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HomeMy WebLinkAboutPass - Title V Inspection Report - 2005 SALEM STREET 5/5/2022 'Commonwealth of Massachusetts RECEIVED�' �= - L Title 5 Official Inspection Form MAY o5wz Subsurface Sewage Disposal System Form - Not for Voluntary Assessments TOWN OF NpRTH ANDOVEh 2005 Salem Street HEALTH DEPARTMENT Property Address — _ i Jake Zelnick Jp C� Owner Owner's Name information is North Andover required for every d -__ _ Ma 01845 3/25/2022 page. CitylTown 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 Dean Dynan key to move your Name of Inspector _ -- cursor-do not Dean Dyna use the return - ___ Company Name — key. 2 Suntaug Street _ „y Company Address Lynnfield Ma 01940 City/Town State Zip Code an 508-726-9935 S112837 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 61" an= Inspector's Signature t 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. t51nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2005 Salem Street Property Address Jake Zelnick Owner Owner's Name information is North Andover Ma 01845 3/25/2022 _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: ® 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. i Comments: 4 Bedroom septic system in working order I I 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.71262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts - _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2005 Salem Street v Property Address Jake Zelnick _ Owner Owner's Name information is required or every North Andover Ma 01845 3/25/2022 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.7I2612018 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 i 2005 Salem Street i Property Address Jake Zelnick Owner Owner's Name information is every North Andover required for eve Ma 01845 3/25/2022 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.7r2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts =,r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2005 Salem Street Property Address - — ---- - Jake Zelnick Owner Owner's Name .__---.__-_-- information is North Andover required for every Ma 01845 3/25/2022 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 % 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. ❑ z 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 15insp.doc-rev.712612016 Title 5 Official Inspection Fortin Subsurface Sewage Disposal System-Page 5 cf 18 Commonwealth of Massachusetts =� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2005 Salem Street Property Address - Jake Zelnick Owner Owner's Name information is North Andover required for every Ma 01845 3/25/2022 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 CM 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)] t5msp.doc•rev.712612018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form -I Subsurface Sewage Disposal System Form - Not for VoluntaryAssessments nts 2005 Salem Street Property Address -- - _ -- --- Jake Zelnick Owner wn-r-'s Name - Owne information is North Andover required for every Ma 01845 3/25/2022 page. City/Town 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): Description: 4 bedroom infiltrator drainfield 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 information in this report.) ❑ Yes © No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 years usage d Well Water Detail: Well water Well is 125'+ from SAS .... ... _..__._. Sump pump? ❑ Yes ® No Last date of occupancy: current Date t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2005 Salem Street v Property Address Jake Zelnick Owner Owner's Name information is required for every North Andover Ma 01845 3/25/2022 page. CityfFown 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: Homeowner/Board of Health pumped 8/2020 as per homeowner 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.7/2 612 01 8 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 8 cf 18 Commonwealth of Massachusetts its Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments W 2005 Salem Street Property Address Jake Zelnick Owner Owner's Name information is North Andover required for every _ _ _ _._ Ma 01845 3/25/2022 page. Clty-mo— - - - -- -- State zip-code Date of Inspection D. System Information (cont.) 4. Type of System: X Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) 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: 7/2013 as per info on file Were sewage odors detected when arriving at the site? ❑ Yes © No 5. Building Sewer(locate on site plan): Depth below grade: 22 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, sewer pipe in good condition / no evidence of leakage t5insp.doc•rev.7/26/2016 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 2005 Salem Street roperty Address - — Jake Zelnick Owner _..me _..--- - — - Owners — - information is North Andover required for every -_ Ma 01845 3/25/2022 page. Cityffown -- - — — _ State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 10" feet --- - Material of construction- ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 gallon septic tank with cast iron cover to grade If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'X 5'X 5'8" Sludge depth: 6 Distance from top of sludge to bottom of outlet tee or baffle 29 -- Scum thickness 0-2 Distance from top of scum to top of outlet tee or baffle 5 ---- — Distance from bottom of scum to bottom of outlet tee or baffle 13"— ----- - ----- — How were dimensions determined? in field with measure stick and 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.): 1500 gallon concrete septic tank with PVC inlet and outlet T / Tank in working order with separation from inlet to outlet / no evidence of leakeage cast iron cover to grade Filter in outlet/filter was cleaned during inspection recommend pumping every three to four years depending on usage and number of occupants Filter requires minimum annual cleaning / remove , rinse , reinsert/ to avoid possible backup t5msp,clot•rev.7126/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts j 11 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2005 Salem Street Property Address Jake Zelnick Owner Owners Name — information is North Andover required for every Ma 01845 3/25/2022 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): i 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 l5insp.doc•rev.7/26/2018 TRIe 5 Official Inspection Form:Subsurface Sewage Disposal System•Pago 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2005 Salem Street Property Address Jake Zelnick Owner Owner's Name information is required for every North Andover Ma 01845 3/25/2022 page. City/Town 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 liquid at 0"above invert 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.): 6 Outlet concreteHD box level with 5 outlet pipes with levelers / little evidence of solids carryover / no evidence of leakage into or out of box/d box in good condition D box in working order D Box is 16" below grade t5insp.doc-rev.7/26J2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i7 2005 Salem Street -_- PropertyAddress Jake Zelnick Owner _. --- - - wner's Name information is North Andover required for every _ Ma 01845 3/25/2022 page. Clty/Town - — — __... - State Zip Codd e 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: ❑X leaching fields number, dimensions: 1 @ 14.2'X 40' ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: --- - l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts rix -4- 1.2, Title 5 official Inspection Form , Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2005 Salem Street Property Address Jake Zelnick Owner ---------- wner's Name -- - information is North Andover required for every Ma 01845 3/25/2022 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.): Infiltrators found in sloping lawn area/ soils in good condition / no signs of hydraulic failure/ no ponding/ no damp soil 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.): t51nsp.doc,•rev.7/2 612 01 8 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 2005 Salem Street j Property Address Jake Zelnick _ Owner Owner's Name information is required for every North Andover Ma 01845 3/25/2022 page. CitylTown 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.): 15hsp doc,rev.7/262018 Title 5 ofricial Inspection Forth:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts j - � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2005 Salem Street Property Address Jake Zelnick Owner Owner's Name - information is North Andover required for every Ma 01845 3/25/2022 page. Cityrrown 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 j ® drawing attached separately I I I I t5insp.doc•rev.7/26/2018 Td!e 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts x _ -;' Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c ' q �r 2005 Salem Street _ — - Property Address Jake Zelnick --- --------- Owner Owners Name information is North Andover required for every Ma 01845 3/25/2022 _ page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water Z Check cellar ® Shallow wells Estimated depth to high ground water: 60 + feet Please indicate all methods used to determine the high ground water elevation: ❑X Obtained from system design plans on record If checked, date of design plan reviewed: 2013 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: System Plans on file at BOH dated 2013 conducted by Merrimac Eng Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pago 17 of 18 Commonwealth of Massachusetts ^ � Title 5 Official Inspection Form 6 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2005 Salem Street Property Address Jake Zelnick Owner Owner's Name - information is North Andover required for every _ Ma 01845 _ 3/25/2022 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 4 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 t5lnsp.doc•fev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 SUMMARY OF INVERTS BUILDING TIES SEWER ® FDTN. 147.69 BLDG. CORNER A B C D SEPTIC TANK IN 147.39 SEPTIC TANK OUT 13,9 36.0 - _ NorE• THIS PLAN & CERTIFICATION IS NOT A OF THE SEPTIC TANK OUT 147.02 DIST. BOX 147.7165.81 SYSTEM.AITT IS A RECORD�OFR THE ELOCA IONL DIST. BOX IN 141.07 AND ELEVATION OF THE EXISTING SYSTEM DIST. BOX CUT 140.88 COMPONENTS. INV. !N CHAMBER 140.82 INV. I CHAMBER 140.52 '1 HEREBY CERTIFY THE LOCATIONS, ELEVATIONS, TIES, COVER MATERIAL.. BOTEXPOSED COMPONENT COVERS ETC., SHOWN ON THIS AS-BUILT SUBSTANTIALLY AGREE WITH THE APPROVED PLAN AND HAVE DETERMINED THAT THE BREAK OUT ELEVATIONS, IF APPLICABLE, HAVE BEEN MET.' RECEIVED APPROVED DESIGNS PLANS. JUN "Lf, 2013 6?k/&6.dAY!/Ce/rlc� Z .3 TOWN OF NORTH ANDOVER SIGNATURE OF DESIGNER D TE HEALTH DEPARTMENT O � O / 1 Q� �P Gv% � OF LQT I (129,181 S.F.) I 1n/e l r 5 O CO �Ci1CN UNo1v�F.• j 51.26 r � �o 1500 GAL SEPIC TAMN LL40i MD W/26MWATOR CMUMM T-4 PORT T-3 T-2 YWi PRIVATE DRIVE ZH OF NLO.iCHErtOK AS BUILT PLAN OF SUBSURFACE DISPOSAL SYSTEM LOCATED IN NORTH ANDOVER, MASS./2005 SALEM STREET AS PREPARED FOR GEORGE HASELTINE TW 1O8A DATE: 6—22-13 TL: 2 SCALE: 1"=40' 0 20 ao Bo MERRIMACK ENGINEERING SERVICES 66 PARK STREET ANDOVER, MASSACHUSETTS 01810 K�r i PUBLIC HEALTH DEPARTMENT Cwrvody Dttdopmtal Diosiaa I TOWN OF NORTH ANDOVER ; SEPTIC DISPOSAL SYSTEM—INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System( constructed;()repaired; By: l-( 1A1`�Fn (Print Name) Located at: 2dq?2 �2ALGl-f S-r (installation Address) Was installed in conformance with the North Andover Board of Health approved plan,originally dated �d and lest revised on None- with a design flow of gallons per day.The materials used were in conformance with these specified on the approved plan,the system was installed in accordance with the provisions of 310.CMR 15.000,Title 5 and local reguintions,and the final grading agrees substantially with the approved plan.All work is accurately represented on the As-built which has been submitted to the Board of Health. Bottom of Bed Inspection Dot,: EngineerRepresen ative(Signature) _U Ft1eS6jF, And-Print Name 1 Final Construction Inspection Date: -Z(— (� Engineer Represe tative(Signature) IJIL.I� Ll� Fitt%�►1r% And-Print Name Installer. (Signature) Date: T F--i Gl-A� And-Print Name Eegintr. \ (slgeatom) Date: And-Print Name 1600 Osgood Street,North Andover,Massachusetts 01845 j Phone 978.688.9540 Fox 978.688.8476 Web http:f/www.townofnorthandover.cam ' i i f f ���s r,+�� m„ :1�' •�` �.' ~r T...t v Y �,�>Y.'� ����,y� , �t ,,,7 Tt �, M-cy,:1•L 1 Y� f'>l'' -q'I � ro, ;*;�O.a}rt ata� � a -1`•[ `c4`'M phi �T �'vT•��'�` '. F, S a •�� tl.}.'\ ����✓ V � V 1 I� �. F. max.•. r g r i `r 'P' QO S) � �r tY'r d,�s, i!✓��,3.',r�_fr .71 }� IIIXXX sew ry'�"r ,y S.!p' j2. r �wwar.t a * KA r t . �'rSCu �'? ` ek34 t> i Caring for your Septic System: ,A Reference Guide for Homeowners Caring for Your Septic System (Conventional Septic System, Innovative/Alternative (I/A) System, or Cesspool) The accumulated solids in the bottom of the septic tank should be pumped out every three years to prolong the life of your system. Septic systems must be maintained regularly to stay working. Neglect or abuse of your system can cause it to fail. Failing systems can • cause a serious health threat to your family and neighbors, • degrade the environment, especially lakes, streams and groundwater, • reduce the value of your property, • be very expensive to repair, • and, put thousand of water supply users at risk if you live in a public water supply watershed and fail to maintain your system. Be alert to these warning signs of a failing system: • sewage surfacing over the drainfield (especially after storms), • sewage back-ups in the house, • lush, green growth over the drainfield, • slow draining toilets or drains, • sewage odors n Fr- V _ 'V V Ir dn'et> ro7 .G3! � -^-- ro dstnbubin Tips to Avoid Trouble • DO have your tank pumped out and system inspected every 3 to 5 years by a licensed septic contractor (listed in the yellow pages). iittps://.vvrv.townolnev�bury.org/prinL/,l71 1/3 10/5/2020 Caring for your Septic,'§§% ni:A Reference Guide for Homeowners • DO keep a record of pumping, inspections, and other maintenance. Use the back page of this brochure to record maintenance dates. • DO practice water conservation. Repair dripping faucets and leaking toilets, run washing machines and dishwashers only when full, avoid long showers, and use water-saving features in faucets, shower heads and toilets. • DO learn the location of your septic system and drainfield. Keep a sketch of it handy for service visits. If your system has a flow diversion valve, learn its location, and turn it once a year. Flow diverters can add many years to the life of your system. • DO divert roof drains and surface water from driveways and hillsides away from the septic system. Keep sump pumps and house footing drains away from the septic system as well. • DO take leftover hazardous household chemicals to your approved hazardous waste collection center for disposal. Use bleach, disinfectants, and drain and toilet bowl cleaners sparingly and in accordance with product labels. • DON'T allow anyone to drive or park over any part of the system. The area over the drainfield should be left undisturbed with only a mowed grass cover. Roots from nearby trees or shrubs may clog and damage your drain lines. • DON'T make or allow repairs to your septic system without obtaining the required health department permit. Use professional licensed contractors when needed. • DONT use commercial septic tank additives. These products usually do not help and some may hurt your system in the long run. • DON'T use your toilet as a trash can by dumping nondegradables down your toilet or drains. Also, don't poison your septic system and the groundwater by pouring harmful chemicals down the drain. They can kill the beneficial bacteria that treat your wastewater. Keep the following materials out of your system: Nondegradables grease, disposable diapers, plastics, etc. Poisons gasoline, oil, paint, paint thinner, pesticides, antifreeze, etc. Septic System Explained Septic systems are individual wastewater treatment systems (conventional septic systems, innovative/alternative (I/A) systems, or cesspools) that use the soil to treat small wastewater flows, usually from individual homes. They are typically used in rural or large lot settings where centralized wastewater treatment is impractical. There are many types of septic systems in use today. While all systems are individually designed for each site, most systems are based on the same principles. Your septic system treats your household wastewater by temporarily holding it in the septic tank where heavy solids and lighter scum are allowed to separate from the wastewater. This separation process is known as primary treatment.The solids stored in the tank are decomposed by bacteria and later removed, along with the lighter scum, by a professional septic tank pumper. separates After partially treated wastewater leaves the tank, it flows into a distribution box, this flow evenly into a network of drainfield trenches. Drainage holes at the bottom of each line allow the wastewater to drain into gravel trenches for temporary storage. This effluent then slowly seeps Into the subsurface soil where it is further treated and purified (secondary treatment). A properly functioning septic system does not pollute the groundwater. f