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HomeMy WebLinkAboutPass - Title V Inspection Report - 2017 SALEM STREET 2/25/2021 ecexV5o c Commonwealth of Massachusetts R 25 TO � Title 5 Official Inspection Form FE©�No����tq Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t1 ��NpEpP u 2017 Salem Street Property Address Gabrielle and Stefano Sesito _ Owner Owner's Name information is North Andover------.----- MA 01845 2/9/21 required for every __ — page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, use only the tab William McNeice ___ key to move your Name of Inspector cursor-do not William McNeice Site Services use the return Company Name key. 5 Springdale Ave - Q Company Address Canton MA 01867 City/Town State Zip Code 781-727-9990 S 114447 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails ----- - 2/11/21 ------- 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts �n = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2017 Salem Street Property Address Gabrielle and Stefano Sesito Owner -- - Owner's Name information is North Andover MA 01845 2/9/21 required for every __ _-_ _-________ _ page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: System Passes all componets in good working condition. 2) 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments �a 2017 Salem Street Property Address Gabrielle and Stefano Sesito Owner Owner's Name information is required for every North Andover MA 01845 2/9/21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2017 Salem Street Property Address Gabrielle and Stefano Se_sito Owner Owner's Name information is North Andover _ MA 01845 2/9/21 required for every __ page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2017 Salem Street Property Address Gabrielle and Stefano Sesito Owner Owner's Name information is required for every North Andover MA 01845 2/9/21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 1/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form f' i1; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2017 Salem Street Property Address Gabrielle and Stefano Sesito _ Owner Owner's Name information is required for every North Andover MA 01845 2/9/21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no" for each of the following for all inspections: 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)] t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 2017 Salem Street Property Address Gabrielle and Stefano Sesito _ Owner Owner's Name information is required for every North Andover MA 01845 2/9/21 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. 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 Description: Number of current residents: 4 Does residence have a garbage grinder? ® Yes ❑ No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: 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 Well Water 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c Commonwealth of Massachusetts �x Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2017 Salem Street Property Address Gabrielle and Stefano Sesito Owner Owner's Name information is required for every North Andover _ _ MA 01845 2/9/21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: — Last date of occupancy/use: date Other(describe below): 3. Pumping Records: Source of information: See Attached for Past Pump Outs Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments . � 2017 Salem Street Property Address Gabrielle and Stefano Ses_ito Owner Owner's Name information is required for every North Andover MA 01845 2/9/21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known)and source of information: 8/30/19 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 4'2 — feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipe out in good working condtion no evidence of leaks t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 \ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 2017 Salem Street Property Address Gabrielle and Stefano Sesito Owner Owner's Name information is North Andover MA 01845 2/9/21 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 3- feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: - — ---- years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 5.5'x 5.5'x 8' 9 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 4 Scum thickness 12 Distance from top of scum to top of outlet tee or baffle 18 — Distance from bottom of scum to bottom of outlet tee or baffle 19 — 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.): Septic tank and fiter in good condition. t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 c Commonwealth of Massachusetts �n Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2017 Salem Street Property Address Gabrielle and Stefano Sesito Owner Owner's Name information is required for every North Andover MA 01845 2/9/21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: — gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2017 Salem Street Property Address Gabrielle and Stefano Sesito Owner Owner's Name information is required for every North Andover ___ MA 01845 2/9/21 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 - Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No evidence of leaks or solids carry over. all outlets level. l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts A Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /Y 2017 Salem Street Property Address Gabrielle and Stefano Sesito Owner Owner's Name information is required for every North Andover MA 01845 2/9/21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. 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: ® leaching trenches number, length: 3 @ 36' ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �� 2017 Salem Street Property Address Gabrielle and Stefano Sesito Owner Owner's Name information is North Andover MA 01845 2/9/21 required for every _Andover------ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): no evidence of vegitation of ponding! 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2017 Salem Street Property Address Gabrielle and Stefano Sesito Owner Owner's Name information is required for every North Andover MA 01845 2/9/21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts �x Title 5 Official Inspection Form >; Subsurface Sewage Disposal System Form Not for Voluntary Assessments 2017 Salem Street Property Address Gabrielle and Stefan_o Sesito _ Owner Owner's Name information is required for every North Andover MA 01845 2/9/21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form Not for Voluntary Assessments 2017 Salem Street u - Property Address Gabrielle and Stefano Sesito Owner Owner's Name information is required for every North Andover MA 01845 2/9/21 — - page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 4.5' 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: 8/30/19 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Please see attached plans for Test holes for ground water elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form w Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2017 Salem Street Property Address Gabrielle and Stefano Sesito Owner Owner's Name information is required for every North Andover _ MA 01845 2/9/21 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 :�. Commonwealth of Massachusetts City/Town of NORTH ANDOVER, MASSACHUSETTS System Pumping Record Y Form 4 DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling ou 1. System location: forms on the r computer.use !y a o w V1 S onty the tab key Address to move your North Andover MA 01845 cursor-do not use the return C'�rrovm" State— Zip Code key. 2 System Owner Name Address(if different from location) — T City/Torm State -^^ 2C� Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Oate Gallon-- -- --- - 2. Quantity Pumped: s - s 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): ----- — - 4. Effluent Tee Filter present? ❑ Yes 2�'No if yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System. q 6. System Pumped By: G Name Vehicle License Number Wind River Environmental Company 7. location where contents were disposed: t� Signature of Hauler Datet4y http://www.mass.gov(dep/water/approvals/t5forms.htm#inspect 98fto 1 83VI ` jolo-e1 t5fonn4.doc•06/03 r ,ping Record•Page t of t Commonwealth of Massachusetts F F-cmV :N City/Town of NORTH ANDOVER System Pumping Record Form 4 #� � k DEP has provided this form for use by local Boards of Health, Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351, A. Facility Information Important:When filling out forms 1. System Location: on the computer, 2350 TURNPIKE STREET use only the tab key to move your Address cursor-do not NORTH ANDOVER MA 01846 use the return ---- - — --- Key. CitylTown Stabs Zip Code 2 System Owner: V JC FENCE COMPANY Name ,a^r: Address(if different from location) C fy—ffown' State — Zip Code _ _-- ---------...- — Telephone Number B. Pumping Record 1. Date of Pumping -- ---8130/19 Quantity-- 2. Qtity 1500 Pumped: - ---- Date Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): _----- - _--_-._-.--- 4. Effluent Tee Filter present? ❑ Yes ❑ No if yes,was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: GOOD 6. System Pumped By: JAY CURRIER H79406 Name Vehicle License Number J'S SEPTIC&DRAIN Company ---- Location where contents were disposed: GLSD 8/30/19 Sign gj4r Date Signature of Receiving Facility{or attach facility receipt) Date 2 11,2021 IMG_5788.1P9 CERTIFIED SOIL EVALUATOR NOV 1995 LIC It SEt91b '"( ROOK 4C37 pa( VvITNESSED BY ERIN KIRCHNER NORTH ANDOVER R D H 6 PLAN REFERENCE PLAN 17692. SYSTEM ELEVATIONS 7 THEP,E ARE,NO Y TRIBUTARIES L tS THAN325 Fi.VY1T E. LOCATION DESIGN INVERT DRAINS LESS THAN 50 THAN HOUSE OUT toB 00 6 ILT INVEttt SYSTEM FEET FRO SEPTIC TANK IN 10580 103 7Z SEPTIC TANK OUT 10555 10342 10304 8 THIS PR OISTRI13UTION BOX IN 97 14PROPERTY IS NGT LOCATE 47 58 9 SYS7E DISTRIBUTION BOX OUT 9697 97 g8 M ►S NOT DESIGNED T( 1D SYSTEM at HAIL"E HIANTAIN�IEAVVISE "QutAED sy T CaNSTRU �'�� CURRENT PROPERTY OWNER cz1pN do��g 1 EXISTING MftmuM OF F4 FILL ANC RDM KELSEY LLC OF THE S01L gAEET LATI 2017 SALEM STREET MEETING THE R= RATION I NORTH ANDOVER.MA 01845 SHALL BE AT TI�%Ike£► TOP Ei.E 2 THE INSTALLER'* %-r— CMR 15 255(3 S.4)TO 11 AS-BUILT TIES LEACH TRENCH CHAMBER THE TITLE 5 SAND MATEI 1 -T-IN ELEVATIONS LACfMF 26.8' 3 PRIOR TO THE P 2-T-IN 19 7' DESIGN AS-BUILT EXCAVATION SMALL BE 1-TOUT 32 6' A,97 20' A 07 284 PLACED DURING RAIN C 2-TOUT 196, B 97 20' B 97 27' EXCAVATION SHALL BE 1 -D-BOX 76.3' C 97 20' C 97 25' 2-D-BOX 67.5' D 07 03' D 97 04' 4 FILL USED IN AREAS 01 1 Opt 620, E 97 03' E 97 02' CLEAN AND FREE FROI F 97 03' F 9705' 2-OP1 88 2' DELETERIOUS MATERI, i -OP2 78 0' 2-OP2 BOB, 5 DISTURBED AREAS,IN 1-OP3 909, AS-BUILT LEACH PIPE SLOPE ACCESSING THE SITE 2-OP3 93.5' A-D 0 006 FTIFT RAKED FREE OF STOP B-E 0 D07 FTIFT C-F 0 005 FTIFT 6 UNDERGROUND UT112 SHOWN ARE APPR07 7 ALL DISPOSAL SYST AS-BUILT PERFORMED ON 08/13/2019 BY RANGER ENGINEERING CONSTRUCTED USII $, ALL CONSTRUCTIOI "I CPRTIFVTUF I nrnTlnr.Ic cI C\/nTl/lAlO T�re� n'.�rrn.a.rr+-..., .-.,r..�....-.-- 2111/2021 IMG_5789.jpg t P4lII2:KCYt£/.VllYfAtil t' `_ ♦ � BWMtSoiYt ` TT#S11EL3/F�/ t-� C-_ 1 � 1 t �q�cvrs etv rceltorx i \ i 1 MArA 1 \ 1 ' � Ff/TRT..�u� Re YGr+UXET>,,CST I _.. �'� �51.74T�i I �IyF� I 2Xf Slf6V SrP=ET ` y:' ^` 4A tl TAW y' Y 1VEI�'i \ _ LSCO GALLON MONOLITHIC SEPTIC TAIh: raa-,bTaw _ 015TRIHUTION sox ROZONE �- 6fo I 1 1 yl Nov Qn) 2 9SALEMSTRE7: iON TORN WATER; LIMIT OF SAND BEV i a � ~ �' SS>717g,F r TOP WO Pft s if i �>j bye ¢Oro SOIL TESTING DATA: DESIGN NOTES. PERFORMED ON 12/14/18 BY BENJAMIN C OSGOOD,JR.CERTIFIED SOIL EVALUATOR SOILTEXTURE: SANC,Y NOV. 1995 LIC#SE1818 WITNESSED BY ERIN KIRCHNER NORTH ANDOVER B.O.N. SOIL CLASS: 1 PERCOLATION RA-CE.11NWINC LOADING RATE:G 56%jpISF SOIL LOG PROPOSED USE:4 bEGR00M o DA1LY FLOW RATE: 150Gpp1flF rop ELEV. 94.00 ESHGW 90.50 TOP ELEV. 94.20 FSVIGW 90.10 00 ;1 TPI TP2 PROPOSED SYSTEM: DEPTfI SO[LIIORJT_dN SUIL COLUR 'dILTPYIUR SOIL D>vn SOIL fIORI7ON SOILCOLOR 'OILTEXTLlR' SQR REQUIRED SYSTEM AREA,A4 z btOTTLINC MOTTLING 0"-8" A 10YR 2/2 SL 0"•8" A MR 213 SL PROPOSED SYSTEM 0.REA; LINEAR FEET OF TREX" 6%96 9w IOYR 3/6 SL 8"-24"'-74 6w IQYR A SL LINEAR FT OF INF1tTRA1OR: 26'-96" C 2.SY 516 FS �342- 24'-79' C 2.SY 51b FS 10YR 5/9 PROPOSED LEACHIN3cAp USE 3-38'LONG TRENCl tOP ELEV. 93.80 ESHGW 90.47 TOP ELEV. 93.80 ESHGW 90.41 112.2 LF x 7SFILF=7F5A S TP3 TP4 REQUIRED SEPTIClk%K. SOLL DEPTH SOIL}IORIZON SOIL COLOR OILTEXTU SOIL 200%OF 440 GPD=b% U1,1111i SOIL HORIZON sou COLOR OIL TEXTVR- MUMILING MOTTI.[NG PROPOSED SEPTIC lki, Llvc 10YR212 SL0"8" A IOYR2R SL IOYR41b SL8"-28" 8w 10YR416 SL 2.SY yq LS Q40" 28"•90" C 2.5Y 516 FS Q10` ►OYR S!8 lOYR SIB GENERAL NOTE 1. DWELLING LoC, PERCOLATION TEST: FROM AN ON # ��= HOLE# PTI Pl 2 2. RANGER ENGlFg DEPTH OF PERC. 241111611 24"119" ENG\NEERIWG .�` START PRE SOAK 8:59 9:021ZL� 5 cXCEPS N END PRE SOAK 9:14 9:17 1MPLiEa,\StdtAi a 9Gpf,Np eT:14, � 3a . , • '.ppL Town of North Andover HEALTH DEPARTMENT ,sSACHU`+Et CHECK#: ,�. DATE: �S Z,Cl2,l LOCATION: H/O NAME: CONTRACTOR NAME: / ' ec ,kLC e. 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 $ ❑ TrashlSolid 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 $ fi Title 5 Report P(,'55 $ ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer