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HomeMy WebLinkAboutMiscellaneous - 981 JOHNSON STREET 4/30/2018�� ���''"`— ,�� ter. ��_. . �a; ��� U °.�' �_ 0o U -80 ooX2� o w U � @ a) N m 0 6 4i L1 N �U = U U U) CL U) a) r U) p a2LliUS O N N O N F-mo 0 Y m a@i ` m O @ c C c J N @ O O O_ D F- F- F- IL a of 0 0 J m n Pi m E O U —I o F- IL E O W C a a O OCM O U U LO m m Z3 ��H�� N N (O O Q Z W z W x O N U LO �� a o Ot v2 (n O z w @ 111 O m N LLL mdU _ N O p rn Y V rn or DCD C CKcn2 Q nQ oa �m Moa}a a mR ai ai ai v C D cc aoF-i -@O 0 0 a) a) a) a) @ m m m cU)U)U)(n J J O J Y N N O N F-mo 0 Y m a@i ` m O @ c C c J N @ O O O_ D F- F- F- IL a of 0 0 J m n Pi m E O U —I o Z o O O OCM Q LO N N (O Q Z W CD W Q' W = CD U N �L zip C-4 Ot ¢x zom¢ J w d' o2 2 Li m ¢ C CKcn2 a O ¢ L� 00 00 N (O N H � a0 U O J J Y S� r 0) It ■ > 00 N (OD ■ Z rn a0o } Z�� � O zN H O wO 2 M QO oo OM uo z LL — W 0 Z r_ rpt f` p.. tim, Q W gN '4 �.1 > m m cn s m (n¢ oo N z C `° I z dr- V� 0 (D� ' 0 1;T 't O W P O CL @@ 00 U 1� CL tt F- O D c o F - x �= O z N U CL ao 0 Go 0 It � M � Z N N its N dj a 7 r (V ¢ >aj�0� Za O @ N co 7 V)(n� U �m E "0)c� UY000 v QmLLm 0fn000Z C7 Lim Z co co co co u 0 M 0 m N C7 C9 O O9 IL �� Ln m 00 0 �¢ c Q m� .O E -o m z c U- c ii y `a U oo i�Q:H V w>- CDUao Z W 0 m �y r- C4 F- F- N m� � W X iii U U)LL ' ' ' 'Fa aD iii iri It C" aM °o o m mcy�0L�- °ssY c7 -D E '5.:.. U .r Hc@OLi2wcoO ew mmQ ro N UNJLmL U 2C9ZCJ ~ ° a CL < @ac >_ o -H aw v W !A f/) Lu Li S Li iL U a > Vi North Andover Board of Assessors Public Access Page 1 of 1 Parcel ID: 210/107.A-0222-0000.0 Community: North Andover SKETCH Click on Sketch to Enlarge PHOTO Location: 981 JOHNSON STREET Owner Name: WAHL, MARTIN DEBORAH WAHL Owner Address: 981 JOHNSON STREET City: NORTH ANDOVER State: MA ZIP: 01845 Neighborhood: 7 - 7 Land Area: 1.03 acres Use Code: 101- SNGL-FAM-RES Total Finished Area: 2384 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 467,000 446,600 Building Value: 267,800 257,000 Land Value: 199,200 189,600 Market Land Value: 199,200 Chapter Land Value: LATESTSALE Sale Price: 319,000 Sale Date: 06/30/1999 Arms Length Sale Code: Y -YES -VALID Grantor: PAUL ROKOS/FARNHAM S Cert Doc: Book: 05484 Page: 0277 http://csc-ma.us/NandoverPubAcc/j sp/Home.j sp?Page=3 &Linkld=468263 7/l/2005 COMMONWEALTH OF EXECUTIVE OFFICE DEPARTMENT OF ENVIRONMENTAL AFFAIRS TITLE 5 AL PROTECTION RECEIVE® JUN 2 0 2005 TOWN OF NORTH ANDOVER HEALTH' DEPARTMENT i OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: _981 Johnson Street_ _ North Andover_ Owner's Name: _Martin Wahl_ Owner's Address: _981 Johnson StreetNorth Andover NaA 01845 Date of Inspection 6/3/2005_ Name of Inspector: Neil J. BBateson_ Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, Ma. 01810_ Telephone Number: ( 978 ) 475-4786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority K Inspector's Signature: FailDate: _6/3/2005_ The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments: After permit from B.O.H., install new 1500 gallon septic tank & d -box, inspection from B.O.H., septic system now passes Title 5 Inspection. ****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. COMMONWEALTH OF MASSACHUSETTS ,f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTEC N TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 981 Johnson Street _ North Andover_ Owner's Name: _Martin Wahl_ Owner's Address: _981 Johnson Street_ North Andover, MA 01845_ Date of Inspection 5/17/2005_ Name of Inspector: Neil J Bateson Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road- - Andover, oad__Andover, Ma. 01810_ Telephone Number: _( 978 ) 475-4786 RECEIVED MAY 2 5 2005 TOWN OF,,URTH ANDOVER HEALTH DEPARTMENT CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: Passes X Conditionally Passes Needs Further Evaluation by the Local Approving Authority Is Inspector's Signature: Date: _5/17/2005_ The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments: ****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. Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 981 Johnson Street_ _ North Andover— Owner: _Wahl Date of Inspection: 5/17/2005_ 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: X 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. Septic Tank & D -Boz Needs Replaced. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. Y The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: N Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain: N The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _981 Johnson Street _ North Andover— Owner: _Wahl Date of Inspection: _5/17/2005_ C. Further Evaluation is Required by the Board of Health: Conditions exist which require finther 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 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _981 Johnson Street _ — North Andover — Owner: _Wahl Date of Inspection: _5/17/2005_ D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool No Liquid depth in cesspool is less than 6" below invert or available volume is'h day flow. —No7 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped No_ Any portion of the SAS, cesspool or privy is below high ground water elevation. _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] _No_ (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either "yes" or `no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone 11 of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: _981 Johnson Street _ North Andover— Owner: _Wahl Date of Inspection: _5/17/2005_ Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No Yes — Pumping information was provided by the owner, occupant, or Board of Health No Were any of the system components pumped out in the previous two weeks ? Yes_ _ Has the system received normal flows in the previous two week period ? No Have large volumes of water been introduced to the system recently or as part of this inspection ? _Yes _ Were as built plans of the system obtained and examined? Yes_ — Was the facility or dwelling inspected for signs of sewage back up ? Yes _ Was the site inspected for signs of break out ? _Yes _ Were all system components, excluding the SAS, located on site ? _Yes_ _ 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 ? _Yes_ _ 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: Yes no _Yes_ _ Existing information. _Yes_ _ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: _981 Johnson Street _ _ North Andover– Owner: _Wahl _ Date of Inspection: _5/17/2005_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): _4_ Number of bedrooms (actual): 3_ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): _600_ Number of current residents: _3 Does residence have a garbage grinder (yes or no): Yes_ Is laundry on a separate sewage system (yes or no): _ No_ Laundry system inspected (yes or no): _ Seasonal use: (yes or no): No_ Water meter reading: Yes _ Sump pump (yes or no): _No_ Last date of occupancy: — Current-COMMERCIAL/INDUSTRIAL Type of establishment: _ _ Design flow (based on 310 CMR 15.203): ___Md Basis of design flow (seats/persons/sgft,etc.): Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): — Non -sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: _ OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: Pumped two weeks ago, owner_ Was system pumped as part of the inspection (yes or no): No_ If yes, volume pumped: _ gallons -- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank, distribution box, soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank _ Attach a copy of the DEP approval — Other (describe): _ _ Approximate age of all components, date installed (if known) and source of information:_ 22 years old, 12/16/1983, as built plan _ Were sewage odors detected when arriving at the site (yes or no): _No Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _981 Johnson Street _ North Andover _ Owner: _Wahl Date of Inspection: _5/17/2005_ BUILDING SEWER _ X _ (locate on site plan) Depth below grade: _22"_ Materials of construction: _ X_ cast iron _40 PVC other Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.) SEPTIC TANKS: X 4" Cast iron thru wall, 3" PVC in house _ Depth below grade: _10"_ Material of construction: X concrete — metal _fiberglass _polyethylene _other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) Dimensions: _10'x 5' x 4' Sludge depth: _0"_ Distance from top of sludge to bottom of outlet tee or bale: 25" _ 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: _17" _ 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 tee ok. Outlet tee ok. Depth of liquid below outlet invert. Evidence of tank leaking. _ GREASE TRAP: _(locate on site plan) Depth below grade: _ 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: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _981 Johnson Street- - North Andover— Owner: _Wahl Date of Inspection: 5/17/2005 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: X Depth of liquid level above outlet invert: --111— Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.) _D -box level & distribution equal. Evidence of leakage. Evidence of carryover._ PUMP CHAMBER: , (locate on site plan) Pump in working order (yes or no): _ Alarm in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): _ Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 981 Johnson Street_ _ North Andover _ Owner: _Wahl Date of Inspection: _5/17/2005_ SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan, excavation not required) If SAS not located explain why: Type X_ leaching pits, number: _2_ 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.): _ Soil ok. Vegetation ok.. Camera drywells thru outlets in d -box, both pits holding no liquid _ 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 sludge layer: _ Depth of scum layer: _ Dimensions of cesspool: _ Materials of construction: . Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): _ PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 10 of 11 UBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _981 Johnson Street _ North Andover — Owner: _Wahl _ Date of Inspection: _5/17/2005_ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A to D -Boz = 2914" B to Tank =15'5" B to D -Boz = 37'8" Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 981 Johnson Street _ North Andover Owner: _Wahl Date of Inspection: _5/17/2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater _4'_ Please indicate (check) all methods used to determine the high ground water elevation: _X_ Obtained from system design plans on record - If checked, date of design plan reviewed: _12/16/1983_ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: _ Checked with local excavators, installers- (attach documentation) _ Accessed USGS database -explain: _ You must describe how you established the high ground water elevation: As per design plan_ Summary Record Card generated on 5/17/2005 12:50:05 PM by Lisa Warren Town of North Andover Tax Map # 210-107.A-0222-0000.0 981 JOHNSON STREET WAHL, MARTIN 981 JOHNSON STREET NORTH ANDOVER, MA 01845 Page 1 _ Class 101 Single Family Property Type 1 Residential Size Total 1.03 Acres FY 2005 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until WAHL, MARTIN Payor 981 JOHNSON STREET NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 8021.0 - 981 JOHNSON ST Last Billing Date 3/9/2005 2100677 02 Cycle 02 Active UB Services Maint. Service Code Rate Charge Multiplier/Users MISCFEE'ADMIN FEE 0.63 5/8 7.82 1/ WTR WATER 01 ALL METER SIZE 95.51 /1 UB Meter Maintenance . Serial No Status Location Brand Type Size YTD Cons 132421 17 a Active ERT HH METE METE w Water 0.63 0.63 0 Date Reading Code Consumption Posted Date Variance 5/3/2005 165 a Actual 23 -5% 2/15/2005 142 a Actual 29 3/15/2005 -11% 11/15/2004 113 aActual 32 12/17/2004 1% 8/17/2004 81 a Actual 32 9/20/2004 -5% 5/18/2004 49 a Actual 36 6/14/2004 -6% 2/11/2004 13 c Correction 35 4/16/2004 0% C/O 22+ERT 13=35 11/14/2003 2705 n New Meter 0 11/14/2003 0% z` t!/S RCCOIINT HISTORY '1.1006'1'7-UAHI., MARTIN MLIiiH t11.: 2100677 BH:981 JOHNSON ;tT 8 CYCLP EE.RUICE PRIOR CORRFN7 HSE Un 11711 SFUEH FEES TOTAL 1 2000 12 08/05/1999 2`7.58 2258 H 0.00 0.00 "4iH0 22 12/10/1999 2258 2295 37 101.01 0.00 0.00 101.01 ] 2.000-32 03/IS/2000 2291, 23'1.1 26 70.98 0.00 0.00 70.96 q 2000-4). 05/2l./'7.00N 23'21 2.354 33 90.09 0.00 0.00 90.09 S 2000-2C 10/08/79990 0 0 8.19 0.00 8.19 g zr 6 2001-42 08/08/2000 2354 2384 30 81.90 0.00 11.00 92.98 �1 tIA 7 1001-32 11/(5/2000 2384 2411. ''7 73.71 0.00 11.00 84.71 aa« 8 2001-3'. 02/20/2001 2411 2431 20 54.60 0.00 11.00 65.60 Y 2001 42 05/21/2001 2431 2458 27 ?3.71 0.00 11.00 84.?1 10 2002 22 12/05/2001 2483 2513 30 76.34 0.00 5.55 81.89 Teak t1 2002-32 03/19/2002 2!13 2539 21, 66.46 0.00 !1.55 72.01 ' 1 200? 42 05/17/200'7. 2539 2553 14 34.58 0.00 5.55 40.13 13 7007 12R 08/07/2001 2458 2483 2S 67.35 0.00 5.55 72.90 tt£a I4 tid3 1'2 08/12/2002 2tiS3 2576 23 59.00 0.00 5.97 64.97 I S 2.003 -22 11/07/2002 2576 7.599 23 59.(10 0.00 5.97 64.97 -_ 1.6 2003 32 02/07/2003 2599 2623 24 61.38 0.00 S.917 67.35 17 2003-42 05/07/2003 2623 2649 26 70.40 0.00 S.97 76.37 1H 211014-12 0N/t9/7.003 2649 2681 34 90.03 0.00 7.42 97.45 REUIEW CHOICE tl or <E:NTER> MORE HISTORY: r RN �t '£TileEdi..: 'Yw"Illat Ippls. T�bla J!^^'*•p', _ :T}�e/J �A °astir: iCr l`iP.'T'i �. _ S 1009'e » Normal - renes New Raman 12 H I 4 6 7 Page 1 Sec 1 111 At 6.4" Ln 3 Col 1 5tert 6 d D*b - - Microsoft OAlook I '�? GOM..N • W.1.71,4 • R...?t� eosror>f ald, Cam - W*k ., .Telnet 10.1.71 -SS __ Dolvnerd2 • Mkrmsnft .., lay? •; JS� 12;54 PM Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 981 Johnson Street, North Andover Owner: Wahl Date of Inspection: 5/17/2005 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Neil J. Bateson Bateson Enterprises, Inc. ~ I LERt 1'Y THA "ti[ trP Tl1 � `-t++'1'.A.. K , All DA.. _!•to,t 7I.41b 1- UJ . ;. 1,.,i, )c ++F ,(-.Eh1 • PCPERTY DESCRIPTION FROM FORM' •A'BY PLAJSTOW CONSULTANTS INC, i jrt`UNO , IVN r(LOCArION A` SUMEO ) T I 1 : O 19 _ 10' CE T i 1 LA -E- 12-16-,L37. S LE 1-40 t G f,— r t 4 212.71 5T11\1E' 21OA7 ?_Q9 90 f o -t3ax iNLu 209. jo PIT`1 208,47 PIT•Z 204D 4 CE T i 1 LA -E- 12-16-,L37. S LE 1-40 t G f,— r t 4 �Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 981 Johnson Street Property Address Owner Martha Westphal l Owners Name l information is Ss required for North Andover MA 01845 5/18/2015 every page. City/Town State Zip Code Date of Inspection jv 6 9 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. _ .���►rt�VCA Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. ISI A. General Information Inspector: MAY 27 2015 SFO. Neil Bateson TOWN OTN ®� RRTH MDEONT R Name of Inspector r Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover City/Town 978-475-4786 Telephone Number B. Certification MA State S115 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Ned urther valuation by the Local Approving Authority " (- 5/18/2015 Ins e r Signature V 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 hoi( the system will perform in the future under the same or different conditions of use. t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 981 Johnson Street Property Address Martha Westphal Owners Name North Andover City/Town B. Certification (cont.) MA 01845 State Zip Code 5/18/2015 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): t5ins • 3113 Title 5 Official Inspection form: Subsurface Sewage Disposal System •Page 2 of 17 I L, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 981 Johnson Street Property Address Martha Westphal Owner Owner's Name information is required for North Andover MA 01845 5/18/2015 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 981 Johnson Street Property Address Martha Westphal Owner's Name North Andover Cityfrown B. Certification (cont.) MA 01845 State Zip Code 5/18/2015 Date of Inspection 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/Z day flow t5ins • 3/13 Title 5 official Inspection Form: Subsurface Sewage Disposal System •Page 4 of 17 ❑ ® 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 1:1 El 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 Ins pedion Forth: Subsurface Sewage Disposal System •Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .•'` 981 Johnson Street Property Address Martha Westphal Owner Owner's Name information is required for North Andover MA 01845 5/18/2015 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® 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 1:1 El 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 Ins pedion Forth: 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 '°< 981 Johnson Street Property Address Martha Westphal Owner Owner's Name information is required for North Andover MA 01845 every page. Cityrrown State Zip Code C. Checklist 5/18/2015 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)] 1 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): t5ins • 3/13 Tide 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 �K\', Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 981 Johnson Street Property Address Martha Westphal Owner Owner's Name information is required for North Andover MA 01845 5/18/2015 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/industrial Flow Conditions: Type of Establishment: Design flow (based on 31.0 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ® Yes ❑ No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ® No Yes ® Yes ❑ No Current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts ED Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 981 Johnson Street Property Address Martha Westphal Owner Owner's Name information is required for North Andover MA 01845 5/18/2015 every 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 2014, owner gallons Type of System: ® Septic tank, distribution box, soil absorption'system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Owner information is required for every page. t5ins • 3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 981 Johnson Street Property Address Martha Westphal Owner's Name North Andover MA 01845 5/18/2015 Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Septic tank & d -box was replaced 2005. Pits were installed 12/16/1983, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 1.6 feet Material of construction: ® cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" Cast iron through wall, 3"PVC in house, No leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal U feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 10'x 5' x 4' Sludge depth: 2" ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 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 981 Johnson Street Property Address Martha Westphal Owner's Name North Andover MA 01845 5/18/2015 CiWrown State Zip Code D. System Information (cont.) 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 How were dimensions determined? Date of Inspection 21- 8" "8" 13" 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 tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness ❑ fiberglass Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: feet ❑ polyethylene ❑ other (explain): Date t5ins • 3l13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 981 Johnson Street Property Address Martha Westphal Owner Owner's Name information is required for North Andover MA 01845 5/18/2015 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: Design Flow: Alarm present: Alarm level: gallons 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 • 3/13 Title 5 Official Inspection Fonn: 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 981 Johnson Street Property Address Martha Westphal Owner's Name North Andover MA 01845 5/18/2015 Cityfrown 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 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D -box level & distribution equal, has flow levelers. No evidence of leakage. Evidence of carryover, pumped d -box to clean. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 3113 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 12 of 17 4, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 981 Johnson Street Property Address Martha Westphal Owner Owner's Name information is required for North Andover MA 01845 5/18/2015 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ 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.): Soil Ok. Vegetation ok. No sign of ponding to surface. Camera inside of pits through outlets in d -box , no liquid to inverts. 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 Title 5 Official Insp Subsurface Sewage Disposal System Form 981 Johnson Street 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 ection Form - Not for Voluntary Assessments Property Address Martha Westphal Owner Owner's Name information is required for North Andover MA 01845 5/18/2015 every page. Cityrrown 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 981 Johnson Street Property Address Martha Westphal Owner Owner's Name information is required for North Andover MA 01845 5/18/2015 every page. Citylrown 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 '.ve Rz� � w I Aa 0-" P� t t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 981 Johnson Street Property Address Martha Westphal Owner's Name North Andover MA 01845. 5/18/2015 City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 4 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 12/16/1983 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Design plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: As per test pit data on design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 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 981 Johnson Street Property Address Martha Westphal Owner's Name North Andover MA 01845 5/18/2015 City/Town State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems) completed E System Information — Estimated depth to high groundwater E 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 4 Summary Record Card generated on 5/11/2015 9:40:05 AM by Maureen McAuley Town of North Andover Tax Map # 210-107.A-0222-0000.0 Parcel Id 18028 981 JOHNSON STREET MARTHA ANN TRACY WESTPHAL 981 JOHNSON STREET NORTH ANDOVER, MA 01845 Page 1 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.03 Acres FY 2015 UB Mailing-index Name/Address Type Loan Number Active/Inact. From Until MARTHAANN TRACY WESTPHAL Owner 981 JOHNSON STREET NORTH ANDOVER, MA 01845 WAHL,.MARTIN Previous Customer Inactive 6/23/2005 981 JOHNSON STREET NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 13891.0 - 981 JOHNSON STREET Last Billing Date 3/5/2015 2100677 02 Cycle 02 Active UB Services Maint. Account No. 2100677 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 45.60 /1 UB Meter Maintenance Account No. 2100677 Serial No Status Location Brand Type Size YTD Cons 13242117 a Active ERT HH METE METE w Water 0.63 0.63 543 Date Reading Code Consumption Posted Date Variance 5/5/2015 1018 a Actual 13 10% 2/3/2015 1005 a Actual 12 3/20/2015 8% 11/3/2014 993 aActual 11 12/15/2014 -10% 8/4/2014 982 aActual 12 9/11/2014 -5% 5/7/2014 970 a Actual 13 6/12/2014 13% 2/4/2014 957 a Actual 12 3/17/2014 -13% 10/31/2013 945 aActual 13 12/20/2013 12% 8/2/2013 932 a Actual 12 9/18/2013 -9% 5/1/2013 920 aActual 12 6/18/2013 -32% 2/5/2013 908 a Actual 20 3/13/2013 2% 10/31/2012 888 aActual 18 12/13/2012 -34% 8/3/2012 870 a Actual 28 9/26/2012 46% 5/3/2012 842 a Actual 19 6/20/2012 -19% 2/2/2012 823 a Actual 24 3/14/2012 -13% 11/1/2011 799 aActual 27 12/15/2011 -33% 8/2/2011 772 a Actual 40 9/14/2011 139% 5/4/2011 732 a Actual 16 6/13/2011 -9% 2/7/2011 716 a Actual 20 3/15/2011 -13% 11/1/2010 696 aActual 21 12/13/2010 -15% 8/3/2010 675 a Actual 25 9/13/2010 39% 5/4/2010 650 a Actual 18 6/9/2010 -9% 2/2/2010 632 aActual 20 3/11/2010 -8% 11/2/2009 612 aActual 21 12/11/2009 -12% 8/5/2009 591 aActual 25 9/11/2009 -9% 5/4/2009 566 a Actual 26 6/16/2009 24% 2/5/2009 540 a Actual 22 3/16/2009 -7% Commonwealth of Massachusetts !� ' = City/Town of System Pumping- Records' S YTowN ur , i Form 4 H&4 , 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 Ahis 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 ih�of Left / Right rear of house, Left / right side of house, Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address Cidy/Town State Trp Code 2. System Owner. Address (if different from location) City/'rown B. Pumping Record 1. Date of Pumping 3. Type of system. ❑ ❑ Other (describe): Lc-c95-i�-( — 2. Quantity Pumped Septic Tank Date Cesspool(s) State Lf Trp Code ; Telephone Number 1 Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yeas LSO If yes, was it cleaned? ❑ Yes ❑ No; 5. Condition of Sy tem: 6. System Pumped By: 7. Neil. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company contents were disposed: t5form4.doc- 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts _ City/Town of W° System Pumping Record DEC 16 2011 Form 4 TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. Other forms rA2=U&N-1 I 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 / Right front of house, Left / Right rear of house, Left / right side of house, Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck City/Town 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ State Zip Code Stat ty —466n 4 C6Zi�Code Telephone Number C25-_ rc:�— � ( s----� -) Date 2. Quantity Pumped: Gallons Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condi ion of S st, � em:� u� 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Locafion--where contents were disposed: xll"CG. LS. Lowell Waste Water 04 F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 rot * i a' A PUBLIC HEALTH DEPARTMENT Community Development Division 6 q 915chn�4. To: All North Andover Residents with Septic Systems and Garbage Grinders Please note that due to recent reviews of Title 5 Reports, your property has been identified as maintaining a working garbage grinder that is being used in conjunction with a septic system. The Health Department is concerned for the longevity of your septic system. Garbage grinders are never recommended where septic systems are used, but if they are installed, the system must be specifically designed to handle the waste from them; your system can not handle the waste as designed. Please note that continued use of this grinder could quickly cause a pre -mature failure of your septic system, resulting in a large expenditure to replace it. The North Andover Health Department recommends that you remove it from your home as soon as possible. Some information regarding regular maintenance of your septic system is attached. Please call the Health Department --at 978.688.9540 if you have any questions, or e-mail your questions to: healthdept(cc�townofnorthandover. com. Thank you for taking the time to consider the impact that your current setup has on your septic system and'the environment. Sincerely, Susan Y. Sawyer, REHS ;r Public Health Director /pfd Enc: Septic System Information: http://www.mass. og v/de-o/water/wastewater/dodont htm 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web http://www.townofnortharidover.com 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 City/Town of ZFe. ED System Pumping Record 2009 Form 4 ANDOVER DEP has provided this form for use by local Boards of used, but the information must be substantially the same as that prousing 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 front, left rear, left side of house igh front, r ght rear, right si of Nous . Address Citylrown State �f �J �Zip Code l� 2. System Owner: Name Address (if different from location) Cityrrown B. Pumping Record 1. Date of Pumping 3. Type of system: El State /1 7,ip c Telephone Number (O Date 2. Quantity Pumped Cesspool(s) Septic Tank Other (describe): 4. Effluent Tee Filter present? [I Yes CrNo l S� Gallons Tight Tank If yes, was it cleaned? 0 Yes [j No 5. Condition of System: (euak� d����. 6. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatjomere contents were disposed: S. Lowell Waste Water 4.L.0 r igna ure of H "r Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts RECEIVE® City/Town of System Pumping Record JUN o 9 2008 arm FOriYI 4 TOWN OF NORTH , ikj,'.st, HEALTH DEPART E Vl Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. DEP has provided this form for use by local Boards of Health. Oth 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 City/Town 2. System Owner: Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping Q�) —'-�—>—� Date Zip Code State �� ^ 4( Tip Code Telephone Number rcO Quantity Pumped: c� Gallons 3. Type of system: ❑ Cesspool(s) 2-1S p is Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 2 -No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition System:tc-o�-,ej � 6. System um-P--��al\ p�31 Name Vehicle License Number Company 7. Location vftre contents m c, L-�, 'M➢ t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 TOWN OF NORTH ANDOVEP, SYSTEM PUMPINQ UCC)KD 9V Johnson ��- OU- alvdovet / %y%Cj' DATEOFPVWNQ:__. NTTTY PUMPED; VtSSPOOL: NO­"......yF,8 sop(ic link: tqu Es NArURUOF5BRVICE: R0u'rlNE.­-'..6MER0bNC'y zn5 ObsId-AVAT10N& 0400\JER GOOD CONDITION FULL'M CoyER0 -T HEAVY OREMB BAFFLES IN PLACE VAEN- ROOTS LEACKFIBLD RVNBACK 5=4161VE SOLIDS FLOODED -SOLID CAKAY0YBR­­ 07ifER EXPLAIN VUMMENTS. L:vNi*twr,s rmwem&) ru w &A DATE OF PLIMplNo: 0 TOWN OF NORTH ANDOVE?, JAN 6 2005 SYSTEM PUMPINQ UCORL) TD, ,.r, - r -005 ]�ER T�l -"""OVER L KESS SYSTEM YITEM LOCATION 0 k:krSSPOOL: SOPtic Tank: NU YESX NA rURE OF SERVICE: ROU-rINE� UbsF.RvA*rlQN3; 000V CON'DI'TION PULL 'M COVER HEAVY ORWE BAFFLES IN PLACE. ROOTS LWKnELD RUNBACK 8XCESSIVE SOL]IDS.__. FLOODED SOLID CARRYOVER .,_. OTKER EXPLAIN NYstom Pwnp,.d by 0 )IZ7" 4na VUMMENTS. CUN mm's rKANsybxKfjL) I'Ll w 13 EZ9 O ti. . TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD lee, g APR - 7 2003 TEM OWNER & ADDRESS SYSTEM LOCATION k (example: left front of house) /eft x e -, 'A v / w 111M. U \,IC OF PUMPING: to QUANTITY P U M P C D /600 C LLc��� NO YES SEPTIC TANK: NO YES ATURE OF SERVICE: ROUTINE EMERCENCY lel F[I VATIONS: GOOD CONDITION. FULL TO COVER HFAVY CREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK CXCESSIYE SOLIDS FLOODED SOLIDS CARRYOVER O�HFR (EXPLAIN) i / l u1 1.1yi FLATS: � UN I l;'.N I'S' T)I ANSf CIZRED TO: G 0 TOWN OF NORTH ANDOVER ; SOT 2 5 201 SYSTEM PUMPING RECORD DATE: 1P -- l�l�C� 1 'STEM OWNER & ADDRESS U�� 1 SYSTEM LOCATION (example: left front of house) 0 q DATE OF PUMPING:' Of tO"6UANTITY PUMPED / GALLONS CESSPOOL: NO YES SEPTIC TANK: NO' YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: CONTENTS TRANSFERRED TO: CO- L, FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) 0 Commonwealth of Massachusetts M° Massachusetts Svstem Pumping Record System Owner f,� �,Os Date of Pumping. G( (g-- 9q Cesspool: No l lf- Yes Ll System Location C� is c -3-o Wn—<�" 3 -j - Quantity Pumped: (5-4c�gallons Septic Tank: No U Yes [4---� System Pumped by: vared re 50&'tft ed License # Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: 4 ARGEO PAUL CELLUCCI Governor C n COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS .O. -W Cv�u� DEPARTMENT OF ENVIRONMENTAL. PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 NOF NORTH ANDOVER/ BOARD OF HEALTH TRUDY CORE i�iFtR 19 , Secretary i DAVID B. STRUHS s— -'-- '_-�Cottimissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A -1 �` CERTiRCATiON Property Aaarcsa: ELJ 1/W\ `S Name of Owner't� l j 9M t�� Address of Owner:. �z� t V [J+►__h_ ��1^y Date of Inspection: — 1 O .� l , r O `� � ko ul I me Naof Inspector: (Please Print) r 1 ams DM am ved system '"Wectmpursuarrt to Section 15.340 of Tide 5 (310 CMR 15.000) Company Name: C `�`a0� Y\ 1-P S ' . �v1en MmTrng Address: V r (Ho' o I g/ U Telephone Number: Q 1 z ) 7e CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of 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 T Needs Further Evaluation By the Local Approving Authority F 'Is (2 Inspector's Signatrre: / `" Date: .' I 11_� The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)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. NOTES AND COMMENTS revised 9/2/98 Page 1 of 11 0 Printed on Recycled Paper 0 SUBSURFACE SEWAGE DISPOSAL SYSTEM NSPECTION FORM PART A CERTIFICATION (continued) Property Owner: U Y<OS Date of Inspection: INSPECTION SUMMARY: Check A, B, C, or A A. SYS ES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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. Indicate yes, 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is 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 complying septic tank as approved by the Board of Health. _ 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(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Proporty Address: q 6 I ����►�SC�i1 �;� I{'� ��--� Owner: PC) Date of brspectioq: O 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 the public health, safety and 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 N A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER. IF ANY) DETERMINES THAT THE SYSTEM IS FUNCTIONING N A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone i of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or mote from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER m: revised 9/2/98 Page 3ofIt • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: q�-S 1 J _ �►�S�]h 1�%� � �C1Q�t' P� Owner: Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described In 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS 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 then 6" below invert or available volume is less than 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipets). 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. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: 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: 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412). Please consult the focal regional office of the Department for further inforpnation. revised 9/2/98 Page 4of11 C O SUBSURFACE SEWAGE (DISPOSAL SYSTEM WSPECTION FORM PART B CHECKLIST Property Address: Owner: � Date of Inspection: ok 3 - i 0_q Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes e— information by the or Board Health. Pumping was provided owner, occupant, of _✓ _ None of the system components have been pumped for at least two weeks and the system hes been-receivingtttinn flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this Inspection. 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. The system does not receive non -sanitary or industrial waste flow. The site was inspected for signs of breakout. / All system components, excluding the Soil Absorption System, have been located on the site. The 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. /�– The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H. L� Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)l _The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SubSurface Disposal Systems. i revised 9/2/98 PageSofll SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM IIFORMATION Property Address:`l�G�1� 4 "`"'-"--�`�'�-''� Owner: cc Date of k,spe" : o 3 ( o r �� FLOW CONDITIONS RESIDENTIAL: Design flow. V 5gg.p.d./bedro m. Number of bedrooms (design): Number of bedrooms (actual) Total DESIGN flow (des Number of current residents: Garbage grinder lyes or no):_N�6S Laundry (separate system) (yes or no):AJO If yes, separate. inspection required Laundry system inspected (yes or no) -A0 Seasonal use (yes or no): No -4 5'7000 + 7 S t -1a7, 5� 1 ` Water meter readings, if available (last two year's usage (gpd): :'T. d h CLQ -� Sump Pump (yes or no): Nd t Last date of occupancy: c) \ L4 COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gpd 1 Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non -sanitary waste discharged to the Title 5 system: (yes or no)_, Water meter readings, if available: Last date of occupancy: OTHER: (Describe) ' Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: I J CQ R System pumped as part of ins action: (yes or no) Q-> If yes, volume pumped: E t� allo s Reason for pumping: I V\S Q_C3jj��k--- TYPE OF Septic tank/distribution box/soil absorption system Single cesspool , Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other t/ APPRO MATE AGE of p11 components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: lyes or no) NQ revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM NSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Addressr f V� �� S� �0� 4"t- J of Owner: PC) �� o Date of inspection: Io -9 ef BUILDING SEWERL,- - (Locate on site plan) tt Depth below grade: a n Material of construction, ✓cast iron t-40 PVCothe C�c�- ;coV\ �Cu qua Distance fro. rrl ppvate water supply well or suction line Diameter t f of joints, venting, evidence of leakage, etc.) SEPTIC TANK-L--- (locate ANK:t/(locate on site plan) �I Depth below grade: Material of construction: _oncretemetal _Fiberglass _Polyethylene ,_„.other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance ,_ (YeslNo) Dimensions: 10 � � `X t�7 ! x7i IS. Sludge depth: L4 r / . Distance from top of sludge to bottom of outlet tee or baffle: ­)' Scum thickness:—a " I1 Distance from top of scum to top of outlet tee or baffle: I q If Distance from bottom of scum to bo om�off qutllet tee r b ffle: How dimensions were determined: U XNA �G Ar Comments: (recommendation for pum evidence of leakaige, etc#) GREASE TRAP•_Q \,ie (locate on site plan) or baffles, depth of liquid level in Depth below grade:_ 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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, i¢tructural integrity, evidence of leakage, etc.) revised 9/2/98 Page 7of11 LJ � �.f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMA,TIION�(co�jndwed) Property address: Owner: Date of Inspection: TIGHT OR HOLDING TANK:nVIS�A� (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade: Material of construction: _ concrete _metal _Fiberglass _Polyethylene „other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order: Yes _ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: C> Comments: (\ (note if i vela dis ributiop`i ual, evidence of solid�,car er, evince of leakage int r o'of ox,ketc. C)- to /1 VVi� Pmt y CAN` - 1 Ci'R ow moi_ W GLS I i G (P-k&7F. PUMP CHAMBER: VO "t= —�( �lJ I S�S--Q.A_ (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8of11 . C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMA PART C SYSTEMA INFORMATION (cowed) Property Address! Gi � ( z O �Y-<� S'- / SCJ C ``� u, Owner: �� S Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, location may be approximated by non -intrusive methods) If not located, explain: Type: leaching pits, number:r� leaching chambers, number:_ . leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: CESSPOOLSALONke (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 (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: <Q (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.) 4 revised 9/2/98 Page4ofll u� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (con*KNdl Property Address q S, i o�Y�� 10 CA—kA- 44 Owne.Date \—C C — Q S Date of Inspection: , 3-10-90t SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) OPropeirty Address: Date of ktspactiorn: �okOs NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Ll Feet Please indicate II the methods used to determine High Groundwater Elevation: r btained from Design Plans on record Qtew Obse ite (Abu lig property, observation hole, basement sump etc.) Determi from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) revised 9/2/98 Page 11 of 11 c Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating -Water.& sewer Lines -Septic Systems & Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: q e5t --'Y��y\Sc-jr\�� �b0-k1,94"14)U?,C Owner: Date of Inspection: 3 `� My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations,and I hereby disclaim any further operation of your current septic system. /) Neil J. "Bateson Bateson Enterprises, Inc. f r. I i • ' COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 0V r6lfW50N CE Owner's Name: wRRL. 7.RECEIVED Owner's Address: Date of Inspection: s 3/as" AY 18 2005 Name of Inspector: (please print) 54-t" QUSA T�HEA�LTH DEPARTM TER Company Name: �fJrJ/LTff.��ST FNy/RO�Viti1/TAL Mailing Address: tU6CMNsT DA-N!/X�,eS Al/f Telephone Number: 97�-7/L —SyOS !c CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: Passes ✓Conditionally Passes Needs Further Evaluation by the Local Approving Authority .. Fails Inspector's Signature: Date: 3 - °-r The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments S EF P A 6 E Z, — 02 / 6 iNAG TO QE 114/45:D ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Pie 2 of I I' . •` , OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 9<9/ .TV #AISON T7— AICl/Z_)'7q AV,00tl6e Owner: 0A1/L 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: P'*"* One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. y�$ ✓ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass. inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: A10 Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain: ND The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND explain: 1 --Page 3.of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 99,1 J'Q14NSON sT A2-ne7%I Amt 6'7,P Owner: W ASL Date of Inspection:3/rt5" C. Further Evaluation is Required by the Board of Health: A11 A 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 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 I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 K� r � • OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: f -/ ,7011/41SOIV S-7— Owner: '7Owner: Q L _ Date of Inspection: 1 IF D. System Failure Criteria applicable to all systems: You must indicate "yes"' or "no" to each of the following for all inspections: Yes No eBackup 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 _A�/f1 Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface 7 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 front a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] NO (YPescr)ibed he system fails. I have determined that one or more of the above failure criteria exist as 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: �/c To be considered a large the system must serve a facility with a design now of 10,000 gpd to 15,000 gpd. You must indicate either "yes" or "no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well _ If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. " Page 5 of 11 ,X r OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ?tql /V IS7— _-A)0A'-7# ANdOV" Owner: Date of Inspection: �n 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 �5 iLwA,rzn, ✓ 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 ? — r 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 ? V/ _ 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: Yes no v"-- 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) [3 10 CMR 15.302(3)(b)] 5 Page 6 of 11 ,,. r e►. R r I r 0 R OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 9 g/ 70HA,'JoN 57- Nd�17Y /4N00(J/�,Q Owner• tkA/,:G Date of Inspection: yr O FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: 2 - Does Does residence have a garbage grinder (yes or no): il/D Is laundry on a separate sewage system (yes or no): 1,V [if yes separate inspection required] Laundry system inspected (yes or no): �fj Seasonal use: (yes or no): AVO Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or no): A10 Last date of occupancy: /-- COMMERCIAL/INDUSTRIAL COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): _ gpd Basis of design flow (seats/persons/sgft,etc.): Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): Non -sanitary waste discharged to the Title 5 system (yes or no): _ Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records I Source of information: 30f-{ Z STe U-ArzT5 r 0(0VG.QS Was system pumped as part of the inspection (yes or no):e,65 If yes, volume pumped: /SV gallons -- How was quantity pumped determined? 0A6£z_4 to Reason for pumping: 77.oAJ TYPE OF SYSTEM _✓Septic tank, distribution box, soil absorption system _ Single cesspool Overflow cesspool Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) _ Tight tank _ Attach a copy of the DEP approval Other (describe): Approximate age of all components, date installed (if know) and source of information: --1 z YDS Were sewage odors detected when arriving at the site (yes or no): NO -* Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 99/ 'To H'VS6'V S Owner: Date of Inspection: BUILDING SEWER (locate on site plan) Depth below grade:1,� Materials of construction: _cast iron ✓ 40 PVC _other (explain): Distance from private water supply well or suction line: Comments (on condition of joints, vent , evidence of leakage, etc.): 6oc>'o C and ii74V SEPTIC TANK: _ (locate on site plan) Depth below grade: Material of construction: P-Oconcrete _metal _fiberglass _polyethylene —other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) I Dimensions: G X// X a Aprok i s r*, a Sludge depth: / " Distance from top of sludge to bottom of outlet tee or baffle: .Z 9' Scum thickness: D" Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle:' How were dimensions determined: F i 4110 019,5–_'..P W -D 1)6 t–ANS Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): GREASE TRAP: _(locate on site plan) Depth below grade: 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: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 ,a. * • Page 8 of 1 I ` s OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: vn111U b,/ ST Owner: QA f)G Date of Inspection: TIGHT or HOLDING TANK: jotank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: 1✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: O �� Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Kboz) ('©n_.,U/ n oA_1 PUMP CHAMBER:ocate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): 8 -W. « es i Page 9 of 11 - OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 9el 7a1VA1S01V ST - .f blz77-1 Owner: LtJA� Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type // ✓ leaching pits, number: 2, f S, x , e A*.o , I -e,,- C_ e,7 k,,ed i,7 /9t 'x 1 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.): it Q o T H f �l�a�►+�t D�,� S 14AL1,6"- z" oc T,� 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 or no): Comments (note condition of soil, signs of hydraulic .failure, level of ponding, condition of vegetation, etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page l0;of 11 # A OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION (continued) Property Address: ( e/ 16 /Wso/v sr Owner: 4j lMOO-774 l+ L Date of Inspection: F 11 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. SEE A-TTPcNEi) SHFIF- 5 '-IZ+ 7"13 ALsd) t. I. i V F W A V 1 +4 -OL -5 F- 10 A x 5 7-1%ET-- Page 1 I of 11 • OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION (continued) Property Address: &/ 7011,160A) 57" Owner: cu I+H4 Date of Inspection: SITE EXAM Slope 9-1576, Surface water > q6v Check cellar /VO U 1— Agyp Ov111P Shallow wells > 7 Estimated depth to ground water %,,.deet Please indicate (check) all methods used to determine the high ground water elevation: PasObtained from system design plans on record - If checked, date of design plan reviewed: 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: y"/L L �A�2,F�Ni` /`1i4 T 2.,,A /_ . Vl? h` i//IIuS TiS'S r i0/ wT, r� CTOWn of North Andover 4J Office of the Health Department Community Development and Services Division 400 OSGOOD STREET North Andover, Massachusetts 01845 Susan Y. Sawyer, REHS/RS Public Health Director 978.688.9540 - Phone 978.688.8476 - Fax CEq7I�FIGA�IE OAF C09K<1'GIANCE As of: ,dune 15, 2005 q -his is to cert that the individua(subsurface di sposaf system Constructed(L) or Repaired—Septic lank 6� D-Bo,-� (X) 6y Todd (Bateson at 981,7ohnson Street North Andover, JKA 01845 has been instaffed in accordance with the provisions of 7itfe v of the State Sanitary Code and with the North Andover0oardofWea(th regulations. 'The Issuance _of this certificate shalf not 6e construed as a guarantee that the system wiCC function actorily. Sushn T Sawyer Puffic Ifealth (Director BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 TOWN OF NORTH ANDOVER NORTH Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 27 CHARLES STREET NORTH ANDOVER MASSACHUSETTS 01845 ''�S Susan Y. Sawyer, R.EHS/RS 978.688.9540 — Phone Public Health Director 978.688.9542 — FAX SEPTIC SYSTEM CONSTRUCTION NOTES ADDRESS: �I� / a �.,, -SS+-MAP:_ LOT: INSTALLER: 7'"e.�d t3afzs®, DESIGNER: PLAN DATE: cr►-, BOH APPROVAL DATE ON PLAN: DATE OF BED BOTTOM INSPECTION: -S': S 2 , - , 4- -"47. & z...+ DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SELECT SYSTEM TYPE GRAVITY DISTRIBUTION PRESSURE DISTRIBUTION PRESSURE DOSING HOLDING TANK ADVANCED TREATMENT OTHER COMPONENT SUMMARY FROM PLAN GALLON TANK = 1.5'0 LOADING OF SEPTIC TANK = GALLON PUMP CHAMBER = LOADING OF PUMP CHAMBER = TYPE OF SAS = DIMENSIONS AND DETAILS OF SAS: SITE CONDITIONS Comments: Existing septic tank properly abandoned AlAlInternal plumbing all to one building sewer ❑ Topography not appreciably altered Page 1 of 2 TOWN OF NORTH ANDOVER "Th Office of COMMUNITY DEVELOPMENT AND SERVICES �r�9 v? ffl `gyooL HEALTH DEPARTMENT • " .. _ A 27 CHARLES STREET NORTH ANDOVER, MASSACI-IUSETTS 01845 �CNUS Susan Y. Sawyer, REHSIRS 978.688.9540 — Phone Public Health Director 978.688.9542 — FAX SEPTIC TANK l Bottom of tank hole has 6" stone base El7 Weep hole plugged L---* -+ -- �- y ❑ 1Sn ballon tank has been installed (H-10 or H-20) (monolithic or 2 piece) ❑ Water tightness of tank has been achieved (Visual or Vacuum Test or Water held for 24hrs) ❑ Inlet tee installed, under access port Outlet tee (gas baffle or effluent filter) installed, under access port ❑ inch cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present L Hydraulic cement around inlet & outlet Comments: / PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑'-,,Weep hole plugged ❑ g on Pump Chamber installed (H-10 H-20) (monolithic or 2 piece) ❑ Inlet tee in Iled, under access port ❑ Pump(s) instal on stable base ❑ Alarm float working ❑ Pump On/Off float works ❑ Drain hole in pressure line ❑ inch cover to within 6" of fin rade installed over one access port ❑ Water tightness of tank has been achi d Visual or Vacuum Test or Water he or 24 hrs ❑ Hydraulic cement around inlet & outlet Comments: Page 2 of 2 f f , i TOWN OF NORTH ANDOVER F KaRTH q Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT I.= A 27 CHA.RI.ES STREET NORTH ANDOVER, MASSACHUSETTS 01845 3�s°"^r`°'`£<� S�C/iUs Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.9542 — FAX D -BOX Installed on stable stone base Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets Observed even distribution Speed levelers provided (not required) Comments: SOIL ABSORPTION SYSTEM ❑ Bottom of SAS excav ed w' to soil layer, as provided on plan Size of SAS exca t as pe plan ❑ Title 5 sand inst I d, if spec' ied on plan 3/4-1 Y2" doub ed sto a installed 1/8-1/2"(pe ne) double ashed stone installed lateral ns led and ends connected to header (and ven d if i pervious mat ial above) Or' ices 5 & 7 o'clock ositions ravel ss disposal systems: type, number and ocati as per plan Elev ions of laterals installed as on approved plan 40 it HDPE barrier installed ❑ Re ining wall (boulder / concrete / timber/ block) ❑ Fi al cover as per plan Comments: PRESSURE DISTRIBUTION ❑ inch manifold ❑ laterals installed with end sweeps size: material: ❑ Squirt test ft in height ❑ Equal distribution to all laterals ❑ orifice size inch as per plan Comments: Page 3 of 3 TOWN OF NORTH ANDOVER of ro y ftTq Office of COMMUNITY DEVELOPMENT AND SERVICE S �? ��'` .,6.,"°t HEALTH DEPARTMENT n 27 CHARLES STREET �a NORTH ANDOVER, MASSACHUSETTS 01845 5+1CNUSE Susan Y. Sawyer, R.EHS/RS 97$.688.9540 -Phone Public Health Director 978.688.9542 - FAX CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: ❑ Comments: Rated for exterior if placed outside SYSTEM ELEVATIONS Benchmark: Rod at Benchmark: Height of Instrument: INVERT ON DESIGN PLAN ELEV TOP OF PIPE INVERT ELEVATION Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN D -Box OUT Manifold Lateral 1 HIGH Lateral 1 LOW Lateral 2 HIGH Lateral 2 LOW Lateral 3 HIGH Lateral 3 LOW Lateral 4 HIGH Lateral 4 LOW Lateral 5 HIGH Lateral 5 LOW Page 4 of 4 r MOATM �, Commonwealth of Massachusetts Map -Block -Lot ?O; ..a° •• yo 107.A- 0222 - 1 Board of Health Permit No • _t _ s BHP -2005-0130 -- North Andover ____-_-_ • o, _._.» .. ' P.I. FEE ass KNust� F.I. ---- $125.00 Disposal Works Construction Permit Permission is hereby granted Todd Bateson - - - - ---- -- to (Repair-Tank,D-Box,Pipe) an Individual Sewage Disposal System. at No 981 JOHNSON STREET -- ------------- - as shown on the application for Disposal Works Construction Permit No. BHP -20057013 Dated May -27,200-5 ------------ - - �`-/-- Issued On: May -27-2005 Board of Health pOWTm Map -Block -Lot o�•,,.° . �ti Commonwealth of Massachusetts 107.A- 0222 - SO Board of Health t North Andover �� Certificate of Compliance °sic»os� THIS i'S TO CERTIFY,That the Individual Sewage D' a System (Repair-Tank,D-Box,Pipe) by Todd Bateson ----------------------- - - -- ---------------- ------------------- Installer at No 981 JOHNSON STREET ,,-- ----------------------- - ----------------------- --------------- -- ------------ - --- ---------------- has been installed in accordan ith the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. BHP -2005-013 Dated - - May_ 27_,_ 2005 --------- - - _ - Printed On: Jun -15-2005 Board of Health ---------------------- --- ------ 11 --------------- - -- - .u.. nnn. ......u.0 n. nnnn.00•....uu...uo................................ r.... ,. ..... ..�s.e..... w. .....0 li,!.... ...� .r.. . .. .V.V11...el�J �✓ 0 TOWN OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 400 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845o c iggyb 978.688.9540 — Phone Susan Y. Sawyer, REHS/RS 978.688.9542 — FAX Public Health Director heaithdegt(a-townofnorthandover.com - e-mail www.townofnorthandover.com - website APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: --�� LOCATION: LICENSED INSTALLER NAME. PLEASE PRINT SIGNATURE: TELEPHONE# 4 CHECK ONE: FULL SYSTEM REPAIR: ($250) VCOMPONENT REPAIR (indicate what parts)�� �� �X ($125) * NEW CONSTRUCTION: * If NEW CONSTRUCTION, please attach the Foundation As -Built Plan. $250.00 or 125 Fee Attached? Project Manager O i n rom Attached? Foundation As -Built? Floor Plans? Yes_ Nom Yes No Yes No Yes No Approval of Health Agent Date: ��"V-5 INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at 6 g I Ae h AAS,1N 51 relative to the application of ° .84 -&&/dated -*S-- oS`e�' for plans by and dated with revisions dated I understand the following obligations for management of this project: 1. As the installer I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer I must call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item three shall be applicable. 3. As the installer I am required to have the necgssary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Tile 5 and the Board of Health Regulations may result in a $54.00 fine being levied against my company. a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As -built or verbal OK from engineer must be submitted to Board of Health, after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade — Installer must request inspection when all grading is complete. Does not have to be on site. 4. As the installer I understand that only I_may perform the work (other than simple excavation) required to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation or suspension of my license to operate in the Town of North Andover; significant fines to all persons involved are also possible. 5. As the Installer I understand that I must be on site during the performance of the following constructionsteps: a) Determination that the proper elevation of the excavation has been reached. b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff or consultant•chamber, retaining wall and other d) Installation of tank, D -box, pipes, stone, vent, pump components. 6. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersig d Licensed Septic Installer Date: -0 5 Disposal Works Construction Permit # Board of Hbalth BEPTIC SZSTEli North An ,.er .' a• INSTALLATICK CHECK LIST nn LOT" f w- J b ti DISUFRUVED �`+ ••^` 4D `' ea SDn3t 0 OK Distance Tot a. Wetlands b. Drains c.. Well 2. Water Line Location 3. No PPC Pipe 4. Septic Tank a. --Length & To Clean Out Covers _Tees b. Cement Pipe to Tank - On Both Sides of Tank 5. Distribution Box a. Covers k Box - No Cracks b. All Lines Flowing Squat Amounts r c. No Back Flow 6. Leach Field oTreach a. Dimensiods b. Stone th — c. Capp,6d Ends d. Cxn Double Washed Stone' 7. Leach Pits a. Dimensions b. Stone Depth c. Splash Pads d. Tees e. Cement Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. No Garbage -Disposal 9. Yir►a1 Grading Inspection 10. Barricading Covered System 11. - As Built Submitted a. Lot Location b. Dimensions of System c. -Location with Regard -to Perc Test d. Elevations e: Water Table ti ' l ,1 odd of Health ror+,., Indover,MaBs SUBSURFACE DISPOSAL DESIGN CHDCg LIST —�LOT iZ Xo*Vae`a ApPRCNED DATE DISAPPRU DATE Provi • Reasonss • Z A/C 3 At Title V FAIL CK Reg 2.5The submitted plan mint show as a mf ni �m; the lot to be served -area, dimensions lot #,abutters location and log deep observation hoes -distance to ties location and results percolation tests -distance to ties design calculations & calculations showing required leaching area (e) location and dimensions of system -including reserve area f) g) existing and proposed contours location any vat areas Athin 100' of sere disposal system or • disclaimer -check wetlands mapping disposal h) surface and subsurface drains within 1001 of sejv�ge (i) system or disclaimer location any drainage easements within. 1001 of stege disposal system or disclairtir-Planning Board files disposal 6 �) kno= sources of water s=ply within 2401 of sevage _ k system or discl.ainer location of any proposed veil to serve lot -1001 from leaching facill ter lines on propErty-101 from leaching facility .location of mea I m) location of benchmark ® .000 �g) garbage disposals } (q) no PVC to be used in construction of system -elevations of basement, plumb, pipe, septic tank, profile distribution box inlets and outlets, distribution field piping and r) OtLer elevations ,�artrr-gym ground mater elution in area se disposal system j (s) plan rmst be prepared by a Professional Mg inser or ocher professional authorized by law to prepare such plans Reg 6Septic (a) Tanks capacities -150 of flow, water table, tees, depth of tees, access, pu-.ming cleanout 101 from cellar -.-ail or inground sera. ng pool I (d) 251 from subsurfa^e drains Reg 10.2I Distribution Foxes a) s ope greater than 0.08 Reg 10.1 I b) su� r SihCsAce DesiQ " { FAIL Reg 15.1 15.4 15.8 3.7 Reg 14.1 14.3 14.4 14.6 14.7 .10 Reg 9.1 9.6 Check' List Pa Pe 2 Leaching Pits /beaching pits are preferred where the installation is possible calculations of Ieachifig area -n nim„m 500 aq ft spacing �� face drainage 2 cover material ,2'x2 tx4II splash pad f tee at elbow g) no bends in pipe from d -box to pipe Leachin Fields a} no greater ti 0 minutes/inch b) area- 900 sq ft c} cons on of field d) surf a drainage 2 % e) 20 fpm cellar vl or-inground smarming pool Leaching �° renche a) calculations eaching area -fin 500 sq ft b) spacing -4 min 6 ft with reserve betueen c) dim-islq d) cons ction e) s - f) dace drainage 2% Do,,uhf.? !L PROFILE & PERCOLATION TEST ' '�A North Andover, Masa. Street No =0%A%1S0n1 ST Lot No Loc/Subdiv. Pland Owner I.ANI> VEST Investigator SE}A$00 Observer "TIZ i SOIL PROFILE DATES l.Elev 2.Elev 3.Elev 4.Elev S' 23 183 N. 0 0 0 T� S Ties Pits est -T- s 34 3 3 4 4 Til..l. Til\ 5 �'sToNES w S�t`IES 5 6 6 7r 7 8 1t.�o t 8 9 No we.TEQ. 3 9 9 10 l0 10 Benchmark Location Elevation Datum PERCOLATION TESTS SEs &1(,le3 41&&83 Pit Number 1(-V(' 2' (t 3 4 Start Saturatitma Soak -Minutes Z. 3 z: AO Start, a �S 8 Drop of 3" -Time 'i: 44 2: 5 Drop of 6" -Time `i: S I : o Mms - Ist 3" dry -I 13 Mins.2nd " Drcp -1 15 Percolation 4 S tc*.j0\k WErLe.I.—,D 5 (wrote Q)