. Ce co"Pe z I C, Date of Inspection: ) 46 SOIL ABSORPTION SYSTEM (SAS)! (locate on sib plan, if possible; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Type! leaching pits, number._ leaching chambers, number:— leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) " 6 f( I "�3APay'ejAj J, CESSPOOLS: _ (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: innow (cesspool must be pumped as part of inspection) 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.) (revised 11/03/95) I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Addreee: q,20 ,It � Ns C/'1Ovnet- Date of Inspection: SEMS OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent references landmarks or benchmarks ----- ---- �` locate all wells within 100' Fc/ -N T /A 76 /0/eT z2, L-, c, -11e r / DEPTH TO GROUNDWATER Depth to groundwater.._ feet method of dstarmination or acomia Jzt V 7L (revised 11/03/95) 9 ' APPLICATION FOR SEWAGE DISPOSAL INSTALLATION HEAL'T'H DEPARTMENT - NORTH ANDOVER, MASS. I hereb make app ca ion for a permit for a sewage disposal installation at 1770 I will install this system in ac- cordance with all the laws of the Commonwealth of Massachusetts and regulations of the Board of Health of the Town of North Andover. Further, I will construct the house sewer of bell and spigot pipe, the minimum diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre- ceding the septic tank, where the grade shall not exceed 2%. I will install a con- crete septic tank of / a --r-' in size. A manhole (s) permitting easy cleaning will be provided with removable cover (s) of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with 4 inch perforated or open jointed pipe and laid in a series of trenches, the bottom of which will pro- vide a minimum of t lineal (square) feet of effective absorption area. The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling the trench, 2 inches of gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single tile line will exceed 100 feet in length and in any case, two lines of tile will be installed. A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No part of the installation will be less than 100 feet from any private water supply, 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. I further agree not to cover any portion of this installation until approved by the inspection officer, as provided below, and to incorporate any additional requirements that may be attached to the permit. Plot Plans must be submitted with application. DATE Signature of Applicant I hereby issue the above permit for the Board of Health of the Town of North Andover, Massachusetts. DATE Si tur of Health Agent I have inspected the uncovered system indicated above and find everything done as described. , DATE /49 ' / O calf Percolation Test Garbage Grinder 0-J'A-, Signature o specting Officer BOARD OF HEALTH TOWN OF NORTH ANDOVER, MASS. V 1. NAME 1�Y `mss os -rg- // i DATE 2. ADDRESS 7v -Tcy r( r S?` LOT NO. TEL. 3. NO. OF BEDROOMS DEN YES NO 4. GARBAGE GRINDER YES N0_ 5. SHOW DIMENSIONS OF HOUSE 6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES 7. SHOW DIMENSIONS OF LOT 8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL 9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM 10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC. 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY. BOARD OF HEALTH OF NORTH ANDOVER, MASSACHUSETTS SEWAGE DISPOSAL DATE_ Y �� NAME OF APPLICANT LOCATION 9 7 D Address f lot no. BUILDING: Dwelling KC Other SYSTEM: New X Repair I GENERAL DESCRIPTION OF LAND SUBSOIL: Clay avel Sand PERCOLATION TEST minutes per inch. MINIMUM INSTALLATION RECOMMENDATIONS CONCRETE SEPTIC TANK_) &-&-p _gallon capacity. LEACH FIELD_ I g-0 lineal feet of drain pipe. J- iam J. Dr*dpll, Engineer Board of HealthJ