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Home My WebLink AboutBuilding Permit #Exception - 23 GILMAN LANE 5/1/2018 f 00RTF1 q BUILDING PERMIT TOWN OF NORTH ANDOVER ° APPLICATION FOR PLAN EXAMINATION - b Permit NO: Date Received Date Issued: ��SS�CHUS IMPORTANT:Applicant must complete all items on this page LOCATION C23 w1no, LA. /f/, Ayleye c Yr, be- P,iPROPERTY OWNER S �- 5 10 VLOn Print MAP NO: PARCEL:� �2!!!-ZONING DISTRICT: R-44-I'Historic District yes no Machine Shop Village yes n TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial it Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ! ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑ Water/Sewer U0 AA C /q X /g/ 60ree✓7 00001 oil Identification Please Type or Print Clearly) OWNER: Name: ss,� 4(-e4 Phone: Address: /V1 Xrolo Ue✓ l�ti CONTRACTOR Name: 603 Phone: a2 9—7s0 7 Address: "q(t IV1� 03�3g�j l ��V" � Supervisor's Construction icense: Exp. Date: � Home Improvement License: Exp: Date: 1-177 , s 3/ 90X8 ARCHITECT/ENGINEER Phone: 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: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaran un Signature of Agent/Owner Signature of contracto i Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVE PLANNING & DEVELOPMENT ❑ ❑ 8)3Z�1 COMENTS � OA�0 - Oul CONSERVATION ❑ ❑ COMMENTS. DATE REJECTED DAT- APPROVED HEALTH c 'b"13) , COMMENTS r� Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes_ Planning Board Decision: Comments Conservation Decision: Comments ' Water & Sewer Connection/Signature&Date Driveway Permit Located at 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes no Located at 124 Main Street Fire Depart nentsignature/date COMMENTS t sir 4 T/ r 7 Of pORTq� Town of North Andover HEALTH DEPARTMENT �S3CHU / CHECK#: 1630 DATE: V LOCATION: ?nn 1 it PI H/O NAME: l� CONT ACT R NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other:(Indicate) $ ealth A ent Initials White-Applicant Yellow-Health Pink-Treasurer • � CommomwSlth of Massactipsetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Asses 'RECEIVED 23 Gilman St. Property Address [`1 -- 4 2010f McMahon Owner Owner's Name TOWN OF NORTH ANDOVER information is ortAndover MA 01845 required for every Nhi *WftPEPARTMENT I.Jam/ page. City/Town State Zip Code Date of Inspection ail Inspection results must be submitted on this form. Inspection forms may not be altered in any'Vf°,f way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Chad Jablonski use the return Name of Inspector key. Jablonski &Sons Inc. raa Company Name 167 Willow Ave Company Address Haverhill MA 01835 City/Town State Zip Code 978-360-9358 4574 Telephone Number License Number B. Certification 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: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority �/3 l Zo ra 1 IrispectoP Si p eure Date The sy errTjnspector shall submit a copy of this inspection report to the Approving Authority(Board of Heal 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. ****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. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '•v1 23 Gilman St. Property Address McMahon Owner Owner's Name information is required for every North Andover MA 01845 5/3/2010 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: I I 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. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M °V 23 Gilman St. Property Address McMahon Owner Owner's Name information ievery required for eNorth Andover MA 01845 5/3/2010 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ® 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): I ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): j ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): Distribution box is cracked from corrosion and needs to be replaced. Outlet baffle needs to be replaced I ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): I i 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 t5ins•09/08 Title 5 Official Inspection Form:Subsudace Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts •z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M ,.''• 23 Gilman St. Property Address McMahon Owner Owner's Name information is required for every North Andover MA 01845 5/3/2010 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent 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. 3. Other: I I D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No El Backup of sewage into facility or system component due to overloaded or ® clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/z day flow t5ins•09/08 Title 5 Official Inspection Form:Subsudace Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts . W Title 5 Official Inspection Form R s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Gilman St. Property Address McMahon Owner Owner's Name information ievery required for eNorth Andover MA 01845 5/3/2010 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No Required pumping more than 4 times in the last year NOT due to clogged or F1 ® obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. � An portion of cesspool E] ® y p poo 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 fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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. For large systems, you must indicate either`fires"or"no"to each of the following, in addition to the questions in Section D. 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. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Gilman St. Property Address McMahon Owner Owner's Name information is N required for every orth Andover MA 01845 5/3/2010 page. Citylrown State Zip Code Date of Inspection i C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® El available as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ 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(5)] D. System Information Residential Flow Conditions: 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): 600 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 j Commonwealth of Massachusetts w Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .'' 23 Gilman St. Property Address McMahon Owner Owner's Name information iso, required for every North Andover MA 01845 5/3/2010 page. City/Town State Zip Code Date of Inspection i D. System Information Description: i Number of current residents: 2 Does residence have a garbage grinder? ® Yes ❑ No I Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No i Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gPd))� Attached Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 23 Gilman St. Property Address McMahon Owner i Owner's Name information is required for every North Andover MA 01845 5/3/2010 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: North Andover BoH Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: na gallons How was quantity pumped determined? na Reason for pumping: na Type of System: ® 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official inspection Form 0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M - 23 Gilman St. Property Address McMahon _ Owner Owner's Name information is f/ required for every North Andover MA 01845 5/3/2010 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: As-built plan dated 8-13-1982 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): I Depth below grade: 1711eet Material of construction: I ® cast iron ❑ 40PVC ❑ other(explain): Distance from private water supply well or suction line: na feet Comments(on condition of joints, venting, evidence of leakage, etc.): Watertight at foundation. Septic Tank(locate on site plan): 3" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: na years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ® No Dimensions: 10'6 x 65 x 64 Sludge depth: 2" t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 23 Gilman St. Property Address McMahon Owner Owner's Name information is required North Andover MA 01845 5/3/2010 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 36" Scum thickness <1" Distance from top of scum to top of outlet tee or baffle top of baffle is corroded Distance from bottom of scum to bottom of outlet tee or baffle top of baffle is corroded How were dimensions determined? Measuring tape 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 is structurally sound, but outlet baffle needs replacement. Grease Trap (locate on site plan): Depth below grade: feet 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: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 23 Gilman St. Property Address McMahon Owner Owner's Name information is required for every North Andover MA 01845 5/3/2010 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): i 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 per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): it Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M °• 23 Gilman St. Property Address McMahon Owner Owner's Name information is required for every North Andover MA 01845 5/3/2010 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(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.): Box is cracked from corrosion and needs to be replaced. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): i Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 23 Gilman St. Property Address McMahon Owner Owner's Name information is I required for every North Andover MA 01845 5/3/2010 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 - 25' x40' I ❑ 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.): No sign of hydraulic failure or ponding. 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 ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts w • Title 5 Official Inspection Form R o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 23 Gilman St. Property Address McMahon Owner Owner's Name information is required for every North Andover MA 01845 5/3/2010 page. i Cityfrown State Zip Code Date of Inspection i D. System Information (cont.) 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments f' 23 Gilman St. Property Address ----•- -.--- _i= McMahon Owner Owner's Name information Is North Andover MA 01845 5/3/2010 required for every page. City/Town State Zip Code Date of Inspection �,✓ D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: I ❑ hand-sketch in the area below ® drawing attached separately I I I C i I I I t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .'' 23 Gilman St. Property Address McMahon Owner Owner's Name information is required for every North Andover MA 01845 5/3/2010 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 4' below stone feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 6/3/1981 Date ❑ 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: Soils test performed 3/21/1981 by W.S. McLeod and witnessed by T. Murphy Before filing this Inspection Report, please see Report Completeness s Checklist on next page. t5ins•09/06 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Gilman St. Property Address McMahon Owner Owner's Name information is required for every North Andover MA 01845 5/3/2010 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TANK ! 268. 42 _ TANK C - DIST. B DIST. Bt - A END O - -LOT 25. wi3 1 I o - PIPE FROM I Z SEPTIC NOT IN Al TANK � I I L 5141 t_ ._ 25 �+ 32.4 S�s� AN 20' - PATRICK S. 202 LACY NORTH ANC GILMAN L LOT NO. 25-A - - - - - - - - - - - - - - - - - - - - - - - - - ^ - - v.9�o - - - - - - andover consultants inc. Summary Record Card generated on 5/3/20101:23:15 PM by Lisa Evans Page 1 Town of North Andover Tax Map # 210-107.A-0152-0000.0 Parcel Id 17977 23 GILMAN LANE MCMAHON, RICHARD F. 23 GILMAN LANE N. ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 1.21 Acres FY 2010 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until MCMAHON,RICHARD F. Payor 23 GILMAN LANE N.ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 14214.0-23 GILMAN LANE Last Billing Date 3/2/2010 2100210 02 Cycle 02 Active UB Services Maint, Account No.2100210 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE, 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 7.60 /1 UB Meter Maintenance Account No.2100210 Serial No Status Location Brand Type Size YTD Cons 34644535 a Active ERT HH b Badger w Water 0.63 0.63 12 Date Reading Code Consumption Posted Date Variance 2/1/2010 12 a Actual 2 3/11/2010 0% 11/2/2009 10 a Actual 2 12/11/2009 -36% 8/3/2009 8 a Actual 3 9/11/2009 7% 5/7/2009 5 a Actual 3 6/16/2009 20% 2/2/2009 2 a Actual 2 3/16/2009 11/19/2008 0 a Actual 12/10/2008 10/30/2008 0 n New Meter 0 12/10/2008 0% 8/1/2008 3646 m Manual estimate 80 9/12/2008 287% 5/2/2008 3566 m Manual estimate 20 6/18/2008 8% 2/4/2008 3546 m Manual estimate 20 3/14/2008 -56% MSG 11/1/2007 3526 a Actual 44 1/15/2008 -53% 8/2/2007 3482 a Actual 92 9/14/2007 -100% 5/4/2007 3390 c Correction 0 6/26/2007 -100% SEE NOTE 2/28/2007 3390 m Manual estimate 16 3/23/2007 -38% 11/2/2006 3374 a Actual 16 12/22/2006 -35% 8/21/2006 3358 a Actual 37 9/13/2006 243% 5/4/2006 3321 a Actual 9 6/20/2006 12% 2/2/2006 3312 a Actual 8 3/13/2006 -73% 11/3/2005 3304 a Actual 28 12/14/2005 43% 8/8/2005 3276 a Actual 20 9/12/2005 61% 5/11/2005 3256 a Actual 12 6/8/2005 57% 2/14/2005 3244 a Actual 8 3/15/2005 -34% 11/16/2004 3236 a Actual 13 12/17/2004 -56% 8/11/2004 3223 aActual 26 9/20/2004 81% Town of North Andover Licensed Septic System Installers (Disposal Works Installer's) Please note that the se tic installer is licensed onl -- not the com an Five or more Installations within the last Name 18 months #of Affiliated Company Phone# 1 Amor,Robert 0 R.T.Amor 978-887-5468 2 Bateson,Todd 20 Bateson Enterprises,Inc. 978-475-1474 3 Beaulieu,Serge R. 1 0 Roadway Excavators 603.893.9189 _4 Breen,Peter 0 I Peter Breen Excavating,Inc. 978-682-7774 ,5113-riscoe,Daniel R. 1 Daniel R.Briscoe 978-372-2200 6 Bsby,Philip A.Jr. 0 Busby Construction Co.,Inc. 603-362-6015 7 Carr,John 0 Ramey Construction 978-633-6791 8 Colosi,Philip A. 0 Colosi Construction LLC 978-777-5679 9 Coyle,Kevin 0 Kevin Coyle 603-944-8501 10 Currier,James H. 1 James H.Currier Construction Co,In 978-774-6685 11 Daigle,Robert K. 1 Robert K.Daigle,Jr. 978-887-3703 12 DeLucia,Rocci Jr. 0 Frank DeLucia&Son,Inc. 978-686-8200 _13 DiVincenzo,John L. 2 Andover Septic/J&S Dev.Corp. 978-372-7471 14 Giard,Daniel 0 Daniel A.Giard Septic Service 978-686-7653 15 Hall,Bill,Inc.. _ 0 Bill Hall,Inc. 978-689-3711 16 Hartigan,James 0 James Hartigan 978-766-0087 17 Hoehn,Bruce 0 Bruce Hoehn 978-372-8274 18 Hutton,Arthur 0 Hutton's General Construction,Inc. 978-685-2667 Innis,Robert L. 0 R.L.I.Corp_ 978-663-6006 10 Jablonski,Chad 0 Jablonski&Sons 978-360-9358 21 Kellett,James 3 Kellett Excavating 781.953.7146 22 Marsh,Steve 0 The Westchester Co. 978-742-9778 23 Maynard,Dave 0 Maynard Construction 978-375-7228 24 Murray,David 1 Ranger Development Corp. 978-360-8506 25 jOsgood,Ben 1New England Engineering 978-686-1768 26 Pearce,Warren 0 Pearce Construction 978-664-5264 27 Petrosino,Angelo 0 Angelo Petrosino 978-664-2030 28 Quinlan,Timothy 0 Quinlan&Rand Builders 978-457-0528 29 Reilly,Mike 0 F.P.Reilly&Sons 978-475-1237 30 Sawyer,William T. 1 rExcavators,rs,Inc. 603-642-8910 31 Shaw,JohnIII 0 avation,Inc. 978-474-8088 32 Soucy,John J. 8 Service 800.541.9379 33 Sullivan,Jack 0 978-352-7871 34 Surianello,Joseph 0 llo,Inc. 617-799-3900 35 Todd,Charles R. 0 Charles R.Todd Contractor,Inc. 978-667-4270 36 Waelty,Craig(Skip) 0 Craig Waelty 978-664-2126 37 Watson,Joseph 0 JW Watson,Jr.Inc. 978-475-8581 38 Zaher,Charles 0 Charles Zaher 978-804-7786 39 zaloga,Dave "Dave Zaloga 603-765-9296 Total Installatiohs 1MI07.717108 39 Note: The Septic Installer Exam is held in January.March,May.Ju/v and September of each year. You must call the Health Department to sign up for the exam at 978.688.9540. The testing fee is L $25. ast Updated:717108 Last Updated: 7/7/2008