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HomeMy WebLinkAboutMiscellaneous - 234 Bridges ,� 23� �J�'�C`��'��? � � COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION .t TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A qs� CE/RTIFICATION Property Address: a _ Owner's Name: )C e01- Owner's Address: Date of Inspection: r " Name of Inspector: ( lease print) Company Name: r /�� Mailing Address: Telephone Number: - • 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 S tion 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further .valuation by the Local Approving Authority Fails V Inspector's Signature: l� Date: hr 16 Z The system inspector sha/Lb-it a copy of this inspection report to a Approving Authority(Board of Health or DEP)within 30 days of ceting this inspection.If the system is a shared system or has a design now 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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: /e / Date of Inspection: /Jd... Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Systein 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: a r 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. Answer yes,no or not determined(Y,N,ND)in the 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. ND explain: 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 pipes)are replaced 1 obstruction is removed distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: �J7 !J/ /('� ' Lal)e, Owner: �C Date of Inspection: 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,js 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 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**.Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nifrate 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: 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address• a1,3 /r'1 ePs Owner: Q Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ZDischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or 1�- clogged SAS�or cesspool Static liquid liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or esspool _ Liquid depth in cesspool is less than 6"below invert or available volume is less than'h day flow :;�4equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number times pumped t2Any portion of the SAS,cesspool or privy is below high ground water elevation. ny portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface ater supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. �y 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 compooeds 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.] (� (Yes/No)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 sysfem must serve a facility with a design flow of 10,000 gpd to`15,000 gpd• 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) 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST r Property Address: Owner: /? Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Y-0 Pumping information was provided by the owner,occupant, or Board of Health -k1 —/Were any bf die 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? _60*000*_ 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. l 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)(b)] 5 r f Page 6 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property a Address:�3 &A-1427-5t _ . Owner• Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CW 5.203(for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no):,!�� L pl �� e In 0 t-1-Q, Is laundry on a separate sewage system(yes or no). )6[if yes separate inspection required] Lamadry system.inspectedr(ye or ho):- k Seasonal use: yes or no)' b Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):/'�U 4A Last date of occupancy:O A` 1,u PJ 1 4 GC. COMMERCIALANDUST�R`IAAL�r Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): 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: 2z>&-z, ; Was system pumped as part of thdZspection(yes or no): If yes,volume pumped/rx9 0gallons--How wasguant pumped determined? Reason for Pumping: /A) �j` N K t i TYPE F SYSTEM ' eptic 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) _Tight tank _Attach a copy of the DEP approval —Other(describe): Approxim to age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: / J BUILDING SEWER(locate on site plan) �r Depth below grade: n Materials of construction: f iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_ ocate on site plan) Depth below grade: 01 Material of construction:—t-wrcrete_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) 6 �r Dimensions: U — Sludge depth: / r" Distance from top of sludge to bottom of outlet tee or baffle: 3 Scum thickness: 0 Distance from top of scum to top of outlet tee or baffle: 2 Distance from bottom of scum to bottom of outlet tee or baffle:/ How were dimensions determined: -770.x 12ne,4-S U meq. Comments(on pumping recommendations,inl�outlet tee or baffle condition,structural.integrity,liquid levels as`rel to outlet invert evid'e ce of leaka e,etc.): / /-eS /AJ o opal 5�a. GREASE TRAP:_(locate on site plan) s40 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.): 7 Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner:,/�11 64 Date of Inspection: 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): Dimi,nsions: Capi�city:V, 0" gallons P x' 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: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leaks a into or out of b x,etc. e 4e 1,ha c /A� ip�'a A26 o �. o S PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Cor6ments(note condition of pump chamber,condition of pumps and appurtenances,etc.): , 1 8 4 Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) T + s� Property Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not-required) If SAS not located explain why: Ty �¢ leaching its,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: eaching fields,number,dimensions: c2o-) 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.): n Dwa o 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: r Depth of scum layer: t Dimensions of cesspool: Materials of construction: , Indication of groundwater inflow(yes or no): t .� 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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT,FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART C SYSTEM'INFORMATION(continued) Property Address:C78 Owner: C 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. �- � Cl ' V11 3 4 i 10 Page 1 l of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM IN/F,ORMATION(continued) Property Address: hl Com! Owner: ? Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground wate-: feet Please indicate(check)all methods used to determine the high ground water elevation: !/Obtained from system design plans on record-If checked,date of design plan reviewed-AJ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked.with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you establis4ed the h' h ground water elevation: nut d eA.) 611 f c 4 ' 11 !-address ,.. RiWeA -/-At/ Title of File Page of Date f=ile Open: Date file closed: , Doc Document/Action Title action Date of Refer to other Purpose of Documennt/Action and notes — Document/ document/ Num. Action Department Board of Appeals — Board of Health Plann4ng Board _ Conservation Commission — Building De artrme�t Board of Health t � North AndoverzN.aaa- 5EP1'IC S25Tai INSTAMATICK COCK LIS, LOT `J ' f Il AF CUED DATE DISAPPROVED X AVATICN OK AIL ea Bans i F-UM OK 1. Distance Tot a. Wetlands b. Drains Co. Well 2. Water Line Location 3• No PVC Pipe 4. Septic Tank ---- a. Tees -_Length & To Clean Out Cr or-, b. Cement Pipe to Tank- On Both Side, of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flo wing Equal Amounts c. No Back Flow 6. Leach Field or Trench a. Dimensions b. Stone Depth c. Capped lads d. Clean Double Washed Stone 7. Leach Pits a. Dimensions b. Stone Depth c. Splash Pads d. Tees e. Cement Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. No Garbage Disposal 9. Anal Grading Inspection �j 10. Barricading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System c. Location with Regard-to Pere Test d. Elevations ` e; Water Table - a Board of Health pi-t —Andover,Masz SUBSURFACE DISPOSAL DFMGN CHECK LIST r LOT i ���►� A PROM DATE 5 oI / _ DIWY PROM DATE W�' Provided: VReasonss 5'S �wC 2z1 Title V FAIL OK Reg 2.5 The snbmitted plan must show as a minimums a) the lot to be served-area,dimensions lot #,abutters blocation and log deep observation holes-distance to ties c location and results percolation testa-distance to ties __- d design calculations & calculations showing required leaching area (e) location and dimensions of system-including reserve area f) existing and proposed contours (g) location any wet areas within 100' of sewage disposal system or disclaimer-check wetlands mapping (h) surface and subsurface drains within 100' of se0age disposal system or disclaimer (i) location any drainage easements within 3.001 of sewage disposal system or disclaimer-Planning Board files (J) knoym sources of water supply within 2001 of sewage disposal o . system or disclaimer (k) location of any proposed well to serve lot-1001 from leaching facility (1) location of water lines on property-101 from leaching facility (m) location of benchmark (n) driveways (o) garbage disposals (p) no PVC to be used in construction (q) profile of system-elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and Mer elevations (r) maximum ground water elevation in area sewage disposal system s) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Reg 6 Septic_Tanks - -- (a) capacities-15D;& of flow, water table, tees, depth of tees, acceas, pumping (b) cleanout (c) 101 from cellar wall or inground swimming pool (d) 251 from subsurface drains Reg 10.2 Distribution Boxes (a) slope greater 0.08 Reg 10.1 b) sump SOIL PROFILE & PERCOLATION TEST DATA �CNorth Andover, Mass. Street No � J Lot No Loc/Subdiv. Pland Owner Investigator _ Observer n � SOIL PROFILE DATES 1:Aev 2.Elev 3.Elev Z�X 4.Elev 7 Ties to Test Pits 3 3 3 3 r 5Y 5 5 _ 5 6 6 6 6 9 9 9 9 l0- = .10 10 ; — 10 Benchmark--m Lo cation.-L Elevation- - Datum _ PERCOLATION TESTS DATES Pit Number-_ ._ ..- i- 2 3 Start Saturation Soak--l',inutes — - - - Drop of 311-Time _ _— Drop of 611--Tine 311 drop - -- --- - Niins.2_nd 3" Drop Percolati(,n _�-- OF NORr"S OFFICES OF: o ."-' �0°� Town of 120 Main Street m APPEALSNORTH ANDOVER North) Andover, BUILDING Mi1SSildills0tS 184 7) CONSERVATION °j°"°B` DIVISION 01= (617)685-4775 X HEALTH PLANNING PLANNING & COMMUNITY DEVELOPMENT KAREN H.P. NELSON, DIRECTOR Tylicki 2_3-88 234 Bridges La. Health Dept. N. Andover, Ma. This office has no objection to the 18 by 14 foot addition which as described will not add any bedrooms as long as the additions foundation does not impair or obstruct the per- formance or maintainance of the septic system. Sincerely, Mike Graf 2 -S-3F o f IoT nerdsr�� )5 TCS be@���� _' �w�►� v5T �a��S �i �e-�� "due '�'T �1"T _ i 101 HIGH STREET, P.O.BOX 40, NORWICH, CT 06360 FOUNDED 1840 INSURAN7CMPAItNIES (860)887-3553 — CT 1-800-962-0800 — MA-RI 1-800-243-4080 — FAX(860)886-8270 — www.nlcinsurance.com March 2, 1999 TOWN OF NORTH ANQOVER/-1 O RD OF HEALTH HEALTH INSPECTOR MM �.8 TOWN HALL NORTH ANDOVER MA 01845 SUBJECT: Date of Loss: 02/28/99 Type of Loss: WATER DAMAGE Claim Number: A91112 Policy Number: H5038921 Insured: PAUL & LORRAINE MCGOVERN Address: 234 BRIDGES LANE N ANDOVER MA Dear Sir/Madam: Claim has been made involving loss, damage, and or destruction of the above captioned property which may either exceed $1,000 or cause Massachusetts General Law, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 3B, is appropriate, please direct it to the attention of this writer below and include a reference to the captioned insured, location, policy number, file reference and date of loss. i Thank you for your cooperation. Very truly yours, NLC Insurance Companies LISA A SUCHOCKI Property Adjuster NEW LONDON COUNTY MUTUAL INSURANCE COMPANY THAMES INSURANCE COMPANY / TO: NORTH ANDOVER, MASS �— 19 BOARD OF HEALTH FROM: DESIGN ENGINEER Re: $:oil Absorption Sewage System Inspection This/is to certify that I have inspected the construction of the said disposal system at z0 �:/ C1 �R / 6: L—�_5 ,vim North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated ci1 p /4 ���o�� COM�yONIy e®r. g. n er/ e ni Ian C( 9��qN S tl�s�a�a� `r\, 71, L l\NsETI s CS w Zn C ty -, 7 z !meqC�S Ct Crol Noo ,r7 MMt.w dww-A~R1ti ly RZ A WIAJ4 Z07- 4:5;q,4,b1A16 A SATE : .2 OWAlee ",L 41 ZOCA7-1,oA.I: tj� BAR SAL-,-,4Z 4. n We.5-rWARb AAO- 'NN /G Ad DA TA 51f_. T y R-E OF 6W14 AOIAICv 4e 6 1,4' 7)Z., fey (� r- — \ ,.. \� ' ki �� SEI�!/.4GE J4r:-4AO W d E5rlW-4 72F SC,17-IC- 7--4A1,4(< 00 4 R A � G�9!. o", * -/I'- z 7 cy o ,P6er-,n4-4r1oAi 72_-sr3 4CL4 r,-- i-t -I I 78- &4 7X4e,4 r/,OA/ MAI 30 — 7 MAI Af MIA1, AfIAI. MI-71A/ Al. TEST PITS TDP EC�I�.4T/DA! 76; Sob '-sole- y WATER 7-Aate L4CAT/DN. -1'4c SA c A1OAld 0 /�tr, TESTS 7&:A eY 7EST5 W1 7 6y PeAAl - '" u.uo...■ ewwnr.oruusw.eva..nu .. ........ . CBCT/A�. BED E�t./D �E/'Tin �i SPEC/F/Cg7-10AI-5 - S4r zowse ��sreieur�o�v � •_"_ . Zia �SDO d4L. CONG2ETE SE.oT/C TANK ¢'4f.5'cYiv P./I.G. SE4LED TO/N7� �. "o ¢� PE�2F. P.i!�'. S-.per• r 4-6-5c p7 IQAJ OE,D /PG A AJ _ /UOT• 7o cS'C.�tLE r a ` ' SEALED .• - - - • - 197 8J; .Toiwr, JEGEGT _t. SAS HED f Rllaw Ole CD - 193 � N --- n 180 p -¢ C�G/BC,E w•4t�/Eo �.-��.s_z"l�a_�11,.S.._-�fF.i.0/._�Ga/lr�l, --�'/�N�_f .G r�t..Y•�_L ,BS:J�PT/ON BED cS�EG•T R F/L E c'a�PT/On/ r o�Ea� i Y Commonwealth of Massachusetts p�Noo H�o�H N pt0 Executive Office of Environmental Affairs �►e artntant of Environmental Protection S�Q William F.Weld Go"mor Trudy Coxe 3eeretery.EOEA David B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address:a �K`.4�­ eSSZ(—V) IV.r ,t Address of Owner: Date of Inspeclion: Fla (If different) Name of Inspector: N6k S. Company Name, Address and telephone Number: C A SPi11Q(I SCR_Icz. T"e• h�CERTIFICATION STATEMENT �t= o t vto Sly?5--`-f ? 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: _ Passes 1/Eonditfonally Passes Needs Further Evaluation By the Local Approving Authority F ils — Bjacs-_�� Inspector's Signature: Date: A The System Inspector sh I bmit a c y 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: 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. BI SYSTEM NDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or(repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"no=ILert. d", explain why not) The septic tank is metal, cracked, structurally unsound, showssubstan ' infiltration or or tank failure is imminent. The system will pass inspection if the existing septic tank replaced with a conforming septic tank as approved by the Board of Health. (revised 9/15/95) 1 One Winter Street a Boston,Massachusetts 02106 a FAX(617)$56-1049 is Telephone(617)292-5500 ti Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: eS "` t " ` ► Owner: Date of Inspection: C,-3 aJ'` 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): t broken pipe(s)are replaced (C0 V A-A L 3---AID ID— 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: _ 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: T iii ,,,,t,., ;.d> ,, srp;" tni i. a ,:: soil absorption systcm and is within 100 feet to a surface water supp!y or tribe!?.)'t^ a surface water supply. _ The system has a septic tank and soil 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 systen, 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: win failure criteria as defined in 310 CMR 15.303. The basis that the system violates one or more of the following I have determined t y for this determination is identified below. The Board of 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 . i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:j3L{ j6c�A p,A ('( . Owner: Date of Inspection: n—a.3_(?S- D) SYSTEM FAILS(continued): '" Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. 'y Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day Flow. y 4equlr-1 oornping more than 4 times in the last year J�0 due to clogged or obstructed pipe(s): Number of times pumped AlAny portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. ly An portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Y P P P Y PP Y rY PP Y• dAny portion of a cesspool or privy is within a Zone I of a public well. I 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: 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 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 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: Check if the follohave been done: . Pump! nformation 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 durin hat period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _As bui plans have been obtained and examined. Note if they are not available with N/A. The f ' ' or dwelling was inspected for signs of sewage back-up. LY g P B ��IeSite The system does not receive non-sanitary or industrial waste flow �was inspected for signs of breakout. IZXI system components, excluding the Soil Absorption System, have been located on the site. :f'heseptic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, terial 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 existing information or app ximated by non-intrusive methods. L. The facility ov.ner (and occu ants, if different from owner) were provided with information on the proper maintenance of Sub- Surface P Surface Disposal System. (zeviaed 8/15/95) 4 I i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 2L-3L4 'a�C. (eS �_ 0•/�YuISf Owner: Hc- Nw�V�ne.C" Date of Inspection: (� R(, 1Il �� " S' FLOW CONDITIONS RESIDENTTIIAAL- Design flow: "t40 gallons Number of bedrooms: 1 Number of current residents. 4 Garbage grinder(yes or no): eS Laundry connected to sy��,te,m (yes or no):�5 / �-r Seasonal use (Yrra car no)! 1� •— ,� ���'. q� ! s Water meter readings, if available: J'�t 1 "I c�a atf �(� t Ab Last date of occupancy: `1 COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)____ t+00,6arsltIVY WA610 direHargad to the Title S 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: `5 k�7_UE� t ',S System pumped as part of ins)ection: (yes or no) If yes, volume pumpe 1 g 110115 Reason for pumping: TYPE OF TEM 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) Other(explain) APPROTMATEXE of all components, date installed (if known)and source of information: Sewage odors detected when arriving at the site: (yes or no) fv� (revised 8/15/95) S l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: a 314 �� k) . Owner: H../ 4 / Date of Inspection: a3--gs SEPTIC TANK:v (locate on site plan) Depth below grade: &k � Material of construction: L--concrete —metal ,_FRP —other(explain) I Dimensions: )c X Sludge depth: I�t Distance from top of judge to bottom of outlet tee or baffle: V« n//A} Scum thickness: Distance from top of scum to top of outlet tee or baffle: N/ ix- Distance from bottom of scum to bottom of outlet tee or baffle: AW Comments: (recommendation for pumping, conditio f inlet and utlet tees or baffles, epthliquid level in r lation to Midt invert structural integrity, evidence eaka a etc.) , i ®� GREASE TRAP.r!� (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 tee or baffle: oi$tance from hottem IKtttrrm (11 ()tt!iet lee or WITtle' 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 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �] SYSTEM INFORMATION (continued) Property Address: `a�j({ k7�� e—S � t /�W�4�t�1Q2 Owner: c• H04A1V1-,C- Date of Inspection: �` y� TIGHT OR HOLDING TANK: �hei (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: (locate on site plan) Depth of liquid level above outlet invert. 0 Comments: ^ _�0?�- ! to if level and distribution is equal, e\idence of solids cart o� r eviden e of I kage i to or tout of box, etc.) D uKA-S. V��iv s r- co PUMP CHAMBERX\0Ae, (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 SYSTEM INFORMATION (continued) Property Address: a 3 �es. I , �-- Up�c Owner: Date of Inspection:Q _l 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:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: `` t leaching fields, number, dimensions: DO KJ`—U f overflow cesspool, number: it r lev I of n 4ondition of a etati etc.) Comments: (not co d'tion o soil, signs of h ra lic fa a q,�G lt.;'�E'- c wAU.. Do � l l CESSPOOLS: 1QO� (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.) i PRIVY: �n wCi n (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 8/15/95) 8 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: `' Y" ' ��� ✓L"� Owner: Dale of inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent r s a dmarks or benchmarks locate all wells within 100' 4-Vo sa 3 y ) rf �cays� 53t)�Ue�.) n - 107'G" -3 D rGlh. 0-BOX DEPTH TO GROUNDWATER l Depth to groundwater: I(D feet .� 1 1 i S ©��5� method of determination or approximation. -��, R (revised 8/15/95) 9 A.D. GIBSON, JR. Excavation & Landscape Contractor oWN o�ao p S eoA Septic System Repair& Installation 1 .� 47 Old County Road Andover, Massachusetts 01810 (508) 475-2496 October 15, 1995 To: North Andover Board of Health Main Street North Andover, Massachusetts Re: The property at 234 Bridges Lane, North Andover, Massachusetts in need of septic system repair before passing a Title 5 inspection. The system conditionally passed on September 23, 1995 but needed some repairs. These repairs were made by me on October 12, 1995. They included replacing the septic tank (1500 gallon) and repairing several broken pipes as indicated in the report. A permit was drawn for this repair, #779. The new septic tank is located in the same location as the previous one, but turned 90 degrees, all other components remaining the same. Refer to the inspection report for the Ari Buil drawing. Sincerely Yours, A. D. Gibson, Jr. ,�.� Copyint to pr erty owner, Matt Ammer OJEA� E OF N��FNHE o�H SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F S Of PART C G3 SYSTEM INFORMATION (continued) \ 1g9 k�Property Address: a�j�f Q�L""t" O" ' , HSC. OG Owner: Date of Inspection: q -a3-Rs' SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent r s a dmarks or benchmarks locate all wells within 100' UtWa X10 to 'fo 5b 6 e wli46-0 lt44j K 4, :51 Z> dew fro v f '� al� t�-----�— l�t'eb to C eJ e 3 ��� saA Flo 40 � p 0-Bax 1�t✓C e.sS,�2t,1 R eh� 2 s M � Oct �2, �9,5 /.0 DEPTH TO GROUNDWATER 1 Depth to groundwater: �� feet T�� l.�s c16.5) V\ method of determination or approximation: (revised 8/15/95) 9 i I Town of North Andover, Massachusetts Form No.3 ! &ORTN BOARD OF HEALTH 3? e.T, •e O19 q �,s^,ro�•��h DISPOSAL WORKS CONSTRUCTION PERMIT SACHUSE Applicant_ "ME t ' ADDRESS TELEPHONE Site Location Permission is hereby granted to Construct ( ) or Repair (Van Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN, BOAKD OF HEALTH Fee D.W.C. No. 779 i i I i I I i