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HomeMy WebLinkAboutMiscellaneous - 1 SCOTT CIRCLE 4/30/2018North Andover Board of Assessors Public Access KOR7y F 1 r 8�/1[NLI�S` Return to the Home page click on logo New Search Sales Summary Residence Detached Structure Condo Commercial Comparable Sales TOQVTk Of North Anclover Uoewd Of Assessors 3 Page 1 of 1 Property Record Card Location: 1 SCOTT CIRCLE Owner Name: KINGSWOOD, ANDREW C KARYN A KINGSWOOD Owner Address: 1 SCOTT CIRCLE City: NORTH ANDOVER State: MA ZIP: 01845 Neighborhood: 6 - 6 Land Area: 3.79 acres Use Code: 101 - SNGL-FAM-RES Total Finished Area: 3665 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 658,900 758,600 Building Value: 429,000 505,400 Land Value: 229,900 253,200 Market Land Value: 229,900 Chapter Land Value: LATESTSALE Sale Price: 539,500 Sale Date: 12/19/2000 Arms Length Sale Code: Y -YES -VALID Grantor: DAVID DICKERSON Cert Doc: Book: 05958 Page: 0150 http://csc-ma.us/NandoverPubAcc/jsp/Home.jsp?Page=3&Linkld=1180928 2/19/2008 L-EvA-r i otq . \�Z�Z1 (a±'SF. �l' q FRANtC �a C. TLINAS L -.o. 22738 C) _ i coo �7Q. 1- t sap-r►c T4N1c A, s & u i L -r 5 u k3- 5► u w. FAr,e D I S Po`?Al. IN T-OPEEF-> T PA, -r E—= 1= t,4 V- ►JaS ASSVGta.'TES �hlG�N�.�i2S�. �G?C,sr-tITEGTS -4 SI .a.N DGri/ i2 `3'T r-4 1'::>. AN 63"T 'T _ it4i,zz tS ti to I-V L tz4.07` auTDI<Z IZS. 9(,0 _ 114 PVT- Z 1 Z to -I INRT 3 (Z3.Z0 1►.1 PIT 4� 12-S. l 3 _ \�Z�Z1 (a±'SF. �l' q FRANtC �a C. TLINAS L -.o. 22738 C) _ i coo �7Q. 1- t sap-r►c T4N1c A, s & u i L -r 5 u k3- 5► u w. FAr,e D I S Po`?Al. IN T-OPEEF-> T PA, -r E—= 1= t,4 V- ►JaS ASSVGta.'TES �hlG�N�.�i2S�. �G?C,sr-tITEGTS -4 SI .a.N DGri/ i2 `3'T r-4 1'::>. AN Town of North Andover f NORTa Office of the Health Department ;?°' Community Development and Services Division - 400 OSGOOD STREET `►° North Andover, Massachusetts 01845 �+s Susan Y. Sawyer, REHS/RS Public Health Director 978.688.9540 - Phone 978.688.8476 - Fax C�E�I�FICA2iE OAF C09bL�LIANCE As o£ December 2, 2005 This is to cert that the individual subsurface disposal system was Septic Tank eplacement by Joseph R. (Buddy) Watson At: 1 Scott Circle North Andover, 911,4 01845 Yfas been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of ifealth regulations. The Issuance of this certificate shall not 6e construed as a guarantee that the system will function satisfactorily. Public Yfeafth inspector BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Carlmonwealth of Massachusetts 01' ,,- � otic Map -Block -Lot °4 ,.. 105.D- 0068 - Board of Health ------- ~ n Permit No North Andover BHP -2005-0715 P.I. '4t" •..,° ..•• <h FEE SS4C Mutt F.I. $125.00 Disposal Works Construction Permit Permission is hereby granted JOSEPH R. WATSON --------------- -- to (Repair -TANK ONLY) an Individual Sewage Disposal System. at No 1 SCOTT CIRCLE as shown on the application for Disposal --------------------------------Works Construction Permit No. BHP -2005-071 Dated November 10 2005 ---- - _ Health G' Issued On: Nov -10-2005 <<- rt ...- ...... _.------------- ---------------- ----- - Board of h NOR7M Commonwealth of Massachusetts Map -Block -Lot 105.D- 0068 - Board of Health ---- k 4 North Andover Certificate of Compliance g��MUgt THIS IS TO CERTIFY, That the Individual Sewage Disposal System`(. Repair -TANK ONLY) by JOSEPH R. WATSON - installer — -- — — at No 1 SCOTT CIRCLE - . --- -- has been installed in acco ce with the provisions of TITLE 5 of the State Environmental Code as described in the application for Djsp sal Works Construction Permit No. BHP -2005-071 Dated November 10 2005 -------------- Printed On: Nov -10-2005 ---- ------__.... ---- ---. ..... Board of Health ............................................................... .. r -Li Important: When filling out forms on the computer, use only the tab key to move your cursor- do not use the return key. Q Application for Septic Disposal System &- /- 0,4, Construction Permit —TOWN OF TODAY'S DATE NORTH ANDOVER MA 01845 —Full Repair � �omponent Application is hereby made fora Permit to: Construct a new on-site sewage disposal system* ❑ Repair or replace an existing on-site sewage disposal 7�� * =// D� �epair or replace an existing system component � A. Facility Information J Address or Lot # &0 ,c A A010V AP Y- City/Town 2.- *TYPE OF/SEPTIC SYSTEM*: ❑ Pump E Gravity (choose one) * *If pump system, attach copy of electrical permit to application*** Conventional System (pipe and stone system) ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D -Box Present) S.A.S. 2. Owner Information Name 0 0 ` Address (if different from above) 0> City/Town State Zip Code Telephone Number 3. Installer Information Out I/ /A/a_j�sa 1. cTfn/ 4A_t3a y Ty. Cit Name Name of Company 6 *3 Address �j� /� City/T/7 la/,ar/moi( /ri // 0/5/0 State Zip Code Telephone Number (Cell Phone # if possible please) 4. Designer Information Name Name of Company Address City/Town State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit - Page 1 of 2 Ar N°RTS Application for Septic Disposal System -Construction Permit -TOWN OF TODAYS DATE '• •'' NORTH ANDOVER, MA 01845 $ 250.00 - Full Repair c,,,,�s�i' $125.00 - Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: Residential Dwelling or ❑Commercial B. Agreement The undersigned agrees to ensure the construction ana7e 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, and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Names Date By: ( (vaid of Health Representative) Date Disapproved for the following reasons: For Office Use Only: 1. Fee Attached? Ye� No 2. Project Manager Obligation Form Attached? Yes No I I Pump System? Ifso, Attach copy ofElectrical Permit Yes 1.No 4. Foundation As -Built. (hew construction ronly): (Same scale as approved plan) 5. Floor Plans? (new construction only): Yes No Yes No Application for Disposal System Construction Permit • Page 2 of 2 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1 Scott Circle _ —North Andover_ Owner's Name: _Andrew Kingswood_ Owner's Address: _1 Scott Circle _ North Andover, Ma 01845_ Date of Inspection: _12/2/2005 Name of Inspector: _Neil J. Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, Ma. 01810_ Telephone Number: _( 978 ) 4754786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of 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: _Xr Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ails Inspector's Signature: Date: _12/2/2005_ The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments: After permit from B.O.H., installing new septic tank by J.W. Watson, inspection from B.O.H., septic system now passes Title 5 Inspection. ****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. N COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1 Scott Circle —North Andover_ Owner's Name: _Andrew Kingswood _ Owner's Address: _1 Scott Circle _ _ North Andover, MA 01845_ Date of Inspection: _11/30/2007_ Name of Inspector: Neil J. Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, MA 01810_ Telephone Number: _( 978 ) 475-4786_ RECEIVED DEC 1 12007 TOWiv ur raurtTH ANDOVER HEALTH DEPARTMENT CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: _X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ail Inspector's Signature: \ Date: _11/30/2007 The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments: ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _1 Scott Circle_ _ North Andover— Owner: -Kingswood_ Date of Inspection: _11/30/2007 _ Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. _ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND exnlain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1 Scott Circle_ _ North Andover— Owner: Kingswood_ Date of Inspection: _11/30/2007 _ C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance , **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1 Scott Circle_ _ North Andover_ Owner: Kingswood _ Date of Inspection: _11/30/2007 _ D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: _ No Backup of sewage into facility or system component due to overloaded or closed SAS or cesspool _No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool No Liquid depth in cesspool is less than 6" below invert or available volume is 1/2 day flow. _No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _No_ Any portion of the SAS, cesspool or privy is below high ground water elevation. _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either "yes" or `no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1 Scott Circle _ _ North Andover _ Owner: Kingswood _ Date of Inspection: _11/30/2007 Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No Yes_ _ Pumping information was provided by the owner, occupant, or Board of Health No_ Were any of the system components pumped out in the previous two weeks ? Yes_ _ Has the system received normal flows in the previous two week period ? No Have large volumes of water been introduced to the system recently or as part of this inspection ? _Yes_ ` Were as built plans of the system obtained and examined? Yes_ — Was the facility or dwelling inspected for signs of sewage back up ? Yes_ _ Was the site inspected for signs of break out ? Yes_ _ Were all system components, excluding the SAS, located on site ? _Yes_ _ 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 ? _Yes_ _ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes No _Yes_ _ Existing information. _Yes_ _ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1 Scott Circle_ _ North Andover— Owner: Kingswood _ Date of Inspection: _11/30/2007_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): _4Number of bedrooms (actual): _4_ DESIGN flow based on 310 CMR_ 15.203 _440_ Number of current residents: _4 Does residence.have a garbage grinder (yes or no): Yes_ Is laundry on a separate sewage system (yes or no): _No _ Laundry system inspected (yes or no): Seasonal use: (yes or no): _No_ Water meter reading: _On well water_ Sump pump (yes or no): No_ Last date of occupancy: _ Current_ CONMIERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sqft,etc.): Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): Non -sanitary waste discharged to the Title 5 system (yes or no): _ Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: Pumped 2005,owner _ Was system pumped as part of the inspection (yes or no): Yes_ If yes, volume pumped: _1500_ gallons -- How was quantity pumped determined? _Measured tank_ Reason for pumping: _Inspect tank & tees_ TYPE OF SYSTEM X Septic tank, distribution box, soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank _ Attach a copy of the DEP approval Other (describe): _ _ Approximate age of all components, date installed (if known) and source of information _Tank was replaced last year, d -box & field 27 years old, 8/22/1980, as built plan _ Were sewage odors detected when arriving at the site (yes or no): _No Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 Scott Circle_ _ North Andover _ Owner: Kingswood_ Date of Inspection: _11/30/2007 BUILDING SEWER _ X _ (locate on site plan) Depth below grade: _36" Materials of construction: _X_ cast iron _X_ 40 PVC _other Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.) _ 4" Cast iron thru wall, 3" PVC in house, no leaks visible SEPTIC TANK: X Depth below grade: _20" _ Material of construction: X concrete _ metal _fiberglass _polyethylene _other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) Dimensions: _10' x 5' x 4' Sludge depth: 6"_ Distance from top of sludge to bottom of outlet tee or baffle: 21" _ Scum thickness: _6" Distance from top of scum to top of outlet tee or baffle: -811 _ Distance from bottom of scum to bottom of outlet tee or baffle: 15" How were dimensions determined: _ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc_ Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. _ GREASE TRAP: _(locate on site plan) Depth below grade: _ Material of construction: _concrete _metal _fiberglass __polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 Scott Circle _ North Andover— Owner: Kingswood_ Date of Inspection: _11/30/2007_ TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX_X_ Depth below grade _6"_ Depth of liquid level above outlet invert: _ 0" _ Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.) _ D -box level & distribution equal. No carryover. No leakage._ PUMP CHAMBER: _ (locate on site plan) Pump in working order (yes or no): Alarm in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 Scott Circle _ _ North Andover— Owner: Kingswood_ Date of Inspection: _11/30/2007_ SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan, excavation not required) If SAS not located explain why: Type X leaching pits, number: _3_ leaching chambers, number: leaching galleries, number: _ leaching trench, number, length: leaching field, number, dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.):—Soil ok. Vegetation ok. No sign of ponding to surface. Dug up covers on all pits, no water up to inverts_ CESSPOOLS: Number and configuration: _ Depth — top of liquid to inlet invert: _ Depth of sludge layer: _ Depth of scum layer: _ Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): — Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1 Scott Circle _ _ North Andover— Owner: Kingswood_ Date of Inspection: _11/30/200?_ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building ' Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 Scott Circle _ _ North Andover— Owner: Kingswood_ Date of Inspection: _11/30/2007 _ SITE EXAM Slope _ No _ Surface water _ No _ Check cellar _ Dry _ Shallow wells _ No _ Estimated depth to ground water _ 4'_ Please indicate (check) all methods used to determine the high ground water elevation: X Obtained from system design plans on record - If checked, date of design plan reviewed: _8/20/1980_ 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: _ 4' deep, as per design plan info_ A a .. S\- Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other fomes 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. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key.. --h �� A. Facility Information 1. Systm Address � ��j "l � � I/ " • �"�V� CAy/Town State Zip Code 2. System Owner Name Address (iF different from location) City/Town B. Pumping Record 1. Date of Pumping Date State � � I � Zip Code Telephone Number 2. Quantity Pumped: Is c� Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Titer present? ❑ Yes D—N6 - if yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: f J� _ I �� E),&,A �44-s 6. Sy umped Fy� � 4 Name Vehicle License Number Company 7 t5form4.doc• 06/03 where conterg* were disposed: NEW -M l /--- Date System Pumping Record • Page 1 of 1 Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating -Water& Sewer Lines -Septic Systems & Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 1 Scott Circle, North Andover Owner: Kingswood Date of Inspection: 11/30/2007 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. 41�B!aton Bateson Enterprises, Inc. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. VQ IL�1 Commonwealth of Massachusetts RECEIVED City/Town of DEC 1 1 2007 System Pumping Record Form 4 TOWN OF NORTH ANDOVER 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. A. Facility Information 1. Syst m Location: In o v 16U--se— Address City/Town State Zip Code 2. System Owner: 1 ,(R L&JO� Name Address (if different from location) City/Town State � � � � Zip Code Telephone Number B. Pumping Record t ( 30 --c-il I L� 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes [a'ITo - If yes, was it cleaned? ❑ Yes ❑ No 5. Condition System: L A Pik 6. Sy m umped I , L �- Name Vehicle License Number Company 7. Locationwhere Uj to�were disposed: f - -). Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 1 f COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WIIMR STREET, BOSTON MA 02108 (617) 292-5500 TRUDY COXE 9 ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor C,omminioner . SUBSURFACE SEWAGE DISPOSAL SYSTEM NOII SPECTIFOR11 PART A CERT RCAIION Property Address: 1 Scott Circle, North Andover Name of Owner. David Dickerson Address of Owner: 1 Scott Circle, North Andover, MA. 01845 Date of Inspection: 418/2000 Name of Inspector: Neil J. Bateson I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Bateson Enterprises Inc. Mailing Address: 111 Argilla Road Andover, MA 01810 Telephone Number. ( 978 ) 475-4786 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _X Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fai 6ajlt4� Inspector's Signature: Date: 4/8/2000 The System Inspector smit a this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of completing this inspectiokAfesystem is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS APR 14 revised 9/2/98 Page I of 11 Printed on Recycled Paper 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1 Scott Circle, North Andover Owner: Dickerson Date of Inspection: 41812000 INSPECTION SUMMARY: Check A, B, C, or D.- A. :A. SYSTEM PASSES: _X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or move system components as described in the'Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or NO). Describe basis of determination in all instances. If "not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Properly Address: 1 Scott Circle, North Andover Owner: Dickerson Date of Inspection: 4/13/2000 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 (1)(b) THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water. Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH AND PUBLIC WATER SUPPLIER, IF ANY) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 912198 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1 Scott Circle, North Andover Owner: Dickerson Date of Inspection: 41812000 D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS - You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area @ IWPA) or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1 Scott Circle, North Andover Owner: Dickerson Date of Inspection: 4/8/2000 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No _X Pumping information was provided by the owner, occupant, or Board of Health. _X None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _X As built plans have been obtained and examined. Note if they are not available with NIA _X The facility or dwelling was inspected for signs of sewage back-up. _X The system does not receive non -sanitary or industrial waste flow. The site was inspected for signs of breakout. X All system components, excluding the Soil Absorption System, have been located on the site. _X The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _X Existing information. For example, Plan at B.O.H. _X Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [I 5.302(3)(b)) _X The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 Property Address: 1 Scott Circle, Andover Owner: Dickerson Date of Inspection: 41812000 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL: Design flow _ 110 g.p.d./bedroom. Number of bedrooms (design): -4 _ Number of bedrooms (actual-4— Total actual4_Total DESIGN flow _440 _ Number of current residents: –4 – Garbage grinder (yes or no): _ Yes_ Laundry (separate system) (yes or no):_ No If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):_ No_ Water meter readings. On well water Sump Pump (yes or no): _ No Last date of occupancy: Current COMMERCIALII NDUSTRIAL: Type of establishment: Design flow: gpd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no) Industrial Waste Holding Tank present: (yes or no) Non -sanitary waste discharged to the Title 5 system: (yes or no) Water meter readings, if available: Last date of occupancy: OTHER: (Describe) _ Lara date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Pumped Dec. 97, owner System pumped as part of inspection: (yes or no)_Yes _ If yes, volume pumped: _1500_gallons Reason for pumping: Inspect tank & tees. TYPE OF SYSTEM _X_ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed (if known) and source of information: 20 years old, 8/22/1980, as built plan. Sewage odors detected when arriving at the site: (yes or no)— No- revised 9/2/98 Page 6 of 11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 Scott Circle, North Andover Owner: Dickerson Date of Inspection: 4/812000 BUILDING SEWER: X (Locate on site plan) Depth below grade: 36" Material of construction: _X cast iron _X 40 PVC _ other (explain) Distance from private water supply well or suction line: Diameter :4" Comments: 4" cast iron thru wall, 3" PVC in House. SEPTIC TANK:X (locate on site plan) Depth below grade: 20" Material of construction _X_ concrete _metal _Fiberglass _Polyethylene _other (explain) If tank is metal, list age _Is age confirmed by Certificate of Compliance _ (Yes/No) Dimensions: 10' x 5' x 4' x 7.5 = 1500 gallons. Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle: 21" Scum thickness: 6" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 15" How dimensions were determined: Subtract scum & sludge depths to tee length Comments: Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: . Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: revised 9/2/98 Page 7 of 11 , r r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 Scott Circle, North Andover Owner: Dickerson Date of Inspection: 4/812000 TIGHT OR HOLDING TANK: _None (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade: Material of construction: concrete_ metal _Fiberglass Polyethylene _other(explain) Dimensions: Capacity:_gallons Design flow:_allons/day Alarm present Alarm level: Alarm in working order: Yes _ No Date of previous pumping: Comments: DISTRIBUTION BOX. _X (locate on site plan) Depth of liquid level above outlet invert: 0 Comments: D -box level & distribution equal. No leakage. No carryover. PUMP CHAMBER: —None, gravity system_ (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: Revised 912/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued)) Property Address: 1 Scott Circle, North Andover Owner: Dickerson Date of Inspection: 4/8/2000 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan, if possible; excavation not required, location may be approximated by non -intrusive methods) If not located, explain: Type: leaching pits, number: 3 leaching chambers, number: leaching galleries, number: leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: Soil ok. Vegetation ok. Pit # 1 empty. Pit # 2 holding 2" of water. Pit #3 holding 4" of water. CESSPOOLS: None (locate on site plan) Number and configuration: Depth -top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 Scott Circle, North Andover Owner: Dickerson Date of Inspection: 41812000 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) Ato2= 16' Ato3=20'5" A to Drop Box = 26'6" B to 1 = 20'5" Bto2=23'5" Bto3=27' B to Drop Box = 32'4" C to D -Box = 36' C to Pit #1= 55' C to Pit #2 = 41' C to Pit #3 = 63' D to D -Box = 52' DtoPit #1=70' D to Pit #2 = 48' D to Pit #3 = 49' revised 9/2/98 Page 10 of 1113ox S • 3 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 Scott Circle, North Andover Owner: Dickerson Date of Inspection: 418/2000 NRCS Report name Sal Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 4 Feet Please indicate all the methods used to determine High Groundwater Elevation: _X Obtained from Design Plans on record _X Observed Site (Abutting property, observation hole, basement sump etc.) —X—Determined from local conditions —X—Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) As per design plan. revised 912198 Page 11 of 11 Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 1 Scott Circle, North Andover Owner: Dickerson Date of Inspection: 4/8/2000 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Bateson Enterprises, Inc. WILLIAM F. WELD Governor BO.t4-. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL P,.R TECTION ONE WINTER STREET. BOSTON. AIA 02108 617.2934W 29 TRUDY COXE Secretary ARGEO PAUL CELLUCCIDAVID B. STRUHS Lt. Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A /,�� �•,C,�ER�TIFICATION Property Address:�� ' CC c . f jC�r /�1^�.�`('uQA ,Address of Owner: Date of Inspection: —1Z Of different) Name of Inspector. Q` �$• 1 am a DE approved system inspe for pursuant to,Section 15.340 of Title 5 (310 CMR. 1S.000) Company Name: �r2� Tc-i/l� C(S2S Mailing Address: i _4116k f v "'r • 0 ��� U Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete *as of the time of inspection. The inspection was perfortned based on my training and experience in the proper. function and Maintenance of on-site sewage sposal systems. The system: _ Passes Conditionally Passes _ Needs Further Evaluation By the local Approving Authority Fails Inspector's Signature: 'tom-' Date: (C -y t 3 7 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 go or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or d. A] SYSTEM PASSr-r 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. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section .teed to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or NO). Describe basis of determination in all instances, If 'not determined", expiain why not. _ The septic tank is metal, unless the owner of opei-atoi has provided the systefn inspector With a Copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The systern will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health.. . (sivisod 04/25/07) ta(ta i of 10 DEP on the world VMe Web: hap:/f ~.M691*Lttate.ft.us/dep 0 IPdoted on Recyeled.Paper SUBSURFACE SEWAGE- DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: T7 B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static'water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s) ane replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s),are replaced obstruction is removed 0 C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by. the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT.- Cesspool NVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy. is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD,6F HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING INA MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation .not valid). 3) OTHER f (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ` CERTIFICATION (continued) Property Address: cs �' . � C4K.qt , , Owner: �%C�e�'� � i Date of Inspection: OJ SYSTEM FAILS; You must indicate either "Yes" or "No" as to each of the following: 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. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. _ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or avaVable volume is less than 1/2 day flow. _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. r 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. 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. El LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 (orated in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone 11 of a public water supply well The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. • (revia&d 04/2S/97) Pago 3 of 20 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B ��. CHECKLIST Property Address: Owner: Date of Inspection: ust indicate either "Yes" or "No" as to each of the following: Check if the following have been done: You m Yes o t or Board of Health. Pumping information was provided by the owner, occupant, normal _ n recelvl None of the system components have been pumped for at least wattwo have of beend n introduced nttothe system grecently or flow rates during that period. Large volumes of as pan of this inspection. f/ As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. r _ The system does noI receive non -sanitary or industrial.v". a flow. The site was inspected for signs of breakout. em, have been located on the site. All system components, excluding the Soil Absorption Syst is tank was inspected for condition of The septic tank manholes. were uncovered, opened, and the interior of the sept _ baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The `size and location of the Soil Absorption System on the site has been determined on: maintenance of The facility owner (and occupants, if different from owner) were providedwith information on the proper Sub -Surface Disposal System. Existing information.Ex. Plan at B.O.H. _ to Part C is at issue, approximation of distance is Determined in the field (if any of the failure criteria related unacceptable) [15.302(3)(b)) page 4 of l0 (r,via*d 04/4S/'97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: (2vz- � Owner: 6 C Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: 0./bedroom for S.A.S. Number of bedrooms: Number of current residents Garbage grinder (yes or no): 2S Laundry connected to syqein (yes or no):-Ve-s Seasonal use (yes or no): I Q Water meter readings, if v ilable (last two (2) year usage (gpd): Sump Pump (yes or no):� Last date of occupancy: W �C COMMERCI ALJIN DUSTRIAL: Type of establishment: r Design flow: gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non -sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as pan of inspection: (yes or no)'0405 If yes, volume pump ��If��ilonk Reason for pumping: TYPE OF 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) VA Technology etc. Copy of up to date contract? Other APPRO IMATEA E of II components, date installed (if known) and source of information: C-�- iT,, Sewage odors detected when arriving at the site: (yes or no) (revised 0{/25/97) Paye 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properly Address: Owner: V -N Date of Inspection; BUILDING SEWER: (Locate on site plan) Depth below grade: tr Material of constructio : t iron AO other (ex la'y�) q Distance frgm Q�ivate water supply well or suction lire Diameter z -t Comments: (capd1tion of joints, venting, evidence of leakage, etc.) SEPTIC TANK;, (locate on site plan) :1-o<ncrete Depth belowgrade: �Material of construction: metal Fiberglass Polyethylene `other(explain) If tank is metal, list age Is age confirmed by Certificate of Compliance (Yes/No) Dimensions. to x t X 4( Y-2. S= I S� Sludge depth: r^2 Distance from cop 1sludge to bottom of outlet tee or baffle:,Q_ Scum thickness:�- r r Distance from top of scum to top of outlet tee or baffle: ' _, H, Distance from bottom of scum to bottom of outlet tee or baffle:_ Now dimensions were determined: Comments: (recommendation for pumping, condi ' f inlet and outIR tee or s, deptU�-�A liquidtlevel ip integrity_ evidence of.leakatte, etc.)y it t � 52 _ -Q,� `r-'' - { GREASE TRAP: (locate on site plan) Depth below grade::_,. Material of construction: _concrete _metal _Fiberglass _Polyethylene __other(explain) Dimensions: Sam thickness:_ Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (rov*aad 04/25/97) raga 6 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection; 0 M TIGHT OR HOLDING TANK: (rank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal Fiberglass _Polyethylene other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in working order Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX._ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if levelland distribuiion_is equal,,evidence of solids carryover, evidence,,of lVakage into or out of box, etc.) l PUMP CHAMBER:�v. —Qfzq U V (locate on site plan) ����jjjj Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) f (revised 04/35/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C "f SYSTEM INFORMATION (continued) Property Address: Owner: y ' Date of Inspection. a ► �`,` T 3 --q►f' j SOIL ABSORPTION SYSTEM (SAS): a- llocate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: %-caaw vvu: Y,y V (locate on site plan) Number and configuration: Depth -top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: indication of groundwater. inflow (cesspool must be pumped as part of inspection) Comments: 1 (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: ' v� (locate on site plan) . Materials of construction: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (zaviaad 04/25/07) Vag? 8 of 10 Dimensions: h SUBSURFACE SEWAGE' DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: - Owner: Date of inspection:' �`C�fi►� SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at I rmai locate all wells withi 100' (Local references landmarks or benchmarks sere public water supply comes into house) (revised 04/95/97) Page 9 of 10 Droki-) j1 `T l / It O- �,Xr Sa i 761 L 11. As Built Submitted -- _ a. Lot Location- b. ocation-b. Dimensions of System c. Location Nith Regard_to pert Test d..Elevations e: Water Table r, 1fIJ1n••y111A1 unluy'& "al Lur ' OVFD DATE DI PROV =� OK I. Distance Tot a. Wetlands b. Drains c. Well 2. Water Line Location 3• no M Pipe. j %. Septic Tank - - - ' a. - -Tess -_Length & To Clean -Out Cowers. Y . b. Cce�ipe to Tank - Qi Both Sides of Tank 5. Distribution Box Covers & Box - No Cracks ioll b. `All Lines Flooring Equal. Amounts c. No Back Flow 6. Trench - 'Leach F/Eaa a. Dima b. Stone s c: Capp.. d. Claim Double Washed Stone! 7. Leach Pits . - . a. Dimensions b. Stone Depth c. Splash Pads d. Tees `• e. Cerixmt Pipe to Pit Both Sides f. Clean Double Washed Stone 8. No Garbage Disposal 9. Thal Grading Inspection . " 10. Barricading Covered System 11. As Built Submitted -- _ a. Lot Location- b. ocation-b. Dimensions of System c. Location Nith Regard_to pert Test d..Elevations e: Water Table SUBSURFACE DISPOSAL SYSTEM CHECK LIST r ¢ 1 4V . NORTH ANDOVER BOARD OF HEALTH APPROVED DATE PROVIDED A f Title 5 Reg. 2.5 A-411AI-4 Reg. 6 sr - 7e DI PPROVED DATE TIME REASON5 o� Ir ail OK The submitted plan must show asp a minumum• �, P � . *a- cud d ¢� - -(-a) the lot to be served (area,dimensions,l,ot #,abutter w (Planning Board files) (b) location and log of deep observation holes-distance to ties � (c) location and results of percolation tests -distance to ties (d) design calculations & calculations showing required _ leaching area location and dimensions of system (including reserve area) f existing and proposed contours g -- location of any wet areas within 100' of the sewage disposal system or disclaimer (check wetlands mapping) (-h)- surface and subsurface drains within 100' of sewage disposal system or disclaimer location of any drainage easements within 100' of sewage disposal system or disclaimer (planning board files) (J---)- _ known sources of water supply within 200' of sewage i disposal system or disclaimer (k) location of any proposed well to serve the lot (100' from leaching facility) -f(1) location of water lines on property (10' from leaching facilities) (m) location of benchmark (n)-- driveways (o) garbage disposers (p) no PVC is to be used in construction (q) a profile of the system (elevations of basement, plumbers pipe septic tank, distribution box inlets and outlets, distribution field piping and any other elevations) =`(r) maximum ground water elevation in area of sewage disposal' .system (s) ---plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Septic Tanks (a) Capacities - 150% of flow, water table, tees, depth of tees, access, pumping, (b) Cleanout (c) 10' from cellar wall or inground swimming pool (d) 25' from subsurface drains ivorzn xnaaver ouQsuriace uibposal sys-;em cnecx ±1st - rage Reg.10.2 Reg.10.4 Distribution Boxes rssu lop`e grdater than 0.08 bmp Leaching Pits Leaching pits are preferred where the installation is possible Reg.11.2(a) Calculations of leaching area (minimum 500 S.F.) "b Reg.11.4 Spacing Reg.11.10 Surface drainage 2% Re g.11 .11A" e.,materialv 40.,4 7e) o Leaching Fields Reg.15.1 (a) NDGreater than 20 minutes/inch Reg.15.1 (b) Area (minimum 900 S.F.) Reg.15.4 (c) Construction of field Reg.15.8 (d) Surface drainage 2% Reg. 3.7 (e 20' from -cellar wall or inground swimming pool Leaching Trenches Reg.14.1 (a) Calculations of leaching area (min. 500 S.F.) Reg.14.3 Reg.14.4 (b) Spacing (4 ft. min. 6 ft. with reserve between) (c Dimensions 14.5 Reg.14.6 (d) Construction Reg.14.7 (e) Stone Reg.14.1 (f) Surface drainage 2% Downhill Slope . (a) Slope y/x = (to be shown (b) X 150 y/x = (to be shown Pump s Reg. 9.1 (a) Approval Reg. 9.6 (b) Stand-by power SOIL PROFILE & PERCOLATION TEST DATA North Andover,Mass. No . &Street r Lot No.,/ Loc./Subdiv. Plan Owner Investigator �� .�� Observer�_PJ�� _ SOIL PROFILES -DATE 1' Elev. 2.Elev. 3• 4-Elev. Elev. 0 0 _ 0 0 1 1 1 1 Ties to Test Pits 2 2 2 2 3 3 3 3 4 5 6 4 5 6 7 8' 4 5 6 7 8 4 5 6 7 8 !SA �- f QED 2 9 9 9 9 Off`` 10 10 10 10 Benchmark Location Elevation Datum Percolation Tests -Date 6"7 Pit Number 1 2 3 4 S Start Saturation Soak -Mins. Start Test -Time 1 Drop of 3" -Time - Dro of 6" -Time Mins.lst 3"Dro Mins.2nd 3"Dro Notes & Sketches on Back ulLFACE aspos� OF LOT 1 SCOTT C o rC L E a � NORTH AN Do jCR MA, P R L PA.R..E-p F p R- 3 5 am TP 5T 3u����NUr4�v, MA, 0803 YST IGN RANK- C . GLL.1N.s.S ANo ASsoc%^.'TE.% E.NG4NL�RS AtNLD At-c-w1TLLTg NOi�T A,raaco, s-w-O-.-v.%c. pe, Rv NoR�rN 4,r+c> q p IM 4" aqs Tiny _0.1_9_la _ RcViSE,� AUCstisr/? )97a W DESIGN DATA 4 CAI`CU LA -TIONS `'S61LNOSSERVATIONS BY: Tom• 5WPf,QAIdb WITNESS L. PHILLIPS PERCOLAT tom -TEST NO. -1 2---- -- -3 -� 4 5 - DAT I -I Z2. 7 5110178 PITS , TOP-ELEV4TtoN 7.p 130.0 _ BOTTOM-ELEVA-tION —o, _0. - o-ov -- - - - - SA"TURA710M -MINS. GPD /PIT 600 GP D FLOW a-2. Ile _� . ��., no- Mo P - Mms . PARE PARENT SOIL 1t Z q .. _ 6aL./LIN.FT. G" D ROP - M ►Ns. — - C•'^O� GAL/ LIN. rte'. PE p- c.. RAZ E - M IW US2_�.F CTRA V GL 3QN y SOIL KoF%LE-DEEP 'P%T No. i 2. 3 4 5 DATE 5114 178 5110178 PITS , -TOP- EL_EVATION - - - /30.0 130.0 -TOPSOIL —o, _0. - o-ov -- - - - - _ _ _ _ 24L f0 GPD /PIT 600 GP D FLOW a-2. Ile _� . ��., no- 7R EN [ H as PARE PARENT SOIL 1t Z q .. _ 6aL./LIN.FT. ZOTTOM AREA LV') WATERTAALE S''9" C•'^O� GAL/ LIN. rte'. GPD w -- ���LW.Ft.a I`.F.TR>:NCNES REQ'D. US2_�.F CTRA V GL 3QN y S'-91. 7C� G(XAVCL 4 7'-6 " REFuSA L R+:rusa L Vo w,o-rEfZ NO wA-rfR. WATER TABt.E ELEVATION /22, 5 /e2,5 � �Z_�• 0 _ / 2 4.0 BOTTOM F-LEVATIO14 BU lLD1raG-T'YPE DWEt. - IM(, 4 a.R,,oR 'A / &AL. JUNIT = Coon GPD FLOW 600 GPD Flow X IS7w/*a 900 GPD USE 1000 GAL.S EPTtC-TANK LEA cH 1 NcT ARBA 61= fl FLAW Y, SF�Gro►�.= SF BED USE SF PITS , Type Mvi;t- MPti SNEA SHALLOW PITS W/Z'-00 57�NE j A�R�MEIMn S I DEWALL AREA : 816 3 SF x 1.83 CTAU%. j SF iS 7. 9.3 GPD BOTTOM AREA /09. ? SF x • 77 GALs./ SF =Z9.17 GPD -TOTAL PIT LEAC,HfNG CAPACITY _ _ _ _ _ _ _ _ 24L f0 GPD /PIT 600 GP D FLOW a-2. Ile PIPS RE4D . USE,�.3 _ PITS 7R EN [ H as SIDEWALL AREA .Fx. GALS ISF = 6aL./LIN.FT. ZOTTOM AREA LV') GALS/SF = GAL/ LIN.FT. -TOTAL 'MEKC+-1 ACNtNG CAPA�.IT�Y GAL/ LIN. rte'. GPD w -- ���LW.Ft.a I`.F.TR>:NCNES REQ'D. US2_�.F No,T Es: or- 'IT 11 FEE NUMBER THE COMMONWEALTH OF MASSACHUSETTS $25.00 �— TOWN ---------of ............. NQRTH..AND.QVZR------------ ............. This is to Certify that ......... Vi-e.r•ca... idR-11--CQompany------------------------------------------------------------ NAME 25.3.__Andover Street, ... Georgetown, ADDRESS IS HEREBY GRANTED A LICENSE For ....... Well•_Dr lling P_____L-•_cmittircle._-___......•..................... ----•-•-•--••---•--•.............••--•--.........•--•--•-•••-••--•-••----•-•--- -------------------------•---•--•--...--•--•---•------•------------------ o This license is granted in conformity with the Statutes a `orrdinai relating thereto, and expires --------Decem]De-r31 ---- ...... 1-9.9-3--------•�ss sooner ed o 0 -- v ...�ep temhar----15-,----•--•- 19....3 ...... ...... -- FORM 433 HOBBS & WARREN. INC. a Department of Environmental Management/Division of Water Resources WELL COMPLETION i - REPORT WELL LOC TION Address ,' GEOGRAPHIC DESCRIPTION I I -e°° City/Town (/eer/ SW of Well owner �%� f�/��arQ , 1-IC077—c,-C,/ //e/ /C GG�cJ� I✓ Address (road) Board of Health permit obtained: I^" re°tris/ Ic/rc/e/ yes no [] intersect. w/!/VEyQ(�f WELL USE WELL DATA road/ Domestic [ j Public E] Industrial El Total well depth -S'05' Monitoring 11 Other ft. Depth to bedrock �j 0 Method drilled TR Waler-bearing rock/un losnoc Baled material - Date Date drilled 3 —1,6 ' 9 Me,/ .� Description r I CASING Water -bearing zones: Type 37xce— -f�>? 1) From yi© -- To Siys' Length S'!o ft, Dia(.I.D.) G• In 2) From To Length into bedrock 3) From To Protective well seal: Gravel pack well: dia.. ( f Grout -0 _ Other De�ves1l, Screen: dia. Slot 0 _ length from STATIC WgTER LEVEL (all wells) —1O i Static water level below land surface _'��'-�_ ft Date WELL TEST r (l/p��oduction wells) own �' D l Drawd - �_It. ..after pumping. (' How measured&e6 T �hr.,min. at — Recovery %Oo oft. altergpm__ftr. • ` ��. LOG of FORMATIONS min. COMMENTS ' Materials"' From To p o Driller /,eA t Firm fAddress tl • Glfi� s,�-- t City/Town Supe ising it 'r' e #' • ..Please prim firm/ _ ^ - S - 3 Y rare o/ supervisln registered we// dr///er r.f BARD OF HEALTH COPY BOARD OF M"ALTH ` Town of North Andover,Mass. 1 �1 Date9/3 �S rmi t 2 APPLICATION FOR WELL & PUMP PERMIT plication is hereby made for permit to drill a well (-). Application is de to install (_) a pump system. Lot ## cation: Address �� p l Address()(��� Tel. finer / / Tel el S / !11 Contractor ��� / Address %fly / Contractor Address ���'}'�j���/� Te l imp Contra /V :LL CONTRACTOR (To be completed at time of pump test) 1pe of Well i�C� Well used for iameter of Well — Size of Casing 1<1 epth of Bed Rock Depth casing into Bed Rock /p No ( ) Date of Testing 9-ice 9 as Seal Tested? Yes (K)_ ��a� i Soso _. Well Ended in What. Material__Ea epth --af—�.,�-� — 11 Delivers �' Gals.Per Min. for 4 hours epth to Water_ Z Co feet after pumping y —hours- ,a hours- g GI'�t r a ve d ow n-__��_ -- 'ate of Completion S gnature 11e ntractor UMP INSTALLER (To be' filled in- before iIisua1.l.ati_on) Pump Type Used i ze & Name Pump _.___-.------ — -- ., later Pump DeliversP GPM Size of 'I•anlc -- ,Jpe Material Used in Well: Cast Iron (_) Galvrinized (_) Plastic (_l Jell Pit (_) or Pitless.Adapter (_) las sleeve used to protect pipe? Yes (_) NO(_) 1'ype or Name Well Seal_— )ate k �r iF 1F �t sir tF t�C �t �C�4�r�4�'��Fi4�'t�4�4t�r�M�'c�ki4�'t�'tt4tk�49r�4��t�t�4�r►4�4�'t�4�'rti'r�c'rti—'r54,'r�S'•;�,`;1�t,1ZG��)'.�;(�C �,:D�;��„���s�dtd+rtlr�4 date eater analysis report 'submitted to Board of llcalth_ Date release given tD owner of record & Bl.dg. Insp health Inspector ALLIANCE TESTING & CONSULTING 13 Hersam Street Stoneham MA 02180 4/11/94 Cheryl Dickerson One Scott Circle N.Andover MA 01845 REPORT Sample Date : 4/5/94 Sample Source: One Scott Circle Artesian Well - Lot #1 Reference: Standard Methods for the Examination of Water and Wastewater, 17th edition PARAMETERS CONCENTRATION Total Coliform 0 per 100 ml Chlorides 41 mg/L pH 6.7 Iron 0.14 mg/L Manganese 0.01 mg/L Sodium 19.7 mg/L Nitrates Less than 0.1 mg/L Nitrites Less than 0.1 mg/L Lead Less than 2.0 ppb Hardness 74 mg/L Alan Stevens,Chemist mg/L = parts per million ppb = parts per billion The results of these analyses meet federal and state standards for drinking water. { C, .�$ �liR.�AC1c, 1.11 S POS AL. of SCOTT O rC L E: NoRTK ANDovrP, , MA. P R EPAR.E� F oz S�Q'f`T PA, oPf:QT±F.- 5 lz &yTe R ST a.0 'S-1 Kl Cr TON , M A , 01803 IGN C. �QA!'►K- C • Cavu%.1NA4 Arty ASscoGUa."!'t�'� �tVCatNE.B.R'S Artp AR.C-"rris.c--r s N ORTN I�,Nj�pv R�s„R �i F.F iC�t� PARK. NOR'7t-t AtvO�v�.,ft,MA • O\84S r?4TF Tiny j,6 , q