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HomeMy WebLinkAboutBuilding Permit #715-2017 - 65 SPRING HILL ROAD 1/12/2017/-?4dO� BUILDING PERMIT OWN OF NORTH ANDOVER e—�7 APPLIC ION FOR PLAN EXAMINATI �Lg—o Permit NO: ) i/Date Received 1 Date Issued: Il I X11 TYPE OF IMPROVEMENT 'IMPORTANT: Applicant must complete all items on this Residential Non- Residential LDCiATIbN vbne family "v ❑ Two or more family ❑ Industrial "Iteration No. of units: ROPE OWNER �'+ -- 150CC a' 5� ❑ Others: ❑ Demolition ❑ Other eptic°Welles °> ipodpla 1Netla'rids MAi NQS f4"7. PIRCEL ZOlVIlG i3JSTl TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building vbne family ❑ Addition ❑ Two or more family ❑ Industrial "Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other eptic°Welles °> ipodpla 1Netla'rids x�a �1fateished pistrlc UUIf/Sevuer k wF Llt �a " a-,- (i Z 2XiSf ink,g H i C- -j(7" C.0_ i n lc, a, v,-> r royw,% , l P' Identification Please Type or Print Clearly) q-7�7 0'9631 h OWNER: Name: L2ofriL t 6'iSelti /A/�Sh Phone:g�� �`1 '7600 c Address: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000:00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ 1-15, y UQ . FEE: $ 5 yy Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Plans Submitted ❑ Plans Waived El Certi,�ed P of Plan ❑ Stamped Plans ❑ TYPSOF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art ❑ Swhnming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On COMMENTS Signature. CONSERVATION Reviewed on Signature COMMENTS L HEALTH COMMENTS Reviewed on Sianature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes a Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DP's Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT' -.Temp Dumpster on site yes no Located at 124 Main Street Fire Department signatureldate i.. -.K nn nrk 1— _ iimension 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 of Electrical Inspector Yes No - DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine Doc.Building Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, 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/Cross Section/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 VOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application Ei 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 [OTE: 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 appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doe: PuildingPermit Revised 2014 wool Aeld/wooi snuoq o; ollle LWZ/ZM uo LWZ-96L PeO2J II!H buiadS 99 00,5LL $ pajoalloo seal le}ol 05 L9 $ aad leola10913 00,00 $ -wwoo 00� 993 seE) 0919 $ 993 bulgwnld OO*ObS $ w 00,000`517 Isoo uollonilsuoo uo ;elnoleo aa-4 aanopud uPoN - leo aaI jol lsoo uol;oni;suoo aaju3 E 0 ENO Q 2 LL Q O Q 0 m N u }2 O O LL y N Q N to 0 W CL N z Z m C: O a+ = O LL tao O d' >-N E L U LL 0 W of Z Z J d GO O d' — LL 0 W of Z u J L!J Cl0 O 2' N — LL 0 U WCL Z Q C7 bD p CC C m LL z W F- oC w W 5 U. C m z N CU N N Y O {/) TTww I1 : .�' �o �• n L aW U) z m Q O * 0 p y V J eft d o m d � Otm Q L VQD Cc z CLJ �O Lm n Z� c 40'>c c o:as�� U) W� (1)' o o H V o w •_ s moot W J CA CL� m m ... 0 oo c c ~ � Q L ca :a o _ 0 Q (D '� N o �n 0).2cc m a� W C 'a o o LLI I- C N C O F- (A = t Z W E4) aO O Va o:og' n Q to w Mo '~= O t=- c w Q.ov > w 0 E i O Z N _ C 0:5 v/ •� � W a ~ � — A O i:p.+ v 0 O cu o 0- CL 0- �a o CU M V J m �0-O Cz O U cU U) ti i F' adv 1, �. AU s !� i M } `t NfFSN - 44 H.71 Re/. A/infie, Linda�i MEN 0 VA -5# A# L 6s -1 - - 1 Ia1i,1y - I . 44-1# Ply;t — - 1 Fill FT- - - I T17- _ - i --L �I IIT- - — — -- - - --- -- - -_ I -� '—;- - - -- - __ _ �_ � � _.i._ I I_ ley -✓ — - - N Ol N O N U rt. e j iPP 1" O w Z I X H CD P U N N o a U 4 #•. ` ti d f0 N N C a mcc ` 'O 'O 7 it _moi; i w ii 5 0 NLO N 32 5 ui > Z o a o Z O m in y� . Z N o F- 9 g aoo0 � w�- O d O co v. O M 2 O LL A a r 0 ZO 0 0v J J K n " -i T° m ? 4 �a O U .. 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Y IL ¢ in(Dwwmiuoi%U¢aw (n OE t%ORTF1 1 TOWN OF NORTH ANDOVER ,,,go »` OFFICE OF A BUILDING DEPARTMENT * 120 Main Street y�_'•.T., �r"� fi North Andover, Massachusetts 01845 Donald Belanger Inspector of Buildings HOMEOWNER LICENSE EXEMPTION Building Permit Application Please print DATE: -/-? Telephone (978) 688-9545 Fax (978) 688-9542 JOB LOCATION: GS 51'7en yr,,. ��� �� /2 0� 10_7 59. 11a Number Map/Lot HOMEOWNER 6Pe>4,* L /V-Sk e1_7J_ aSff 51,-16d- a 7� -7,600 m-0 Name Home Phone Work Phone PRESENT MAILING ADDRESS v��► �2 City Town State Zip Code The current exemption for "homeowners" was extended to include owner occupied dwellings of one or two family dwellings and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one -or two- family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. (780 CMR Section 110.R5.1.2) The undersigned "homeowner" assumes responsibility for compliance with State Building Code and other applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 9/16 Form Homeowners Exemption C BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL .'yes no Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑/ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. Permanent Dumpster on Site ❑ W THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT ❑ COMENTS CONSERVATION COMMENTS HEALTH COMMENTS LI DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED ■ Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water $ Sewer Connection/Signature & Date Driveway Permit Located at 384 Osgood Street FIRE DEPARTMENT Temp flumpstor site .'yes no lon Located ,at 124 Main -Street re p vartment s gnat r��d to W CQMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: /, &� g t-4-5 ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA — (For department use) r Doc.Building Permit Revised 2012 O VffSfl - 6� 5pn�hy.'ll adl Alo-7*, A -pillow 5 $'16 5 01' ,2I " 8 E O i 1 J m m 0 7 NVIVAN MEN RINE A. 6" M �OOY 0 / � (/gv Location (D -T d t C L Ab No. _7K- — VLA' / Date j//� ��r?l '7 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ 51t o 00 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 3 91 �k iv J j/` Building Inspector y :? i ~�. / � � � �� , ) § �� j§ �° j/: ,d$l ) ®� j §� a ��, Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 SPRING HILL RD Property Address CEDRIC NASH Owner's Name N. ANDOVER City/Town MA 01845 State Zip Code 01/13/17 Date of Inspection 13/17 ature `' v // Date Ple system inspector shall submit a copVf 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. ****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 • 3/13 lot Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Inspection results must be submitted on this form. Inspection forms may not be alte�d in any way. Please see completeness checklist at the end of the form. � 01 Important: When filling out forms A. General Information ` �► v on the computer, only the tab O\�P���� use key to move your 1. Inspector: cursor - do not John J. Soucy use the return key. Name of Inspector Soucy's Sewer Service Inc. Company Name 78 North Broadway Company Address lob Salem NH 03079 City/Town State Zip Code / 603-898-9339 13397 Telephone Number License Number 33/40, B. Certification 6X7 1 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 13/17 ature `' v // Date Ple system inspector shall submit a copVf 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. ****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 • 3/13 lot Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 SPRING HILL RD Property Address CEDRIC NASH Owner's Name N. ANDOVER City/Town B. Certification (cont.) MA 01845 01/13/17 State Zip Code Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® 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: ❑ 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Commonwealth of Massachusetts H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M ° 65 SPRING HILL RD Property Address CEDRIC NASH Owner Owner's Name information is required for every N. ANDOVER MA 01845 01/13/17 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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): ❑ ❑ ❑ broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ❑ Y ❑ Y ❑ Y ❑ N ❑ N ❑ N ❑ ❑ ❑ ND (Explain below): ND (Explain below): ND (Explain below): ❑ 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): 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 SPRING HILL RD Property Address CEDRIC NASH Owner's Name N. ANDOVER MA 01845 01/13/17 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 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 must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® 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 t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 SPRING HILL RD Property Address CEDRIC NASH Owner Owner's Name Information is required for every N. ANDOVER MA 01845 01/13/17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: E]® Any portion of the SAS, cesspool or privy is below high ground water elevation. El® 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. E]® Any portion of a cesspool or privy is within 50 feet of a private water supply well. El® 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 "yes" 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 SPRING HILL RD Property Address CEDRIC NASH Owner Owner's Name information is Were any of the system components pumped out in the previous two weeks? required for every N. ANDOVER page. Cityrrown C. Checklist MA 01845 State Zip Code 01/13/17 Date of Inspection 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? ® ❑ 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? ® ❑ 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): 440 t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 SPRING HILL RD Property Address CEDRIC NASH Owner Owner's Name information is required for every N. ANDOVER MA 01845 01/13/17 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: THIS SYSTEM IS MADE UP OF A 1,500 GALLON TANK, DISTRIBUTION BOX AND SOIL ABSORPTION SYSTEM. Number of current residents: 2 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d ATTACHED 9 ( Y 9 (gp ))� Detail: RECOMMEND REMOVAL OF GARBAGE DISPOSAL. 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? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts F W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 65 SPRING HILL RD Property Address CEDRIC NASH Owner Owner's Name information is required for every N. ANDOVER MA 01845 01/13/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): Date General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: s Sewer Service Inc 1500 gallons Gauge on truck Maintenance and Inspection ® Yes ❑ No 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 65 SPRING HILL RD Property Address CEDRIC NASH Owner Owner's Name information is required for every N. ANDOVER MA 01845 01/13/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1986 PLANS ON FILE Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): ❑ Yes ® No Depth below grade: 20"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: TOWN WATER feet Comments (on condition of joints, venting, evidence of leakage, etc.): ALL JOINTS ARE SOLID. THERE ARE NO SIGN OF LEAKAGE OR VENTING. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 16" feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10' 10" X 68" X 5' 8" Sludge depth: 3" t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 SPRING HILL RD Property Address CEDRIC NASH Owner Owner's Name information is required for every N. ANDOVER MA 01845 01/13/17 page. Cityrrown 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 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 36" 1/2" INLET SIDE 0" OUTLET SIDE 6" 16" How were dimensions determined? TAPE MEASURE AND SLUDGE JUDGE Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): RECOMMEND YEARLY PUMPING. H2O TANK IS STRUCTURALLY SOUND, NO EVIDENCE OF LEAKAGE. TEES ARE IN PLACE. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness ❑ fiberglass 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: t5ins • 3/13 feet ❑ polyethylene ❑ other (explain): Date 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 ;M 65 SPRING HILL RD MA 01845 State Zip Code 01/13/17 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.): 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.) * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Property Address CEDRIC NASH Owner Owner's Name information is required for every N. ANDOVER page. City/Town MA 01845 State Zip Code 01/13/17 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.): 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.) * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 SPRING HILL RD Property Address CEDRIC NASH Owner's Name N. ANDOVER MA 01845 01/13/17 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 61 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 REPLACED PRIOR TO INSPECTION, SEE PERMIT. 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.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 65 SPRING HILL RD Property Address CEDRIC NASH Owner Owner's Name information is N. ANDOVER required for every page. City/Town D. System Information (cont.) Type: MA 01845 01/13/17 State Zip Code Date of Inspection ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2 @ 60' ❑ 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.): THERE ARE NO SIGNS OF HYDRAULIC FAILURE. 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 SPRING HILL RD Property Address CEDRIC NASH Owner Owner's Name information is N. ANDOVER required for every page. City/Town MA 01845 State Zip Code 01/13/17 Date of Inspection 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.): t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 SPRING HILL RD Property Address CEDRIC NASH Owner Owner's Name information is N. ANDOVER required for every page. City/Town MA 01845 01/13/17 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: ❑ hand -sketch in the area below ❑ drawing attached separately t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 SPRING HILL RD Property Address CEDRIC NASH Owner Owners Name information is N. ANDOVER required for every page. CityfTown D. System Information (cont.) Site Exam: ❑ Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated An th to hi h round water MA 01845 State Zip Code 42" 01/13/17 Date of Inspection F g g 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: 1986 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: THE HIGH GROUND WATER ELEVATION WAS ESTABLISHED THE 1986 TITLE V INSPECTION ON FILE WITH THE BOARD OF HEALTH. DUG HOLE WITH AUGER 0) 42", NO WATER. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins - 3/13 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 °M 65 SPRING HILL RD Property Address CEDRIC NASH Owner Owner's Name information is N. ANDOVER MA required for every page. Cityfrown State E. Report Completeness Checklist 01845 01/13/17 Zip Code Date of Inspection ❑ 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Summary Record Card generated on 1/1312017 10:43;02AM by Karen Hanlon Page 1 Town of North Andover Tax Map # 210-107.A-0242-0000.0 Parcel Id 18067 65 SPRING HILL ROAD NASH, CEDRIC 65 SPRING HILL ROAD N. ANDOVER, MA 01845 Class 101 Single Family Zoning2 1 Residential Size Total 1.33 Acres FY_2017... ... ......... - .. -- Property Type Zoning3 ---...... ------ - ------ _. ---- ......... 1 Residential 1 Residential .. . UB Mailina Index Name/Address Type Loan Number Activelinact, From Until NASH, CEDRIC Payor 65 SPRING HILL ROAD N. ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Activellnactive Bldg Id, 14257.0 - 65 SPRING HILL ROAD Last Billing Date 121612016 2100251 02 Cycle 02 Active UB Services Maint. Account No. 2100251 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.63518 7.82 1/ WTR WATER 01 ALL METER SIZE 49.40 /1 UB Meter Maintenance Account No. 2100251 Serial No Status Location Brand Type Size YTD Cons 36207189 a Active ERT HH b Badger w Water 0.63 0.63 1149 Date Reading Code Consumption Posted Date Variance 11/2/2016 1173 aActual 13 12/19/2016 -81% 8/3/2016 1160 a Actual 69 9/21/2016 437% 5/4/2016 1091 a Actual 13 6/21/2016 -24% 2/2/2016 1078 a Actual 17 3/28/2016 -62% 11/2/2015 1061 a Actual 44 12/30/2015 -46% 8/4/2015 1017 aActual 83 9/14/2015 419% 5/5/2015 934 a Actual 16 6/22/2015 -5% 2/3/2015 918 a Actual 17 3/20/2015 -57% 11/3/2014 901 aActual 39 12/15/2014 -38% 8/4/2014 862 aActual 63 9/11/2014 228% 5/5/2014 799 a Actual 19 6/12/2014 -8% 2/4/2014 780 a Actual 22 3/17/2014 -69% 10/31/2013 758 aActual 67 12/20/2013 -47% 8/1/2013 691 aActual 120 9/18/2013 614% 5/6/2013 571 aActual 17 6/18/2013 -20% 2/7/2013 554 a Actual 24 3/13/2013 -47% 10/30/2012 530 a Actual 40 12/13/2012 -54% 8/3/2012 490 a Actual 92 9/26/2012 348% 5/2/2012 398 a Actual 19 6/20/2012 -14% 2/6/2012 379 a Actual 25 3/14/2012 -48% 11/1/2011 354 aActual 45 12/15/2011 -38% 8/2/2011 309 aActual 73 9/14/2011 156% 5/2/2011 236 a Actual 27 6/13/2011 40% 2/4/2011 209 a Actual 21 3/15/2011 -62% 11/1/2010 188 aActual 53 12/13/2010 -38% 8/3/2010 135 a Actual 87 9/13/2010 266% 5/4/2010 48 a Actual 24 6/9/2010 -22% 2/1/2010 24 aActual 24 3/11/2010 -100% 11/21/2009 0 n New Meter 0 3/11/2010 -100% Commonwealth of Massachusetts BOARD OF HEALTH North Andover N Map7fflock-Lot 10TA0242 Permit No BHP -2016-0487 FEE N F.I. $175M ............ NW DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted JOhn. �S.OUCY ------- --- --- -- - ----- ----- ------- to (Repair) an Individual Sewage Disposal System. at No as shownon the application for Disposal Works Construction Permit No. BHP -2016-048 Dated December 05, 2016 ------------- P Issued On: Dec -05-2016 ARD OF HEALTH . .. . ....... ............. . Type of Permit or License: (Check box) 7760 ❑ Animal $ • : y Body Art Establishment Town of North Andover '�'•� ; o :. ,S5 CHUSt1 HEALTH DEPARTMENT . CHECK #: Z( 9 DATE:W�/ LOCATION: 65 S ri /SH/ONAME: $ Cedric 4VG 7 1/ $ ❑ CONTRACTOR NAME: 5 -00 r— ❑ 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 $ G Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ TrasWSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ xTitle 5Inspector $ 1370 ❑ Title 5 Report $ ❑ Other: (Indicate) $ HealthAgent Initials White - Applicant Yellow - Health Pink - Treasurer North Andover Health Department (ommunity and Economic Development Division 11/21/16 Address: 65 Spring Hill Rd. All North Andover Residents with Septic Systems and Garbage Disposals Please note that due to a recent review of a Title 5 Report, your property has been identified as maintaining a working garbage disposal that is being used in conjunction with a septic system. The Health Department is concerned for the longevity of your septic system. Garbage disposals are never recommended where septic systems are used, but if they are installed, the system must be specifically designed to handle the waste from them; your system can not handle the waste as designed. Please note that continued use of this disposal could quickly cause a pre -mature failure of your septic system, resulting in a large expenditure to replace it. The North Andover Health Department recommends that you remove it from your home as soon as possible. Some information regarding regular maintenance of your septic system is attached. Please call the Health Department at 978.688.9540 if you have any questions, or e-mail your questions to: healthdept@northandoverma.gov. Thank you for taking the time to consider the impact that your current setup has on your septic system and the environment. Sincerely, w rian LaGrasse, CERT Director of Public Health 120 Main Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web http://www.northandoverma.gov Commonwealth of Massachusetts w Title 5 Official Inspection Form =' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 Spring Hill Road Property Address Cedric Nash Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. & rerom Owner's Name North Andover City/Town MA 01845 State Zip Code 10/27/2016 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information Inspector: RECEIVE® Nov 18 2016 Robert Herrick �ryeFNBRTH�yp�VER Name of Inspector HEALTH DEPARTMENT/� Wind River Environmental n_lSi7�t/1 Company Name 163 Western Avenue Company Address Gloucester City/Town (99� 282-7315 Telephone Number B. Certification MA 01930 State Zip Code SI 13758 License Number 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 Irl'spector's Signature 10/27/2016 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 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.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 Spring Hill Road Property Address Cedric Nash Owner's Name North Andover MA 01845 10/27/2016 City/Town 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: ❑ 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: ® 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.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 Commonwealth of Massachusetts - r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .y 65 Spring Hill Road --- Property Address Cedric Nash Owner Owner's Name information is required for every North Andover MA 01845 10/27/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board. of Health approval if pumps/alarms are repaired. 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): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): The distribution box is rotted and needs to be replaced. ❑ 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): 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.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form IS Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 Spring Hill Road Property Address Cedric Nash Owner information is required for every page. Owner's Name North Andover MA 01845 10/27/2016 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 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 must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® 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 '/2 day flow l5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 Spring Hill Road Property Address Cedric Nash Owner Owner's Name information is required for every North Andover MA 01845 10/27/2016 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 obstructed pipe(s). Number of times pumped: ❑ 2 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 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 "yes" 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.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a� 65 Spring Hill Road Property Address Cedric Nash Owner Owner's Name information is required for every North Andover MA 01845 10/27/2016 page. City/Town State Zip Code Date of Inspection 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? ® ❑ 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? ® ❑ 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): 440 gpd t5ins.doc • rev. 6116 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts w Iw Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 Spring Hill Road Property Address Cedric Nash Owner Owner's Name information is required for every North Andover MA 01845 10/27/2016 page. City/Town State Zip Code Date of Inspection D. System Information Description: This system is made up of a 1,500 gallon tank, distribution box and soil absorption system. Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: ❑ Yes ® No Occupied Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t51ns.doc - rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 2 Number of current residents: Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No N/A Water meter readings, if available last 2 ears usage d 9 ( Y 9 (gp ))� Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: ❑ Yes ® No Occupied Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t51ns.doc - rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments d 65 Spring Hill Road J Property Address Cedric Nash Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: MA 01845 10/27/2016 State Zip Code Date of Inspection General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Date Wind River Environmental and Home Owner 1,500 gallons Truck Siaht Glass To Inspect Tank Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ® Yes ❑ No ❑ 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.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9/ 65 Spring Hill Road Property Address Cedric Nash Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) MA 01845 10/27/2016 State Zip Code Date of Inspection Approximate age of all components, date installed (if known) and source of information: 1986. Plans on File Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan) Depth below grade: ❑t Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: Town Water feet Comments (on condition of joints, venting, evidence of leakage, etc.): All joints are solids. There are no signs of leakage or venting. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal in feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1010" x 68" x 58" Sludge depth: 3" t5ins.doc • rev_ 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts w0 Title 5 Official Inspection Form sl Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 Spring Hill Road Property Address Cedric Nash Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) State Zip Code Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 36" 0 6" 16" 10/27/2016 Date of Inspection How were dimensions determined? Tape measure and Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Recommend pumping yearly. The inlet and outlet are solid. There are no signs of leakage and the liquid level is OK in relation to the inverts. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness ❑ fiberglass 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: t5ins.doc • rev. 6/16 feet ❑ polyethylene ❑ other (explain): Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 Spring Hill Road Property Address Cedric Nash Owner Owner's Name information is North Andover MA required for every page. City/Town State 01845 10/27/2016 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.): 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: Design Flow: gallons 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.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins.doc • rev. 6/16 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 65 Spring Hill Road Property Address Cedric Nash Owner Owner's Name information is required for every North Andover MA 01845 10/27/2016 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.): The distribution box is rotted and showing signs of leakage; needs to be replaced in order to pass the Title V Inspection. 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.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Commonwealth of Massachusetts R = w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 Spring Hill Road Property Address Cedric Nash Owner Owner's Name information is required for every North Andover MA 01845 10/27/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2 @ 60' ❑ 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.): There are no signs of hydraulic failure, no ponding and the soil is dry. The vegetation is normal for the area. 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 t51ns.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 Spring Hill Road Property Address Cedric Nash Owner's Name North Andover MA 01845 10/27/2016 City/Town State Zip Code Date of Inspection 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.): l5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts —w� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 Spring Hill Road Property Address Cedric Nash Owner Owner's Name information is required for every North Andover MA 01845 10/27/2016 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: ❑ hand -sketch in the area below ® drawing attached separately t51ns doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 � � t r ti 5, x Commonwealth of Massachusetts r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 Spring Hill Road Property Address Cedric Nash Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells MA 01845 10/27/2016 State Zip Code Date of Inspection 42" Estimated depth to high ground water. 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: 1986 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: The hioh around water elevation was established usina the 1986 Title V I Board of Health. on on file with the Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc • rev 6116 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 F Commonwealth of Massachusetts -- Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /r awe 65 Spring Hill Road Property Address Cedric Nash Owner Owner's Name information is required for every North Andover MA 01845 10/27/2016 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.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 North Andover Health Department (ommunity and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 65 Spring Hill Rd. MAP: 107.A LOT: 0242 `w INSTALLER: John Soucy DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS D -box INSPECTION: 1a '6t' [/0 DATE OF BED BOTTOM INSPEC ON: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: SEPTIC TANK ❑ Contractor reports any changes to design plan El Existing septic tank.properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Watertightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port PUBLIC HEALTH DEPARTMENT Town of North Andover Community and Economic Development Division CERTIFICATE OF COMPLIANCE As of: 12/9/16 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Repair of D -Box By: John Soucy At: 65 Spring Hill Road Map 107.A Lot 0242 No Andover, MA 01845 Th issuance of this c�i�fiTsh c tall not �e construed as a guarantee that the system will function satisfactorily. Michele Grant Public Health Agent 120 Main St., North Andover, Massachusetts 01845 Phone 918.688.9540 Fax 918.688.9542 Web www.northandoverma.gov ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade j installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION -BOX Installed on stable stone base H-20 D -Box Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets Observed even distribution Speed levelers provided (not required) Schedule 40 PVC Pipe Comments: Commonwealth of Massachusetts Map -Block -Lot 107.A0242 BOARD OF HEALTH Permit No North Andover - BHP -2016-0487 - --------------------- FEE $175.00 ----------------------- DISPOSAL WORKS C.ONSTTRUCTION PERMIT Permission is hereby granted 7ohn-Soumy ----------------------------------------------------------------------------------------------------- to (Repair) an Individual Sewage Disposal System. ftatNo 65SPRING HILL ROAD I) -V as shown on the application for Disposal Works Construction Permit No. BHP -20, q-048 Dated December 05, 2016 - -- -- p ---------------------- ----------------------------------- Issued On: Dec -05-2016 BOARD OF HEALTH Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. VkA Application for Septic Disposal System Construction Permit —TOWN OF NORTH ANDOVER, MA 01845 Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system* 12/2/16 TODAY'S DATE ❑ Repair or replace an existing on-site sewage disposal system* [Repair or replace an existing system component — What? "D" BOX A. Facility Information 65 SPRING HILL ROAD Address or Lot # N. ANDOVER 00 - Full Repair RECEIVED City/Town 2.- *TYPE OF SEKIC SYSTEM*: DEC U 5 2016 ➢ ❑ Pump Z] Gravity (choose one) ***If pump jydrem, attach copy of electrical permit to application*** TOWN OF NORTH ANDOVER ➢9 Conventional System (pipe and stone system) HEALTH DEPARTMENT ➢ El or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.l ➢ ❑ Pressure Distribution S.A.S. (No D -Box) ➢ ❑ Pressure Dosed (D -Box Present) S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No if yes, does plan specify make and model of filter. YES = (no further info. needed) NO = (installer must specify brand of filter before DWC issuance) What is the Make? 2. Owner Information CEDRIC NASH What is the Model. Name 65 SPRING HILL ROAD Address (if different from above) N. ANDOVER MA 01845 City/Town CEDRICNASH@COMCAST.NET Email address 3. Installer Information JOHN SOUCY Name 72 N BROADWAY Address SALEM City/Town State Zip Code 978-973-7600 Telephone Number SOUCY SEWER SERVICE INC Name of Company am State 603-216-7175 03079 Zip Code Telephone Number (Cell Phone # if possible please) 4. Desi ner Information Name VName of Company Address City/Town State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 Application for Septic Disposal System 12 c� Construction Permit —TOWN OF TODAL'S ATE NORTH ANDOVER, MA 01845 $350.00 - Full Repair $175.00 - Component. PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: ®Residential Dwelling or []Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover. I understa that until a final Certificate of Compliance has been issued by this Boprof Health, the " st lied system is not approved. 12/02/16 Date licati Approvet( rd Health Representative) L ame Date Application Disapproved for the following reasons: For Office Use Only: / L Fee Attached. Yes V No 2. Project Manager Obligation Form Attached. les—, No 3. Pump S sv tem? If so, Attach copy ofElectrical Permit Yes No Applicant received copy of "Electrical Inspection Notes for Septic Systems" Yes No Handout? 4. Reviewed approval letter, all paperwork received. Yes No M1SSlllg' 5. Foundation As -Built? (new construction only): Yes No (Same scale as approved plan) G. Floor Plans? (new construction only): Yes No Application for Disposal System Construction Permit • Page 2 of 2 ter. �oX lM t�8.73._ a x ar.L /'-:�,A/o -�lN� !�S•a9 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received 7- — t Date Issued: IMPORTANT: Applicant must Icom lete all items on this page LOCATION Jt— pc( ,t int PROPERTY OWNER ceave L CGI Print /� MAP NO: �� ` PARCEL: o��i ZONING DISTRICT: o` Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑•Addition Iteration XOne family ❑ Two or more family No. of units: ❑ Industrial ❑ Commercial ❑ Repair, replacement ❑ Demolition ❑ Assessory Bldg ❑ Other El Others: Septic. Wella i®IFloodnlain 'Fly WPflan 't+o i* DESCRIPTION OF WORK 10 EE PE R F 0 R ME-- DI: e1c�c v.s�cel vie w OWNER: Name: L e Address-, SP CONTRACTOR', Name: e Type or PAnt Clearly) tis V-\ f 97lt Phone: -� 3 3- 7 3 Address: lU CII�� .Y A"k I" �r A-11� Supervisor's Construction License: Exp. Date: j Home Improvement License: t c 0 1 Exp. Date: ARCHITECT/ENGINEER �v Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT: $1Z00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $_ >C) r 7D FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with ; gistered contactors do not have access to th t -a;;;--' fund Plans Submitted ❑ Plans Waived ❑ Certified Piot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody 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 PLANNING & DEVELOPMENT' COMMENTS CONSERVATION Reviewed COMMENTS HEALTH DATE REJECTED 1-1 Reviewed on $/,-`or%! / COMMENTS 2✓ !i C3 ij- -t-1 DATE APPROVED Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board'Decision: Com Conservation Decision: Comments Water & Server Connection/Signature & Date Driveway Permit DPW Town )Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Al 4y �/B L//t/�' l�8•ag Co4f I(v 1 x fr ILI t .� 4r N U CNN\" TS, -e633- 7�;-2)7 Commonwealth of Massachusetts RF-(;tlVku W City/Town of No. Andover h1AY 11011 a System Pumping Record Form 4 TOWN OF NORTH ANDOVER wM HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may be used, but 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 within 14 days from the pumping date in accordance with 310 CMR 15.351. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. rab few A. Facility Information 1. System Location: 65 Spring Hill Rd Address No. Andover City/Town 2. System Owner: Nash Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 4/11/11 Date Ma State State Telephone Number 2. Quantity Pumped: 3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: Good Condition 01845 Zip Code Zip Code 1500 Gallons ❑ Grease Trap If yes, was it cleaned? ❑ Yes ❑ No 6. stem Pumped By: G F 1 Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant. 20 So. Mill Bradford. Ma 01835 Signature of Hau Signature of Receiving Date 1 Dat t5form4.doc• 03/06 System Pumping Record - Page 1 of 1 Commonwealth of Massachusetts N _ City/Town of North Andover ao System Pumping Record JAN 1 G 2 011 4 Form 4 -, 9 DEP has provided this form for use by local Boards of Health. Other forms may be used, but 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 within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out forms 1 on the computer, use only the tab key to move your cursor - do not se re to t System Location: 4,5 Sotonoi 41 Address North ANDOVER ueurn City/Town key. Q 2. System O7,61, Name Address (if different from location) Cityrrown B. Pumping Record Ma State State Telephone Number Zip Code Zip Code 1. Date of Pumping D t ! � a% 2. Quantity Pumped: fl -II /6 ae 3. Type of system: ❑ Cesspool(s) ❑ Other (describe): a ons ® Septic Tank ❑ Tight Tank ❑ Grease Trap 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: a. / If yes, was it cleaned? ❑ Yes ❑ No 6. System Pumped '`< Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Signature of Receiving Facility Date Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts -- City/Town of No Andover . System Pumping Record OCT C 7 2 01 Form 4 TOWN OF NORTH H ArVD w" OVER HEALTHDEPORTMI=� rr DEP has provided this form for use by local Boards of Health. Other fi -rrms may be,used;,Kb t 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 within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out forms 1. System Location: on the computer, jJ^ use only the tab key to move your Address cursor - do not No Andover use the return key. City/Town 2. System Owner: Tran Name Address (if different from location) City/Town . B. Pumping Record Date (fSeptic 2. Quantity Pumped: ElCesspool(s) Tank ❑ Tight Tank 1. Date of Pumping 3. Type of system; ❑ Other (describe) )Dnrl Q h1O.l 2Oci Ma State State Telephone Number Zip Code Zip Code /S`d a Gallons ❑ Grease Trap 4. Effluent Tee Filter present? ❑ Yes lCJ 4 o If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Name Stewart's Septic Service Company 7. Location where contents were disposed: Stewaq&Pre-treatment Plant, 20 So. Mill Bradford of nature of Receiving Facility Vehicle License Number Ma 01835 Date Date t5form4.doc• 03/06 System Pumping Record •Page 1 of 1 j!�J���4f;�'•1•�:. .. it 7, ;a_ r A 89§141 C%°i'�1 U S 4r -r V . ecor '..�.y•,:� � o�'7;'�J � �f.��'Y � ,. JUL 0 7 2008 provided 04 form for use by local Bo r�f,a��t ba eubmltjad to the local Board of Health or oth rr auviv���l�'PtTFT �1 � Pumpin� -. .. FAQ 1�hW= raT A;. Faclllty Jntorr�,atIon rilan9 out 1, System LcU(Jon,` the laD key Addrasj Ad — rrcum �.. S t� it 41- �•.,.,•f.,t;.rj�,,.. ,...;. P.ddroi� (If Woronl town bc4Uon) --- ;, 9AV z� � ,. Telephone NumCor Aumpltlg Re.�ord ,�, � 1�'v,'�t u, , rr1(�,,r �Rc1l�'}?)til i,J�'•rl Xg ,Ile --Nf Date of Purn**;i �- ,,3;'`-T,iPB P� by3iem�,, ❑ C8s9p001(3) JOther (deacrlba�; Efflurren„l•Tea Flit p e(r�senr7 ❑Yes ❑ No - , i', ,l'�! a�W 1f��'•'r i' J'�'���f14,1 j.�l .. ' it jlt>f -„r!' ,•C.ondl�Jori1.Q.�,`,SY�1, �n.i, ' 7 II,.1V 1C it(4:1' � \{la ���•I ::'• I Primped By �CG y) { y.64 r � .�(, r�''�, 1: Fr, (,^,\ ��ti 1M�li��q ll •(1^�''`!irl dl�l'�,I�I,���'���', � corllenka'Were disposed; r , .i. „ h U ;�, � JJ J�` (.t.1 �i4f,{. ,.• .:r,r t{4.'.Id'1r�.1%r. r".��hvww•ma`s�� 8ov/de�Nrale�/approvaJsJ}6lcrms,htm#inspect i QuantJry Pumped: Cru �o o� Septic Tank ❑ Tight Tank It yes, was it cleaned? ❑ Yes wJ I VohlGo Ucen+o Numbs( Voll _ Sy�;em Pumpin� Recc,m ; 44 y p Commonwealth of Massachusetts RECEIVED imp(City/Town of NORTH ANDOVER MASSA USE;TT'St 2010 S stem Pum in Record [TOWN OF NORTH ANDOVER Form 4 HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving authority. State Telephone Number Zip Code Zip Code B. Pumping Record 1. Date of Pumping A -I A LO 2. Quantity Pumped: /S� -o Date Gallons 3. Type of system: ❑ Cesspool(s) j, Septic Tank ❑ Tight Tank -0 Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: 6. Sy tem Pumpe By: �,e I'� Company 7. Location where contents were disposed: 1 Signature of Hauler http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect If yei,'Was it cleaned? ❑ Yes ❑ No Vehicle License Number Date t5fonn4.docc 06/03 System Pumping Record • Page 1 of 1 A. Facility Information Important: When filling out forms to the computer, use 1. $y tem Lo tion: 6 �c I n fl I) 1 TO( only the tab key to move your cursor - do not �A dress �� use the return �ty/To� wn key. 2. System Owner: N c6y � �. _ Rame Address (if different from location) Citylrown State Telephone Number Zip Code Zip Code B. Pumping Record 1. Date of Pumping A -I A LO 2. Quantity Pumped: /S� -o Date Gallons 3. Type of system: ❑ Cesspool(s) j, Septic Tank ❑ Tight Tank -0 Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: 6. Sy tem Pumpe By: �,e I'� Company 7. Location where contents were disposed: 1 Signature of Hauler http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect If yei,'Was it cleaned? ❑ Yes ❑ No Vehicle License Number Date t5fonn4.docc 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts _ City/Town of NORTH ANDOVER, MA; System Pumping Record r` Form 4 DEP has provided this form for use by local Boards of He be submitted to the local Board of Health or other approv Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. 4I�� D iram.. CH R�P�` -, . The System Pumping Record must authority. A. Facility InformationTowTM NOFNORTH HEACD . AN , PMTt , 1. System Lodation: City/Town 2. System Owner: i_ Name Address (if different from location) City/Town .._ 1"ir�' i t State Zip Code State Zip --ode Telephone Number B:= -Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: - Gallons jf 3. _ Type of system: ❑ Cesspool(s) MI Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes dNo If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6.. ystem Pumped By: N e VSK ehicle t.lcense Number Company 7. Location where contents were disposed: Signature o'fSauler http://www.mass.gov/dep/water/approvals/t5forms. htm#inspect Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Grant, Michele From: Grant, Michele Sent: Monday, June 06, 2011 3:14 PM To: 'cedricnash@comcast.net' Cc: Sawyer, Susan; DelleChiaie, Pamela Subject: FW: Attachments: 20110606150005251.pdf Dear Cedric, Please print out and have you contractor draw in the work that is going to done as well as the distances form the septic system. Please have him call us he has any questions. Many Thanks Michele E. Grant Public Health Agent North Andover Health Department North Andover, MA. 01845- 978-688-9540 1845978-688-9540 978-688-8476 - Fax -----Original Message ----- From: noreply(atownofnorthandover.com [mailto:noreplyiatownofnorthandover.coml Sent: Monday, June 06, 2011 3:00 PM To: Grant, Michele Subject: This E-mail was sent from "RNPOA428C" (Aficio MP C5000). Scan Date: 06.06.2011 15:00:05 (-0400) Queries to: noreply(altownofnorthandover.com Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more information please refer to: http://www.sec.state.ma.us/pre/preidx.htm. Please consider the environment before printing this email. 1 In/ "A . P/A q.l�l./. 4 Vic' ! Z �s •S /�/ � � / lye• / 18.0 9 _,28_ wry: y r _,28_ CMM O - ��y S1t3SA��aS`J, �1 VP 00 17 kX L� iq .. ; Grant, Michele From: Ryan Norman [ryan@normanprops.com] Sent: Tuesday, June 07, 2011 12:36 PM To: Grant, Michele Subject: 65 Spring Hill Road Deck / Septic Attachments: 65 -spring -hill -rd. pdf Hi Michele, Please see the attached diagram with the deck shown in relation the septic tank and leach field. If you need any further please call my cell phone at 978-833-7337. Thanks, Ryan Ryan Norman I Norman Properties Home Building & Remodeling 603.974.2874 - 978.833.7337 www.NormanProps.com Email scanned by PC Tools - No viruses or spyware found. (Email Guard: 7.0.0.21, Virus/Spyware Database: 6.17680) http://www.pctools.com Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more information please refer to: http://www.sec.state.ma.us/pre/preidx.htm. Please consider the environment before printing this email. 11 HA ., - /"= z �a I -.28- PETER F. REILLY AFFILIATED WITH F.P. REILLY AND SONS, 206 ANDOVER STREET, SUITE 11 ANDOVER, MA 01810 (978) 475-4370 INC. �o�,, SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART A - CERTIFICATION Property Address: Address of Owner (if different) Name of Inspector: Company Name, Address, Phone # CERTIFICATION STATEMENT 65 Spring Hill Road, North Andover, MA 01845 N/A Peter F. Reilly (I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) F.P. Reilly & Sons, 206 Andover St., Suite 11 Andover, MA 01810 (978) 475-1237 / (978) 475-4370 I certify that I have personally inspected the sewage disposal system at this address and that the information is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: ✓ Passes N/A Conditionally Passes N/A Needs Further Evaluation By the Local Approving Authority N/A Fails Inspector's Signature: Date: July 18, 1998 Peter F. Reilly The system inspector shall submit a copy of this inspection report to the approving authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: A. SYSTEM PASSES: Check A, B, C or D ✓ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART A - CERTIFICATION (continued) Property Address: 65 Spring Hill Road, North Andover, MA Owner's Name: Ronald Sley Date of Inspection: 7/18/98 B. SYSTEM CONDITIONALLY PASSES: N/A One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, ND). Describe basis of determination in all instances. If "not determined", explain why not) N The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. N Sewage backup or breakout or static high 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): N/A broken pipe(s) are replaced N/A obstruction is removed N/A 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): N/A broken pipe(s) are replaced N/A obstruction is removed 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 environment. 1. SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: N/A Cesspool of privy is within 50 feet of a surface water N/A Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh. 2. SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: N/A The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. N/A The system has a septic tank and soil absorption and is within a Zone I of a public water supply well. N/A The system has a septic tank and soil absorption and is less than 100 feet but 50 feet or more from a private water supply well, unless a water 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 N/A (approximation not valid). SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART A - CERTIFICATION (continued) Property Address: 65 Spring Hill Road, North Andover, MA Owner's Name: Ronald Sley Date of Inspection: 7/18/98 D. SYSTEM FAILS: N/A I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. N Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. N Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. N Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. N/A Liquid depth in cesspool <6" below invert or available volume <'/z day flow. N required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: none N Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. N/A Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. N/A Any portion of a cesspool or privy is within a Zone I of a private water supply well. N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well. N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above. N/A The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: N The system is within 400 feet of a surface drinking water supply N The system is within 200 feet of a tributary to a surface drinking water supply N The system is located in a nitrogen sensitive area (Interim Wellhead Area (IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the DEP for further information. SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART B - CHECKLIST Property Address: 65 Spring Hill Road, North Andover, MA Owner's Name: Ronald Sley Date of Inspection: 7/18/98 Check if the following have been done: ✓ Pumping information was requested of the owner, occupant and Board of Health. ✓ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ✓ As built plans have been obtained and examined. Note they are not available with N/A. ✓ The facility or dwelling was inspected for signs of sewage backup. ✓ The system does not receive non -sanitary or industrial waste flow. ✓ The site was inspected for signs of breakout. ✓ All system components, excluding the SAS, have been located on the site. ✓ The septic tank manholes were uncovered, opened and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of SCUM. ✓ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. The size and location of the SAS on the site has been determined based on: ✓ Existing information (Example: Plan at BOH). DESIGN PLAN / "AS -BUILT" PLAN N/A Determined in the field if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable [15.302(3)(b)]. PART C - SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL: Design Flow (gpd/bedroom for SAS): Number of bedrooms: Current residents: Garbage grinder: Laundry connected to system: Seasonal use: Water meter readings, if available: Sump Pump (yes or no): Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of Establishment: Design Flow: Grease trap present: Industrial waste holding tank Non -sanitary waste discharged the Title 5 system Water meter readings, if available: Last date of occupancy: OTHER: Describe: Last date of occupancy: 440 gallons/day (110 gallons/bedroom) 4 2 no yes no 272,250 gal. 1996-97 / 373 gpd (includes irrigation) no current N/A N/A N/A N/A N/A N/A N/A N/A N/A SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 65 Spring Hill Road, North Andover, MA Owner's Name: Ronald Sley Date of Inspection: 7/18/98 GENERAL INFORMATION PUMPING RECORDS and source of information: last pumping: about two years according to owner System pumped as part of inspection: no if yes, volume pumped: N/A gallons Reason for pumping: N/A TYPE OF SYSTEM ✓ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy NO Shared system (yes or no - if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: System installed when dwelling was constructed in 1985. Sewage odors detected when arriving at the site NO BUILDING SEWER: (locate on site plan) Depth below grade: 10"-12" material of construction: ✓ cast iron 40 PVC other (explain) Distance from private,water supply well or suction line N/A Diameter: 4" Comments: Condition of joints, venting, evidence of leakage, etc.) Building sewer was watertight and appeared sound. SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 6" material of construction: ✓ concrete metal FRP other (explain) Dimensions: rectangular - 1,500 gallons 1 " sludge depth 32" distance from top of sludge to bottom of outlet tee or baffle 1 " scum thickness 7" distance from top of scum to top of outlet tee or baffle 15" distance from bottom of scum to bottom of outlet tee or baffle Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc.) Tank was watertight and functioning properly. SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 65 Spring Hill Road, North Andover, MA Owner's Name: Ronald Sley Date of Inspection: 7/18/98 GREASE TRAP: N/A (locate on site plan) Depth below grade: material of construction: concrete metal FRP other (explain) Dimensions: scum thickness distance from top of scum to top of outlet tee or baffle distance from bottom of scum to bottom of outlet tee or baffle Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc.) N/A TIGHT OR HOLDING TANK: N/A (locate on site plan) Depth below grade: material of construction: concrete metal FRP other (explain) Dimensions: N/A Capacity: N/A gallons per day Design Flow: N/A gallons per day Alarm level: N/A Alarm in working order N/A Date of previous pumping: N/A Comments: (condition of inlet tee, condition of alarm and float switches, etc.) N/A DISTRIBUTION BOX: ✓ (locate on site plan) 0" depth of liquid above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc.) The d -box was level and distributing equally. Two lines leaving box, one was accepting nearly all effluent. Overall flow rate was below average. PUMP CHAMBER: N/A (locate on site plan) N/A Pumps in working order (yes or no) N/A Alarms in working order (yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs, etc.) N/A SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 65 Spring Hill Road, North Andover, MA Owner's Name: Ronald Sley Date of Inspection: 7/18/98 SOIL ABSORPTION SYSTEM (SAS): ✓ (locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: not applicable Type leaching pits and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number alternative system (name of technology) N/A N/A N/A two (2) trenches, 60' long each, per "as -built" plan N/A N/A N/A Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance, repairs, etc.) Soils over leaching area were good, no evidence of breakout. CESSPOOLS: N/A (locate on site plan) number and configuration N/A depth -top of liquid to inlet invert N/A depth of solids layer N/A depth of scum layer N/A dimensions of cesspool N/A materials of construction N/A indication of groundwater inflow (cesspool must be pumped as part of inspection) N/A Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc.) not applicable PRIVY: N/A (locate on site plan) materials of construction dimensions depth of solids N/A N/A N/A Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc.) not applicable SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 65 Spring Hill Road, North Andover, MA Owner's Name: Ronald Sley Date of Inspection: 7/18/98 SKETCH OF SEWAGE DISPOSAL SYSTEM: indicate at least two permanent references, landmarks, or benchmarks locate where public water system enters house locate all wells within 100' N/A R94 -R y�9-sZ D G4P-40F D] /50 yet //,,I w4el- 52rv/cq- Iq ok sE y n cr 6 id y se weer C B O 2 — ( -�L re.,ehcs SEPTIC TANK TIES: A to Inlet (1) 19'4" A to Center (C) 21'8" A to Outlet (0) 23'9" D -BOX TIES: A to Box 30'0" NOTE: The system is in the rear yard B to Inlet 20'0" B to Center 20'8" B to Outlet 21'9" B to Box 16'4" ,',vc . %r-C-� SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 65 Spring Hill Road, North Andover, MA Owner's Name: Ronald Sley Date of Inspection: 7/18/98 DEPTH TO GROUNDWATER Depth to Groundwater >4' (below bottom of SAS) Indicate all methods used to determine High Groundwater Elevation: Y Obtained from Design Plans on record Y Observation of Site (abutting property, observation hole, basement sump, etc.) Y Determined from local conditions Y Check with Local BOH N Check FEMA Maps N Check pumping records Y Check local excavators, installers N Use USGS Data Describe in words how High Groundwater Elevation was established: Four feet separation indicated on septic design plan. Grade changes in the area indicated no groundwater in the SAS. DISCLAIMER This passing septic inspection under Massachusetts Title V in no way guarantees the septic system. The inspection is a "snapshot in time" and does not constitute a complete assessment of the quality or potential longevity of the septic system. The pass/fail criteria are specific and outlined in detail in this report. Under the limited criteria of a Title V inspection, it is impossible to determine how long any septic system will last. The inspector made a diligent effort to certify the septic system based on the criteria required under Title V. Under Massachusetts Title V, soil evaluation is the accepted method of determining the high groundwater elevation. This inspector is not a certified soil evaluator and is therefore not qualified under Title V to determine or establish the high groundwater elevation. The method used to estimate the high groundwater for this inspection was based on the public records and methods of observation described on the previous page. Groundwater levels can vary greatly from season to season, year to year and soil evaluation is considered the most reliable method of groundwater determination under Title V. kxA 11 Peter F. Reilly Inspector July 18, 1998 TOWN OF`NO$TH ANDOVER ..:SYSTEM PUMPING} RECORD DATE O V• X • SYSTEM OWNER & ADDRESS SYSTEM LOCATION Sp�n�9 �i 1 l A r�v ffO r�4i Glnic,�Uer- Ma-, DATE OF PUMPING}QUANTITY PUMPED c CESSPOOL NO YES SEPTIC TANK NO YES`-- NATURE OF SERVICE; %RQ_VTINE EMERGENCY OBSERVATIONS: GOOD CONDITION: FULL TO COVER MAVY ROOTS GREASE BAFFLES IN LACE LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLID CARRYOVER OTHER EXPLAIN SYSTEM PUMPED BY1-7 �. COMMENTS: CONTENTS TRANSFERRED TO of TOWN OF NORTH ANCK)VEP, UA tl. SYSTEM PUMPINO RECORD SYSTEM 0 WANBA AFRU-5-S SYSTEM LOCA710 1S 1a"4 L/ x/, a DATE. OF PVMPINQ:-- 1:1;11POOL: PUMPED;_ SoNc Tank: NU. y Es- NArURU OF SERVICE: RounNE.., 6MEROENCY KECEIVED 016SERVAMN& MAY 11 2005 .. e GOOD CONDITION PULL. T ') y COVER TOWN OF NORTH ANDOVER HUYY OUk3BBAFFLES IN PLACE. HEALTH DEPARTMENT ROOTS LWKRPLD RUNBACK BXCUSIVE SOLIDS,_ FLOODED -SOLID CAKRYOYBR,—,-. OrtfER EXPLAIN syltom Nmp"d �y 177a. WIVIMENTS. ,-:vm rwns rmNsnmt) I-() . Ohl BOARD OF HEALTH No.Andover, Mass. APPROVED - DATE -.5 Provided: L /� Title, -7 I FAIL I IK Reg 2.5 SUBSURFACE DISPOSAL DESIGN CHkK LIST LOT DISAPPRGME DATE Reasons: �\ The submitted plan must show as a miziimi, s a) the lot to be served-area,dimensions lit #,abutters b location and log deep observation hots -distance to ties c location and results percolation testy -distance to ties d design calculations & calculations shc;ing required leaching area (e) location and dimensions of system- aeiding reserve area f) existing and proposed contours (g) location any wet areas within 1001 of sewage disposal system or disclaimer -check wetlands mapping 1. (h) surface and subsurface drains within 3.001 of sewage disposal system or disclaimer (i) location any drainaf;e easements vithin 1001 of serge disposal system or disclaimer -Planning Hoard files (j) know sources of water supply within 2001 of sewage disposal e system or disclaimer Ll4Rp of H6C�w i i -I NdI�TH AtiIpnvEI�, M.4. 06 S5 . 1W Q) CoN91T J5: UISQPPRnvEp RtE;45oNs ~ ,A ?PL CAIv I_ M4�u�j Y wqO �rl, sllPit7 rbwtV D wEc. — APPRO uED N-Fc— stPr� c sy s ► �,� v�,si <-� pA-rt- D/� TE IWOUIN6 AUTI-IDl'?ITy D StP�"(C SYSTEM 1.kJ S`1i0 U 4 -Tl o� j c-'X404T(o,�-) )ticFlt�-.G —no&j PArC ux�KS Gcrp 7fif i��SS ❑ FAlt FWAL I Q5PFGTlon) AP�I�dVE1� Glu C-- �4�1�IT(D�AL 1�15r�-c,�'�jtiS �l►- A�y� D►SA Pl'j?o\j&p DA rE FZj�65o NS FR AL APPF�DVAL SYS I`�M c t-�Jti6�- D,OrE °i APP)30vv--t 6u i mogi l-\/ Commonwealth of Massachusetts RECEIVED �1 City/Town of NORTH ANDOVER MASSAC USETTS _ System Pumping Record Nov 132006 Form 4 2006 TOWN ur NORTH ANDOVER DEP has provided this form for use by local Boards of Health. Thd System HEALTH Dump ng DEPARTMENTPumpingmu: be submitted to the local Board of Health or other approving authority. A. Facility Information — - Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. vQ ��x - 1. System Location: Address City/Town — State Zip Code 2. System Owner: ------ ----- - _..- __ - ----- - - - - Name -- ---- --- ._..ie- -- __ _ ---- __..- - - - - - - - ----- ddress (if different from location) - -- - - - - - _ _ City/Town B. Pumping Record Date of Pumping State Zip Code elephone Number - ----- cA�- Date 2. Quantity p GPumped: - io._.._._-.-. allons 3. Type of system: ❑ Cesspool(s) PT"ceptic Tank ❑ Tight Tank ❑ Other (describe):.__... - 4. Effluent Tee Filter present? ❑ Yes JZNo If yes, was it cleaned? ❑ Yes ❑ No r 5. Condition of System: 6. Sy em Pumped By: Name //CCt Vehicle License Number Comp 7. Location where contents were disposed: Si ature of Haug/ --- _ _ -�W_Jz Date ------ http://www.mass gov/dep/water/ provals/t5forms.htm#inspect t5form4.doc• 06/03 System Pumping Record • Page 1 of ..r i� i} "j. TOWN .OF NORTH ANDOVER*01 SYSTEM PUMPING RECORD jI it Akl.v 11:kAi.rlkt�#t! tVyi�i�,,� k,F'7i1� �.'.,,,.. f .. .. SYSTEM OWNER *ADDRESS SYSTEM LOCATION /\a(cumplk: `I, front of house) 10. ,e� ii � �C �`1>�t �X t� au"f'3s"Lr. {PRxry4.,..i�'„ rre »•++. .k �•.t .K... _.. _ ..,. . , R I;+, { 5— 7 —0)QUANTITY PUMPEDr00 t � d GALLONS , 9 rMir �rcatt It41!�'haai " ., �,' ,o-; di'71' i + ' r� OFSS.P• ,OOL: J NO.. YES -SEPTIC TANK: NO YES „I I x' 'h �tJ--tij �117{'ljrllF} ta. OF SERVICE:Y' ROUTINE ' EMERGENCY j li"'+ �ltt!i ��{� t 5''•k%"} 5 �ri�{''` �, r�;ll ` �s.: h } rv� t "'^ 2 ... .. .... .. R A k TONS: VA¢ lmfGOOD ` CONDITION t FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS EXCESSIVE SOLIDS LEACHFIELD RUNBACK t FLOODED SOLIDS CARRYOVER'- �^• OTHER (EXPLAIN) LlY�TF'ry`. A�7fry��% V �}, � 3y+/' I!.r+� A �++� F. F R .,�V(V .. ^I.xO, i.. LyyLK�7�"�jjri I ;.. 1pM�>�1'{"91f�riiY12' P.i' �{ ' FYI Tl,��i{130plR.J©F tK—e I 0.�01'� ys 1�3 O�VIMN • �1�� �i Q,� t:� h�i' , ... f1 _•+ •L,00l Er NT i L+ T 1,RS �w M���!�/'�• ��((/ , ri-r,• r.l ""wpm* rl , rv^"q fi 011! �ttt "JY rii1 I�I,�IIle Ji p! f,•rM i^ i i �I§ i S, i r 9A a y�yl ry1Y t Zitt - - t�hrtr� ti�*,, ,1tl,a ri.•, TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD SYSTEM OWNER & ADDRESS Mr /vas &5 H Na SYSTEM LOCATION (example: left front of house) -:P��Jk DATE OF PUMPING: o�—��caZ QUANTITY PUMPED /5d 0 GALLONS CESSPOOL: NO `� YES SEPTIC TANK: NO YES V NATURE OF SERVICE: ROUTINE ✓ EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) CONTENTS TRANSFERRED TO: pC (� — `( ( ( UJB