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Home My WebLink AboutMiscellaneous - Exception (151)t ro Pi n `r ' • ,,,�'YY � x f .f _4 ��{.;� .wM[ 4r+1h� �ii+N yr r �1� '. - ..: � u:. � , � ,,. �. sir '' 2 "i _ .� •. r �}�� - �tl.....i •_��}i1� +Y .t . X�M✓S+.t�- r K,t,!7 {�� .1` _r:. ,. MAP # td j; n LOT �x -- PARCEL # STREET ' �ONSTRUCTIO.N APPROV _,. - HAS PLAN REVIEW FEE .BEEN PAID? YES NO PLAN APPROVAL: DATE PP. BY� DESIGNER: PLAN DA•f E. 0. 171 CONDITION WATER SUPPL WELL PERMIT WELL TESTS: COMMENTS: WELL DRILLER.`•_._•_ 6'"M 1 ICL BAC -TER I I BACTERIA II DAZE APPROVED DA 1 E ()PPRUVED DATE APPROVED FORM U APPROVAL: APPROVAL TO ISSUL- YES NO DATE ISSUED /` BY CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NU SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NO ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: BY: r•i t :x SPP C �SY�Z t't _� NSIBL.L$ZI.4Zl .J ri; 11 j � J •''\ :-}Y-. •, ..J• i 't•'+•e, ix'1 A'L t %� `tY—\ 1 ''�•'��t J i � _ _ _ 1 ' nr . YES, NO kr IS 'THE INSTALLER LICENSED? `.TYPE. OF CONSTRUCTION: NEW 'REPAIR ' NEW CONSTRUCTION:,.,. CERTIFIED PLOT PLAN REVIEW NO YES NO CONDITIONS OF:. APPROVAL �.: (FROM FORM U) "-ISSUANCE OF +DWC PERMIT r.,` YESJ NO • ' :r ` lf' , " INSTALLER: DWC PERMIT N0. - .'BEGIN.INSPECTION_ =' 0- -~ -NEEDED: :.: ='-_EXCAVATION .INSPECTION: _ , • •r %fix _ "�'4 •. . ` - .•' .I', BY ;PASSED -- - :'CONSTRUCTION INSPECTIONS NEEDED: ; AS BUILT PLAN SATISFACTb_. r tj APPROVAL. TO BACKFILL: DATE. " ,FINAL. GRADING APPROVAL: DATE 4#BY I1, DATE: BY ''' FINAL CONSTRUCTION APPROVAL: TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE: 09/24/99 This is to certify that the individual subsurface disposal system constructed ( x ) or repaired ( ) by Lou Baldoumas at Lot I Long Pasture Estates has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations as described in the Design Approval Site System Permit # 876 dated 4/4/97. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Board of Health Inspector 4 OF fv1li AiVi��V�R f M112 RtZ Si F1cA�LE u 1 1 tine► 0 1998 TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System constructed- ( ) repaired; by located at r_y v 1 '� , l'.. was installed in conformance with the North Andover Board of Health approved plan, System Design Permit 't-Z74—dated % % with an approved design flow of gallons per day. The materials used were in conformance with those specified on the approved plan; the system was installed in accordance with the provisions of 310 CiV1R 15.000, Title 5 and local regulations, and the final grading agrees substantially with the appZurd d plan. All work is accurately represented on the As -built which has been submitted tote . Bed inspection date: Final insl Installer: Design Engineer: Lic. 9:101 41 [) �IlDate: //. 31) - Date: /I 14 - AS -BUILT CHECKLIST LOT NUMBER, STREET NAME ASSESSORS MAP & PARCEL NUMBER LOT LINES & LOCATION OF DWELLINGS LOCATION & DEMENSIONS OF SYSTEM, INCLUDING RESERVE TIES TO LOT LINES & DWELLING, WELLS a. FROM SEPTIC TANK b. FROM LEACH AREA LOCATIONS OF DEEP HOLES & PERC TESTS ELEVATIONS OF DISPOSAL SYSTEM TOP OF FDN ELEVATION coo f r-� /'f-tEll cSi � LOCATIONS OF WELLS, DRAINS, WATERCOURSES W/IN 150' OF SYSTEM LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK & D -BOX STAMP & SIGNATURE IMPERVIOUS AREAS - DRIVEWAYS, ETC. NORTH ARROW FINAL CONTOURS fC LOCATION & ELEVATION OF BENCHMARK USED LOCUSPLAN Iv..x I , 1 114 --- - - ---- -1-1��, � Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor = do not use the return key. VQ reran Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 485 Forest Street Property Address William Nigro Owner's Name North Andover City/Town MA 01845 August 13, 2014 State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information Inspector: Mike Graham Name of Inspector Wind River Environmental Company Name 163 Western Ave Company Address Gloucester City/Town 978-282-7315 MA State 13560 Telephone Number License Number B. Certification AUG 27 2014 01930 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 an*complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority q r Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 485 Forest Street Property Address William Nigro Owner Owner's Name information is North Andover MA 01845 August 13, 2014 required for every 9 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 "2m Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 485 Forest Street Property Address William Nigro Owner Owner's Name information is required for every North Andover MA 01845 August 13, 2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ 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 • 3113 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 485 Forest Street Property Address William Nigro Owner's Name North Andover MA 01845 August 13, 2014 City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 485 Forest Street Property Address William Nigro Owner Owner's Name tiis required for every North Andover g MA 01845 August 13, 2014 for page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 i ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 485 Forest Street Property Address William Nigro Owner Owner's Name information is North Andover MA 01845 August 13 2014 required for every 9 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 485 Forest Street Property Address William Nigro Owner Owner's Name information is North Andover MA 01845 August 13, 2014 required for every g page. City/Town State Zip Code Date of Inspection D. System Information Description: Septic tank. distrubution box. SAS Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d .044 gpd 9 ( Y 9 (gpd)): Detail: Water records obtained. 242 x 7.5 / 730. Sump pump? ❑ Yes ® No Last date of occupancy: April 1, 2014 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 0 485 Forest Street M D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: MA 01845 State Zip Code Current Date General Information Was system pumped as part of the inspection? Owner/WRE August 13, 2014 Date of Inspection If yes, volume pumped: 1500 gallons gallons How was quantity pumped determined? Pump truck/tape measu Reason for pumping: Check structural intergri Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ® Yes ❑ No ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Property Address William Nigro Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: MA 01845 State Zip Code Current Date General Information Was system pumped as part of the inspection? Owner/WRE August 13, 2014 Date of Inspection If yes, volume pumped: 1500 gallons gallons How was quantity pumped determined? Pump truck/tape measu Reason for pumping: Check structural intergri Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ® Yes ❑ No ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 485 Forest Street Property Address William Nigro Owner Owner's Name information is required for every North Andover MA 01845 August 13, 2014 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: The system was installed on September 16, 1999. Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan) Depth below grade: Material of construction: ® cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: ❑ Yes ® No 33" feet feet Comments (on condition of joints, venting, evidence of leakage, etc.): All joints and venting are in good shape. No evidence of any leakage. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 27" 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'x5'x5' Sludge depth: 4" ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 485 Forest Street Property Address William Nigro Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) Septic Tank (cont.) State Zip Code 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 u Distance from bottom of scum to bottom of outlet tee or baffle 14" August 13, 2014 Date of Inspection How were dimensions determined? Sludge judge/tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Recommend yearly pump. The inlet and outlet tee are in place. The structural integrity of tank is good. The liquid level is good. There is no evidence of leakage. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: t5ins • 3/13 Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 485 Forest Street Property Address William Nigro Owner Owner's Name information is North Andover MA 01845 August 13 2014 required for every g page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ No Alarm in working order: Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ❑ Yes ❑ No * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 485 Forest Street Property Address William Nigro Owner Owner's Name information is North Andover MA 01845 August 13, 2014 required for every � page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert N1 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box is level and distributing to all outlets equally. There is no evidence of carryover or leakaae into or out of box. The box is 9" deep. Pump Chamber (locate on site plan): Pumps in working order: ® Yes ❑ No* Alarms in working order: ® Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): The pump chamber is in good working order. All appurtenances and pump are working fine. * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 485 Forest Street D. System Information (cont.) State 01845 August 13, 2014 Zip Code Date of Inspection Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2 x 60' ❑ 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.): The condition of the soil is good. No signs of hydraulic failure or ponding or damp soil. There is grass over the field. 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17 Property Address William Nigro Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) State 01845 August 13, 2014 Zip Code Date of Inspection Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2 x 60' ❑ 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.): The condition of the soil is good. No signs of hydraulic failure or ponding or damp soil. There is grass over the field. 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 485 Forest Street Property Address William Nigro Owner's Name North Andover City/Town D. System Information (cont.) MA 01845 August 13, 2014 State Zip Code Date of Inspection Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 485 Forest Street Property Address William Nigro Owner Owner's Name information is rth Andover MA 01845 August 13 2014 required for every No page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below F— drawina attached separately t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 + q /) ,131, Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 485 Forest Street Property Address William Nigro Owner Owner's Name information is required for every North Andover MA 01845 August 13, 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 84"+ 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: March 17, 1997 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Plans on file at the Board of Health ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain.- You xplain: You must describe how you established the high ground water elevation: The Board of Health dug on the property, ESHG at 84"+, performed by Daniel O'Connell, witnessed by Sandv Star of the Board of Health. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 485 Forest Street Property Address William Nigro Owner Owner's Name information is required for every North Andover MA 01845 page. City/Town State Zip Code n E. Report Completeness Checklist August 13, 2014 Date of Inspection ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 3 I a a D Work Order #0 �.(3' -6,% WRE Internal Comments System Owher Cust # 1A3666 CCLS Approx. Gal, Custom Clean Customer Home Zabel Filter System Type T5 Frequency Service bate , Previous Service Build Up �} Depth Below Grade Services Description Customer Since Tech Comments 5ystem Location LIY,S FOr.eS! S f - N - V4 -v% &at-�f PI 6 M Tqs— Quantity Unit Price Ext Price O 0 Location Comments Location Diagram Subtotal To Total Tank Observations, Potential Solutions: Payment Details ❑ System Operating Fine We suggest these 4 keys to keep your system healthy: 1) Regular Servicing Payment Type 2) Bacteria "Boost° at time of service Credit Card 3) Use Wind River Bacteria Additive 4 Use a filter Card #: ❑ Excessive Solids Utilize Wind River Bacteria Additive Security Code Introduce additional bacteria via Wind River Boast program ❑ Heavy Sludge Exp. Date Utilize Wind River Bacteria Additive -j nIyr; 444uru Level c.ouia oe an mareation of system in hydraulic failure, Suggest a system evaluation and/or a custom cleaning. Call the office ag oon asossible 978 841-50i Distribution Bax Issue We observed the follawino issues: The observations and solutions identified may require additional treatment. Please call Dur Customer Solutions Specialist at 978-841-5017 for additional information, or call )ur Customer Service line at 800-499-1682 with off questions. 'ech Notes: — (fiM f%1 li -Tim ► ,2�'-- ime Arrive Time Left Tech Initiols PrintcdpnmcycleJp;Ijit;f Terms: Customer Signature Accounting Copy wo-001 Rev 2/09 NORTH -., T H , A q ,SSACHUS�t Applicant NAM Site Location Town of North Andover, Massachusetts BOARD OF HEALTH DISPOSAL WORKS CONSTRUCTION PERMIT s Form No. 3 a t' 19_=/__,L___ TELEPHON Permission is hereby granted to Construct (4 or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. -$ X Fee 95 CI 0' CHAIRMAN, BOARD OF HEALTH D.W.C. No. APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: �- CURRENT INSTALLER'S LICENSE# /d/ - 6D WX LOCATION: LICENSED INSTALLER: l',l /J �E! I44(41m'fol SIGNATURE: TELEPHONE#� CHECK ONE: REPAIR: NEW CONSTRUCTION: IF NEW CONSTRUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. Administrative Use Only $75.00 Fee Attached? Yes No Foundation As -built? Yes No - - Floor plans on file? Y s � No— Approval /! Date: /`� CHRISTIANSEN & SERGI, INC. PROFESSIONAL ENGINEERS AND LAND SURVEYORS 160 SUMMER STREET HAVERHILL, MASSACHUSETTS 01830 March 17, 1997 Ms. Sandra Starr North Andover Board of Health 146 Main Street North Andover, MA 01845 Re: Lot I Long Pasture Dear Ms. Starr: (508) 373-0310 FAX: (508) 372-3960 Thank you for your recent comments on the septic system design for the above referenced location. I have the following responses to your reasons for disapproval: The capacity of the proposed pump over a range of head values is shown on the Pump Selection Curve. The design operating point that corresponds to the predicted system demand has been added to the curve. The actual pumping rate will vary with the changes in total dynamic head within the system. 2. Calculations indicating that the pump controls will be set to pump a dose of 111 gallons (four times per day at the design flow rate) have been added to the plan. This complies with the Title V requirement for dosing in Class I soils. Calculations indicating the emergency storage volume available in the pump chamber have been added to the plan. The available emergency storage above the alarm level is 709 gallons, or approximately 1.6 days at the design flow rate. 4. The Assessors Map reference has been added to the Title Block on the plans. 5. The required note stating that the first two feet of the distribution outlet pipes from the d -box are to be laid level has been added to the Plan. Enclosed are three sets of the revised plans for your review. Please contact me if you have any questions regarding this designs. ROBERT G. ABRUZESE FELIX J. CONSILVIO, JR. ROBIN M. BARCLAY KATHLEEN A. DESMOND ABRUZESE, CONSILVIO & BARCLAY ATTORNEYS AT LAW 92 HIGH STREET MEDFORD, MASSACHUSETTS 02155 TELEPHONE: (617) 395-5211 FAX (617) 395-3420 June 6, 1996 Ms. Sandra Star, Director Board of Health Town of North Andover North Andover Town Hall 120 Main Street North Andover, MA 01845 TdO/ OF N0RTF; _AN�� F`LF;i SOARD OF HEEALTH FJ�W-1996 RE: Lona Pastures Development, N. Andover, Massachusetts Dear Ms. Star: ANDOVER OFFICE 68 MAIN STREET ANDOVER, MA01810 (508) 475-4891 As you may recall, I had several meetings with you and various Town officials last year to discuss my concerns with regard to the Long Pastures Development. As described in.a letter dated June 21, 1995 (copy attached)•,�I indicated that we may. -experience a serious problem with our well water, and f loodingshould this development go forward - as planned. -Mt.' Mahoney, - who.. has since departed for Russia, assured me that if, indeed; a=problem would becreated he would negotiate.on my behalf with the developer to, atIIa-minimum, see that we were hooked up to the public water system at no charge. Further, you advised me that the development could not proceed until the lots were perc tested. You also committed'to inspecting my land in my presence with reference to this problem. I was assured that the development would not proceed until these two items had been completed. However, despite numerous letters and phone calls, I never heard back from you since my last letter of September 22, 1995. Therefore, I assume that the.development was not proceeding and the issues were moot. To say the least, I was shocked to see the development is now underway without any further contact from Town officials. At this time I demand an explanation as to exactly why the development is proceeding without any attention being paid to the concerns I raised. Further, we have now been informed that yet another residential home is being constructed on a wetland resource area at 410 Forest Street. When we first moved into this'property. four years ago, the Conservation Department -'officials advised that none of this building could .ever occur. Weare now doubly concerned about'*the impact on our well system as we are undoubtedly drawing water from. across the street. I spoke with the developer',' Joseph Barbagallo, and he indicated that he would provide documentation to Page Two June 6, 1996 show that the new well will not draw on groundwater. However, I remain concerned as to whether or not appropriate arrangements have been made with regard to the removal of soil. Also, apparently, there has been no inspection to be sure that the new septic system will be far enough away from our well or to determine if that system will impact on the quality of the groundwater. My husband attended the public hearing on June 5, 1996 but had to leave early before the matter was addressed. Therefore, consider this letter as our objection to any construction at 410 Forest Street unless and until our concerns are resolved. •-aI hope I will hear back from you within the next week; otherwise, I will be required to take further action. Thank you for your anticipated cooperation. RMB:rmc Enclosure cc: Planning Board Conservation Commission Board of Selectmen Mr. Robert Halpin Town Manager 95-338.1tr Very truly yours, r s�� Robin M. 4c ZZ,; Barclay I ABRUZESE, C®NSILVIO & BARCLAY ATTORNEYS AT LAW 92 HIGH STREET MEDFORD, MASSACHUSETTS 02155 ROBERT G. ABRUZESE FELIX J. CONSILVIO, JR. ROBIN,M. BARCLAY KATHLEEN A. DESMOND June 21, '1995 VIA TELECOPIER - 508-688-9556 CERTIFIED MAIL - RETURN RECEIPT and First Class Mail Planning Board Town of North Andover North Andover Town Hall 120 Main Street North Andover, MA 01845 Conservation Commission Town of North Andover North Andover Town Hall 120 Main Street North Andover, MA 01845 Board,•of Selectmen Town of North Andover North Andover Town Hall 120 Main Street North Andover, MA 01845 Mr. James Gordon Town Manager Town of North Andover North Andover Town Hall 120 Main Street North Andover, MA 01845 (617) 395-5211 FAX (617) 395-3420 RE: Long Pastures Development Dear"Sir/Madam: Please be advised that I have been: a�. resident of 425 Forest Street in North Andover for the past three years. Late last evening it came to my attention that the Town Planning Board was about to approve the building of a development in the wetlands behind my property. Consider this letter as a demand that the Town cease all activity relative to approving plans for such a Page Two June 21, 1995 development and, further, that the Town take all actions necessary to stop any building from being commenced until proper procedures are followed relative to notice to abutters. Three, years ago, when I purchased my 3-1/2 acre lot, I inquired of Town officials, including the Conservation Commission, as to how much of my 2+ acres of undeveloped land I would be permitted to clear. I was informed at that time that the most land that could be cleared was approximately one-half acre and that I would not be allowed to interfere further with the wetlands because of the negative environmental impact. Now I am finding out that the Town intends to approve the clearance of 16 acres of wetlands in`this exact same area. Approximately one year ago I heard ,.through a neighbor that a developer intended to seek Town approval': for the building of a 15 - home development in the wetlands behind my property. I immediately contacted Town officials to express my concerns. I was, however, informed that the Town intended - to deny these plans and that under no circumstances would any building be allowed in that area. For this reason, the Town felt that no notice to abutters was necessary. I have heard nothing since March of 1994. My initial concerns should be abundantly clear. I am most interested in seeing the environmental impact study and any expert reports which determined that the clearance of 16 acres of wetlands will have no negative environmental impact. Also, if the developer is entitled to demolish 16 acres of wetlands, I expect that my neighbors and I may feel free to clear our remaining undeveloped acres. In addition, I have been informed that the developer intends to change the elevation of the land which will cause a''serious negative impact to my property as well as the other abutters' lots. Prior to my moving in to 425 Forest Street I understand that there was a serious problem with flooding in the lower_ levels of my land which would be the same exact area which would be impacted by the runoff from the planned elevation at Long Pastures. Also, I am serviced by well water and a septic system. I understand that the new homes will be on Town water but will be permitted to have septic systems. Therefore, the problems with runoff,anticipated and the additional septic systems will cause serious problems with my well water and my leaching field as well as those of my neighbors. . Therefore, I demand to review the expert analysis performed on behalf of the Town that will demonstrate that we have no reason for concern. Should this building commence and a negative impact be discovered, I assure you, we will be in litigation with the Town. Therefore, I strongly urge the Town to provide notice and an opportunity to be heard by all of us who will be negatively impacted by this development. i 11 Page Three June 21, 1995 Further, in reviewing the plans last night, I was, shocked to see that we are not even listed as abutters, the former `owners are, and I have a serious problem with the Town's lack of regard for existing citizens' concerns. My demands are as follows: 1. No further action to approve the plan be taken and that the Town prohibit any building without proper notice to abutters. 2. That copies of all. relevant. documents, including expert reports and Court pleadings, if any, be made accessible to the abutters immediately. 3. That a meeting be held with all abutters and Town officials for the purpose of informing us as to exactly what is going on with this development and what the Town has 'done to protect our interests; and finally, 4. Following this meeting, that a public hearing be held for the purpose of permitting the abutters an opportunity to express our complaints or concerns. Again, I expect that the aforementioned steps will be taken immediately and that someone will contact my office by the end of business tomorrow with a full explanation. Otherwise, I'assure you, I will commence litigation, and.I hope that the Town is prepared to pay the high costs anticipated. I am deeply worried about the negative impact of these proposals on my land, and I will not stand by and allow the Town to ignore my concerns. Thank you. RMB:rmc \95\95-338.1tr ve Robin M PLAN REVIEW CHECKLIST 0 ADDRESS-,,-/- /4 -0,06 iU�ENGINEER 7" GENERAL / / 3 COPIES �/ STAMP(/ LOCUSy NORTH ARROW L,� SCALE CONTOURS t� PROFILE(/ SECTION ti� BENCHMARK C/ SOIL & C./ PERCS t/ ELEVATIONS WETS. DISCLAIMER/--' WELLS & WETS WATERSHED? Ah DRIVEWAY �Elev) WATER LINEi--' FDN DRAIN 4-� SCH40 L,-' TESTS CURRENT? t/ SOIL EVAL SEPTIC TANK / MIN 1500G(� .17 INVERT DROP v GARB. GRINDER(2 comps +200) 10' TO FDN t::,f" MANHOLE ELEV GW �-� ## COMPS. GB D -BOX SIZE ## LINES FIRST 2' LEVEL STATEMENT INLET OUTLET /1)4.3. _ l 7 (2 " OR .17 FT) TEE REQ' D? S LEACHING MIN 440 GPD? RESERVE AREA L"' 4' FROM PRIMARY? �2% SLOPE 100' TO WETLANDS `-100' TO WELLS 4,,-' 4' TO S.H.GW Ll----(5'>2M/IN) 20' TO FND & INTRCPTR DRAINS L/ 400' TO SURFACE H2O SUPP L✓ 4' PERM. SOIL BELOW FACILITY L--� MIN 12" COVER I/ FILL? �15' BREAKOUT MET? 1--� TRENCHES MIN 440 gpd SLOPE (min .005 or 611/1001) �SIDEWALL DIST. 3X EFF. W OR D (MIN 61) r_/ RESERVE BETWEEN TRENCHES? L -----IN FILL? - MUST BE 10' MIN. L--"4-1 PEA STONE? L/WEVENTS '� (>3' COVER; LINES >50') BOT 3 + SIDE X LDNG ' 7 = TOT (L x W x #) (DxLx2x#) (G/ft2) Copyright 0 1996 by S.L. Starr i� PITS MIN 440 LEACHING MIN 1 (13'x16') PIT MANHOLE/PIT GW MIN 4' BELOW BOTTOM EXC 2x EFF W OR D 12"-48" STONE BOT + SIDE x LOAD = TOTAL (L x W x ##) (2x(L+W)xD x #) (G/ft2) CHAMBERS MIN 440 LEACHING GW MIN 4" BELOW COVER >3 FT - VENT MANHOLES 12"-48" STONE SPLASH PADS SLOPE .005 BED/TRENCH (Bed max. 60' X 601) MIN 13' X 16' PIT BOT (L x W x ##) + SIDE X LOAD = TOTAL (2 x (L+W)xD x ##) (G/ft2) FIELDS MIN 440 GPD 900 ft2 BED GW MIN 4' BELOW BOTTOM OF FIELD PIPE ENDS JOINED?4" PEA ST NE? V DIST LINE SLOPE .005? >31COVER-VENT SCH 40 N COVER RATE ( X ) X = TOTAL L W LDG DOSING TANKS AND PUMPS DIMENSIONS X X = PUMP CAPACITY 4_gpm L W D Vol. DISCHARGE SIZE ag.6i DISCHARGE RATE DISCHARGE TIME gpm MANHOLES TO GRADE ✓ ALARM SEP. CIRC. L---' GW_Z,-Kin. 1' below inlet) HWL_L6L-6,7 LWLqc'!�34( CHECK VALVE_L,,-' BLEEDER HOLE 6---- MANUAL OP. SWITCH ENUF STORAGE? TDH WEIGHTED? Copyright 0 1996 by S.L. Starr CHRISTIANSEN & SERGI, INC. PROFESSIONAL ENGINEERS AND LAND SURVEYORS 160 SUMMER STREET HAVERHILL, MASSACHUSETTS 01830 (508) 373-0310 FAX: (508) 372-3960 T4: Ms. Sandra Starr 'Board of Health North Andover RE: Septic System Design Plans Date: a '2 4 17AC460 4,2E PZ4,uS _ A 0r Z4 This design is a new submittal a revision with the following changes 1&j OF Pur,)RTH A111LJUVasn B.OARJ OF i' .�SLTH EOCT 5 1996 4 D,VG PSTU,e L _ FORM 11 SOIL EVALUATOR FORM Page 1 of 3 No. Date: Commonwealth of Massachusetts Massachusetts Soil Suitability Assessment for On-site Sewage Disposal Di9N(C OGONNGL-L Date: Performed By:....... ^ i4NO2l9 Silq � f I`Iol�7f'l grveoutJ2 OtTR2� o� K �i[.�.�(................................... Witnessed By:...................................................................................................................... .... ................... ' 1.ocasion Address or (i(7T 1A 'A W V& Pio STLM4 `r owner's Name. LONG PW STL4P— Lot IAddress, and �rLEST S nL� Telephone I P.O. . 5<:)k 343 140P-T14AAJ0ouV'1 0, GoxwRz-n, MA o(9 L( ' ew Construction C. Repair ❑ Office Review Published Soil Survey Available: No ❑ Yes Year Published ..... Publication Scale / i.5,.e4c3 Soil Map Unit ........... Drainage Class EKr-CsS i.v..V.�y..... Soil Limitations......................................................................................................................... ' OP—AIN90 ❑ Surficial Geologic Report Available: No 2 Yes Year Published Publication Scale ' Geologic Material (Map Unit)........................................................................................................................................................ I Landform....................................................... ......................................... i.................................................................................................................. Flood Insurance Rate Map: Above 500 year flood boundary No []Yes Within 500 year flood boundary No []Yes ❑ Within 100 year flood boundary No ❑ Yes ❑ Wetland Area: National Wetland Inventory Map (map unit) ............ ........................................................................ . Wetlands Conservancy Program Map (map unit).................................................................................................. Current Water Resource Conditions (USGS): Month Range :Above Normal []Normal ❑ Bels v Normal ❑ Other References Reviewed: iiDEP APPROVED FORM - 12107195 FORM 11 - SOIL EVALUATOR FORM Page 2of3 Location Address or Lot No. LOT 1A ,, W N& Int S11 UIZE On-site Review Deep Hole Number 6--S Date:.....5�%.L3�94 Time:. ..:..Zt /U Weather PI91irTl.y CCau:�ti �S Location (identify on site plan) ...:..:.. .::::::................ Soil Mottling Other (Structure, Stones, Bounders, Consistency, % Land Use -........ W, DS :. Slope (%) .L) " 3 Surface Stones Al O Vegetation . W HOT (at Ni i'W ..P( ....M141°L4� Landform .....(3uZ::W11:51-f .P". W .:.. FSL 1044 ll Position on� landscape (sketch on the back) Distances from: 3 Open Water Body feet Drainage way feet i Possible Wet Area /Sb. 'l" feet Property Line ..3ri!+ feet Drinking Water Well ::::::.:. feet Other _ .::......: ..... DEEP OBSERVATION HOLE :.OG' Depth from Surface (Inches) Soil Horizon Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other (Structure, Stones, Bounders, Consistency, % AP FSL 1044 ll /VIHSSNE, F121f9GGE1 Mi9NK 3 �{�fu�� vuArs(.�ii conyhu� ieool� c , SilZ(4ill-rrr� 1=—M� IowI24/G GZD a��w W�64K M�•�SIV�, b �,vNy�n - s 1�/vc �riw(Nti�, SW1`crJS 6u ln�os� 2� - v c Z f vl4+ZS'f. (`'l% z 1 > 1 ��4 u ITi Al iml UV/'jb (y12 A/l4 L0-1 TO Sl1uG u, (."v AA-!; So4N� Iva/v SCS 6o -1016 c3 FS MINIMUM Ur c nv�ca nauvu.w .-.. �..-... ..... ......- -•-• --- --• - -- - 7 Parent Material (geologic) &i -Ac -1H L 0 &# 491 DepthtoBedrock: Depth to Groundwater: Standing Water in the Hole: 4-ce" Weeping from Pit Face: Estimated Seasonal High Ground Water:— jj.r rr --- DEP APPROVED FORM - 12107/95 F0F,M 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. LOT T / A �' 4/& 51 UILIL' On-site Review I(, - CD .:. Time:. S..�L. 1 �4' Z t - Weather PAI-TI,H Ct. wu '4 Deep Hole Number Date:. Location (identify on site plan) ..:::::.::.:::.......... . Land Use .... W CU OS Slope (%) % 3 Surface Stones A10 Vegetation Wi1.IJ� hLN� ..�.:..N1f U1 PfN.�.:.,Mr41'� ..o-qK..:.. Landform ...... Position on- landscape (sketch on the back) Distances from: Open Water Body feet Drainage way feet Possible Wet Area .110 feet Property Line feet Drinking Water Well :. ::... .. feet Other DEEP OBSERVATION HOLE :.OG' Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (Inches) (USDA) (Munsell) Mottling (Structure, Stones, Boulders. Consistency, (� I 64 (D I —S t I rO�fLL(( I I Mi4sSl I (3� Fs c l�H►?-¢�� sy&(3 A4M0IUCI r— 14gL4, C.,,.VK PZmot� Cz0 • srrr.�nr'r� Z,Sy��¢ 6 w�K �eraui�t — ��,vuuq-�L C.. v F—O"f r3ow-e" N IS6 L-Oui 34 S4nMS �- � wutv�� Noss r � � c,C�6� C� 3�►" e s�� i� or wr Parent Material (geologic) U%4 (14 #,S)/ DepthtoSedrock: 50 C S. aAlo 0�( Depth to Groundwater: Standing Water in the Hole: 30 Weeping from Pit Face: I/ Estimated Seasonal High Ground Water: -- DEP APPROVED FORM - 12/07/95 FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. UT T l A " W N & �� 57 UtLli On-site Review Deep Hole Number Time:. :310 5 Weather P/4RX0 Location (identify on site plan) .:.:::::::........... Land Use _.. WOO 0S Slope (%) d 3 Surface Stones N O ._ Vegetation . W i1J.f� Ipl.!1/� _�....N1 TU'l. PfN .I..:. Mr4t° � R2 m 04K Landform r3L4T-Witslf .K441A) ... ... Position on- landscape (sketch on the back) Distances from: Open Water Body . feet Drainage way feet r Possible Wet Area �..+.. feet Property Line .3s -f" feet Drinking Water Well . feet Other DEEP OBSERVATION HOLE _OG` Soil Horizon Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other (Structure, Stones, Boulders, Consistency, % GraveP Depth from Surface f►nches) P PS C 104 11,31 Z 41IRSSWC1 MV9N1 fuO15 rL fj FS C I OK vt 3`, 5 rfl13 ,��ssf u�, r—y u��c�l co�wr�w t2oor� CLQ -- (1-06 c( STUTIF(C9 2 ��¢ g�zL°'� i.l{Y141C MfrsslG� - Sfn/GI.tL�rLat^'/�� M — C" I ra 65 L`f�" lu . r= 141A u fL e- SJgNq Parent Material (geologic) &LAc,n4'l. U f'W'+'5lj DepthtoBedrock: /( Depth to Groundwater: Standing Water in the Hole: _�-7 Weeping from Pit Face: — vv +( Estimated Seasonal High Ground Water: DEP APPROVED APPROVED FORM - 12107/95 FORM 11 - SOIL EVALUATOR FORM Page 3 of 3 Location Address or Lot No. COT /A LONG P44" WR-ff for Seasonal High Water Table Method Used: ❑ Depth observed standing in observation hole ................. inches ❑ Depth weeping from side of observation hole ................. inches Depth to soil mottles .G inches ❑ Ground water adjustment ................... feet Index Well Number .................. Reading Date ................... Index well level ............. Adjustment factor ................... Adjusted ground water level .................................................. Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? y4-5 If not, what is the depth of naturally occurring pervious material? Certification I certify that on O ,� (date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature AVDate /o LSA(, ii. - DEP APPROVED FORM - 12/07/95 - � -- -�— ' ` � -- � � - -' • — - ---•-^'.tea FORM 12 - PERCOLATION TEST Location Address or Lot No. Go7 /!g "LO?JG PtgS i U1_ COMMONWEALTH OF MASSACHUSETTS NoYLrl4 Ggniba v (x . Massachusetts Percolation Test* Date: Iob ?/7(o 6 ZZ:.. Observation Hole # 76-7 4 Depth of Perc Start Pre-soak 10 3 10 " / L End Pre-soak woLILbnir 110c)v 10,(b SoA< Time at 12" Time at 9" /0: L Z Time at 6" /0 Time (9"-6") .7 Rate Min./Inch Z 3 * Minimum of 1 percolation test must be performed in both the primary area AND reserve area. Site Passed I Site Failed ❑ Performed By: CH(<157AA)N lU 4 Witnessed By: M I S 6-!4 r_ _ (03A S,qA u4 S 1T)vlu2 % 1 Y V 4 Comments: Il DEP APPROVED FORM - 12/07195 NORT01 O � F w 9 SSACMUSEt Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 2 � 19--9 �a DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM ApplicantTI -' ITest No. Site Location T 1"9 "'t6 Reference Plans and Specs. DX Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. Fe CH -Al RMAN, BOARD OF HEALTH Site System Permit No. !2 iL Town of North Andover NORTH f , OFFICE OF 3�0.'"6 6BOOL COMMUNITY DEVELOPMENT AND SERVICES 146 Main Street, North Andover, Massachusetts 01845 WMLIAM J. SCOTT SA HU Director April 8, 1997 Christiansen & Sergi 160 Summer Street Haverhill, MA 01830 Re: Lot IA Long Pasture Dear Phil: This is to inform you that the proposed plans for the site referenced above have been approved. If you have any questions, please do not hesitate to call the Board of Health Office at the number below. Sincerely, Sandra Starr, R.S. Health Administrator SS/cjp cc: Long Pasture Realty Trust BOARD OF APPEALS 688-9541 BUaDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 - PLANNING 688-9535 FORM U - IAT RELEASE FORM / INSTRUCTIONS: This form is used to verify approvals/permits from Boards and Departments that all necessary have been obtained. This does not rlie ehappli jurisdiction landowner from compliance with applicant an regulations or requirements, any applicable local or state law, ****************Applicant fills out this �se�qtion*****************APPLICANT• �,�3;?2-?�- LOCATION: • Phone Assessor's Ma p Numbe Parcel Subdivision h(�C ,� /�S//2/ Lot(s) Street p - S117 St. Number ************************pfficial Use Only******************** RECOMMENDATIONS OF TOWN AGENTS **** : Conservation Administrator Date Approved Date Rejected Comments Town Planner Date Approved Comments Date Rejected Food Insp ctor-Health Date Approved Date Rejected p c spector-Health Date Approved -Z/ Comments Date Rejected , Public Works - sewer/water connections veway permit Fir �L p(rtment � Received by Buil ing Inspector Date LOCATION: SEPTIC PLAN SUBMITTALS ? , ZA v eo NEW PLANS: YES $60.00/Plan REVISED PLANS: $25.00/Plan �---� DATE: lAh.z DESIGN ENGINEER: AeI67-1) V56 -N When the submission is all in place, route to the Health Secretary SEPTIC PLAN SUBMITTALS LOCATION: NEW PLANS: YES REVISED PLANS: YES DATE: DESIGN ENGINEER: (LA-s- $60.00/Plan � $25.00/Plan When the submission is all in place, route to the Health Secretary Town of North Andover, Massachusetts Form No. 1 p10RTly - BOARD OF HEALTH / ,✓ �2py �S�ED l 6 4ehp0 p "7 APPLICATION FOR SITE TESTING/INSPECTION �� A�RATEO PPp �.�C% SSACHUS� Applicant Site Location Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time Fee %-6-17) , CHAIRMAN, BOARD OF HEALTH Test No. -741&')-_j S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. e Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. _Q r� Commonwealth of Massachusetts ' V-1) Title 5 Official Inspection Form V�� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 485 Forest Street �F NOR(N ZMEN� Property Address Susan Sauls Owner's Name North Andover MA 01845 3/6/2017 City/Town State Zip Code e-of.tnspedtfon Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information Inspector: Neil James Bateson 'Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover City/Town 978-475-4786 Telephone Number B. Certification MA State SI -15 License Number 01810 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: 0 Passes ❑ Conditionally Passes ❑ Fails ❑ aNd Further Evaluation by the Local Approving Authority 3/6/2017 Inspgnatur Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc - rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner , information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 485 Forest Street Property Address Susan Sauls Owner's Name North Andover MA 01845 3/6/2017 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 485 Forest Street Property Address Susan Sauls Owner owner's Name information is required for every North Andover MA 01845 3/6/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 485 Forest Street Property Address Susan Sauls Owner Owner's Name information is required for every North Andover MA 01845 3/6/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) .System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins.doc - rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form vuSubsurface Sewage Disposal System Form : Not for Voluntary Assessments 485 Forest Street Property Address Susan Sauls Owner Owner's Name information is required for every North Andover page. Cityrrown MA 01845 3/6/2017 State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 485 Forest Street 3/6/2017 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Property Address Susan Sauls Owner Owner's Name information is required for every North Andover MA 01845 page. Cityfrown State Zip Code C. Checklist 3/6/2017 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 l5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 4N Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 485 Forest Street D. System Information Description: MA 01845 3/6/2017 State Zip Code Date of Inspection Property Address ❑ Susan Sauls Owner Owner's Name information is required for every North Andover page. Cityrrown D. System Information Description: MA 01845 3/6/2017 State Zip Code Date of Inspection Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: ❑ Yes ❑ No Number of current residents: 4 ❑ No Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Yes Detail: Sump pump? ❑ Yes ®' No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 485 Forest Street ,p Property Address Susan Sauls Owner Owner's Name information is required for every North Andover MA 01845 3/6/2017 page. Cityrrown 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 two years ago, owner 1500 gallons Measured tank. Inspect tank ® Yes ❑ No Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 485 Forest Street Property Address Susan Sauls Owner Owners Name information is North Andover MA 01845 3/6/2017 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 18 years old, 9/24/1999, certificate of compliance Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): 3 feet Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" PVC through floor, 3" PVC in house, no leaks. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 2 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 t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 485 Forest Street Property Address Susan Sauls Owner Owner's Name information is required for every North Andover MA 01845 3/6/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 13" 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 at outlet invert. No evidence of leakage. Center cover has riser to grade. Pumped septic tank. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form _ Not for Voluntary Assessments 485 Forest Street Property Address Susan Sauls Owner Owner's Name information is required for every North Andover MA 01845 3/6/2017 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: El concrete ❑ metal ❑ fiberglass Dimensions: Capacity: Design Flow: Alarm present: Alarm level: gallons ❑ polyethylene ❑ other (explain): gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 485 Forest Street Property Address Susan Sauls Owner's Name North Andover MA 01845 3/6/2017 Cityrrown 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 9 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D -box level & distribution equal. No evidence of leakage. No evidence of carryover. Pump Chamber (locate on site plan): Pumps in working order: ® Yes ❑ No* Alarms in working order: ® Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump Tank ok. Pump ok. Alarm ok, has both visual & audible. Pump tank has cover to grade. * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t " 485 Forest Street Property Address Susan Sauls Owner Owner's Name information is required for every North Andover MA 01845 page. Cityrrown State Zip Code D. System Information (cont.) 3/6/2017 Date of Inspection Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system 2 trenches 60' long Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetaion ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 485 Forest Street D. System Information (cont.) RAA 01845 3/6/2017 Zip Code Date of Inspection Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Property Address Susan Sauls Owner Owner's Name information is required for every North Andover page. Cityrrown D. System Information (cont.) RAA 01845 3/6/2017 Zip Code Date of Inspection Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 485 Forest Street Property Address Susan Sauls Owner's Name North Andover MA 01845 3/6/2017 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: t5ins.doc • rev. 6/16 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 485 Forest Street Property Address Susan Sauls Owners Name North Andover Cityrrown D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: MA 01845 State Zip Code >4 feet 3/6/2017 Date of Inspection Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 5/23/1996 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Wealth - 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 test pit data on design plan. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 485 Forest Street Property Address Susan Sauls Owner Owners Name information is North Andover required for every page. Cityrrown MA 01845 State Zip Code E. Report Completeness Checklist 3/6/2017 Date of Inspection ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Summary Record Card generated on 2/27/2017 1:26:52 PM by Tara Hurley Town of North Andover Tax Map #'210-106.B-0218-0000.0 Parcel Id 17616 485 FOREST STREET SAULS, RYAN, R Since Jan 2015 SAULS, SUSAN, L. 485 FOREST STREET NORTH ANDOVER, MA 01845 Page 1 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 2 Acres FY 2017 UB Mailina:Index Name/Address SUSAN SAULS 485 FOREST STREET NORTH ANDOVER MA 01845 NIGRO, WILLIAM J 485 FOREST STREET NORTH.ANDOVER, MA 01845 UB Account Maint. Account No Cycle Bldg Id. 17597.0 - 485 FOREST STREET 3170267 03 Cycle 03 UB Services Maint. Account No. 3170267 Service Code MISCFEEADMIN FEE WTR WATER UB Meter Maintenance Account No. 3170267 Type Loan Number Owner Previous Customer Activellnact. From Inactive 9/12/2014 Occupant Name Active/Inactive Last Billing Date 1/13/2017 Active Rate Charge Multiplier/Users 1 1 9.18 1/ 01 ALL METER SIZE 209.75 /1 Serial No Status Location Brand Type 13306717 a Active ERT HH METE METE w Water Date Reading Code Consumption Posted Date 12/20/2016 2541 aActual 45 1/23/2017 9/7/2016 2496 a Actual 205 10/24/2016 6/9/2016 .2291 a Actual 23 8/2/2016 3/9/2016. 2268 a Actual 24 4/22/2016 12/10/201:5 2244 aActual 60 1/20/2016 9/9/2015 2184 a Actual 166 10/16/2015 6/8%2015 2018 a Actual 72 7/24/2015 3/11/2615 1946 aActual 22 4/28/2015 12/11/2014 1924 aActual 42 1/15/2015 9/10/2014 1882 f Final Bill 72 9/10/2014 6/11/2014 1810 aActual 0 7/16/2014 3/12/2014 1810 aActual 0 4/11/2014 12/10/2013 1810 a Actual 1 1/17/2014 9/11/2013 1809 aActual 53 10/15/2013 6/11/2013 1756 a Actual 5 7/24/2013 3/13/2013 1751 a Actual 9 4/22/2013 12/11/2012 1742 aActual 34 1/9/2013 9/13/201.2 1708 a Actual 117 10/15/2012 6/11/2012 1591 a Actual 23 7/16/2012 3/13/2012 1568 a Actual 24 4/14/2012 12/13/2011 1544 aActual 22 1/17/2012 9/12/2011 1522 a Actual 66 10/13/2011 6/8/2011 1456 a Actual 27 7/20/2011 3/8/2011 1429 a Actual 29 4/13/2011 Size 11 Until YTD Cons 1637 Variance -81% 811% -6% -59% -63% 121% 231% -46% -42% -100% -100% -100% -98% 937% -43% -74% -69% 387% -3% 10% -65% 134% -10% -25% 17 Commonwealth of Massachusetts City/Town of . System Pumping. Record Form 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.this form, check with your local Board of Health to determine the forrh they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facfl!ty. Informi�ation 1. System Location; Left /Right front of Hous , e /Righ ear of Nous , Left./ right side of house, Left Right side of building, Left / Right front of bul Ing, Left / Righ rear of building, Under deck Address L4 C(R-5 City/rown State Zip Code 2. System Owner. Name' Address (if different from location) City/rown ' Stater Zip Code Telephone Number + a i Pump'Ing 1. Date of Pumping 3. Type -of system: ❑ ❑ Other (describe): gate 2. Quantity Pumped: Gallons Cesspool(s) aseptic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes L - o If yes, was It cleaned? ❑ Yes ❑ Na 5. Condition of System: p V"Lit 6. System Pumped By: Neil. Bateson ' Name Bateson Enterprises Inc Company 7. Locati contents -were disposed: G -66-R 4 Lowell Waste Water i. F5821 Vehicle License Number Date t5formCdoc 06103 System Pumping Record • Page 1 of 1 if Type of Permit or License: (Check box) ti Ot,AORTs, - o 7787 •e s $ ❑ Town of North Andover $ i,.'•�,,,,, .. HEALTH DEPARTMENT ,s$ACMUStS Body Art Practitioner $ ❑ CHECK #: /2— '1,3ZDTE;�:3 /6 O LOCATION: `� S Food Service - Type: H/O NAME: ,,,(.I 1-5' CONTRACTOR NAME:TYZI � Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ Title 5 Report $� ' ❑ Other. (Indicate) $ . /<!:�/R He t -h -Agent Initials White - Applicant Yellow - Health Pink - Treasurer