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Building Permit #446-13 - 195 CANDLESTICK ROAD 11/19/2013
i TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION I i Permit N0: Date Received i I � Date Issued: 1 3 ' IMPORTANT:Applicant must complete all items on this age WL I L Q- T- 0,N' 00 ;Print 1 /J 'PROPE.RTFY OWNER:- _ �-CL re - ... Old StN 100 Year ctu _ yes fio- _ x - t _ no EMAP NO. /a_1P,,ARCEL�� ZONIN,G DISTRICT - _ Historic District yes �--- Machine.ShopVillage yes �no ; TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family 11 Addition El Two or more family El Industrial 11 Alteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑Demolition ❑ Other Sept �01Nell '�F oodplan - Wetlands 1 kVllatershed Dstncf'. fix. .!-. S" ..•-" t DESCRIPTION OF WORK TO BE PERFORMED: Identification Pleas Type or Pt Clearly) OWNER: Name �► �� �h�P 1I Phone: Address: ' �-5 CwAx G)X- y ' O4j RU 45T _ iPlione= `E on SupennsorsCstruction3�Lticense - _. _ Y EXp - Da__ !Ho—MellmprovementLicense::._. to ARCHITECT/ENGINEER Phone: E Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ �i� FEE: $ ---- 1 Check No.: Receipt No.: I 1 a � cess to the uaran and have ac h'.f rlrC toys do not ha g NOTE: Persons contracting with unregistered cont g gh S� Mature,of contractor._ Si nature of A ent/Ow er Plans Submitted 0 fans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ . I • ��osry X20{��eo k6 Qy o TO F Y lei OF 1;Y ORTH ANDD OVER Td OFFICE OF o Ig bhh ,� BUILDING DEPARTMX NT :'1600 Osgood Street Building 20,-Suite 2-36 yes Acuus��`� •North Andover,Massachusetts 01845 Gerald A.Brown Inspector of Buildings Telephone(978)688-9545 i H0.100)ITER"LICENSE EXENjpTION Fax (978)688-9542 BWDING PERYHT APPLICATION Pleasevrint • , ' DATE: JOB LOCATION: C)C I • G Number StreetAddress ` Map/Lot Name. Home Phone Work Phone PRESENT MAILING.ADDRESS en CLQ f -9 To,=m sL-te lip CC)de The current exemption for"homeowners"was extended to include owner-occupied cl�vellings to i�vo units or less and to aII° 'su.h ho meo�,vers to engage andividuaLfor hire who does not possess a license,provided That the owner 1 acts as supervisor). State13u1ding (Code Section.108.3.5.i_) DEFINITION OFHOMBOWNER Parson(s)who fa a parcel ur land on which.he/she resides or intends to reside,on which there is,oris intended to be,a one or two family structures. A person who constructs more that one home in a which there O shall not e considered a homeowner. The undersigned"homeowner"assumes responsibility for compliances Applicable codes,by-laws,rules andregulationswith the State Building Code and other, t � The undersigned"homeowner"cert�es that he/she understands the Town of North Andover Building De minimum inspection procedures and requirements and that he/she will comply with,said procedures and paztment requirements, I� HOMEOWNERS SMNAT .APPROVAL OF BUILDING OFFICIAL ' I Revised 7.2009 Form Homeowners Exemption "BOARD OF APPEALS 688-9541 CONSERVATION 686-9530 HEALTH 688-9540 PLANNING 688-9535 i Location I � C',+'AGI Date No. I a TOWN OF NORTH ANDOVER " L Certificate of Occupancy $ Building/Frame Permit Fee i Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# `� J 8 Building inspector I i i Plans Submitted❑ '.Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 'I'YP�OF-SEWERAGEDiRAOSAL immEl Public Sewer ❑ Tanning/MassageBodyArt ❑. . S��' mg P°ols Well ❑ Tobacco.Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc_. E] -Permanent Dumpster on Site El THE.FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM . DATE REJECTED DATEAPPR_OVED i PLANNING & DEVELOPMENT ❑ ❑ e COMMENTS a f CONSERVATION Reviewed on Signature Q COMMENTS HEALTH Reviewed on Signature x i COMMENTS t D Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes i Planning Board Decision: Comments _ - c Conservation Decision: :Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW'ToNb : Engineer: Signature: Located 384 Osgood Street FIRE D-EPARTMF_- T - Temp Dumpster on site .yes no ` .Located'at 124 Mair Street; Fire Depa`rtmerftsignatu"r_e/date- Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. -Total-land-area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval Electrical Inspector Yes pp al of No DANGER ZONE LITERfURE: Yes MGL-.Chapter166.Seetion21A-F and G min.$100-$1000:fine N® NOTES and DATA — (For department use I I . j ® Notified for pickup - Date E x.Building permit Revised 2010 I I Building Department The foli swing is-alist of the req uired.forms to be filled out for the appropriate:permit to.be obtained. Roofirg, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ' ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include-Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apw-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm-tted with the building application � i Doc: Doc.Bui.ding permit Revised 2012 .� The Commonwealth of Massachusetts - Department of Industrigl Accidents Office of Investigations k1i 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/lndividual): D v ' T V` ov Address: City/State/Zip: ��'� (A VV Phone Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I ' 6. FJ New construction f employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. I• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. g ❑$ g addition [No workers' comp.insurance 5. F-1Weare a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.al am a homeowner doing all work right of exemption per MGL 11.[]Plumbing repairs or additions ys elf. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs � insurance required.]t employees.[No workers' comp.insurance required.] 13.1-1 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they a're doing all work and then hire outside contractors must submit a new affidavit indicating such. toontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250:00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cert under the plains an dR enalties ofperjury that the information provided above is true and correct. Signature) I C� Date: \\jPhone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express orimplied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not producedacceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Y p Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Pleasee b sure that the affidavit is complete and printed legibly. The Department hasp rovided a space at the bottom p of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant, Please be sure to fill.in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or'-permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone aiid fax number: The Cmmonwoaltlz of MossachUsPtts Department of kdustrial Accidents Office ofUvestig-ations 600 Washington.Street Boston,,MA,02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAJFE Revised 5-26-05 Fax#617-727-7749 %AORTH Town Of 2 ndover ver, Mass, I � o coc NIc Nlwlc" �d ADRATED 01**P S U BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System • THIS CERTIFIES THAT .,,,,,,,,,,,,,,,,,,,,,,,,,,, BUILDING INSPECTOR ................. .-........... ..�. .. .... .. ... . . . . .. has permission to erect ......... buildings on JAC CO3�„�',�"�„Vice..... Foundation Rough to be occupied as .. .� ....Daoeww ... .. .. . w..%.NAo.vso .... Chimney provided that the person accepting this permit shall in every espect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MO THS ELECTRICAL INSPECTOR ' UNLESS CONSTRU 10 ARTS Rough Service .......P........................ .................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE Code End PU3 apo 11111111111111111111 Code Start :P84S apo Staple oldejS IOIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII I 200 CANDLESTICK ROAD )ad Z] 210/106.A-0196-0000.0 V l r l I I I I� Commonwealth of Massachusetts City/Town of RECEIVED System Pumping.Record MAY 1 1 2015 Form 4 V� TOWN OF NORTH ANDOVER DEP has provided this form for use-by local Boards of Health. Other formsiuma he do(It the 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. A. Facility Information 1. System Locatio . Lft/ ig f Nous , Left/Right rear of house, Left/right side of house, Left/ Right side of bui5iff9,Left/ I9 t front of buildin9. Left/Right near of building, Under deck Address ! /� -� City/Town State Zip Code 2. System Owner. Name Address('d different from location) Citylrown Zip e , Telephone Number B. Pumping Record 1. Date of Pumping Date ;2. Quan' umped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes If yes,was It cleaned? ❑ Yes ❑ Na ' 5. Condition Q�System: 6.. System Pumped By: Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc' Company 7. Location where contents were disposed. I ACS. _ Lowell Waste Water + Sign Haul Date 1 t5form4.doc-06103 System Pumping Record•Page 1 of 1 RECE1VEp Commonwealth of Massachusetts3UL '15 2013 'TOWN OF NR7MCitJ /Town ofkL/�ai N�A � Epg AND oVERRTMENr�o * System Pumping Record Facility Information: i System Location: Address City/Town State Zip Code System Owner: Name: Adress (if different from location of pump) City/Town State Zip Code i 9 ?s- -C) Telephone Number Pumping Record Date of Pumping /j Quantity Pumped _ (�J gallons Type of System__X Septic Tank Grease Trap Other (what) T` System Pumped by: 601u _ I /h""-� Company: ROOTER-MAN 46 Portland Street Lawrence,MA 01843 Location where contents were disposed: f - Signature of Hauler Date i i I i Commonwealth ®f Massa c lusetts City/Town ®fN RECEIVED System Pumping Record JUL 14 2009 i ..v OF NORTH ANDOVER FacilityInformation:ation r HEALTH DEPARTMENT System Location- Ale tt'� ((' �d Address City/ own State Zip Code System Owner: k Name: Adress (if different from location of pump) E t k i C:ty/t o vn State ZiD Code I q-7 Telephone Number Pumping Record bate of Pumping_ (P Jd3)69 Quantity Pumped 15oo gallons Type of System—)(—Septic Tank grease Trap Other (what) System Pumped by: __ lau r) -P v Company: ROOTER-MAN 12 East Dracut Rd., Methuen, MA 01844 Location where contents were disposed: �g Signature of Hauler Date t Town of North Andover �4 Health Department Date: Location• (Indicate Address,if Residential,or Name of Business) Check#: Type of Permit or License:(Circle) J ➢ Animal ➢ Dumpster $ ➢ Food Service-Type: $ ➢ Funeral Directors $ ➢ Massage Establishment $ ➢ Massage Practice $ ➢ Offal(Septic)Hauler $ ➢ Recreational Camp $ ➢ SEPTIC PERMITS: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC)$ ❑ Septic Disposal Works Installers(DWI) $ ➢ Sun tanning $ ➢ Swimming Pool $ ➢ Tobacco $ ➢ TrasWSolid Waste Hauler $ ➢ Well Construction $ ➢ OTHER:(Indicate) f G 3 Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer, . I b�r1✓'. �� `713/ob COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS I a DEPARTMENT OF ENVIRONMENTAL PROTECTION r i I TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 200 Candlestick Road I North Andover,Ma.01845 1:ZE—CE JI) Owner'sName: Kevin Sanborn Owner's Address: SAME MAR 2 0 Date of Inspection: 3/14/06 TOWN OF NORTH HEALTH DEPAR Name of Inspector:(please print) Brian S.Murphy Company Name: West Side Septic Mailing Address: 4 Abbey Lane Middleboro,Ma .02346 Telephone Number: (. 508 )947-8200 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: i X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature:,,5:: ,.,, Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. I Notes and Comments I i ""This report only describes conditions at the time of inspection and under the conditions of use at that j time.This inspection does not address how the system will perform in the future under the same or different conditions of use. COPY Page 2 of l 1 . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 200 Candlestick Rd . N.Andover,Ma . Owner: Kevin Sanborn Date of Inspection: 3/14/06 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. 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 tanknot whether metal or ( )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 pipe(s)are replaced 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: Page 3 of 1 I ' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 200 Candlestick Rd. N.Andover,Ma. Owner: Kevin Sanborn Date of Inspection: 3/14/0 6 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 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 y g 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 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. G 3. Other: I Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 200 Candlestick Rd . N.Andover,Ma. Owner: Kevin Sanborn Date of Inspection: 3/14/06 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or X clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than'/s day flow g Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number X of times pumped _ Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. X 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.) NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as I described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. 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. 1\ I ` I Page 5 of I I i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:200 Candlestick Rd. N.Andover,Ma . Owner: Kevin Sanborn Date of Inspection: 3/14/06 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks X _ Has the system received normal flows in the previous two week period i I X Have large volumes of water been introduced to the system recently or as part of this inspection X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up X _ Was the site inspected for signs of break out X _ Were all system components,excluding the SAS, located on site I X _ 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 X _ 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. _ Determined in the field if an of the failure criteria related to Part i ( y C s at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] I I I I Page 6 of 1 I t OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION it Property Address: 200 Candlestick Rd. N.Andover,Ma. Owner: Kevin Sanborn Date of Inspection: - 1 4.1 p 6 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 4x150=600 gpd . Number of current residents: 4 Does residence have a garbage grinder(yes or no): no Is laundryon a separate sewage system(yes or no) :n_o [if yes separate inspection required] ] Laundry system inspected(yes or no): Seasonal use:(yes or no): no Water meter readings,if available(last 2 years usage(gpd)): apex. 214 gpd. Sump pump(yes or no):no Last date of occupancy: rp e s e n t COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,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: system last pumped 6 months,home owner Was system pumped as part of the inspection(yes or no): no 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/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 I Other(describe): Approximate age of all components,date installed(if known)and source of information: 18 yrs. installed 11/87 local BOH records. Were sewage odors detected when arriving at the site(yes or no): no i Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 200 Candlestick RD. N.Andover,Ma. Owner: Kevin Sanborn Date of Inspection: 3/14/06 BUILDING SEWER(locate on site plan) Depth below grade: 2 4" Materials of construction: X cast 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: X (locate on site plan) i Depth below grade: 2 8" Material of construction: X 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: 10 'x 5 'x 4. 51 1500 q al . Sludge depth: 1 " Distance from top of sludge to bottom of outlet tee or baffle: 2 9" Scum thickness: 1 11 Distance from top of scum to top of outlet tee or baffle: 5 Distance from bottom of scum to bottom of outlet tee or baffle: 18" How were dimensions determined: i n f i e l d Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tank and cement inlet baffle in good condition,outlet tee in good condition, liquid level with outlet,no signs of leakage. 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 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: 200 Candlestick RD. N.Andover ,Ma . Owner: Kevin Sanborn Date of Inspection: 3/14/06 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/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: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D—box in fair condition,box shows some signs of deterioration, liquid level with outlet,no signs of carryover or . 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.): I Page 9 of 11 . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 200 Candlestick Rd. N.Andover,Ma. Owner: Kevin Sanborn Date of Inspection: 3/14/06 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) I If SAS not located explain why: Type leaching pits,number:_ f X leaching chambers,number: 3 C 5 x 8 ' leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: 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.): Soil conditions normal ,no signs of hydraulic failure,vegetation j normal . t I CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): 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.): I Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) If Property Address: 200 Candlestick Rd . N.Andover,Ma . Owner: Kevin Sanborn Date of Inspection: 3/14/06 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or 4 benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. 1� PLEASE SEE ATTACHED AS—BUILT PROVIDED BY LOCAL BOH i I !I I I Page 11 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C j SYSTEM INFORMATION(continued) Property Address: 2 0 0Candlestick Rd. N.Andover;Ma. Owner: Kevin Sanborn Date of Inspection: 3/14/0 6 SITE EXAM Slope Surface water j Check cellar j Shallow wells Estimated depth to ground water 6+ feet j 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: Observed site(abutting property/observation hole within 154 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 established the high ground water elevation: Ground water determined from previous inspection reports on record at local BOH,also probed 4 ' below d-box no water encoun ered . I I ��EAITH OF�f � i LrI � a La f Summary RecordCardgenerated on 3/9/2006 4:20:14 PM by Elame Barclay Page 1 Town of North Andover • Tax Map # 210-106.A-0196-0000.0 200 CANDLESTICK ROAD SANBORN, KEVIN & PENELOPE 200 CANDLESTICK ROAD ` NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 1.04 Acres FY 2006 at in UBM {ndeX 1 g Name/Address Type Loan Number Active/Inact. From Until SANBORN, KEVIN& PENELOPE Payor 200 CANDLESTICK ROAD NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 17635.0- 200 CANDLESTICK ROAD Last Billing Date 1/10/2006 3170305 03 Cycle 03 Active UB Services Maint. Service Code Rate Charge Muhiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 115.08 /1 UB Meter Maintenance Serial No Status Location Brand Type Size YT4 Cons 18336454 a Active ERT HH b Badger w Water 0.63 0.63 Date Reading Code Consumption Posted Date Variance 3/8/2006 528 a Actual 16 -34% Trouble Code:03 12/21/2005 512 a Actual 29 1/17/2006 -61% Trouble Code:03 9/20/2005 483 a Actual 68 10/14/2005 -83% Trouble Code:03 ` 6/27/2005 415 a Actual 412 7/15/2005 7770% 3/30/2005 3 a Actual 3 4/5/2005 2/7/2005 0 n New Meter 0 4/5/2005 -100% 2/7/2005 1919 r Replacement 14 4/5/2005 -93% 12/14/2004 1905 a Actual 282 1/1412005 1119% Trouble Code:03 9/24/2004 1623 m Manual estimate 30 10/8/2004 -10% 6/11/2004 1593 a Actual 18 7/30/2004 249 4/15/2004 1575 a Actual 31 5/17 — 0% "12/15 n New e e — T 12!1512003 poi s i i t NEW ENGLAND ENGINEERING SERVICES INCA (� �J /{ (�yy(n� y �1 Iq '- 44ORTH Ai��00, ..1� OFHEAL,►i i NOV 4 2002 November 1, 2002 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT: 200 Candlestick Road,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 an i - y questions lease call me at office, 686 1768. q P Y Sincerely I Benjamin C. Osgoo Jr. I, 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 f COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION CF NORTH A"N; 1 FC,JP..D OF HF,� Hquo �� NOV 4 2002 TITLE 5 - - OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Zoo c Ao p Vis;t e ji, p-D /000-T)4 AAJ'DoJFP- tt1 Owner's Name: ►r,6t`7-e Owner's Address: ' N��'r1-t A.�U 1�D✓�✓L �� Date of Inspection: /c/ 3 o/,)-z- Name Name of Inspector:(please print)0 crv.-rA.,-,A, C Qs&,OD �i 2 Company Name: ► 5,y G.v&-,44,voMailingAddress: &-o g cZ c r�w OfLt:f� n�o a-n-e ���o�r 2 .�,,✓r Telephone Number: 9?g- 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 15340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails I Inspector's Signature: C Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design 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. Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Z-- C Hy o 1-tr s 7 C« P.D - 0 09114 Ntil D O- Lr(Z -AA Owner: K Et iV A-9 J Lj 2 R 3e-1)4 t tt -1-b^rte Date of Inspection: 10 3 C Z",2- Inspection Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: V-1 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 repaired system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or n etermined(Y,N,ND)in the for the following.statements.IV`iot determined"please explain. // �- The septic tank is metal d over 20 years old*or the septic tank(ythther metal or not)is structurally unsound,exhibits substantial in tion or exfiltration or tank failure is-imminent.System will pass inspection if the existing tank is or with a comp.I+ing septic tank as approvedby the Board of Health. *A metal septic tank will pass inspecti�f it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20y ears :!.old is available ND explain: `J Observation of sewage backup or break out 4 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): i' broken pipe(s)are repla* obstruction is removed \ i� 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: Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Zoo GAN 9 I—Cs P c l'-� Q.D Owner: 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 Win to protect public health,safety or the environment. 1. Syste will pass unless Board of Health determines in accordance with 310 CMR 1 03(l)(b)that the system of functioning in a manner which will protect public health,safety a the environment: Cesspool privy is within 50 feet of a surface water Cesspool or ivy is within 50 feet of a bordering vegetated wetland or salt marsh 2. System will fail unless the Board Health(and Public ater Supplier,if any)determines that the system is functioning in a manner that p otects the publi ealth,safety and environment: _ The system has a septic tank andsoil t. system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface er supply. 1 . _ The system has a septic tank and SA and th AS is within a Zone 1 of a public water supply. _ The system has a septic tank SAS and the SA is within 50 feet of a private water SPP1 well. The system has a septic and SAS and the SAS is than 100 feet but 50 feet or more from a private water supply well** ethod used to determine distan **This system passes i e well water analysis,performed at a DE certified laboratory,for coliform bacteria and volatile�'ganic compounds indicates that the well is free om pollution from that facility and the presence of amihonia nitrogen and nitrate nitrogen is equal to or less an 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to thi orm. 3. 0, er: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: zoo c RN p E51 c �Z D Owner:_ _ ye-\--114 0&yP EuZfH jtA�i?�>✓i Date of Inspection: p v Z D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _j/ 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'/�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 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for 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.] A/0 0 (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 system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd- You must indicate either"yes"or`ono"to each of the following: (The folio teria apply to large systems in addition to the criteria above) yes no — _ the system is within feet of a surface drinkin er supply _ the system is within 200 feet o to a surface drinking water supply the system is located ida nitrogen sensitive Interim Wellhead Protection Area–IWPA)or a mapped Zone 1I of a.pulilic water supply well If you h answered"yes"to any question in Section E the system is idered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator y large system considered a significant threat under Section E or failed under Section D shall upgrade the syst 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 C SEWAGE DISPOSAL SYSTEMN I SPECTION FORM PART B CHECKLIST Property Address:_ zoo 2p I'S b2Tx oje R_ /"/4 Owner: the tomf 41-J L,iZA6iTH cc-14 I fb Date of Inspection: a 13-oh:>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,occapant,or Board of Health Were any of the system components pumped out in the previous two weeks? _ Has the system received normal flows in the previous two week period? i _✓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? _V/'_ Were thetic tank manholes sep 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. _ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] f I ,I Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_zoo C R ti o t-rsrl c I, P-D !9- 6^J D OJG 0, MA Owner: V L f-17'( ✓9-,P bnU 2-A #3 Date of Inspection: -njo'i FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): y DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Loo Number of current residents: Y Does residence have a garbage grinder(yes or no):-go Is laundry on a separate sewage system(yes or no):ALO [if yes separate inspection required] Laundry system inspected(yes or no):— Seasonal use:(yes or no): #0 Water meter readings,if available(last 2 years usage(gpd)): ?,o o G-Q P Sump pump(yes or no):-o Last date of occupancy c �r r e nY COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): 2nd- Basis pdBasis of design flow(seats/persons/sgft,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: Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons--How was quantity pumped determined? Reason_for pumping: TYP OF SYSTEM VSeptic 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): Approximate age of all components,date installed(if known)and source of information: Win &7'4 -C-p 19 0-1 PCEZ N5 E3 crT Were sewage odors detected when arriving at the site(yes or no):N 0 Page 7 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2a0 CAS r>c E Silcr� RD K302TN ASwDOur� Owner: K c k-IT �, ELI Date of Inspection: /o/ o f o 2 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: Av A Comments(on condition of joints,venting,evidence of leakage,etc.): ?I M tWoK-t 6-000) i ^-' �AStMG moi' SEPTIC TANK:_(locate on site plan) Depth below Dep grade: 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: )D-o Sludge depth: z" Distance from top of sludge to bottom of outlet tee or baffle: 27" Scum thickness; z Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or—baffle: How were dimensions determined: -,r�A.,,a E S-/I c ,. Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 0, i.v ox, co„_, p,'7on. BOK K0 ?ye 76-L-7 1N Grpo CO) D ,-F)on. 2O-co.,tcNn i,AjSiALcc+lpr, csi 2k ,EIZ5 % 9 w 'T7�ly 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 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: 2 0e c A AJ'O LES << PSA N. De--„62 Owner: KC IT"K 5 C-u2A 3- i f7 c I-t,+n-o-Fr Date of Inspection: i-/,9 z)jaz TIGHT or HOLDING TANK: Al�-(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: Capacitygallons 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.): I DLSTMIMON BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: fj 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.): PoJR 1✓1 DIC ca"p 'T,On- Mo FVIDrNCe oi` 2 i r4V_1gGC lAJ o o R ser 2ky c5,} 2 ;fix is fo S' Scow CT-►'�mDc= 6J11 !S FiZIA40rkk-y/ 9,L,45-'J_CD LEGE EC0A&E/V "li% Z` or &Itftoc 0 rRcI�I��tZ i-��2E ►�sP�c1�h� 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.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: z C,0 C.R-n9 D LC-- c,-cMI(, {ZD Q k�> f?Tl I k/'J-P7 j tk. Owner: ►G,e i Tit 6-N) >^Li?, 66 i-e Date of Inspection: io f 30 0 Z SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type ✓leaching pits,number:_3 )-E A c K P i T s t 0'.j N Z To leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: 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.): R2r V9 0 F S 13T13TV nil ✓..s /?o tLn4.q2 CESSPOOLS: (cesspool must be pumped as part of inspectionxlocate on site plan) j Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): j Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:104-(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 I Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropertyAddress: Zoo c RN D L sTAc.i4, fL9 Owner: EEIiIf AND FL-1ZR&Ei?� CHA Date of Inspection: (o/3 0/;�Z I 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 ental the building. a �IN y 7 III C RJ-v Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: zo c .a u 9 Lcsri c iRq 10 N DpJr 2. MA Owner: 0 i L 12 f+3 E i R FT- Date FDate of Inspection: )0) 3 0 o z SITE EXAM Slope Surface water ,� c Check cellar Shallow wells wo N Estimated depth to ground water I feet Please indicate(check)all methods used to determine the high ground water elevation: t 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) Accessed USGS database-explain: You must describe how you established the high ground water elevation: esi,Aj 'F A36-)e KCC 4 G-23,�-/y p III _�a`iSiuM Loc42 D IN (}n/' fl/!tA —1 fAi L-Jq5 L 6b- /O' f16L�cJ� CO2Cr{NFYL, PgP-S C ►IM- > (,6' $elo� nLj7 Cz2G�e, i i i Z A F n Q2 COMMONWMTH OF MASSACHUSETTS Co EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONNWAL PRIOTi WnON ONE WINTER STREET,BOSTON MA 02108 (617)292-5500 TRUDY COXE 9 ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM NSPECTION FORM PART A CIER I FICAMN Property Address:200 Candlestick Road,North Andover Name of Owner:Lamberto Raffaelli Address of Owner:200 Candlestick Road,North Andover,MA. 01845 Date of Inspection:2/17/2000 Name of Inspector:Neil J.Bateson I am a DEP approved system inspector pursuant to Section 15.340 of TWO 5(310 CMR 15.000) Company Name:Bateson Enterprises Inc. Mailing Address:111 Argilla Road Andover,MA 01810 Telephone Number.(978)4754786 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: _X Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority tails Inspector's Signature: Date:2/17/2000 The System Inspector sha s mit a c of this inspection report to the Approving Authority(Board of Health or DEP)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. NOTES AND COMMENTS MAR - 2 r 3 revised 9/2/98 Page I of 11 Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:200 Candlestick Road,North Andover Owner:Raffaelli Data of Inspection:2/17/2000 INSPECTION SUMMARY: Check A 8 C or D. A.SYSTEM PASSES: _X 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: I I B.SYSTEM CONDITIONALLY PASSES: One or move 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. i Indicate yes,no,or not determined(Y,N,or NO).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 h Compliance(attacher)indicating that the tank was installer within twenty(20)years prior tet e 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 leveled 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 h h revised 9/2/98 Page 2 of 11 i I � I'I 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:200 Candlestick Road,North Andover Owner:Raffaelli Date of Inspection:2/17/2000 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 the public health safety and the environment. p � �y i 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE ENVIRONMENT: I I The system has a septic tank and sal absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system septic tank and soil absorption tem and the SAS is within a Zone I of a public water supply well. ys has a pt P The system has a septic tank and sal absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and sal absorption system and the SAS 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.Method used to determine distance (approximation not valid). 3) OTHER i I revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) I I Property Address:200 Candlestick Road,North Andover Owner:Raffaelli Date of Inspection:2/17/2000 D.SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I 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 facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_ I 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: I 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 11 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 912/98 Page 4 of 11 II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:200 Candlestick Road,North Andover Owner:Raffaelli Date of Inspection:2117/2000 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No _X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _X As built plans have been obtained and examined.Note if they are not available with NIA _X The facility or dwelling was inspected for signs of sewage back-up. _X The system does not receive non-sanitary or industrial waste flow.The site was inspected for signs of breakout. X All system components,excluding the Soil Absorption System,have been located on the site. _X 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 Sal Absorption System on the site has been determined based on: X Existing information.For example,Plan at B.O.H.No design plan,only as built plan. _X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (I 5.302(3)(b)J _X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. I i i i i revised 9/2/98 Page 5 of 11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:200 Candlestick Road,North Andover I Owner: Raffaelli Date of Inspection:2/17/2000 \ FLOW CONDITIONS RESIDENTIAL: Design flow::_N/A—.g.p.d./bedroom. Number of bedrooms(design):_N/A_ Number of bedrooms(actual- 4-Total DESIGN flow_N/A Number of current residents: 4 Garbage grinder(yes or no):–No– Laundry(separate system)(yes or no):_No If yes,separate inspection required Laundry system inspected(yes or no) Seasonal use(yes or no):_No_ Water meter readings.97 to 99=281 00f x 7.5=210,750 gallons/730 days=289 gallons/day Sump Pump(yes or no):_No Last date of occupancy:_Current COMM ERCIALIINDUSTRIAL: i Type of establishment: Design flow: gDdd(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 i PUMPING RECORDS and source of information:Pumped last year,owner System pumped as part of inspection:(yes or no)_Yes If yes,volume pumped:_1500_gallons Reason for pumping:Inspect Tank&tees. 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date installed(if known)and source of information:13 years old. 11/20/87 As built plan. I Sewage odors detected when arriving at the site:(yes or no)_No_ i i revised 9/2/98 Page 6 of 11 i I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:200 Candlestick Road,North Andover Owner:Raffaelli Date of Inspection:2/1712000 BUILDING SEWER:X (Locate on site plan) Depth below grade:4' Material of construction: _x cast iron X 40 PVC other(explain) Distance from private water supply well or suction line: Diameter:4" Comments:4"cast iron thru wall.3"PVC in house. SEPTIC TANK:X (locate on site plan) Depth below grade:X I hl Material of construction:—X— concrete,metal_Fiberglass—Polyethylene other(explain) ) I If tank is metal,list age_Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: 10'x 5'x 4' x 7.5=1500 gallons. Sludge depth:3" Distance from top of sludge to bottom of outlet tee or baffle:24" Scum thickness:3" Distance from top of scum to top of outlet tee or baffle:8" Distance from bottom of scum to bottom of outlet tee or baffle:18" How dimensions were determined:Subtract scum&sludge depths to tee length. Comments:Pumped septic tank,inlet tee&outlet tees ok.Depth of liquid at outlet invert.No evidence of leakage. GREASE TRAP:None (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: I revised 9/2/98 Page 7 of 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:200 Candlestick Road,North Andover Owner:Raffaelli Date of Inspection:2/17/2000 TIGHT OR HOLDING TANK:_None (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: I DISTRIBUTION BOX.:_X_ (locate on site plan) Depth of liquid level above outlet invert:0 Comments:D-box level&distribution equal,only one line out to pits.No evidence of leakage.Evidence of carryover,pumped d-box to clean. PUMP CHAMBER:—None,gravity system_ (locate on site plan) Pumps in working order.(Yes or No) Alarms in working order(Yes or No) Comments: I i Revised 9/2198 Page 8 of 11 " • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued)) I Property Address:200 Candlestick Road,North Andover Owner:Raffaelli Date of inspection:2/17/2000 SOIL ABSORPTION SYSTEM(SAS):x (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.3 pits in series. leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: ARemative system: Name of Technology: Comments:Soil ok.Vegetation ok.No sign of ponding to surface.Camera pit thru outlet pipe in d-box,water 18"to invert of pipe. I i I I CESSPOOLS:None (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: PRIVY:None (locate on site plan) Materials of construction: Dimensions: Depth of solids: I I Comments: I I i revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION(continued) Property Address:200 Candlestick Road,North Andover Owner.Raffaeili Date of Inspection:2 I7/2000 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) House Garage Driveway A B Water Meter Septic 1 Tank 2 I A to 1 = 14'3" Pit Pit Pit Ato2=21'5" b 3 1 2 A to D-Box=40' B to 1 =44'2" Bto2=38'2" B to D-Box=38' revised 9/2/98 Page 10 of 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:200 Candlestick Road,North Andover Owner:Raffaelli k Date of Inspection:2/17/2000 NRCS Report name Sal Type_ i 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 >6 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record —X—Observed Site(Abutting property,observation hole,basement sump etc.) —X—Determined from local conditions —X—Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers _X Used USGS Data Describe how you established the High Groundwater Elevation.Essex County soil map sheet#36 Canton soil >6'deep. revised 912198 Page 11 of 11 } i Tel: (978) 475-4786 = Fax: (978) 475-5451 i I BATESON ENTERPRISES, INC. Excavating-Water.& Sewer Lines-Septic Systems&Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 200 Candlestick Road, North Andover P Owner: Raffaelli Date of Inspection: 2/17/2000 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. I 4Ba Neil Jon Bateson Enterprises, Inc. i A0 0 - 8 7 ,�tNL?H of�9 Py 84p,.: ' L1-43 a i r /Soo �4/ SEPI 5 i P.v L E 5 FICC, 'onMill weal h of Massachusetts Massachusetts System Pumying Record System Owner System Location l� a� Date of Pumping Quairtity Pumped: l j gallons Cesspool: No Yes L._) Septic Tank: No Yes System Pumped by: Felreeort go&Tpew License # Contents transferrred to : Greater Lawrence Sanitary District Date: _ Inspector- i G 'n Add ress G�nc Tr u�_ Title of File Page of Date f=ile Open: nate file closed:_ Doc Document/Action Tifile Date of Refer to other Purpose of�Docume�nt/Acon and ti action Document/ document/ notes — Num. Action Department i ----------- Board of Appeals — Board of—He-alth Planw.g.Board _ Conservatiion Commission — BuildingDe partm, en,t i FORM U - LOT RELEASE FORM 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. **APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT _ N£�N£� PHONE LOCATION: Assessor's Map Number 6 PARCEL SUBDIVISION // �� LOT (S) 4M STREET 2.» �ca.,d�s�"�/� 2- b , ST. NUMBER *************OFFICIAL USE ONLY*********************************** RECOMMENDATIONS OF TOWN AGENTS: 1 � CONSERVATION ADMINi$TRATOR DATE APPROVED DATE,REJECTED COMMENTS i I TOWN PLANNER DATE/APPROVED DATE REJECTED COMMENTS FOOD INS P TOR-HEALTH DATE APPROVED DATE REJECTED c T INSPE TOR-HEALTH DATE APPROVED y DATE REJECTED COMMENTS¢- Sc��-z�►-�_ � C^_ _ r; PUBLIC WORKS -SEWERIWATER CONNECTIONS DRIVEWAY PERMIT ` FIRE DEPARTMENT i RECEIVED BY BUILDING INSPECTOR DATE Commonwealth orMassachusetis e M sach-SC is 1999 stem Pumping Record System OwnerSystem Location Date or Pumping: ( � Quairtity Pumped: gallons Cesspool: No Septic Tank: No U Yes '— System Humped by: Fctfe4oft License# I Contents transrerrred to : Greater Lawrence Sanitary District Date: Inspector: i i r of M ,►�-� LOT NoI�Tf-I /�tiiX�VE1�, MA. P�� C lvT �vu �4P C*)TI JA c2 _ (�,��Gt'{ SOPf:'L7 _Tbwnl ❑ WEC.L_ ,�P�oyc"".1�1X1'fCC Sy Si�M vE'Sl bPPi�ovt D DArt� APR' OvlN6 /urhoi?iTy (fNPITINJ5 n 4r smuow �'PTttS ��REf DI PPRUVEp D _ / CIWMOCAS ARE 7' 086f, REASoNs DwC �3 SrPr-1 C SYSTEM 1�SQA LI.,QT�a/J L Yl�V�Tt©IJ JA�<<'�G►�p� P/ITG ❑ 13/6S ❑ FAit_ RNAL I VSP6,�i Ionj 4PIVROOE1> /STC AJTHOI?�Ty I NSTi�U,Gc� AVP(T'1o�-),4L� DISl�Pt��Uvr;V D,arC RCA5a tis FML APPN)VAL 6�4 TOWN OF /kj, SYSTEM PUMPING RECORDQF gib,, A DATE: ` «,, ' 6 _ I SYSTEM OWNER& ADDRESS SYSTEM LOCATION v� (example:left front of house) �( DATE OF PUMPING: UANTITY PUMPED : t GALLONS Q � CESSPOOL: NO SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY i OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste �EpLTH op q Jr 3 's"r /NAC SARV Lo f 3 - i I Commonwealth of Massachus s Ci /Town of (�Q� System Pumping RecordRECE'I_ F_ VEp Facility Information: JUL 14 2008 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT System Location: Address City/Town State Zip Code System Owner: Name: i Address (if different from location) City/Town State Zip Code q_7�= qs. a Telephone Number Pumping Record 4,21 � Date of Pumping f �� Quantity Pumped /t � allons Type of System: _ Septic Tank _Grease Trap Other System Pumped by: U e Company: Rooter-Man 12 East Dracut Road, Methuen, MA 01844 Location where con disp osed: Signature of Hauler Date: 61,2 ,S G6f/ IVED R s W ass G ---- Y4 ftnd bv42_A TOWN OF NORTH ANDOVER fHEALTH DEPARTMENT 1ping Record _ F � i fi v e , I lo'l'l tion a Ov CC44 AcNAWA -- ou � N I Stale ` L! Fi _ E �'1 Eye I