HomeMy WebLinkAboutApproved Septic Plan - 187 STONECLEAVE ROAD 8/20/2015 l
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PUBLIC HEALTH DEPARTMENT
'fawn of North Andover
Community Development Division
CERTIFICATE OF
COMPLIANCE
As of: 8/14/15
This is to certify that the individual subsurface disposal system received a
SATISFACTORY INSPECTION of the:
Repair Tank Cover & outlet tee
By: Todd Bateson
At:
187 Stonedeave Rd
Map 104B Lot 132
North Andover, MA 01845
T I Issuance of this certifi ate shajl�not be c nstrued as a guarantee that the system will function satisfactorily.
e
Michele Grant
Public Health Agent
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
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North Andover Health Department
Community and Economic Development division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 187 Stonecleave MAP: 104.13 LOT: 0132
INSTALLER: Todd Bateson
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
�; ❑__ a .._ ❑ �❑� �
INSPECTIONS
Outlet T and tank cover INSPECTION:
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
❑ Contractor reports any changes to design plan
❑ Existing septic tank properly abandoned
❑ Internal plumbing all to one building sewer
❑ Topography not appreciably altered
Comments:
SEPTIC TANK
❑ Building sewer in continuous grade, on
compacted firm base µ
❑ Cleanouts per plan
❑ Bottom of tank hole has 6" stone base ' ti
❑ Weep hole plugged
❑ 1500 gallon tank has been installed
H-10 loading
❑ Monolithic tank construction
❑ Water tightness of tank has been achieved by
visual testing
❑ Inlet tee installed, centered under access port
❑ Outlet tee installed, centered under access port
(gas baffle/effluent filter)
❑ inch cover to within 6" of finish grade
installed over one access port
❑ Hydraulic cement around inlet & outlet
Comments:
PUMP CHAMBER
F-1 Bottom of tank hole has 6" stone base
❑ Weep hole plugged
F-1 1500 gallon Pump Chamber installed
❑ H-10 loading
F-1 Monolithic tank construction
F-1 Inlet tee installed, centered under access port
F-1 Pump(s) installed on stable base
❑ Alarm float working
❑ Pump On/Off floats working
F-1 Separate on/off floats
F-1 Drain hole in pressure line
❑ cover at final grade installed over pump
access port
❑ Watertightness of tank has been achieved by
testing
❑ Hydraulic cement around inlet & outlet
Comments:
CONTROL PANEL
❑ Alarm & Pump are on separate circuits
F-1 Alarm sounds when float is tripped
❑ Location of control panel: basement
F-1 Alarm signal located inside: basement
Comments:
DISTRIBUTION-BOX
F-1 Installed on stable stone base
❑ H-20 D-Box
❑ Inlet tee (if pumped or >0.08'/foot)
❑ Hydraulic cement around inlet & outlets
❑ Observed even distribution
❑ Speed levelers provided (not required)
❑ Schedule 40 PVC Pipe
Comments:
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Commonwealth of Massachusetts 10430°°1322,,
104.B0
BOARD OF HEALTH Permit No
BHP-2015-0235
North Andover -----------------------
P FEE
F.I. $125.00
DISPOSAL T LJ TI N PERMIT
Permission is hereby granted Todd_Bateson _____ ________________
to(Repair)an Individual Sewage Disposal System. r1 at No 1$7 STONECLEAVE ROAD-----------UJAA-`- ,L- lant---(U1-tt- ------------.----
as shown on the application for Disposal Works Construction Permit No. BHP-2015-023 Dated May 28,2015
Issued On:May-28-2015 OF
------- ----- ---
I
y
�- E Application for Septic Disposal gyatem f(/
Construction Permit — TOWN OF DA DATE
$125. ®'- mT 0184 0Cop Repair
Important: Application is hereby made for a permit to:
When filling out ❑Construct a new on-site sewage disposal system*
forms on the
computer,use ❑Repair or replace an existing on-site sewage disposal system*
only the tab key
to move your t
❑C Rdpair or replace an existing system component—What? C ,c �-(t.,1- 14 f..
l'•' �"�/?...,
cursor-do not
use the return A. Facility Information
key. r > ` rJ✓d C,. _.
Address or Lot#
t
City/Town r? .. r.. ..
' 2.- TYPE OF SEPTIC SYSTEM*: TC)Wt4 OF l�i����i ANDOVER
➢ [] Pump ravity(choose one) �jFALTH DEpAr TMENT
***If pump syste r ettach copy of electrical permit to application*`*
Z onventional System (pipe and stone system)
➢ ❑Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system.)
A ❑ Pressure Distribution S.A.S.(No D-Box)
➢ ❑ Pressure Dosed(D-Box Present)S.A.S.
➢ ❑ Does the system require an effluent filter? Yes No
If yes, does plan specify make and model of filter? YES=(no further info. needed)
NO=(installer must specify brand of filter before DWC issuance)
What is the Make. What is the Model's''
2. Owner information
Name
Address(if different from above)
City/Town State Zip Code
Telephone Number
3. Installer Information
Name Name of Compan
/ 0N NTr is
' N01811
Address AN00V �
�,.._ ��,MA, iS1(7
City/Town State Zip Code
Telephone Number(Cell Phone#if possible please)
4. Designer Information
Name Name of Company
Address y —
City/Town State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
6Ndnrij, o Applipati•o ..fr eptic DISPO-SaISVStem
p on trUCti n `Permit ®TOWN O TODAY'S DATE
ORTHANDOVERmA 01845 $.250.60--Full Repair
$125.00-Component
sACHUS '
PAGE 2 OF 2
A. Facility'•information continued....
5. Type*of Building: 0 es, ential Dwelling or❑Commercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore-described
on-slte sewage disposal system In accordance with the provisions of Title 5 of the
Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of
North Andover, and not to place the system 1h operation until a Certificate of Compliance has
been Issue y this Board of Health.
bate
ppr
d o Health RepresenfativeJ
�licatio� A rov B�(Boar
I7 pp � e�
me
.,.r Date
Application Disapproved.fo the following reasons:"
For Office Use Only:
I. ''Fee Attached? Yes No
2- PtolectManaget Ohligatron Form Attache'd? Yes No
3,: PumBv w? Ifso)Attach copy ofElec/�%�al Permit'.; yes® No
4. FouadatronAs Built.?(hew constructlon-ronl '; Yes No
y) � es
(Same scale as npptoyed plan)
b
5. Floor Plans?(he.w construction only) Yes
. : No
Appiiditldn'lor,01 potai 4sterit%06nstruct1on Permit;Rage 2 02
As fha.Npxth hndover.li=sedhiatxilet fAr#�Ee•t atzac#q fa Secpt is system. faae.the�ptQpettystt:
(Adrreail otteptic ayateos) --Praz pUas by
Rt]attvtC to ti�.aPp1%tipri mf lr��� -_ �..._�:,�-/�e-° dr^,� •
(fiat cts amid Abd dated
-
(I4at revised date)
I=detataad the following ObAgatiom for momgemcnt o>'•this ptolect:
i. As the fastaUc4 I araa.obligated to obh&#&pe Wfbr and Board of-Hestith�pprovcd pim to
' �petfotgaiag aay:worh�.a edte: lust hsare thd�hrava5iia�lana��tie p.�ax-t•�atel�p. wa+• °fs
2. As&i id .I.aaiist ii o andidt IEhw;ad mrzse cons ee ect
�' - mauat•r�T
4a enon nnt:aagodated with my&mpMy src�aoee•an l sedan and train is ndt read
Item t tth�all.hi applicable. c y'their
.` As t1 h�stt; rgcd 4ot have add stttary cvr nrx ix� ttdd•p�o the,applYcabk tcvAss
c
x•: : aaly�#�sa is th+ �iipeioi� e�thr1, iclr
ah bar doni i = iat fct' iii a tjt. }6ya: ,jspc liddm{�at'��pu�t ies•n®t ha�v�e to be pr�CSv�i ,..
.®. • • ''®°' 004P+•�FAF .+B�+si.+a.6v for Mss+t+�aMoil�;-t4mp etc, , .
'(or e.�M4•to; L 9 -fr6m the eripper must AW bastibtmited#�i .11oatd'ofHeat ,at� �stfall� ford ,+pacttptt tuaae.-1psta&iaaust
bE pteamt~fnr t]> ,itmpcctitrpt, Vft a pubaF 'aPQtk;tmcuat be teat+ly aad able to
arose ptia t6 work aiad, :to 614M,
Q —ustswer azvst rquW iWecdon wb i 11$rad3st Itirornpltte:`
IOstaiicridoesaot
We to bc!on¢aste. ;
4, As-the kstallm'I um 3' d that :tQof r'(athtrff=,A*k axwoNan)4ad'I atn x�xcd
io CIOM1 left i4W."04thaft of the £Z itfoulf atlon
uaderataecx drat merGv � ; iy`,:aatna 2�Ta love*� .
" tt�t d�S�:Y�t�lt'i �{d •ax aii�,��..t�'„'�f�my�iG tci;�'� �T,�cam a�'
��ificat��i+t��ct+�o`ns.
:'S.. pia the iaatlter�Z widerst�ii tit I trta5t<it ohm ' .sertcef tta folicsittg coastrtician
steps
m
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A Zupe&iYao attkc rAnd xaarda"qp be wed
. � •Paaa:!"a�►arpea�au°hy.r�oautl ul�5ieAltft a�e>�'`ax coaaa�ulAsnt�• • . • . - •
d .tdelfajyGt oftarag pYpa aPtAar, rat,pAm.p. bei;1 �. Jnd other .
CctmpQlteaarM. � . . .
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Commonwealth of Massachusetts ""t E C"",�Izl
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
NCAF �,IORfLIANIi �� w
i
187 Stonecleave Road HEA H is
Property Address
Roger Gauld
Owner Owner's Name
information is
required for North Andover MA 01845 5/5/2015
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 tilling out A. General Information
forms on the
computer,use 1. Inspector:
only the tab key �<
to move your
Neil J. Bateson
cursor-do not i ,
use the return Name of Inspector '�+ro,
key. Bateson Enterprises Inc.
Company Name
111 Argilla Road
Company Address
Andover MA 01810
" Cityrrown State Zip Code
978-475-4786 S115
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
❑ Passes ® Conditionally Passes ❑ Fails
❑ Needs rther valuation by the Local Approving Authority
5/5/2015
Insp ct s P6 nature 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
Title 1 1 Inspection
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
s 187 Stonecleave Road
Property Address
Roger Gauld
Owner Owner's Name
information is
required for North Andover MA 01845 5/5/2015
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cunt.)
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
i
ugTitle 1 Inspection
Subsurface Sewage Disposal System Form_Not for Voluntary Assessments
187 Stonecleave Road
Property Address
Roger Gauld
Owner Owner's Name
information is North Andover MA 01845 5/5/2015
required for
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cunt.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cunt.):
❑ 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):
i
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
187 Stonecleave Road
Property Address
Roger Gauld
Owner Owner's Name
information is
required for North Andover MA 01845 5/5/2015
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fall 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:
Outlet tee&Outlet Cover needs to be replaced.
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ 0 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
❑ E 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title i i Inspection
Subsurface Sewage Disposal System Form o Not for Voluntary Assessments
187 Stonecleave Road
Property Address
Roger Gauld J
Owner Owner's Name
information is
required for North Andover MA 01845 5/5/2015
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (coot.)
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.
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title Official Inspection
Subsurface Sewage Disposal System Form o Not for Voluntary Assessments
187 Stonecleave Road
Property Address
Roger Gauld
Owner Owners Name
information is
required for North Andover MA 01845 5/5/2015
every page. Cityfrown 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:
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): 500
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusettsj
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form v Not for Voluntary Assessments
187 Stonecleave Road
Property Address
Roger Gauld
Owner Owner's Name
information is
required for North Andover MA 01845 5/5/2015
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 3
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)): On well water
Detail
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
Date
Commerciallindustrial 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
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Official Title 5 Inspection
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
187 Stonecleave Road
Property Address
Roger Gauld
Owner Owner's Name
information is
required for North Andover MA 01845 5/5/2015
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cost.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Pumped 2014, owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
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)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval,
❑ Other(describe):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage disposal System Form-Not for Voluntary Assessments
187 Stonecleave Road
Property Address
I
Roger Gauld
Owner Owner's Name
information is
required for North Andover MA 01845 5/5/2015
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cost.)
Approximate age of all components, date installed (if known)and source of information:
31 years old, 10/2/1984, as built plan
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.8
feet
Material of construction:
® cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
4"cast iron through wall, 3" PVC in house, no leaks visible
Septic Tank(locate on site plan):
Depth below grade: ,g
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:
10'x 5'x 4'
Sludge depth:
2"
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title Official Inspection
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
187 Stonecleave Road
Property Address
Roger Gauld
Owner Owner's Name
information is
required for Notch Andover MA 01845 5/5/2015
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (coat.)
Septic Tank(cant.)
Distance from top of sludge to bottom of outlet tee or baffle N/A
2..
Scum thickness
Distance from top of scum to top of outlet tee or baffle N/A=Outlet tee corroded off.
Distance from bottom of scum to bottom of outlet tee or baffle N/A
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& baffle ok. Outlet tee corroded off, needs to be replaced. Depth of liquid at outlet invert.
No evidence of leakage.
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•3113 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
187 Stonecleave Road
Property Address
Roger Gauld
Owner Owner's Name
information is
required for North Andover MA 01845 5/5/2015
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: F-1 Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form o Not for Voluntary Assessments
187 Stonecleave Road
Property Address
Roger Gauld
Owner
Owner's Name
information is
required for North Andover MA 01845 5/5/2015
every page. CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box level &distribution equal. No evidence of carryover. No evidence of leakage.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: F-1 Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title i i Inspection
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
187 Stonecleave Road
Property Address
Roger Gauld
Owner Owner's Name
information is
required for North Andover MA 01845 5/5/2015
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cant.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions: 1 field 20'x 45'
❑ 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.):
Boil Ok. Vegetation 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 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
I
Commonwealth of Massachusetts
Title 1 1 1 Inspection
Subsurface Sewage Disposal System Farm-Not for Voluntary Assessments J
i
$� 187 Stonecleave Road
Property Address
Roger Gauld
Owner Owner's Name
information is
required for North Andover MA 01845 5/5/2015
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cant.)
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•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
187 Stonecleave Road
Property Address i
Roger Gauld
Owner Owner's Name
information is
required for North Andover MA 01845 5/5/2015
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cost.)
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 1'00 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
3
/�- L -3 3 I
LY 1'
D- =3+�j '
t5ins-3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title i i Inspection
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
187 Stonecleave Road
Property Address
Roger Gauld
Owner Owner's Name
information is North Andover MA 01845 5/5/2015
required for
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 4
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 10/2/1984
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
Design plan
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Test pit data on design plan
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
I
i
Commonwealth of Massachusetts
Title Official Inspection
Subsurface Sewage Disposal System Form m Not for Voluntary Assessments
`t 187 Stonecleave Road
� Property Address j
Roger Gauld
Owner Owner's Name
information is
required for North Andover MA 01845 5/5/2015
every page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® 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
i
s
4
az
0 , 0
y
OF MAS`5q
JOSEPH G
).
' BARBAGALLO
y �y c.,
' �,"� Pry <�•� _���,r�w`�'/ f
1
cr0 �
1
Town of ,North Andover,Mass . ,
Permit ; Date ,9_
APPLICATION FOR WELL & PUMP PERMIT
Application is hereby made for permit to drill a well ( ` ) , Application is
made to install (!) a pump system:
Location: Addres � .. �s,� �� Lot
Owner Address
Well Contractor " ;� Address
Tel . -
t
Pump Contracto --Address
- 1'
WELL CONTRACTOR ( To be completed at time of plump test )
Type of Well Well used for
Diameter of Well—_ 1, --- ---Size ' of Casing_- /
Depth of Bed Rock—� -- ---Depth casin g into B+ed Rock—I .
`
Was Seal Tested? Yes ( ) No (A Date -of Testing
De th of Well Well Ended In k.ha Material-,
�
P C `. `
Depth to G'a t e r-------� . ------ ---D e].fi v e r s_ _Ga l s . Per ;`1 i n . f ci h--u r
Drawdown .� .�_ ,✓
� feet asr ter umping__".;/ hours at 6, GPM-
Date of Completion
Sign A t e-i`,e 1 jnra ctor -
!..!.! t.,.L! 1_.1-J_ J_J.a...L. 1_ ,_ t- ..�, •+•-`�_n� ,it. mac_ t --. _ ..'.y._ ..L..�,::^t. ..,``_..�w�. `�.�,� �
PUMP INSTALLER (To be -filled-in-bef-axe- installafion)
Size & Name- Pump Pump Type Used
Water Pump Delivers== GPM Size of -Tank--
Pipe J•iaterial Used in G'ell : Cast Iron ( ) Galvanized . ( ) Plastic ( )
G:ell Pit ( ) or Pitless- _Adapter
Was sleeve used to protect .,Pipe?-.Ye- s . ( ) NO( ) Type or Name Irliel.l. Seal
Date
4.s,.! i .`:..t t. l rnr? 1 11 ! C? _ 3 l nc T -,ta,IT r.t
r. ,c rt rt n r. .s r, ,t „ rti n ri „5[Y
Date -G'ater- analysis report submitted to --Board of Health,_
Date ' release _ given to owner of record & Bldg . .Insp
health Inspector
4
BURLINGTON WATER TREATME14T PLANT
WATER SUPPLY ANALYSIS (mg, per liter)Collector: r R.,^npv
Source A Private Wailer Supply Co Rooney
i
Source B
r
Source C
Source D
i
Source E
Source F A B C D E F
Sample No.
Date of Collection 8-2-84
Date of Receipt 8-2-84
TURBIDITY .78
SEDIMENT 0
FODE 0
0
H
ALKALIN ITY -Total (CaCOj) 42
HARDNESS (CaCOj) 119.7
CALCIUM (Ca)
MAGNESIUM (Mg)
SODIUM (Na)
POTASSIUM (K)
IRON (Fe) .03
MANGANESE (Mn) 0.00
SILICA (SiO2)
SULFATE (SOO
CHLORIDE (CI) 12.5
SPEC. COND. (micromhos/cm 240
NITROGEN (AMMONIA)
NITROGEN (NITRATE)
NITROGEN (NITRITE)
Water Manager
r
1
TO @ICI OF 'BURLINGTON
Department of Public Works
DAC`TRIAL XAItxIIAT70n OF WATER
Collected 84
neciewd 8-1®84 Reported w.D. Keene
Location Sample � oC l.,lwtor- Analyst Collect[on Analysis Coliform bacteria
Number till►c; Time per 100 ml
Membrane Filter
Private Well 650 Rooney Haynes 3pm 5pm O
Water Manager
. Mme
" "4R ,�w � m
North Aydo'velfs
Oland ; �� ":. ....,. _
v,
I,IVC 3'LA 'l,z
Sol L
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`6'S'
Pit l _
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" yra r',f"tips _.
�nn Von W m ._� _..
i
�W-=LL DATA3ASE
AiDREES'
AGE CF D '?T E?' �=L
N Lly .T: ALL LOC. ,TiCN:
W-r:;r..I
: J C
_ v OF DRLTL ?' b. DLC c_ L:i'�IO�N _
-
wa L PER1 T- W= L GCA7cyl,: 11vi,'
IY
T ..L PE3-, .T DA» I �� DES'I"r OF r,T 'i L
TYPE OF ` -ELL: D=LED b. DU c. U�iiC�fOrr/�i
TYPE OF wA EP EEA:yRL\,G ROCK:
7VATE7R.ANALYSIS LATE: EGH NL;',. fGAYrn-'-E: Y �+
I-:[CH IRON: -r N. � OTHER CONTAML,,iANTS: `t' `+
Co
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON. NIA 02108 61 7-292.5500
WILLIAM F.WELD TRUDY COXT-
Scctclar�\
Governo:
ARGEO PAUL CELLUCCI DAVID B.STRUMS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION
U.v._
Property Address: of Owner:
Date of Inspection- (If different)
Name of I am Inspectora *
D approved system Inspector pursuant to Section 15.340 of Title 5 (31p CMR.15.000)
C o ro p a n y N a rn e: V c
Mailing Address: I I J Arvcl\tick Vk-N , fA'N--d\49Q_"' 10
Telephone Number: n_VjjC_
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete'as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
L'I-Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fa' s
Date-
Inspector's Signature:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, 8, C, or d.
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
8) SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y, N, or ND), Describe basis of determination in all instances, If"not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty(20) years prior to the date of the Inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltratioh, or tank
failure is imminent. The system will pass Inspection If the existing septic tank is replaced with 8 conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) page 1 of 10
DEP on the World Wide Web: http:/twww-rnagnetState,Ma.U!VdeP
0 Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATIQN (continued)
Property Address: I PY V Af
Owner:
elate of Inspection: t
Rl SYSTEM CONDITIONALLY PASSES (continued) is due to broken or obstructed
Sewage backup or breakout or high static water level observed in the distribution box
, (s) or due to a broken, settled or uneven distribution box, The system will pass inspection if(with approval of the
pipe
Board of Health). Describe observat ions:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will Pass
inspection if(with approval of the Board of Health):
broken pep (o) oto mpl"cod
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
e if the system is failing to protect the
Conditions exist which require further evaluation by the Board of Health in order to cletermin
public health, safety and the environment. DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
SYSTEM WILL,PASS UNLESS BOARD OF HEALTH
WHICki Wil"t, PROTECT THE PUBLIC HEALTH AND 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.
F HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)SAFETY A ND T D HE NETERMIES THAT
2) SYSTEM WILL FAIL UNLESS THE BOARD O
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND
ENVIRONMENT:
The system has a septic tank and soil absorption. system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.oil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and s
The system has a septic tank and soil absorption s ystem and the SAS is within 50 feet of a private water supply Well.
stem and the SAS is less than 100 feet but 50 feet or more from a
The system has a septic tank and soil absorptanal sy bacteria and volatile organic compounds indicates that
private water supply well, unless a well wateysis for of form
the well is free from pollution from that facility and the presence of ammonia nitrogen anali
vd nitrate nitrogen is equal to or
n.not d).
less than 5 ppm. Method used to determine distance (approximatio
3) OTHER
Pegs 2 of 10
(revised 04/25/97)
o
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: ` wmav�C?C 1� ?c .�,cr G � . IL-�0 -tk, lk". .tX.x),
Owner:
Date of Inspection:
Dj SYSTEM FAILS:
You must indicate either "Yes" or"No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool. "
® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any ponion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
M
® Any portion of a cesspool or privy is within a Zone I of a public well.
r 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
r acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Pago 3 of 10
A
1
j
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B 1
CHECKLIST
Property Address:
Owner: ' 1
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or"No"as to each of the following:
Yes o'"�
C'/ Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection. "
L° As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
sanitary or industrial waste flow.
The system does not receive non
The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
i The facility owner (and occupants,,if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) 115.302(3)(b))
(irovirld 04/85/97) Saga 4 of 20
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: loll 1CaLrp C E ,_. �(^�.�4, r OO'-�� R " _.0 4 J�?
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: f O7—g.p.d./bedroom for S.A.S.
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no): Wa
Laundry connected to syst m (yes or no):–Y-0-5
Seasonal use (yes or no): K0
Water meter readings, if a ailable (last two (2) year usage (gpd): C
Sump Pump (yes or n(,
Last date of occupancy: 6 UC4V AA1
COMMERCIAUINDUSTRIAL•
Type of establishment:
Design flow:_____Sallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)�
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information: VY .
System pumped as pan of inspection: (yes or no) �Jp_.
If yes, volume pumped: (•ji)O7 allons �JJ
Reason for pumping: G tae
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)
I/A Technology etc. Copy of up to date contract?
Other
APPRQXIMATE AGE of all components, date installed (if known) and source of information: /Lj
Sewage odors detected when arriving at the site: (yes or no) Jill)
(revia®d 04/25/97) page 5 of 10
i
1
SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner;
Gate of Inspection:
BUILDING SEWER,,,,, ---
(Locate on site plan)
Depth below grade:,
Material of constr in:lr 'cast iron " 40 P C other (explai
Distance from private water supply well or suction lire
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:—�
(locate an site plan)
Depth below grader
Material of construction: _„_c` oncrete metal ,,.Fiberglass Polyethylene _other(explain)
If tank is metal, list age is age confirmed by Certificate of Compliance —(Yes/No)
1 4
Dimensions:
Sludge depth: r' LJ 0
Distance from top of Sludge to bottom of outlet tee or baffle: r
Scum thickness: �
_!?__.__ r--I "
Distance from tap of scum to tap of outlet tee or baffle: ____ r,
Distance from bottom of scum to battm f outlet tee ar baffle:
How dimensions were determined: � a
Comments: y
(recommendation for pumping, condit' of inlet and outlet tees or baffles, de th of liquid level in to 1 structural
i tegrity evidence of leaka e, etc. ? 1
..
GREASE TRAPOI ,E '-
(locate on site plan)
Depth below grade:
Material of construction: concrete metal Fiberglass Polyethylene �other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffler
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(rav*pwd 44/25/97)
Page b of 10
I
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM j
PART C
SYSTEM INFORMATION (continued)
Property Address: '
Owner; (,.�� ki ii A.
Pate of Inspection: t \\\ qy
TIGHT OR HOLDING TANK:LN-0/�?4Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete —metal Fiberglass Polyethylene —other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/dati
Alarm level: Alarm in working order_ Yes; __._ No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:—
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(n a if level a d distrib tion is eq al, viden e pf solids carryover, evidence of leakage ipto or out of box, etc.)
Q.,.t..rQ_� CCA,..t- ������ , �-X.,t'�:aW` �?. �
PUMP CHAMOER: 'ow
(locate on site plan, C, �
Pumps in working order: (Yes or No)
Alarms in working order (Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revi®ed 04/25/97) Page 7 of 10
I
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1 �y1 �c):\ `.G� e-—ttw„te Q��'c")� C')t�T >�.,.
Owner. c _
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):L---^-'
(locate on site plan, if possible; excavation-'not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:
leaching chambers, number:
leaching galleries, number. w
leaching trenches, number,length: t
leaching fields, number, dimensions: L V -)o X
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(n0A condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.
)
CESSPOOLS: !hPWC
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: f`�'�7v4F
(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.
(revised 04/25/97) page a of 10
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: �^ I
Owner. „.
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
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(revised 04/25/97) Page 9 of 10
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection;
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
L `Observation of Site (Abutting property, observation hole, basement sump etc.)
L, Determine it from local conditions
.r"rJf
L-"Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
ms°'µ Use USGS Data
Describe in your own words how you established the High Groundwater Elevation, (Must be completed)
0c) l►i('t,.' -:C>-6 ( (1 11:.11-A-) A X ()
(revised 04/25/99) page 10 of 10
i
Tel: (978) 475 . 4786
Fax: (978)475 .. 5451 1
f
AT ON V T RPRTSF 2 INC.
gy-Ovoilo p w4w 4 Server 1.10C4-Septic Systems&Pumping Service
t 1 t MON Road Andover, Mass. 0 18 10
Title 5 Inspection Report
Proporty Address:
-e,� I�:
Owner:
: ►ate of Inspection:
My report eonW11ed herein does not constitute a guarantee of fitiure
ljoapp and the fimptiorl,ality of the existing septic system. Such report issued
horowitIl is merely based upon my observations, and I hereby disclaim any
"er operation of your current septic system.
Neil 113ateson
Hateson Enterprises, 1110.
Page 1 I of l l