HomeMy WebLinkAboutMiscellaneous - 159 FOREST STREET 8/20/2015 f
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PUBLIC HEALTH DEPARTMENT
Town of North Andover
Community Development Division
CERTIFICATE OF
COMPLIANCE
As of: 7/27/15
This is to certify that the individual subsurface disposal system received a
SATISFACTORY INSPECTION of the:
Repair of D-box
By: Peter Breen
At:
159 Forest Street
Map 106.A Lot 0179
North Andover, MA 01845
,The uancefof this cert'fic t all no be construed as a guarantee that the system will function satisfactorily.
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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• rrrwr� ,,, , Commonwealth of Massachusetts Map-Block-Lot
106.A0179
BOARD OF HEALTH -----------------------
Permit No
North Andover BHP-2015-031,7
P.I. --------------------
FEE
F.1.
$125.00
DISPOSAL RIB ICI T IJ TI N PERMIT
Permission is hereby granted Peter Breen
--------------
to(Repair)an Individual Sewage Disposal System.
at No 159 FOREST STREET
----- ------ ---------- ----- -
- - ------------
as shown on the application for Disposal Works Construction Permit No. BHP-2015-031, Dated July 22,2015
- - ----- - -----
a
Issued On:Jul-22-2015
-- -----
---------------------- BOARD OF HEALTH
f �
iar ��a
Application for Septic Disposal System
b�l
Construction Permit — TOWN OF TODAY'S DATE
NORTH ANDOVER., MA 01845 $ —Full Repair
$125.00 Component
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 ❑ Repair or replace an existing system component—What?
e,°"
cursor-do not
use the return A. Facility Information
key.
Address or Lot# ).'
City/Town
2.-*TYPE OF SEPTIC SYSTEM*:
➢ ❑ Pump El°'Gravity(choose one)
***If pump system, attach copy of electrical permit to application***
➢ [ Conventional System (pipe and stone system)
➢ ❑ Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system.)
➢ ❑ 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 dieMode]P
2. Owner Information
E
Name
Address(if different from above)
. <;
City/Town State Zip Code
„...1 w
Email address Telephone Number
3. Installer Information
Name Name of ompany
Address
City/Town State Zip Code
Telephone Number(Cell Phone#if possible please)
4. Designer Information
Name Name of Company
Address
City/Town State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
Application for Septic Disposal System
TODAY'S DATE
Construction Permit - 'TOWN OF �
NORTH ANDOVER, MA 01845 $250.00-Full Repair
$125.00 -Component
PAGE 2OF2
A. Facility Information continued....
5. Type of BuildM2: ❑Residential Dwelling or❑Commercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore-described
on-site 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. I understand that until a final Certificate of Compliance has been issued by
this Board of Health, the installed system is not approveed.
Name Date
I � y
litati n Approv, y:;(Board of Health Representative)
I, ) „
am _ Date
Application Disapprove for the following reasons:
For Office Use Only:
Z Fee Attached? Yes V1 No
2. Project ages Obligation Form Attached? Yes No
3. Pump S sy tem? f'so Attach copy of Electrical Permit Yes No
Applicant received copy,of
"ElectriInspection 1 Vgtes for Septic Systems" Yes Na
Handout? n' ".
4. Reviewed approvall'tt ; all paperworkreceived? Yes No
Missing' "^
5. Foundatl As-Built (new construction only): Yes No
(Sam cale approved plan)
G. Floor Plans?(new nstruction only): Yes No
Application for Disposal System Construction Permit•Page 2 of 2
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
/~
(Address^[sq`6z system) For plans 6y
(Engineer)
Relative m the application of
�uJ6u�6
Dated �
u&�o���dvteJ
~/ '� � � (Last revised date)
I understand the following obligations for management ofthis project:
1. Au the installer,� Iao obligated
to obtain all permits and Board of Health approved plans pAor to
performing any work on a site. I must have the approved 121ans and the permit on site when an)�work is
being done.
2. }\a the installer, ImosLcuU6oruoyuuduU6oapccdoum. If homeowner,contractor,project manager,orany
other person not associated with coycompany schedules an inspection and the system is not ready,then
item three shall bcapplicable.
3. 6s the installer,Iucu required toburethouccououryvrorkc000pletrdpzio, tod6oupplicu6lebzupccd000us
indicated below. I understand that requesting an inspection,without completion of the items in accordance
with Title 5 and the Board of Health RegWations ma�result in a$50.00 fine being levied aga�inst me and/or
my compal�
x. Bottom of Bed—Geue,xUr, this is the first (1°) inspection unless there is u retaining nmD,which
should bc done firot. The installer must request the inspection but does not have to6epresent. |
b. Final Construction Inspection—Engineer must Bcot 6o their inspection for elevations, des, etc. i
As-built n[verbal (}K/o�o�nuD�o� ��ouut6c engineer �
' - - |
6cyubui�cJto the Board ofIIe�t6`after n6�c6installer calls for uu inspection time. Installer must
bc present for this inspection. With a pump system,all electrical work must be ready and able to |
cause pump to nm rk and alarm to function.
c. Final Grade—IontuDerozuot request inspection when all grading io complete. Installer does not
have tobeoo'oitc.
4. As the ins taller,I understand that only I may perform the work(otber tball silvple excapatioll)and I am required
to complete the installation of the system identified in the attached application for installation. Bfurther
understand that work done by others unlicensed to install septic systems in North Andover can constitute
reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of
North Andover,significant fines to all.persons involved are also possible.
5. As the installer,I understand that I must be on-site during the performance of the following construction
steps:
a. Dxtxnxwimwti*m that t6xJhmpxrelevation of the excavation has been ,xmrhxo[
b. Inspection of the sand and stone to be wzxwC
c. Final inspection by Board ^fHealth staff orxums*/tamt. |
mC Installation of tank, D-Bm*, pifivs, stone, vent,paxwp m6*x*bxr, retaining wall and other '
xwmpom«mtt, �
& As the installer,I understand that I am solgly responsible for the installation of the system as per the
approved 12lans. No instructions by-the homeowner, general contractor,or any other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer: (Today's Date.)
|
North Andover Health Department
fommunity and Economic Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 159 Forest St. MAP: 106.A LOT: 0179
INSTALLER: Peter Breen
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
INSPECTIONS
D-BOX INSPECTION: 7/27/15
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
❑ Cleanouts per plan
❑ Bottom of tank hole has 6" stone base
❑ 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
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
F-1 1500 gallon Pump Chamber installed
F-1 H-10 loading
❑ Monolithic tank construction
F-1 Inlet tee installed, centered under access port
❑ Pump(s) installed on stable base
❑ Alarm float working
❑ Pump On/Off floats working
❑ Separate on/off floats
❑ Drain hole in pressure line
❑ cover at final grade installed over pump
access port
❑ Water tightness of tank has been achieved by
testing
❑ Hydraulic cement around inlet & outlet
Comments:
CONTROL PANEL
❑ Alarm & Pump are on separate circuits
❑ Alarm sounds when float is tripped
❑ Location of control panel: basement
❑ Alarm signal located inside: basement
Comments:
DISTRIBUTION-BOX
❑ 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:
NEW ENGLAND ENGINEERING SERVICES
~
December 14, 2002
North Andover Board ofHealth
Town Hall Annex
27 Charles Street
North Andover, K8/\O!845
RE: TITLE VRBPORT: 159 Forest Street,North Andover, MA
Dear Sirs:
Enclosed is a copy of the Title V report for the above referenced property. The system PASSED
our inspection. |
)
If there are any questions please call omsu1 n0' offioc 606-1768.
Sincerely
Benjanirn C. OmAood, &�
60 BEECHVVOOD DR|VE-NORTHANDVYER. MAO1V45-(g70)686-1780-(8mq35g-7645'FAX(978)685-1Ogg
f
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COMMONWEALTH OF MASSACHUSETTS 'y f
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS , ° t
DEPARTMENT OF ENVIRONMENTAL PROTECTION.-
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 6j2E57 5T2t
Owner's Name: 5 v J A N s.Ti L L /Y1 A N
Owner's Address: / az -q7-(z E,67
A)o RTH Awpc u c 2
Date of Inspection: zJ t 3 J G 2>
Name of Inspector:(please print) 6 fAa,4.,A(,v C Qs&-o6n
Company Name: NEw 1'iy6-tAyt4O 061 v EF2tAv G-
Mailing Address• (o y aU G%G�-lc�c���� 9,4()6-
• L042T)-t /}AJP OJGlL N e4
Telephone Number: r
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 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:
4 Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: LQ Date: /
The system inspector shall submit a copy of this inspect n report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
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Page 2 of 11
i
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: /,5!J Fv2Esi sT2Ee'i
,V O 1'rN A/yj>(pjiJ,2 ,vela
Owner- RNA po"rnwn/
Date of Inspection: 2.) ,,3 J.z
Inspection Summary: Check ",CD or E)ALWAYS complete all of Section D
A. System Passes:
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:
e or more system components as described in the"Conditional Pass"section need to be replaced or.
repaire Alqe system,upon completion of the replacement or repair,as approved by the Board of Health, in pass.
Answer yes,no o not determined(Y,N,ND)in the for the following.statements.If"not ermined"please
explain.
The septic tank is etal and over 20 years old*or the septic tank(whether etal or not)is structurally
unsound,exhibits substantr mfiltration or exfiltration or tank failure is immi� t.System will pass inspection if the
existing tank is replaced with mplying septic tank as approved by the Board of Health.
*A metal septic tank will pass ins ion if it is structurally sound,not.leaking and if a Certificate of Compliance
indicating that the tank is less than Nyears old is available.
ND explain: `
Observation of sewage backup or break tar high static water level in the distribution box due to broken or
abstracted pipe(s)or due to a broken,settled,oeven distribution box. System will pass inspection if(with
ti
approval of Board of Health): `1
"broken pipe(s)are replaced
obstruction is rem V;i
distribution box is 16yeled or replaced
ND explain:
r
The sy�tem required pumping more than 4 times a year d to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health): ��
broken pipe(s)are replaced r
obstruction is removed
ND explain:
I
Page 3 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued) 1
Property Address:
p L'TN AA)P 0,)G2 1114
Owner: ✓s FFn/ s 'ff-I M PO L-L-/14 A N
Date of Inspection: 1.;Z h 3/$z
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 Ztdhe tem
is fai ling to pr tect public health,safety or the environment.
1. S stemwiwil ass unless Board of Health determines in accordance with 310 CMR 15.303 t the
y �P
system is not4functoning in a manner which will protect public health,safety and the vironment:
Cesspool or vy is within 50 feet of a surface water
_ Cesspool or pri is within 50 feet of a bordering vegetated wetland or a salt sh
X
2. System will fail unless the Board oif ealth(and Public Water upplier,if any)determines that the
system is functioning in a manner that p tests the public heap ,safety and environment:
_ The system has a septic tank and soil�arption�m(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surfter su ly.
_ The system has a septic tank and SAS and e AS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SA and the SAS`i within 50 feet of a private water supply well.
_ The system has a septic tank an SAS and the SAS is less than 100 feet but 50 feet or more from a
pri/se upply well".M od used to determine distance
" passes if th ell water analysis,performed at a D�P certified laboratory,for coliform
baclatile or is compounds indicates that the well is fr�from pollution from that facility and
the amm 'a nitrogen and nitrate nitrogen is equal to or le� than 5 ppm,provided that no other
failare iggered.A copy of the analysis must be attached tosts form.
3. Ot
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: /,�q
iVc72'-17f A(uL>ojFR 4,1,q
Owner: P0L-t-rnAA1
Date of Inspection: 1316 7-
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or'�no?'to each of the following for all inspections:
Yes No
__ILI Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than 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 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 I 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
&0— (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CUR 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. barge Systems:
To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000
gpd.
You mus ' dicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 4�0ket of a surface drinking water-supply
the system is within 200 feet of a iiibotar
y to a surface drinking water supply
the system is located in a nitrogen sensitive area-(Interun Wellhead Protection Area—IWPA)or a mapped
Zone 11 of a publicwat-e-r—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.
Page 5 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
iV o 2J7-1 fkN;p IJc/E2 �V1 r�
Owner: POW
Date of Inspection: 12�J )3 z)2
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
Z'Were any of the system components pumped out in the previous two weeks?
_ Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
Were all system components,excluding the SAS,located on site?
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
Existing information.For example,a plan at the Board of Health.
c/ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[3 10 CMR 15.302(3)(6)]
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Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner:
:J'017 POCUMAv
Date of Inspection: iL) 3 f C)-7—
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Number of current residents: 0
Does residence have a garbage gender(yes or no):-ALO
Is laundry on a separate sewage system(yes or no):IyD [if yes separate inspection required]
Laundry system inspected(yes or no): —
Seasonal use:(yes or no):"
Water meter readings,if available(last 2 years usage(gpd)): We t, .
Sump pump(yes or no):_A/0
Last date of occupancy:r--,rirre
COMMERCIALM41DUSTRUL
Type of establishment:
Design flow(based on 310 CMR 15.203): Pnd
Basis of design flow(seats/persons/sq%ete.):
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/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: (V&fZ c H /aIg 17
Was system pumped as part of the inspection(yes or no):AA9
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason,for pumping:
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/Altemative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):
1
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Page 7 of II t
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 167f X21 s i Si/Lc
a271-1 AeUPoc>E/L 1,4/1
Owner: .S0s18,v f ,51114 Pp[ j.,14 AN
Date of Inspection:
BUILDING SEWER(locate on site plan)
Depth,below grade:
Materials of construction: cast iron 40 PVC other(explain):
Distance from private water supply well or suction line: p `
Comments(on condition of joints,venting,evidence of leakage,etc.):
F,Pe 4,:3c ,,S C�pOr 1N �ft5e-M�rV!
SEPTIC TANK:_(locate on site plan)
Depth below grade: �G
Material of construction: ✓concrete_metal_fiberglass__polyethylene
other(explain)
if—tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 1So v &-19 z Lo N s
Sludge depth: a "
Distance from top of sludge to bottom of outlet tee or baffle: O y`.
Scum thickness; / r
Distance from top of scum to top of outlet tee or baffle: 6
Distance from bottom of scum to bottom of outlet tee or baffle: <P
How were dimensions determined: ,44 ERs u 2 E S7)c.i<
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
—G`47 e-,l7 i'il c1,Z r
GREASE TRAP/1 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 baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
P o fz-T A--,v o oyC/L..o,4
Owner: Su 1M f 6Lj--/pn
Date of Inspection: �J,3 f 1,2,
TIGHT or HOLDING TANK:ItItt (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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Q
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.):
a iN 6-001? co„p,.7i�� is i t21 u�o� F4V,9L r7
4 c,4Jt r+645 IA.) p2 00-1 �2 �s5�cam,os cft2R� v✓E
PUMP CHAMBER:/lo-(locate on site plan)
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.):
I
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) l
i
Property Address: Z 1 lz sT -si,
V O/r 779 AA.)-n QQ 2 /
Owner: 50-Cji/V j JrM POLL-✓ AA/
Date of Inspection: J';Q 3
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Tyre
leaching pits,number:_
leaching chambers,number:
leaching galleries,number:
beaching trendies,number,length: �.,Gvt a E.s ,Sv
leaching fields,number,dimensions:
overflow cesspool,number:
innovativetalternative system Typetname of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
CESSPOOLS:�(cesspool must be pumped as part of inspectionxlocate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer: t
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
I
PRIVY:1f/e (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.):
i
Page 10 of 11
i
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: i& rsi
/too 2719 A u eD c>o- ,.►/t
Owner: 3ra
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
f
�d
log 4-
Et-l'
Gui=c�4.,
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 4-1;cl fi;x Si.
NDfMJ /ANi70 >E/Z
Owner: _j5L.51'fiN �` j j VA ;Pd c.i-rr1 A,v
Date of Inspection: 1�;k/t3 O 2
SITE EXAM
Slope %
Surface water n
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
-f- Obtained from system design plans on record-If checked,date of design plan reviewed:
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)
)t- Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
'Tl=5T P/T5 L'-J )GATE rev L Oql 1- T—I> 1"),
YOUNG'S wATER ANALYSIS
DRINKING WATER LABORATORY
Quick k 8c,.fit8" Sample Pick.-Up
36 Pelharn 13d. (603) 898-2504
al r " NH 03079 (603) 898-652
Laboratory NrJfflber:� 487
" Sample fit :
8-24-87
u b[flitted 'i ;
Saracino Coast .
J
Sample Lot # 27 Forest Street North Andover , Mass , j
nalysi : c r �Analysis,t iStari d Methods ate _.
"iota CcHforai « b « « « . . « , « . ro « « « . , . « . 0 per 100ml
6 . 5
-a ,. « « « « « « « « « « . « « < « . « . « . « « , 7 . 51
Hardrie88 « m « « a « . . . . « « « « « « « ,. . « ® « « « « « w ,. « « . . 58 rnc /L.
iarg,� rn e s,e m « ry » . « « « « . « « , « « m « m « m « « « « 0 . 07 mg/L..
ocliurn . b � � « « . « , . . « . w « « , « w . , « « aW4 « « « « w . « « « « « 27 . 1rT) /L
irr:an « � « « « « « . m . « « « « . « � « � ,w . , « « . « . « � /L
0 . 064
itC'ate a . « « ,> « . m « « m . , « « . . w « , . mm « « . « . , . « . « . « « . 0 . 01 r-n /l_
Nitrite « ro « « ,. , « « « . . . . m « . « . 0. 01 m /L.
Arsenic mm . « w « « . « w « . 003 RPR
This sample meets ''EPA recommended limits .
Oe
ell
An, st
Lo
ua6:14 T� w
n�
A►� oua [ C
ySTL:to
D/�T
M
FPAL 1,9-P6' jVAL
7A 41 APP)3wW6 omaiogiry/,
All
i
commonwealth of Massachusetts 1
City/Town of I `
System Pumping Record � t
Form 4
DEP has provided this form for use b local Boards-of Health. The S s'temi Pump
p Y � ing f'te;cord must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Cation
forms on the r .'.. w ... r .m, >
„ ., .
computer,use
only the tab key Address
to move your
cursor-do not _.._..
use the>return Cityrrown St to Zip Code
key.
2. System Owner:
Name
Address(if different from location)
CityfTown St , p Code
'
.� C
Telephone Number
3. Pumping Record
1. Date.of Pumping
Pate 2. Quantity Pumped
Gallons
3. Type of systeirn: ❑ Cesspool(s) Septic Tank.. ❑ Tight:Tank
❑ Other(describe)`
4. Effluent Tee Filter present? ❑ Yes o f.yes, was it cleaned? ❑ Yes T1 No
5. Condition of System:
6. Syste Pumped By
....
Name Vehicle License Number
C,ompan ..
7. Locatio here contb
9,1sWere Osed::
Signa r f auler Date
http://www.mass.ggv/dep/wate approvals/t5forms.htm#inspect
t5form4.doc•06103 system Pumping Record•Page 1 of 1
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Waverly Realty Trust 1
671 Waverly Road
No. Andover, Ma . 01845f
508-687-1923 {
'i
May 30 , 1990
No. Andover Board of Health
Town of North Andover
120 Main Street
No. Andover, Ma. 01845
Re: Lot 27A Forest Street
Dear Board Members ,
I have recently installed a septic system on lot 27A Forest Street .
The system, installed by Avellino General Contracting , was inadvertently
installed too close to the side yard lot line. The system is 5 feet off
the lot line instead of the required 10 feet. Therefore, I am requesting
a variance from the 10 foot requirement. I would appreciate your under-
standing in this matter. Thank you.
Sincerely,
William K. Barrett
1
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I
Waverly Realty Trust
671 Waverly Road
No. Andover, Ma. 01845
508-687-1923
May 30 , 1990
No. Andover Board of Health
Town of North Andover
120 Main Street
No. Andover, Ma. 01845
Re: Lot 27A Forest Street
Dear Board Members ,
I have recently installed a septic system on lot 27A Forest Street.
The system, installed by Avellino General Contracting, was inadvertently
installed too close to the side yard lot line. The system is 5 feet off
the lot line instead of the required 10 feet. Therefore, I am requesting
a variance from the 10 foot requirement. I would appreciate your under-
standing in this matter. Thank you.
Sincerely, rs
William K. Barrett
I
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............
NEW ENGLAND ENGINEERING SERVICES
....................... I N C
DOVER/
LTH
March 20, 1999
North Andover Board of Health
Town Hall Annex
27 Charles Street
North Andover, MA 01845
RE: TITLE V REPORT: 159,Forest, Street,North Andover,
Enclosed is a copy of the Title V report for the above referenced property. The system passes our
inspection.
If there are any questions please call me at my office, 686-1768.
Yours truly,
C_
Benjamin C. Osgood Jr., E.I.T.
President
3 3 WALKER ROAD-SUITE 23-NOR'rH ANDOVER, MA01845-(976)686-1768-(888)359-7645..FAX(978)685-1099
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
I DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292.5500
TRUDY CORE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commiss"oner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
r ,
Property Address: 6r`e-J -mot Name of Owner L y/
Address of Owner: [.S l rya i7 51 tX('f
a'tc c
Date of Inspection: .3 ZC. et
Name of Inspector:(Please Print) Benjamin C. Osgood, Jr
I am a DEP approved system inspector pursuant to Section 15,340 of Title 5(310 CMR 15.000)
Company Name: New England Engineering Servi tees Inc.
MaAng Address: 33 Walker Rd Stti to 23, North Andover, MA 01845
Telephone Number: 978-686-1768
CERTIFICATION STATEMENT
I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of 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:
t/ Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
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 thirty 130►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-"
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
_Sr 11 C S r
revised 9/2/98 Pagel of II
i
`i PnnuA on Kr<vc lyd I'aVry
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: (p.-e yy S7' /V
Owner: ,
Date of inspection: r�'�' cd•Y'Sc� l!c ��.• �,
P
33
INSPECTION SUMMARY: Check A, B, C, or D:
A PASSES:
1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below((�
COMMENTS: Sc'G ! c 4vt kid! 1 ice` i rC �/ i f In-'� -'''c
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.
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 exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_ The system required pumping-more than four-times a yeardue to broken or absmcted pipe($). The syNtem wilt-
Puss-inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
revised 9/2/98 Page 2ofII
/
/
SUBSURFACE SEWAGE DISPOSAL SYSTEM wyrscnomFORM
PART
opnnncAnom <cuvan"ou>
Property Address: ).5^\ FL-,m,A IT. ,w rq/uu c,(^«'
Owner:
Date mhispecuow:
C. FURTHER EVALUATION o REQUIRED av THE BOARD o+HEALTH: �
�
Conditions exist which,*n"i*mm*'evaluation by the Board m Health m order m determine xthe system ufailing to protect the
|
vvmix oo"|m' ,u,mv and the av"xvnmom.
/) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM �
ms NOT FUNCTIONING /mo MANNER xmH/cuxmcLenuzEor THE puuucuuu/a.AND SAFETY.A-mo THE emooammmsKz-
000pvm or privy is within so feet of surface"mo,
--
Cesspool v,privy ix within ao feet mv bordering vegetated wetland o,usalt marsh.
_
z} SYSTEM MLL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS |
FUNCTIONING xvA MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE EmmnomMsmT:
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 o ,^r/uc*~m",,unv|v.
The system has " septic tank and soil absorption system and the SAS /, within ° Zone / m^public water supply well.
--
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
--
The system has o septic tank and soil absorption system and the SAS u less than 1ou feet but su feet v,more from o
--
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of emmonia nitrogen and nitrate nitrogen is equal to or less
then s ppm. mumoo used to determine distance_� (approximation not m*u).
z> orxen
�
�
�
�
�
|
revised 9/2 /98 Page 3ao �
/
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICAT10N(continued)
Property Address: Ls;,i
Owner:
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
1 have determined that one or more of the following failure conditions exist as described 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 4ecilit"r-system component-due tto en overloaded orc4ugged&AS-or,cesspool. s-- -.
— 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 112 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 portion of a 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 I 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. 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" 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 ie-wit# 200 feet-of-&4fjrutary-toe eurtaoadrdnkiAy-WA ter.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 upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: ISel
Owner:
Date of inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Ye$ No
1/ Pumping information was provided by the owner, occupant, or Board of Health.
None of the system corn;,a s.4&uQb"n pusnpad4or-atJaast two we&"aaad-aWe'system hasAm"amcaluingeasmaJ.flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
✓ As built plans have been obtained and examined. Note if they are not available with NIA.
i
t/ The facility or dwelling was inspected for signs of sewage back-up.
✓ The system does not receive non-sanitary or industrial waste flow.
✓ _ 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 orT the site has been determined based on:
Existing information. For example, 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)1
_ The facility owner (and occupants,if different tram-Dvrner).were.pr.mticied.with intnrmation.,on tha pro iar n aLnren&aca of
SubSurface Disposal Systems.
revised 9/2/98 Pagr5ofII
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
I
Property Address: ),5-( f- ., 5' >T A-
Owner: Pt.,.1, i
Date of Inspection:
FLOW CONDITIONS
RESIDENTLAL:
Design flow: g.p.d./bedroom.
Number of bedrooms (design):_ Number of bedrooms(actual):
Total DESIGN flow
Number of current residents: A
Garbage grinder(yes or no):_L„)
Laundry(separate system) (yes or no);562; If yes, sepacazeinspoction required
Laundry system inspected (yes or not
Seasonal use (yes or nol:_ejL-'
Water meter readings,if available (last two year's usage(gpd):
Sump Pump (yes or no):16&
Last date of occupancy: C 0(' �
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: qpd ( Based on 15.203)
Basis of design flow —
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:
System pumped as part of inspection: (yes or no)Qt
If yes, volume pumped: gallons vv
Reason for pumping:
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (it yes, attach previous inspection records,if any)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
r
APPROXIMATE AGE of all components, date installed4if known)-and source 044n(orrnation:
Sewage odors detected when arriving at the site: (yes or no)/ 1,,,,
revised 9/2/98 Page 6of11
1
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(corttinued)
Property Address: 1511 l sT S7 ^-' ►�..cyti>_��rZ
Owner: 1?k .t. -1
Date of Inspection:
31�
BUILDING SEWER:
(Locate on site plan)
Depth below grade: /'(4
Material of construction:-1z"Cast iron_40 PVC_other(explain)
Distance from private water supply well or suction line
Diameter L_'_ T
Comments: (condition of joints, ventin evidence of toe e,-etc.)
SEPTIC TANK:_
(locate on site plan)
Depth below grade: �.
Material of construction:-Vconcrete_metal_Fiberglass _Polyethylene—other(explain)
If tank is Inetai, list age_ Js.age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: /�c'u _6-C,//c,r'i S
Sludge depth:
Distance from top of sludge to bottom of outlet tee orbaffle:'�E
Scum thickness:_'
(C~
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were determined: fn(G[S G'.ti S 7JG
Comments:
(recommendation for pumping, condition of inlet and outlet tees or•baffies, depth of liquid level in relati n to outle invert, structural integrity,
evidence of leakage, etc.) ^e'r.,L ,s r n '( c .• 1'r li'- c0 K ,r ( ' /1+
GREASE TRAP:
(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 baffle:
Date of lest 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.)
revised 9/2/98 Page 7of II
i
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: I's-Cl / r 1 > AA r 1
Date of kispection:
TIGHT OR HOLD[NG TANK&&(Tank 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/day
Alarm present
Alarm level: Alarm in working order: Yes _ No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches,etc.l
DISTRIBUTION BOX:_
(locate on site plan)
�l
Depth of liquid level above outlet invert: Q
Comments:
(note if level and distribution is equal, evr/dgnce of solids,ca/ryover, evidence of leakage into or out of box, etc.) — - —
'Llx C l H j, ut,. < Y t c'P
PUMP CHAMBER:,
(locate on site plan)
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.)
revised 9/2/98 I'2gC8OfII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
J
PART C
SYSTEM INFORMATION(continued)Property Address:
Date
SOIL ABSORPTION SYSTEM(SAS):_
(locate on site plan, if possible; excavation not required,location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:_
leaching chambers,number:_
leaching galleries,number:_
leaching trenches, number, length: if Ti1t`r)G Gti'S
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydra lic failure, level of ponding, damp/soil, condition of vegetation, etc.)
CESSPOOLS:
(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 pending,condition of.vegetation, etc.)
PRIVY:
(locate on site plan)
Materjals of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation;etc.)
revised 9/2/98 1,2ge9of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
I
Property Address: /S�/ / r'S� <7 1�, Q�
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
Roo 5-C
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revised 9/2/98 _------ �� Page 10 of II
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
i
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: i5JI`t //c Sj��JJ
/ Y^.�� JL.0.-Y SGi dil
Date of Inspection: I
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater_Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site (Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
revised 9/2/98 Page 11 ern