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FILE# NAnd4Q?Q(oA
MDEPARTMENT
TITLE V INSPECTIONS OF NORTH
Dean G. Luscomb II & Sons
P.O. Box 135
Middleton, MA 01949
978-774-4065
Licensed Plumber#20285
SUBSURFACE SEWAGE DISPOSAL SYSTEM INPSECTION FORM
PROPERTY OWNERS NAME JT e-y e Ka r 2.+a
PROPERTY ADDRESS CQh d I e-S L C
A � d MAx Di 8y 5
I' ADDRESS OF OWNER(if different) r`n 2
DATE OF INSPECTION G r 1 a 8� a 0
NAME OF INSPECTOR -a i', 7_ L-t S C.Q m.b
QUALITY IS NUMBER ONE TO US
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
y� DEAN G. LUSCOMB II & SONS
P.O. BOX 135
MIDDLETON, MA 01949
1-978-774-4065
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT_S
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 7Z Cndies-�tG((- i.
Owner's Name:
Owner's Address:
Date of Inspection: z22.—i/ .8 600 6
Name of Inspector:(please print) Dean G. Luscomb II
Company Name:Dean G. Luscomb II & Sons
Mailing Address:p_O_ Box 135
Middleton, MA 01949
Telephone Number: 97 8—7 7 4—4 0 6 5
CERTIFICATION STATEMENT
I certify that 1 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:
V Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: J.�< ` Date: �pri l ����
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.
1
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Vec111 b. LiuSl:vutV 1J. Ot OULI.�
P.O. Box 135
Page 2 of l 1 Middleton, MA 01949
1-978-774-4065
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: c; QZ oa d les , ck—
/01 /fin 4V*C P'
Owner: Ara' r— -
Date of Inspection: 1!1
Inspection Summary: Chec1�A�,C,D or E/ALWAYS complete all of Section D
A. System Passes:
V/I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
I- 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:
/--j 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:
f)j 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:
2
Dean G. Luscomb II & Sons
Page 3 of 1 I P.O. Box 135
Middleton, MA 01949
1-978-774-4065
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: c2 7 2- C Gao(k' T cllfc
Owner:
Date of Inspection:
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
jU 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.
/`j The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
fJ 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:
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P.O. Box 135
Page4 of I I Middleton, MA 01949
1-978-774-4065
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 2 97— LG,n of te,5 Ck I1d,,
"� r4nc6tr —r'
Owner• ci r
Date of Inspection: 2 6�
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_ k-� Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
10 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than_day flow
tj 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.
t-J Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ />ti=' Any portion of a cesspool or privy is within 50 feet of a private water supply well.
P 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.)
.t �" (Yes 70)1Che 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 o
Health to determine what will be necessary to correct the failure.
Large Systems:
To n-idered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000
gpd-
You must indicate tiler"yes"or"no"to each of the following:
(The following criteria aWy to large systems in addition to the criteria above)
yes no
�..,
— — the system is within 400 feet of a s`Urface drinking wateysujiply
the system is within 200 feet of a tribu a surface drinking water supply
— —
.,ram
— the system is located in a n' en sensitive area(Interim We Protection Area—IWPA)or a mapped
Zone 11 of a public r supply well
If you have ans d"yes"to any question in Section E the system is considered a s'gn f an teat or answered
"yes"in, ion D above the large system has failed.The owner or operator of any large system considered a
sign'icant threat under Section E or failed under Section D shall upgrade the system in accordance witFi"340 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
4
VWLL V• 1..1LLJVVlIW 11 u waa..
P.O. Box 135
Page 5 of 11 Middleton, MA 01949
1-978-774-4065
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
� CHECKLIST
Property Address: 07 i�2- �a//"-ta'c C- •
Owner• e
Date of Inspection: 2 k Q 6
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:
Yes no
b'" _ Existing information.For example,a plan at the Board of Health.
i
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15302(3)(b)]
5
` L/CQIl V.LU.7l..lAlW 11 u waa.a ,
P.O. Box 135
Page 6 of 1 I Middleton, MA 01949
1-978-774-4065
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 292-- G(C [Z°(,
N: l�nA(o ve,r
Owner: Qr�
Date of Inspection: �Z� 46
FLOW CONDITIONS
RESIDENTIAL r
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: I
Does residence have a garbage grinder C e or no):
Is laundry on a separate sewage system(yes or4p:NO[if yes separate inspection required]
Laundry system inspected(yes ort&: v�u
Seasonal use:(yes orQ:
Water meter readings,if available(last 2 years usage(gpd)): o w n
Sump pump(yes oro�JO
Last date of occupancy: r"rrf.
COMMERCIALANDUSTRIAL
Ty f
De establment:
on 10CR15.203)osign gpd
Basis of design flow ersons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank prese _
Non-sanitary waste di a to the Title 5 syste s or no):_
Water meteyae�dmgs,if available:
Last.datrof occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: 14!1J `�.�y..�<aQ )l`_ye1$.r-)1 a s
Was system pumped as part of the inspection(yes ovi ): a
If yes,volume pumped:_gallons--How was quantity pumped determined? wtensuc
Reason for pumping:
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 known)and source of information:
Were sewage odors detected when arriving at the site(yes or io 1JCi
6
Ut=Ul V. 111JCt%l AltV - u waa✓
P.O. Box 135
Page 7 of I I Middleton, NIA 01949
1-978-774-4065
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: Z— 01(015 1 R�
NP l4n ov�y`✓'Yta,,
Owner: Alalrd'
Date of Inspection: Zg�or6
BUILDING SEWER(locate on site plan) k/�
Depth below grade: o'`t
Materials of construction:_cast iron V 40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments on cogdiPion of joints,venting,evidence of leakage,etc.):
Sc C i// 41() C;}'f/ . r,,,s�"' IV a S.
SEPTIC TANK: IGS(locate on site plan)
Depth below grade: /5
Material of construction:concrete metal_fiberglass_polyethylene
_other(explain) !rec�,S4- 1ple k—' .aukc.r Ccanc-"e'�
If tank is metal list age:KffIs age confirmed by a Certificate of Compliance(yes or<Q:P''O(attach a copy of
certificate)
Dimensions:S �L�CcnDc ��Lc�. k
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: <4' `.
Distance from top of scum to top of outlet tee or baffle:__ I
Distance from bottom of scum to bottom of outlet tee or baffle: it
How were dimensions determined: 13 Slr,cky ea-14
Comments(on pumping recommend ons,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.): krY,
i f r� ve-r Seri � R,% 4"'* 7e--ec4'
y d L�'csn r!l
GREASE TRAP:ND-(locate on site plan)
Depth below grade:
Material-of concrete_metal_fiberglass_polyethylene_other �J
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee o e:
Distance from bottom of scum to bottom of outlet r
Date of last pumping:
Comments(on pumping recom ions,inlet and outlet tee or baffle con'Atien,�tructural integrity,liquid levels
as related to outlet inve i ence of leakage,etc.): �.._
7
IVC.UJl V♦ LJ4J�..L41W 11 t1 WiVJ ,
P.O. Box 135
Page 8 of 11 Middleton, MA 01949
1-978-774-4065
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM,,// INFORMATION(continued)
Property Address: a2 Q Z Cano(455 ck R01i
'ou,
Owner: 4r�
Date of Inspection: Z C� Duo
TIGHT or HOLDING TANK: N U(tank must be pumped at time of inspection)(locate on site plan)
Depth below grl ade--j___
Material of construction: �a c. ncrete metal fiberglass_polyethylenes other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/da
Alarm present(yes or no): "r
Alarm level: in orking order(yes or no):
Date of last pumpi i-
Commen condition of alarm and float switches,etc.):
DISTRIBUTION BOX: le S(if present must be opened)(locate on site plan) D 13 t S Z I �QW c4 Az
A
Depth of liquid level above outlet invert: �lG
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.): /
�2G ��G.� !J' /e7 �/�l !}G� S•�2 Ct r �GG, ` t!I� � ,�6� e!-Etd ..�'.�d,:l,P-,',
-"'
PUMP CHAMBER:Nd (locate on site plan)
Pumps in working order(yes•oar_no):
Alarms in working order(yes or
Comments(note condition of pump chamber,�cdo and appurtenances,etc.):
P.O. Box 135
Page 9 of I I Middleton, MA 01949
1-978-774-4065
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: Ok $ `C got,
J fn O U42r- ryle.L=
Owner: r
Date of Inspection: 8 Oto
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type /
leaching pits,number:_
leaching chambers,number:
leaching galleries,number: ,r
leaching trenches,number,length: ,ale+wt •^�etr► eG�
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.): �
S f3rJ• !.Y a h < CO i /') F0114 rJ
' , / ?rCQGJ O" u 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: y "
Materials of construction: _
Indication of groundwater inflow_(yes or no):
Comments(note conditioa•ofsoil,signs of hydraulic failure,level of ponding,condition-of vegetation,etc.):
PRIVY: j6)(locate on site plan)
Materials of construction:
Dimensions: "'"---
Depth of solids:
Comments(note condition of soil,signs of [G,level of ponding,condition of vegetation,etc.):
9
P.O. Box 135
Page 10 of 11 Middleton, MA 01949
1-978-774-4065
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: aL � L C nCX�2 S' iGk
Owner re
Date of Inspection: 2 6
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.
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g Middleton, MA 01949
1-978-774-4065
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: Z n AeS�K Ro(,.
n ov4&— tiles .
Owner i-e
Date of Inspection: .Z�- 6 6
SITE EXAM
dope Sjj�, �a 7 11_WuaI
v,Surface water Awn _
,,.,Check cellar `{>" Po
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed: ��A�92
1/ Observed site(abutting property/observation hole within 150 feet of SAS)
_,,/Checked with local Board of Health-explain: 1�cropo 46 PA-�*Qv
Checked with local excavators,installers-(attach ocu�(mentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
77,
.• � ,: -��d.. �� �,� G���� �.er �-� BIZ�` rr��o� ����
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11
T,
RECEIVED
EIVED
7 F) 7 7 Z/o 1. AUG 2 S 2006
TOWN OF NORTH ANDOVER
HEALTH-DEPARTIVIENT