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107 Forest St.
Middleton, MA 01949
(508) 774-2772
0
5�Q�5��J�GE
FILE# 28 9 7/1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PROPERTY OWNER'S
PROPERTY
ADDRESS OF OWNER:
(if different)
DATE OF INSPECTION:
NAME OF INSPECTOR: 7r' 6Y-" /9 s i c -"q S
• THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY 0
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CE TIFICATION
6/- Ano S� N ��� F
Property Address: 7�V y CSS 'address of Owner: So W
Date of Inspection: 28 %} ri L .)Q`l % (If different)
Name of Inspector: �OWAS \, (-V 1 G14s
Company Name, Address and Telephone Number:
FILE#'T2 VA
Currier Septic & Drain Service, Inc.
107 Forest Street, Middleton, MA 01949
(508) 774-2772
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:
_ZPasses
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: ` Date: -�_' 8. /�f'r%� 171917
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector
and the system owner shall submit the report to the appropriate regional office of the Department of Environmental
Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Chec(t�A B, C, or D:
A) YSTEM PASSES:
I have not found any information which indicates that the system viaiates any of the failure criteria as defined in
310 CMR 15.303. Any failure criteria not evaluated are indicated below.
B) SYSTEM CONDITIONALLY 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 dtermination in all instances. If "not determined",
explain not
The septic tank is metal, 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
conforming septic tank as approved by the Board of Health.
(revised 8/15/95)
FILE# �2C9 7 7A
SUBSURFACE SEWAGE. DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (conrixuEd)
B) SYSTEM ONDITIONALLY 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 §y§tom will pan in§pectien
if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
AJ distribution box is levelled or replaced
The system required pumpingmore than four times a year due to broken or obstructedpipe(s). The
Y
system will pass insp tion if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluqtion 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:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply
r or tributary to a surface water supply.
�1 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 system has a septic tank and soil absorption system anti 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) S TEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR
15.303. The basis for this determination is identified below. The Board of Health should be contacted to
determine what will be necessary to correct the failure.
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
FILE# �� 0 1 r� n
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
D) SYSTEM FAILS (continued)
YV Static liquid level in the distribution box above oulet 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 hLa 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.
NA 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:
01The 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)
FILE# 2- 9714
14
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Check if the following have been done:
Zpumping information was requested of the owner, occupant, and Board of Health
YNone of the system components have been pumped for at least two weeks and the system has been receiving
normal flow rates during that period. Large volumes of water have not been introduced into the system
recently or as part of this inspection.
ZAs built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
ZThe system does not receive non -sanitary or industrial waste flow.
e site was inspected for signs of breakout.
II 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.
iThe size and location of the Soil Absorption System on the site has been determined based on existing
information or approximated by non -intrusive methods.
The facility owner (and occupants, if different from owner) were provided with in on the proper
maintenance of SubSurface Disposal System.
(revised 8/15/95)
4
FILE# *2—? 97 A
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
FLOW CONDITIONS
RESIDENTI
Design flow: allonsPer �1
Number of bedrooms:_
Number of current residents:
Garbage grinder (yes or no):_SQ
Laundry connected to system (yes or no): -y2 -s
Seasonal use (yes or no):_h[Q
Water meter readings, if available:_. Un1Q1- I abl P
Last date of occupancy: CUrI`Ct
COMMERCIAL/INDUSTRIAL:
TY e of establishment: ,
Des flow:_�allons/day
Grease ap present: (yes or not)
Industrial aste Holding Tank pr ent: (yes or no)
Non -sanitary aste discharg d'to the Title 5 system: (yes or no)
Water meter re dings. if av�ble:
Last date of
OTHE • escribe)_
Las ate of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
L)yyier r- ?3 C,t4
System pumped as part of inspection: (yes or no)
If yes, volume pumped: O allons
Reason for pumping: I ti /Oh b)D 4e-roAk', .:
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
1 Privy
Shared system (yes or no) (if yes; attach previous inspection records, if any)
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: 1 I Vrs Oat 1 ns -61 led
IN 199b —OWMT
Sewage odors detected when arriving at the site: (yes or no)-Mb—
(revised
o):
(revised 8/15/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SEPTIC TANK: �,S
(locate on site p an
ii
Depth below grade:
Material of construction: /Concrete _Metal _FRP —other(explain)
Dimensions: !O'kA/560 cto I Tan&
Sludge depth:_ltt�"
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: _T
Distance from top of scum to top of outlet tee or baffle:_(
Distance from bottom of scum to bottom of outlet tee or baffler
Comments:
Depth Below Outlet I
FILE#
(recommendation for pumping, condition of inlepnd utlMes or baffles, depth of liquid level in relation tq oytlet invert,
structural integrity, evidence of teakage,etc.) } /�S a e ilj :1 :4 6Y)o���io� ��f`o/cJ dPpi IS
EASE TRAAa �e on site)
Depth belt
Material of
Dimensions: \
Scum thickness:
Distance from top of sc
Distance from bottom c
Comments:
_concrete metal _FRP —other(explain)
1top of outlet tee or baffle:
m o,,bottom of outlet tee or baffle:
Depth Below Outlet Invert:
(recommendgp6n for pumping, conditiohQvinlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,
structural i9tegrity, evidence of leakage, et6._
(revised 8/15/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
HT OR HOLDING TANK:ff
Q
(lo to on site plan)
Depth low grade:
Material o construction: _concrgte _metal _FRP —other(explain)
Dimensions:
Capacity: allons
Design flow: llons
Alarm level:
Comments
(condition onlet tee, condition
and float switches, etc.)
FILE#' 2.897A
DISTRIBUTION BOX:A5_
(locate on site plan)
it
Depth below grade: i J
Depth of liquid level above outlet invert:
o 0,
Dimensions of D -Box:) ' em Depth of ump: �o
Comments:
(no a if level and distribution is equal, evidence of solids carrygver, evidence of leakage into or out of b x, etc.)
s v ' L 5i ti
Ar r Q rne, 11 01m t, n Lkrr woven i -n 1ee,4;i7e /AI 7) . A n v W, AJh
PU CHAMBER:
(locate site plan
Depth below radeo:
Pumps in works der:
Comments:
(note condi ions of pu F
(yes or no)
chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95) 7
b�sEIa
TANK
p p -Box
w
'��'—----30----�
i
f
s
-Vol�w
DEPTH OF GROUNDWATER
Depth to groundwater feet
method of determination or aDoroximat
(revised 8/15/95) 9
v1
Aunai/e!
�io � .- l'L 9
40 Tb = 37'
}dTr 2013,,
FILE#��g 7 A
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SOIL ABSORPTION SYSTEM (SAS):°S
(locate on site plan, if possible va lon not required, but may be approximately by non -intrusive methods)
Depth to bottom of SAS: tonr Pit)
ro
If not determined to be present, explain:
Type:
leaching pits, number:
leaching chambers, number:
leaching galleries, number: I �
leaching trenches, number, length:30 L X ke4Ch L►nG are, S'- a Pi pe-
leaching
eleaching fields, number, dimensions:
CEkSPOOLS:�
(loc a on site p an)
Depth Blow grade:
Number nd configuration:
Depth -top f liquid to inlet i
Depth of so' slayer:
Depth of scum
Dimensions of
Materials of cc
Indication of gi
inflow
must be pumped as part of inspection)
(note condition oNpil, signs of hydraulic failure, level of ponding,..condition of vegetation, etc.)
PRIJ�
(locat on site plan)
Materials oN
Depth of soli
Comments: (
mensions:
ition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 8/15/95) 8
TOWN OF
SYSTI
DATE: V2 aS
SYSTEM OWNER & ADDRESS
RECEIVED
►������rr.�ri.P��
JUN 2 0 2005
TOWN OF NORTH ANDOVER
HEA' ' H DEPARTMENT
SYSTEM LOCATION
(example: left front of house)
rcj�- �vcV o� tiausc
DATE OF PUMPING: e,2 -0S QUANTITY PUMPED: k � p e GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE ✓ EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO:
G.L.S.D
Lowell Waste
TOWN OF I&C
SYSTEM PUMPING RECORD..
DATE: —I — l _ D5
SYSTEM OWNER & ADDRESS
SYSTEM LOCATION
(example: left front of house)
C
c�
DATE OF PUMPING: _ I ^ 0 QUANTITY PUMPED : / GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: � y + 0,
1
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: -Z3—O�
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: S 2-3 O ( QUANTITY PUMPED 0Z) GALLONS
CESSPOOL: NO J YES
NATURE OF SERVICE: ROUTINE
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY:
COMMENTS:
SEPTIC TANK: NO YES
EMERGENCY
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
CONTENTS TRANSFERRED TO: (" ' L-•<5' Y)
Comm nwe lth of Massachusetts
Al, ""a/
Massachusetts
System Pumping Record
System Owner
Date of Pumping: �j — 3 r a,� o
Cesspool: No Yes [I
System Pumped by: gar""
System Location
7i iia lAvvw�cakw
Quantity Pumped: S�� gallons
Septic Tank: No [ ]
License #
Contents transferred to: Greater Lawrence Sanitary District
Date:
Inspector:
,.r
Yes H'
FORM - U - LOT RELEASE FORM
INS TRUCT'IONS: This form is used to verify that all -necessary approval / permits from
Boards and Departments having jurisdiction have been obtained. This, does not relieve the
applicant and or landowner fro compliance with any applicable requirements.
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APPLICANT I T11 k) —PHONE
ASSESSORS MAP NUMBER A' % LOT NUMBER /f/
SUBDIVISION LOT NUMBER
STREET STREET NUMBER
�rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr■rrrrrrrrrrrrrrr■,rrrrrrrrrrrrrrr�rrrrrr■
OFFICIAL USE ONLY
�rrrrrrrrrrrrrrrrrrrrrrrrrrr■■rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr■
RECOMMENDATIONS OF TOWN AGENTS
�rrr•■■rrrrrrrrrr4rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrgoo
rrr■•rrrr•
v � � DATE APPROVED � � � O
CONS VA ON ADMII�JLSTRATOR
DATE REJECTED
DATE APPROVED
TOWN PLANNER
CONB4ENTS
FOOD INSPECTOR -HEALTH
SEPTIC INSPECTOR - HEALTH
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED o�
DATE REJECTED
CON'T i n/7 U N D G- G/ -?,6 A-fU74
PUBLIC WORKS - SEWER / WATER CONNECTIONS
DRIVEWAY PERMrr
DATE APPROVED
FIRE DEPARTMENT
DATE REJECTED
C OMr&NTS
RECEPIED BY BUILDING INSPECTOR DATE
FORM - U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all -necessary approval/ permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve the
applicant and or landowner from compliance with any applicable requirements.
APPLICANT��/��/�'��pp� Q PHONE I I�
ASSESSORS MAP NUMBER LOT NUMBER nim
LOT NUMBER
STREET STREET NUMBER
OFFICIAL USE ONLY
RECOMMENDATIONS OF TOWN AGENTS
no
DATE APPROVED swoons
CONSERVATION ADMINISTRATOR
Pt_ ct
• JNM10►121�1:7
COMMENTS
FOOD INSPECT -HEALTH
SE S OR -
TE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED d
DATE REJECTED
COMMENTS C f� i � / h '"o -z- yay i , to ✓'
_57 /A C
PUBLIC WORKS - SEWER / WATER
DRIVEWAY PERMIT
DATE APPROVED
FIRE DEPARTMENT
DATE REJECTED
COMMENT'S
RECEIVED BY BUILDING INSPECTOR I
DATE
FORM U - LOT RELEASE FORM
•�---mow
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
7"APPLICANT FILLS OUT THIS SECTION*****************" �
APPLICANT
LOCATION: Assessor's Map Number10,94-
SUBDIVISION
STREET(
_) (U�I�'q ("A�t,
tom* t*** t r t* ""� O F F i C IA L USE ONLY
RECOMMENDATIONS OF TOWN AGENTS:
CONSERVATION ADMINISTRATOR DATE APPROVED
DATE REJECTED
COMMENTS
TOWN PLANNER
COMMENTS
FOOD INSPE
/r
S E yil03NSP
R -HEALTH
?�ea.
OR -HEALTH
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
PHONE
PARCEL
LOT (S)
ST. NUMBER
DATE APPROVED 6
DATE REJECTED 7
COMMENTS rrf:c_ ;�-� �•-z�' - 1��� �� r��:�
PUBLIC WORKS - SEWERlWATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING 1NSPECTCR DATE
Revised 9197 jm
Board of Health
North AndaverZN.aaa.
APPRC1VED DATI,
FAIL O-
�
LI
SEPTIC SISTEH
INSMLATICK CHBCB LISP
DI SAPPrgOVID
55
Gasonst
LOT
—tXCAVATI CEJ Ob 'FAIL
1. Distance Tot
a. Wetlands t,J Ht -1 E6
b. Drains d r l.�i lj �• y U` CC�t1G
C.. Well
2. Water Line Location
3. No PVC Pipe
4. Septic Tank
a. Tees -_Length & To Clean Out Cover 3
b. Cement Pipe to Tank On Both Side s of Tank
5. Distribution Box
a. Covers do Box - No Cracks
b. All Lines Flowing Equal Amount -
c. No Back Flow
6. Leach Field or Trench
a. Dimensions
b. Stone Depth
c. Capped maids
d. Clean Double Washed Stone'
7. Leach Pits
a. Dinansions
b. Stone Depth
c. Splash Pads
d. Tees
.e. Ca ent Pipe to Pit - Both Sides
f. Clean Double Washed Stone
8. No Garbage Di spo sal.
9. Anal Grading Inspection
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
ARD 0 -1 -,HEALTH
i.,�ndovcr, ^'pass.
APPROVED
Provided:
r
Title V
Reg 2.5
Reg 6
Reg 10.2
Reg 10.4
DATE -�
MM
SUBSURFACE DI5POSAL DESIGN CHECK LIST
DISJOPROVED DATE
Reasons:
The submitted plan must show as a miniur m:
a) the lot to be served -area dimensions lot #,abutters
b location and log deep observation hoses -distance to ties
c location and results percolation esis-distance to ties
d design calculations & calculatioi.s sl -wing required leaching area
e) location and dimensions of system-inclt?ing eeserve 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 1001 of sewage disposal
system or disclaimer
;i) location any drainage easements within 100' of sewage disposal
system or disclaimer -Planning Board Piles
know sources of vater supply within 2001 of sewage disposal «
system or disclaimer
;k) location of any proposed well to serve lot -1001 from leaching facilit
,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 base,ient, plumb, pipe, septic tank,
distribution box inlets and outlets, distribution field piping and
other elevations
(r) maximum ground water elevation in ar-a sewage disposal system
(s) plan must be prepared by a Professio.al Engineer or other
professional authorized by law to pr -pare such plans
Septic Tanks
a) capacities -15D% of flow, ~rater table, tees, depth of tees,
access, pumping
b) cleanout
c) 101 from cellar wall or inground sig pool
d) 251 from subsurface drains
Distribution Boxes
a) slope greater 0.08
b) sump