HomeMy WebLinkAboutMiscellaneous - 205 CAMPBELL ROAD 10/19/2015 (2) Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
• Environmental Protection
WilBam F.Weld ,
Gowmor
Trudy Cs►xe m ..,, w
$eerstary,ECFA
David B.Struhs
Commissioner
Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
i CERTIFI TION �
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Property Address; °Address of Owner:
Date of Inspection; a (1f,different)
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Name of Inspector: . �
Company Name, Address and Telephone Nurrt er; ; � I
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 an„
maintenance of on-site sewage disposal systems. The system;
Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
inspector's Si attire; Date; "
-e
The Syste m
(rtspector shall ubmit 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, B, C, or D;
JYSTE M PASSES;have not found any information which indicates that the sysem viotates,an 0f"t6 failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES: / 1\
One or more system components nelo be replaced.or.,rep,Ay,41 The system, upon completion,- -the—replacement or repair,
passes inspection. p „
indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not d ermined", explain why not)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfil ration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a con arming septic tank as
approved by the Board of Health.
(revised 9/15/95) 1
One Winter Street • Boston,Massachusetts 02108 a FAX(617)5564049 a Telephone(617)292-3500
Printed on Recycled Paper
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
FART A
CERTIFICATION (continued)
Property Address: g-a r4 �& m
Owner:
Date of Inspection: :
B]SYSTEM CONDITIONALLY PASSES (continued)
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 year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of,Health):
broken pipe(s)are replaced
obstruction is removed'
Cl 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 the
public health, safety and the environment.
1) SYSTEM WiLL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
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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.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT;
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply,or tributary to a
surface water supply.
The system has a septic tank and sail absorption system and is within a Zone i of a public water supply well
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a 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 ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm
D] SYSTEM FAILS:
I have determin ' 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 ai`Health should be contacted to determine what will be necessary to correct
the failure,
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,
(revised 8/15/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address; C g) /Ps be /'/f
Owner:
Date of Inspection:
D)SYSTEM FAILS(continued): d
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
A
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 wateranalysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flow of system is 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:
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 11 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.
OR! (revised 8/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner:
Date of Inspection:
Check if the follgwing have been done:
P'pmping information was requested of the owner, occupant, and 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
6ring that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
7171,built plans have been obtained and examined. Note if they are not available with N/A.
he facility or dwelling was inspected for signs of sewage back-up.
T system does not receive non-sanitary or industrial waste flow
The site was inspected for signs of breakout.
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
6es, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
T size and location of the Soil Absorption System on the site has been determined based on existing information or
p proximated by non-intrusive methods.
—The facility o,,�ne. (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8/15/95) 4
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
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Property Andress: r
Owner:
Date of Inspection: � w e-
Date
CONDITIONS
RESIDENTIAL:
Design flow: gallons
Number of bedrooms:
Number of current residents:
Garbage grinder(yes or no): � "
Laundry connected to system yes or no): e
Seasonal use (yes or no): 14 f'. I v w „
Water meter readings, if available;
Last date of occupancy:
COMMERCIAL/INDUSTRIAL; w ^
Type of establishment:
Design flow:_gallons/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; ;
S
System pumped as part of inspection: (yes or no)_
If yes, volume pumped `4 "Jallons
Reason for pumping; AL71 1'. 12, r .'wfe .
TYPESYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes;or no) (if yes, attach previous inspection retards, if any)
Other(explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information; �
'r Sewage odors detected when arriving at the site: (yes or no)
(revised 9/15/95) 5
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART G
SYSTEM INFORMATION (continued)
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Property Address: , w, . '" 6
Owner:
�
Date of Inspection:
SEPTIC TANK:
(locate on site pl n)
�µ
Depth below grade: Z t
Material of construction ®concrete —metal ®FRP—other(explain)
Dimensions:
Sludge depths r
Distance from top of sludge to bottom of outlet tee or baffle:
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:
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,)
0 0 22 / ;,.c el" gµ.211
GREASE TRAP:_
(locate on site plan)
Depth below grade:
Material of construction; —concrete metal ®FRP other(explain)
Dimensions;
Scum thickness.
Distance from top of scum to top of outlet tae or baffle:
Distance from bottom ni srum t- bottom of outlet tee or battle:
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 8/15/95) 6
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection: " ""
d
TIGHT OR HOLDING TANK;
(locate on site plan)
Depth below grade:
Material of construction: —concrete—metal ®FRP—other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments
(condition of inlet tee, condition of alarm and float switches, etc,)
DISTRIBUTION BOX; µ
(locate on site plan)
Depth of liquid level above outlet invert: t
Comments:
(note,if level and d!stribut;on it e,ua!, evidence of so!ids carryover, evidence of leakage into or out of box, etc.)
,P
PUMP CHAMBER;
(locate on site plan)
Pumps in working order.(yes or no)
Comments
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
(revised 8/15/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
ed)
SYSTEM (c ntinu
INFORMATION
Property Address:
Owner,
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):
(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:
_
leachin g chambers, number:
leaching galleries, number:
leaching trenches, number,length; bole"
leaching fields, number, dimensions;
overflow cesspool, number:.
Comments; (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
ma e
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)
I
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.)
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(revised 8/15/95) 8
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'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
^ 1
PART C
SYSTEM INFORMATION (continued)
Property Address; ("J 44
Owner;
Date of Inspections
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SKETCH OF SEWAGE DISPOSAL SYSTEM:
inc,lud"e,ties..to at least two permanent references landmarks or benchmarks
locate all wells.within 100'
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DEPTH TO GROUNDWATER
Depth to groundwater; e t
method of determination or approximation:
(revised 8/15/95) 9
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APPLICATION FOR SEWAGE DISPOSAL INSTALLATION
HEALTH DEPARTMENT - NORTH ANDOVER, MASS.
I hereby make application for a permit for a sewage disposal installation at
oordancewithalltheH �
I will install this system in ac
• -� J
laws of the Commonwealth of Massachusetts and regulations of
the Board of Health of the Town of North Andover.
Further, I will construct the house sewer of bell and spigot pipe, the minimum
diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre-
ceding the septic tank, where the grade shall not exceed 2%. 1 will install a con-
crete septic tank of ep�w�r °; in size. A manhole (s) permitting easy cleaning
will be provided with removable cover (s) of iron or concrete within 12 inches of
the ground surface. I will provide subsurface disposal field with 4 inch perforated
or open jointed pipe and laid in a series of trenches, the bottom of which will pro-
vide a minimum of °° lineal ".e) feet of effective absorption area.
The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging
in size from 3/4 to 1-112 inches (dia. ) and the pipes will be surrounded by similar
material to a height of 2 inches above the crown of the pipe. The joints of these
pipes will be protected from clogging and before filling the trench, 2 inches of
gravel or stone 1/$" to 1/4" (dia. ) will be placed over the course gravel or stone.
The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single
tile line will exceed 100 feet in length and in any case, two lines of the will be
installed. A minimum of 6 feet will be maintained between the center lines of the
disposal field trenches and the average depth of trench shall not exceed 36 inches.
No part of the installation will be less than 100 feet from any private water supply,
25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line.
I further agree not to cover any portion of this installation until approved by the
ins ection officer, as provided below, and to incorporate any additional requirements
that may be attached to the permit. Plot Plans must be submitted with application.
DATE ,
f
Signature, of Applicant
I hereby issue the above permit for the Board of Health of the Town of North
Andover, Massachusetts.
DATE J ,, � ° 2� "
Signature of Health Agent
I have inspected the uncovered system indicated above and find everything done
as described.
DATE
Signature o£ specting Office
Percolation Test r .: c .,
Garbage Grinder
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BOARD OF HEALTH
TOWN OF NORTH ANDOVER, MASS.
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1. NAME ��� _�. i ° ,' 'u a ' a DATE /-1 r l , `7
2. ADDRESS °a e ,..., LOT NO. � TEL.
3. NO. OF BEDROOMS fl DEN YES__ � NO
4. GARBAGE GRINDER YES NO
SHOW DIMENSIONS OF HOUSE
6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES
7. SHOW DIMENSIONS OF LOT
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM
10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC.
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTES LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
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BOARD OF HEALTH OF NORTH ANDOVER, MASSACHUSETTS
SEWAGE DISPOSAL
DATE lr y 2(, -1-967
NAME OF APPLICANT I'i lli�> ;; a Sul_liv,,.n
LOCATION Lot- Y13, C rii,�)be�ll ,jo d
Address ofmlot no.
BUILDING: Dwelling Other—
SYSTEM: New x Repair
GENERAL DESCRIPTION OF LAND
SUBSOIL: Clay d Gravel
PERCOLATION TEST 5 ®_ minutes per inch.
MINIMUM INSTALLATION RECOMMENDATIONS
CONCRETE SEPTIC TANK �1_, OOO _gallon capacity.
LEACH FIELD ISO
®�®lineal feet of drain pipe.
r ,
illiam JJ. D scoll , Engin er��
Board of Heal• h
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Oonohoe,' (John
Lot 13, G&iapbell X�ki
APPLICATION FOR SEWAGE DISPOSAL INSTALLATION
HEALTH DEPARTMENT NORTH ANDOVER ,MASS.
I hereby make application for a permit for a sewage disposal installation at
L 1 Rd. I will install this system in ac-
jat L31_C
'jo-rdance with all the laws of the Commonwealth of Massachusetts and regulations of
the Board of Health of the Town of North Andover.
Further, I will construct the house sewer of bell and spigot pipe, the minimum
diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre-
ceding the septic tank, where the grade shall not exceed 2%. 1 will install a con-
crete septic tank of In()() [)s in size. A manhole (s) permitting easy cleaning
will be provided with removable cover (s) of iron or concrete within 12 inches of
the ground surface. I will provide subsurface disposal field with 4 inch perforated
or open jointed pipe and laid in a series of trenches, the bottom of which will pro-
vide a minimum of aQp lineal (KqUAkO ) feet of effective absorption area.
The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging
in size from 3/4 to 1-112 inches (dia. ) and the pipes will be surrounded by similar
material to a height of 2 inches above the crown of the pipe. The joints of these
pipes will be protected from clogging and before filling the trench, 2 inches of
gravel or stone 1/81, to 1/41, (dia.) will be placed over the course grave I I or stone.
The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single
tile line will exceed 100 feet in length and in any case, two lines of tile will be
installed. A minimum of 6 feet will be maintained between the center lines of the
disposal field trenches and the average depth of trench shall not exceed 36 inches.
No part of the installation will be less than 100 feet from any private water supply,
25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line.
I further agree not to cover any portion of this installation until approved by the
insvection officer, as provided below, and to incorporate any additional requirements
that may b attachp4, to the permit. Plot Plans,-must be submitted with application.
DATE ....../YY
Si nature
)f Applicant
I hereby issue the above permit for the Board of Health of the Town of North
Andover, Kassachus s.
DATE
)2
;' Signature of Health Agent
1J
I have inspected the uncovered system indicated above and find everything done
as described.
DATE
Signature of Inspecting Officer
Percolation Test 6 mift. Sandy-Clay
Garbage Grinder
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BOARD OF HEALTH
TOWN OF NORTH ANDOVER, MASS. J
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1. NAME o R 6.. . DATE
2. ADDRESS '" + `" LOT NO. "" TEL.
3. NO.- OF BEDROOMS DEN YES- NO
4. GARBAGE GRINDER YES NO
5. SHOW DIMENSIONS OF HOUSE
6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES
7. SHOW DIMENSIONS OF LOT
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
q. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM
10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC.
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
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BOARD OF HEALTH OF NORTH ANDOVER, MASSACHUSETTS J
SEWAGE DISPOSAL
DATE 22, 12( 60-
NAME OF APPLICANT John Don-ho e
LOCATION Lot 4Y13 , 0,aciobell Road
Address of lot no.�.����
BUILDING: Dwelling X Other
SYSTEM: New K Repair
GENERAL DESCRIPTION OF LAND 1-j! h
SUBSOIL: Clay Gravel_ Sand , - r
PERCOLATION TEST 6 minutes per inch.
MINIMUM INSTALLATION RECOMMENDATIONS
CONCRETE SEPTIC TANK 1000 gallon capacity.
LEACH FIELD 200 --lineal feet of drain pipe.
illiam J. D scoll, Engi eer
Board of Hea h
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Commonwealth of MassachusettsREC91VEDµ G u
W City/Town of North Andover C 'i
System Pumping Record °
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Form 4 TOWN OF NNR°rH ANDOVER
HEALTH DEPARTMENT
i �WWWWWduIV,WprvWwuWhWiWrvtl. .XMMpq'NPoIXW�WM f
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the 1
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer, use Cd bd I
only the tab key Address
to move your N.Andover Ma 01845
cursor-do not City/Town State Zip Code
use the return
key. 2 System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
G
1. Date of Pumping Y 2. Quantity Pumped: "l
Date Gallons
3. Type of system: ❑ Cesspool(s) ErSeptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
hilocA
6. ystem Pumped
NaOh&l Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
St rt Pre-treatment lant, 20 So. Mill Bradford, Ma 01835
i nat re of Hauler D /
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Signature of Re ivi F D
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
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