Loading...
HomeMy WebLinkAboutMiscellaneous - 10 CROSSBOW LANE 4/30/2018---n o , cn0 cn CcnW b OZ o m V Q( 0, Lot & Street Map/Parcel CONSTRUCTION APPROVAL Has plan review fee been paid: YES NO Permit# Plan Approval: Date: Designer: Conditions: Approved by: Plan Date: Water Supply: Town Well Well Permit: Driller: Well Tests: Chemical Date Approved Bacteria I Date Approved Bacteria II Date Approved Plumbing Sign -Off: Wiring Sign -off: Comments: Form "U" Approval: Date Issued Conditions: Final Approval: Approval to Issue: YES By: All Permits Paid? YES NO Well Construction Approval? YES NO Septic System Construction Approval? YES NO Certification? YES NO Other? YES NO Any Variance Needed? YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: APPROVED BY: 1- CONDITIONS: Is the installer licensed? Type of Construction: New Construction: Issuance of DWC permit: DWC Permit Paid? DWC Permit # Begin Inspection: xcavation Inspection: Veeded: 8d R SEPTIC SYSTEM INSTALLATION YES NO NEW REPAIR Certified Plot Plan Review YES NO Floor Plan Review YES NO Conditions of Approval from Form U YES NO YES NO YES NO Sassed: By: construction Inspection: Deeded: ks Built Plan Satisfactory: 'ES: approval of Backfill: Date: 'final Grading Approval: Date: final Construction Approval: :ertificate of Compliance: Installer: Date:. By: Approval: Date: YES NO Cf NONTM ,� 5378 e F 9 Town of North Andover HEALTH DEPARTMENT ,s$wCHUStS CHECK #: DATE: LOCATION: H/O NA j CONTRACT A E: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title spector $ itle 5 Report ❑ Other: (Indicate) Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer NORTH 53'3 � - s Town of North Andover HEALTH DEPARTMENT ,SSACNU`+E4 CHECK #: DATE: LOCATION: H/O NA CONTRA Tp AME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Zle pector $ Report $J��. ❑ Other: (Indicate) Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer 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. rdb � ISI Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Asses, 10 CROSBOW LANE Property Address CHRISTOPHER AND KATHERINE TODOSCO 1.4"R - 5 4Oil .TH Owner's Name NORTH ANDOVER MA 01845 3/28/11 City/Town State Zip Code 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 1. Inspector: Benjamin C. Osgood, Jr. Name of Inspector none Company Name 16 Hillside Avenue, Unit 3 Company Address Amesbury MA 01913 Cityrrown State Zip Code 978-834-6585 870 Telephone Number B. Certification 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 � -', 6 /9 1 3/29/11 InspectoPs Signature Date The system inspecor 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. ****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. Owner information is required for every page. N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 CROSBOW LANE Property Address CHRISTOPHER AND KATHERINE TODOSCO Owner's Name NORTH ANDOVER MA 01845 3/28/11 CitylTown State Zip Code Date of Inspection B. Ge rtiliCation (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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): Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 CROSBOW LANE Property Address CHRISTOPHER AND KATHERINE TODOSCO Owner Owner's Name information is required for NORTH ANDOVER MA 01845 3/28/11 every page. Cityrrown state Zip Code Date of Inspection B. C e iiicativii (Cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ 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 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 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 CROSBOW LANE Property Address CHRISTOPHER AND KATHERINE TODOSCO Owner's Name NORTH ANDOVER Ree Cityrrown State B. edliiic-ation (Cont.) 01845 Zip Code 3/28/11 Date of Inspection 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 CROSBOW LANE Property Address CHRISTOPHER AND KATHERINE TODOSCO Owner Owner's Name information is required for NORTH ANDOVER MA 01845 3/28/11 every page. Citylrown state Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ Required pumping more than 4 tames in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ z Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El 0 Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® 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 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 systern considerer) a sign "int 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. Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0 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 N 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 forma 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 11 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 systern considerer) a sign "int 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. i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 CROSBOW LANE Property Address CHRISTOPHER AND KATHERINE TODOSCO Owner Owner's Name information is required for NORTH ANDOVER MA 01845 every page. Citylrown State Zip Code C. Checklist 3/28/11 Date of Inspection Check if the following have been done. You must indicate "yes" or'°no" as to each of the following: Yes No Z ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Z 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 NIA) Was the facility or dwelling inspected for signs of sewage back up? Z ❑ 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? Z ❑ 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. ❑ 0 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). Not Available Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 CROSBOW LANE Property Address CHRISTOPHER AND KATHERINE TODOSCO Owner Owner's Name information is required for NORTH ANDOVER MA 01845 3/28/11 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 4 Number of current residents: Does residence have a garbage grinder? ❑ Yes Z No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes '® No Laundry system inspected? ❑ Yes 0 No Seasonal use? ❑ Yes 0 No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No CURRENT Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: <C\' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 CROSBOW LANE Property Address CHRISTOPHER AND KATHERINE TODOSCO Owner information is required for every page. Owner's Name NORTH ANDOVER Cityrrown D. System information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: State 01845 Zip Code Date General Information 3/28/11 Date of Inspection Source of information: May 2010 per BOH records Was system pumped as part of the inspection? ❑ Yes Z No If yes, volume .pumped: gallons How was quantity pumped determined? Reason for pumping: 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): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 10 CROSBOW LANE v Property Address CHRISTOPHER AND KATHERINE TODOSCO Owner Owner's Name information is NORTH ANDOVER MA 01845 3/28/11 required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date linstalled (if known) and source of information: 27 Years old per Owner Were sewage odors detected when arriving at the site? ❑ Yes Z No Building Sewer (locate on site plan): Depth belowrade: 1.5" g feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pine OK in basement Septic Tank (locate on site plan): Depth below grade: 0. 5 Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, listage: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gallons Sludge depth: < 2" Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 CROSBOW LANE Property Address CHRISTOPHER AND (CATHERINE TODOSCO Owner Owner's Name information is NORTH ANDOVER MA 01845 3/28/11 required for, every page. City/Town 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 28" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 18„ How were dimensions determined? Measure Stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid 'levels as related to outlet invert, evidence of leakage, etc.): Tank in good condition. PVC tee in good condition Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping. Date Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 10 CROSBOW LANE Property Address CHRISTOPHER AND KATHERINE TODOSCO Owner information is required for every page. Owner's Name NORTH ANDOVER MA 01845 3/28/11 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural Integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 CROSBOW LANE Property Address CHRISTOPHER AND KATHERINE TODOSCO Owner Qwriar'$ Name information is required for NORTH ANDOVER MA 01845 3/28/11 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box in good condition. Distribution equal. No evidence of soilids carryover or leakage in or out. Box new in 2005. Box has flow levelers 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 CROSBOW LANE Property Address CHRISTOPHER AND KATHERINE TODOSCO Owner Owner's Name information is NORTH ANDOVER required for' every page. Cityrrown MA 01845 3/28/11 State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: leaching fields 1 field 15'X 45' 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.): Area of leach field looks normal. No evidence of ponding, damp soil, or unusual vegetation. 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 i Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow 0 Yes ❑ No I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 CROSBOW LANE Property Address CHRISTOPHER AND KATHERINE TODOSCO Owner Owner's Name information 'is NORTH ANDOVER MA 01845 3/28/11 required for every page Cityrrown 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.): Owner information lis required for every page„ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 CROSBOW LANE Property Address CHRISTOPHER AND KATHERINE TODOSCO Owner's Name NORTH ANDOVER MA 01845 3/28/11 &W own 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 feetAocate where public water supply enters the building. Check one of the boxes below: 0 hand -sketch in the area below ❑ drawing attached separately DISTANCeS 2—TA-u. Z7,S1 1- Ogori 43>3r t� h 2- D40 -x J� Vd HC>Q SC -riNlr, P -P p, D t 201 r F o Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 CROSBOW LANE Property Address CHRISTOPHER AND KATHERINE TODOSCO Owner Owner's -Name information is required for NORTH ANDOVER MA 01845 3/28/11 every page. CitylTown _ ---State Zip Code _ Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 5 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: 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: usgs maps You must describe how you established the high ground water elevation: System built in an area which was raised between 4 and 5 feet above adjacent area. Inspector present during original test pits when 2' water table was recorded. Before filing this Inspection Report, please see Report Completeness Checklist on next page. � r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments N 10 CROSBOW LANE Property Address CHRISTOPHER AND KATHERINE TODOSCO Owner Owner's Name information is required for NORTH ANDOVER MA 01845 3/28/11 every page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked 0 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 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Commonwealth of Massachusetts City/Town of S t Pin Record NORTH ANDOVE IVE E `,e 112013 Y ern U tYi p gf TOWN of NORTH ANDOVER Form 4 L 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. A. Facility Information 1. System Location: 05 Addrs City`'t'Town State Zip Code 2. System Owner: Name Address (if different frorh I cation CityJTown State Zip Code Telephone Number — B. Pumping Record / { 77 -� 2. Quantity Pum ed: D 1. Date of Pumping ate' - Y p Gallons 3. Type of system: ❑ Cesspool(s) Septic.Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): - — ,,,,��,�ff � 4. Effluent Tee Filter present? ❑ Yes/(�No if yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 11// 6. System Pumped By: Name � � 11?� _ 1..�r .,7✓ � r a Company 7. Location where contents were disposed: Si t uler nature of Recei ` ng Facility Vehicle License Number Date Date t5form4.doc• 03/06 System Pumping Record • Page t of t i' F DelleChiaie, Pamela From: DelleChiaie, Pamela Sent: Monday, March 28, 2011 11:39 AM To: Osgood, Benjamin C. Subject: I. R. -10 Crossbow Lane Attachments: 20110328112426427 Importance: High Hi Ben, Here is the scanned copy of the file for 10 Crossbow Lane that you requested. Pamela DelleChiaie Departmental Assistant I Community Development I Health Department Town of North Andover 1600 Osgood Street I Bldg 201 Suite 2-36 North Andover, MA o1845 2 Office - 978-688-9540 [ Fax - 978.688-8476 f Email - pdellechiaie(&townofnorthandover.com Website bM://www.townofnorthandover.com/Pages/index "We can never see the path of our life if we are too busy focusing on the pebbles under our feet. "--Anonymous IL 'Commonwealth of Massachusetts ` City/Town of System Pumping Record 11AY 25 2010 Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by focal 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. System Location: Left side e, Right side of house, Left front of house, Right front of house, Left rear, of house i ht rear of hous . Left rear of building. Right tear of building. Address j1 o / �G City/Town t, (� 2. System Owner: Name Address (if different from location) Cityfrown La-A-1� -AleState Zip Code Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) 0,8eptf6Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: i 1,A, 6. System Pumped By: Neil Bateson 7. Name Bateson Enterprises Inc _ Company contents were disposed: a ^ Lowell Waste Wf F5821 Vehicle License Number Date t5forrnUoc• 06103 System Pumping Reoord • Page 1 of 1 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the retum key. ®1�1 Commonwealth of Massachusetts Y City/Town of SEP p g 2008 System Pumping Record Fof'iifi 4 i OVJI F CSF 4Jf�F2_M At�3C)W7 �{ '/ ! 1'41 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 two. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Address L—/ Citydrown state rzip Code 2. System Owner: Name Address (if different from location) Cityl'rown State Code Telephone Number B. Pumping Record 1. Date of Pumpingmate 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 0 --No if yes, was it cleaned? ❑ Yes ❑ No 6. Condition of System: V\C)kA��� i $. System Pumped By: Name Vehicle License Number Company 7. Looatio ere contents disposed: Sion re a Bate WOM4.4100• 06103 System Pumping Record • Page 1 of 1 TOWN OF SYSTEM DATE: EM OWNER & ADDRESS Cros4ao Lv' G RECORD RECEIVED MAY 2 5 2005 TOWN Of NORTH ANDOVER HEALTH DEPARTMENT !STEM LOCATION (example: left front of house) 1-4 back ol` 6AS-e, DATE OF PUMPING: iQ' QUANTTTY PUMPED :l O� G ONS CESSPOOL: NO YES EPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACEMLD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D Nowell Waste Town of North Andover Office of the Health Department Community Development and Services Division 27 Charles Street North Andover, Massachusetts 01845 Sandra Starr . Public Health Direcfor TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE 8/15/2003 This is to certify, that Outlet Tee and Distribution Box constructed () or repaired (X) by Todd Bateson at 10 Crossbow Lane Telephone (978) 688-9540 Pax (978) 688-9542 has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. 4;�LaG�rasse Board of Health Inspector BOARD OF APPEALS 688-9541 BUILDNIG 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688 9535 TRANSMISSION VERIFICATION REPORT TIME : 07/13/2007 16:32 NAME HEALTH FAX 9766888476 TEL 9786888476 SER.# 00OW12096O DATE,TIME 07/13 16:28 FAX NO./NAME 813102559826 DURATION 00:03:33 RESULT OK MODE STANDARD ECM North-Andoxer Health D_epartmenr 1608 Osgood Street Building 20, Suite 2.36 North Andover, MA 01845 978.688.9540 - Phone 978.688.8476 — Fax hedltlide 't towno orthandover.toitn : E-mail www.townofnorthandoverxom - Website Letter of Transmittal L ge _/ of & /� FROM: Paimela 0e11001018, Health Deportment assistant W0 aro sending you: L7espy of l effor L] PAIns 17 Other Ifill %n helaw) These are transmitted as chocked below: A ©,Q,�vnred�N�l C1.QsIP�gr1 A C71lsRin�d ➢ I��or;Qgxvs�nr L7ArRvkwzdmnmw ➢ i-7&,vvw-& -- > Ghw*j* for 4"W > L7& *# w*firdo.. North Andover Health Department 1600 Osgood Street Building 20, Suite 2-36 North Andover, MA 01845 978.688.9540 - Phone 978.688.8476 — Fax healthde t(cDtownofnorthandover.com - E-mail www. towndnorthandover com - Website Letter of Transmittal Page -, of T0: � D ^ DATE: � �V (OMPANY: FROM: Pamela DelleChiale, Health Department Assistant Phone: Fax: We are sending you: D Copy of Letter rJP/ans D Other ff>/I in below) These are transmitted as checked below: ➢ L74Wmvdas#bW L7*A**sW ➢ - L7*A*" ➢ Car4i " ➢ L7%r&*wzdwfivtmvwmd REMARKS: COPY TO: COPY TO: COPY TO: SIGNED: ➢ MwA7o a*far ➢ L7&6%ri a sfhrAy.. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM W NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CF.RTYFYCATY0N Property Address: 10 Crossbow lime_ North Andover Owner's Name: _Carl Holmberg,,, Owner's Address: 1007 Parrs Ridge Drive _ Spencerville, MD 20868-9743_ Date of inspection: 8/15/2003 Name !of Inspector: Neil J. Bateson Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road Andover, Ma. 01818 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: { X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fail Inspector's Signature: Date: _8/15/2003_ The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. I ' Notes and Comments: After permit from B.O.H., installation of d -bog & outlet tee in septic tank, 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 fature under the same or different conditions of use. 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 Properity Address: 10 Crossbow Lane North Andover Owner's Name: Carl Holmberg_ Owner's Address: 10 Crossbow Lane North Andover, MA 01845 Date of Inspection: 7/812003_ Name of Inspector: Neil J. Bateson 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 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 X Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails 4— Inspector's Signature:&T24—Date: 7/8/2003_ 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 SU13SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Propeirty Address: 10 Crossbow Lane_ _ North Andover Owner: Holmberg_ Date of Inspection: 7/8/2003_ Inspection Summary: Check A B C,D or E /ALWAYS complete all of Section D A. System Passes: _ I'have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: _ X 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. Outlet tee in septic tank & D -Boa needs replaced. Answer yes, no or not determined MN,ND) in the for the following statements. If "not determined" please explain. N_ 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: N_ 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: N� The system required pumping more than 4 times a year due to broken or obstructed pipe(s). 'Ile system will pass inspection if (with approval of the Board of Health): _ broken pipe(s) are replaced obstruction is removed ND explain: Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) i Property Address: 10 Crossbow Lane —North Andover Owner:Holmberr Date of Inspectlow _7/8/2003 C. Further Evaluation is Required by the Board of Health: Conditions exist which require finthcr 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(I)(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 l l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _10 Crossbow Lane North Andover Owner,: Holmberg_ Date of Inspection: 7/8/2003 D. System Failure Criteria applicable to all systems: You must indicate "yes" or `ho" to each of the following for aA inspections: Yes No _ ­NcL Backup of sewage into facility or system component due to overloaded or clogged 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 less than %: 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 I of a public well. _ INoAny portion of a cesspool or privy is within 50 feet of a private water supply well. INCo Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water 7 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 S 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 `ho" 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 I 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 � of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST I Property Address: 10 Crossbow Lane —North Andover Owner: Holmberg — Date of Inspection: 7/802003 Check if the following have been done. You must indicate "les" or `!nf 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 ? N/A _ Were as built plans of the system obtained and examined? (If they were not available note as N/A) 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 ? 1� Yes_ _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the battles 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 _NIAL, _Existing information. No Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(6)] Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 10 Crossbow Lane _ North Andover Owner: jlolmbergSeero Date of Inspection: _802003 FLAW CONDITIONS RESIDENTIAL Number of bedrooms (design): NIA Number of bedrooms (actual): _4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): N/A Number of current residents: _5 _ Does residence have a garbage grinder (yes or no): No 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 readings: Yes_ Sump pump (yes or no}: No Last date of occupancy: _Current COMMERCIALIMUSTRU L Type of establishment: Design flow (based on 310 CMR 15.203): apd Basis of design flow (seats/persons/sgftetc.): 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): I GENERAL INFORMATION Pumping Records Source of information: Pumped once 26 days ago owner Was system pumped as part of the inspection (yes or no): No If yes, volume pumped: _1500_gallons -- How was quantity pumped determined? _ Reason for pumping: TYPE OF SYSTEM X Septic tank, distribution box, soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Altemative 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: _18 years old, owner _ Were sewage odors detected when arriving at the site (yes or no): No Page 7 of I l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _10 Crossbow Lane_ _ North Andover Owner: Holmberg_ Date oflnspection: _7/8/2003 BUILDMG SEWER (locate on site plan) X Depth 'below grade: I6" 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 to tank. 3 ii PVC in house; no leaks visible. SEPTIC TANK: X locate on site plan) Depth below grade: 3" 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_: 0" Distance from top of sludge to bottom of outlet tee or baffle: N/A Scum thickness: _0"_ Distance from top of scum to top of outlet tee or baffle: N/A N/A = Outlet tee corroded off In septic tank Distance from bottom of scum to bottom of outlet tee or baffle: —N/A11— How N/A"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.): _ Inlet tee ok. Outlet tee corroded off. 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: 18 Crossbow Lane _ North Andover Owner: Holmbergr Date of inspection: 7/8003 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade; Material of construction: conaete meta[ fiberglass polyethylene other(explain): Dimensions: Capacity: Gallons Design Flow: gallonstday 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.): DLS1`RIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: --l"— 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. Evidence of leakage, liquid level below inverts. Evidence of heavy carryover._ PUMP CHAMBER: (locate on site plan) Pump in working order (yes or no): _ Alarms in working order (yes or no): _ Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): �„ Page 9 of 11 OFFICIAL INSPECTION FORM -- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _10 Crossbow Lane North Andover Owner: Holmberg Date of inspection: 7/8/2003_ SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan, excavation not required) If SAS not located explain why: TYpe beaching pits, number: _ leaching chambers, number: ,leaching galleries, number: leaching trenches, number, length: _ X leaching fields, number, dimensions: 1 field 15' x 459 _ overflow cesspool, number: innovative/alternative system Typelname of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation oL No sign of ponding to surface. _ CESSPOOLS: (cesspool must be pumped as part of inspectionxlocate on site plan) I Number and configuration: Depth — top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 10 of I 1 OFFICIAL INSPECTION FORM -- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Crossbow Lane North Andover Owner: Holmberg_ Date of Inspection: 7/8/2003_ 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. Ato1=12'7" Ato2=19'9" A to D -Bog = 4314" B to 1= 2715" B to 2 = 3415" B to D -Bog = 46' 45' 1p Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Crossbow Lane _North Andover Owner: Holmberg_ Date of Inspection: 7/8/2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water > 6 feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: _ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: T Checked with local excavators, installers (attach documentation) X Accessed USGS database -explain; Essex County Soil Map You must describe how you established the high ground water elevation: _ Essex County Soil Map, Sheet # 31, Canton Soil, Water >6 Feet Deep._ Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES INC. i Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service 1 l i Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Addres • 10Crossbow Lane, North Andover Owner: Holmberg Date of Inspection: 7/8/2003 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. Ye'J. N Bateson Enterprises, Inc. � J F O � Fr - M W h r M •1 C9 w W v M Ci N i7 LA•�+s� N Ctf ID C*? N N micro soft h LA ch Lti1 OD ■C N ar .p Ln �Gt r h r h h r C7 hN. �Oo.Nh10'pODNN! LAW w � L(laachirTaoh.h.L'd■ofc I NhLAT r r T T m©OD aaaam©n LA LA LA0aahhhh ill LA N LM a Citi Ch C>ti C1` 1 ■ ■ f / / f ■ ■ ■ / f ! 1 i / 1 + a d © r r r r 1A LA 1A LA 01A LA. LA LA TTTr ©mno�,m©arm©mcandmerd a Mmb�N��tVstLAODhN©o0N1p LaJ • ■ ■ 1 1 •' LAC. 0T-r00NNm H hN tio00 IO LA asM ■C aT-mNLA LA0-dohlbhtor% iAv I rhaf� Lil Cr ry LN 0 W J } Ca NMMNNMNNNC�9NN©MNrco V-!U)C1�'bG�D®�' N N h Q O NC7MC+7L4)jfC' � LALJILALALAIO N?Kih I.rr PlCV N N N itilCV NN NN N N N N NN H w haD�►C9 rbMTLA a�Nr■LnstTO L NNl7C9MC0+i.N44LALLAAIALLAAL011b�cb � N N N N N N N N N N N N N N N N N A W OrN m 0D m 0D 1r r r r atc acccamsn" �vaa9922 Uzi C210000000000=00mm m V ®�MNCYC14 Mr*v—dNrrrr T©©m©0ro©elgIS, TN- ;Cmi 1,11 v IM"NC»TNN0 M 07 1-4 04CMM�9C� x rNM C.1rNC9 r+'7� 446164 11 1 1 1 1 1(! L I L I ©aaloadrr9rmrm219`1d`c�`a1ISa12 �1 dC16T�mmQda ca=CQaa'm1D= Lu N N N N N N N N N N N N N N N N N rcycoirLl) CN m 04CDT- NMsfLA%Oh w rr4-rrrrr or at, it . u 1 .. �R s.LQ 3 d to __`_t �r[•,= ..p rs:�• :�. ' to .1: _ �?y::-•:..:_. 2. t ./A' i T . ei►T : T i' EO bT Tnr DelleChiWe, Pamela From: Osgood, Benjamin C. [BOsgood@Pennoni.com] Sent: Sunday, March 27, 20118:56 AM To: DelleChiaie, Pamela Subject: 1 10 Crosbow lane Good morning Pamela, Would it be possible to send me a copy of the as built plan or any previous Title 5 inspections for 10 Crossbow lane. The file is old so there may not be much. Ben Benjamin C. Osgood, Jr., P.E. Sr. Engine i r PENNONI'ASSOCIATES INC. . Suite 120 ' Suite 201 100 Burtt Road 93 Stiles Road Andover, MA 01810 Salem, NH 03079 Tel: 978-749-9929 x 3712 Tel: 603-226-1950 Fax: 978-749-9920 Fax: 603-226-3235 Cell: 978-435-1324 Note: use the address 300 Ballardvale St., Andover, MA for mapping http:/Iwww.oennoni.com I bosgood@pennoni.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.see.state.ma.us/pre/Preidx.htm. Please consider the environment before printing this email. -CN Commonwealth of Massachusetts m City/Town of MAY 251010 a 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. System Location: Left sidese, Right side of house, Left front of house, Right front of house, Left rear of house,4f Ight rear . of hous Left rear of building. Right rear of building. Address City/Towh State Zip Code 2: System Owner: 1 � �Isc-o Name Address (if different from location) City/Town Stat -Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) [ c'Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of Syst em: � 1. 6. System Pumped By: Neil Bateson F5821 Name Bateson Enterprises Inc Company 7. Location where contents were disposed: C.LTD Lowell Waste Water of t5form4.doc° 06/03 Vehicle License Number Date System Pumping Record • Page 1 of 1 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. &I Commonwealth of Massachusetts FRF- NOCity/Town of Q g 200System Pumping RecordForm 4 NORTH ANDOVER DEPARVIENT 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. System Location: '�- Address "/�, ^�--Z-,^ } V\ Cityfrown State 2. System Owner. Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): �tScCD Zip Code State Zi Code �s�- S� Telephone Number Date 2. Quantity Pumped: Gallons Cesspool(s) eptic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes Q nro If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Ptdmped By: 7. Locatio ere contents we disposed: ,L . Vehicle License Number Date t5fomn4.doc• 06/03 System Pumping Record • Page 1 of 1 TOWN OF SYSTEM DATE: Lv b SYSTEM OWNER & ADDRESS -jfSco o G 046LI,a G RECORD RECEIVED MAY 2 5 2005 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT SYSTEM LOCATION (example: left front of house) -4 V,)Cia oi � CLA S--c- DATE OF PUMPING: (" QUANTITY PUMPED : 8 U GONS CESSPOOL: NO YES SEPTIC TANK: NO YES -.7 NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: 'GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER i FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D_ Dowell Waste Town of North Andover Office of the Health Department Community Development and Services Division 27 Charles Street North Andover, Massachusetts 01845 Sandra Starr Public Healtlz Director TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE 8/15/2003 This is to certify that Outlet Tee and Distribution Box constructed () or repaired (X) by Todd Bateson at 10 Crossbow Lane Telephone (978) 688-9540 Fax(978)688-9542 has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. LaGrasse Board of Health Inspector BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 TRANSMISSION VERIFICATION REPORT TIME 07/13/2007 16:32 NAME HEALTH FAX 9796888476 TEL : 9706888476 SER.# OOOB4J12O96O DATE,TIME 07/13 16:28 FAX NO./NAME 813102559826 DURATION 00:03:33 PAGE(S) 12 RESULT OK MODE STANDARD ECM I North Andover Health Denartment 1608 Osgood Street Building 20, Suite 2.36 North Andover, MA 81845 978.688.9540 - Phone 978.688.8476 — Fax healthdep�p,townofnorthandover.coin - E-mail wwvn .townofnorthandover.com - Website Fetter of Transmittal Page —Z _ of r' O' ��%.to DATE: ZOLI� COMPANY: FROM: DelleChiaie, Health Department Assistant Phone: r` 41 We are sending yore. D Copy of Letter ®Plans 0 Other jfill in helowj These are transmitted as checked below: > L74PnmNfacA / > 17AsRagr zW COPY TO:, i > G7&4ga W �_ L7A4r&1i4VnMiWnWW Q&raw& > 1.fik6irt.... . aprwf r 4pvni > L7sr qivhr&t DATE: ZOLI� COMPANY: FROM: DelleChiaie, Health Department Assistant Phone: r` Ii Fax: 92, 6 / c We are sending yore. D Copy of Letter ®Plans 0 Other jfill in helowj These are transmitted as checked below: > L74PnmNfacA / > 17AsRagr zW COPY TO:, i > G7&4ga W �_ L7A4r&1i4VnMiWnWW Q&raw& > 1.fik6irt.... . aprwf r 4pvni > L7sr qivhr&t G North Andover Health Department 1600 Osgood Street Building 20, Suite 2-36 North Andover, MA 01845 918.688.9540 - Phone 918.688.8476 — Fax healthdept(aD-townofnorthandover.com.- E-mail www.tbwnofnorthandover.com - Website Letter of Transmittal Page _ of 0? 0`�t4ev, '6'6ryO\ � eyy COCMIC aWKM T0: DATE: � & l% COMPANY: FROM: Pamela DelleChiaie, Health Department Assistant Phone: "1 / / / RE: Fax: cg)D. 49, 57, COPY TO: We ore sending you: O Copy of Letter O Plans O Other tfill in below) These are transmitted as checked below: ➢ L7*pvvedlasflloW ➢ L7*Rqt&d ➢ L7kr4Pivd ➢ L7&R&*wamYwnrsW ➢ Okrrowi* ➢ L7.Sr" a fw&t. REMARKS: COPY TO: COPY TO: SIGNED: COPY TO: 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 R7 CERTIFICATION �� -�4 i Property Address: _10 Crossbow Lane_ j North Andover_ Owner's Name: _Carl Holmberg_ ' Owner's Address: _1007 Parrs Ridge Drive-- _ Spencerville, MD 20868-9743_ Date of Inspection: _8/15/2003_ Name of Inspector: Neil J. Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, Ma. 01810 Telephone Number: j 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: _X Passes — Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fail Inspector's Signature: Date: _8/15/2003_ 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 IJEP. 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., installation of d -box & outlet tee in septic tank, inspection from B.O.A., 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. 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: 10 Crossbow Lane_ North Andover_ Owner's Name: _Carl Holmberg_ Owner's Address: _10 Crossbow Lane_ North Andover, MA 01845_ Date of Inspection 7/8/2003_ Name of Inspector: Neil J Bateson_ 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 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 _X Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: ate: _7/8/2003_ 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: 10 Crossbow Lane_ _ North Andover_ Owner: Holmberg_ Date of Inspection: _7/8/2003_ Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: _ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B! System Conditionally Passes: _ X_ 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. Outlet tee in septic tank & D -Box needs replaced. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. _ N_ 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: N_ 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: N_ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _10 Crossbow Lane_ _ North Andover — Owner; Holmberg_ Date of Inspection: _7/8/2003_ 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. I 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: 10 Crossbow Lane _ North Andover_ Owner: Holmberg_ Date of Inspection: _7/8/2003 D. System Failure Criteria applicable to all systems: You must indicate "yes" or `no" to each of the following for all inspections: Yes No No Backup of sewage into facility or system component due to overloaded or clogged 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 less than V2 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. __NoL 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 gld- You must indicate either "yes" or `oto" 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: 10 Crossbow Lane_ _ North Andover— Owner: Holmberg_ Date of Inspection: _7/8/2003_ if the following have been done. You must indicate "yes" or "no" as to each of the followin 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 ? N/A Were as built plans of the system obtained and examined? (If they were not available note as N/A) 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 —N/A—Existing Existing information. _No_ 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: _10 Crossbow Lane_ _ North Andover_ Owner: HolmbergSeero Date of Inspection: _7/8/2003_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): N/A Number of bedrooms (actual): _4_ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): _N/A_ Number of current residents: _5 Does residence have a garbage grinder (yes or no): _No_ 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 readings: Yes_ Sump pump (yes or no): No_ Last date of occupancy: _Current COMMERCIALANDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgft,etc.): Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): _ Non -sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: Pumped once 26 days ago owner Was system pumped as part of the inspection (yes or no): _No If yes, volume pumped: _1500_gallons -- How was quantity pumped determined? Reason for pumping: _ TYPE OF SYSTEM X Septic tank, distribution box, soil absorption system Single cesspool _ Overflow cesspool _ Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank _ Attach a copy of the DEP approval Other (describe): _ Approximate age of all components, date installed (if known) and source of information: _18 years old, owner _ Were sewage odors detected when arriving at the site (yes or no): _No • J Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Crossbow Lane_ North Andover— Owner: Holmberg_ Date of Inspection: 7/8/2003_ BUILDING SEWER (locate on site plan) X Depth below grade: _16"_ 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 to tank. 3 " PVC in house, no leaks visible. SEPTIC TANK: X locate on site plan) Depth below grade: _3"_ 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 depth0"_ Distance from top of sludge to bottom of outlet tee or baffle: N/A Scum thickness: _0" Distance from top of scum to top of outlet tee or baffle: _N/A N/A = Outlet tee corroded off in septic tank Distance from bottom of scum to bottom of outlet tee or baffle: _N/A"_ 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.): _ Inlet tee ok. Outlet tee corroded off. 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: 10 Crossbow Lane_ North Andover— Owner: Holmberg Date of Inspection: _7/8/2003_ TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass ,polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: --l"— 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. Evidence of leakage, liquid level below inverts. Evidence of heavy carryover._ PUMP CHAMBER: (locate on site plan) Pump in working order (yes or no): _ Alarms in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): _ Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Crossbow Lane_ _North Andover— Owner: Holmberg - Date of Inspection: _7/8/2003_ SOIL ABSORPTION SYSTEM (SAS): _X (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: _ leaching trenches, number, length: _ _X_ leaching fields, number, dimensions: —1 field 15' x 451 _ overflow cesspool, number: innovative/altemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): —Soil oL Vegetation oL No sign of ponding to surface. _ CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth — top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _10 Crossbow Lane_ _North Andover— Owner: Holmberg_ Date of Inspection: _7/8/2003_ 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. Ato1=12'7" Ato2=19'9" A to D -Box = 43'4" 1 Bto1=27'5" Bto2=34'5" B to D -Box = 46' Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Crossbow Lane- - North ane__North Andover— Owner: Holmberg - Date of Inspection: 7/8/2003_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water > 6 feet Please indicate (check) all methods used to determine the high ground water elevation: _ Obtained from system design plans on record - If checked, date of design plan reviewed: _ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: _ Checked with local excavators, installers- (attach documentation) X Accessed USGS database -explain: _Essex County Soil Map You must describe how you established the high ground water elevation: _ Essex County Soil Map, Sheet # 31, Canton Soil, Water >6 Feet Deep._ BATE S ON ENTERPRISES, INC. Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 10 Crossbow Lane, North Andover Owner: Holmberg Date of Inspection: 7/8/2003 Tel: (978) 475-4786 Fax: (978) 475-5451 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. Nei J4Bason Bateson Enterprises, Inc. 17 s . .. ... �. MNM#Ll1r.7NCrOMNNI-LA0.M: L' OC hG # N ©# LA 0 .0 r• I� r M1 M1 r M M1 N # -O CT N M1 +O K7 00 N L!1 r L4 C0 r Lt1 u t LA 04 00 NM1 T- W N . v .0 %0 I N N 0 j T T r r I ■o OP M W Q © © © © © © © Ll1 L6 U) LAC N P !. N I% N W 000vvvvvLllLnLf1Ll1©aao CT Q© LL ■ • . • r ■ ■ r ■ ■ ■ ■ ■ U M1 DQpDTTrT111L11L11LA©y1111Ll1Llt x':�..:..;' �; ■� vvv©vovvovvv©©vvv W . . . . . . . . . . . . . . . . ■ v v v v ©oLU v a v ©v v v a v v v W 0 r � • I 0NM4 0r#N#LMCCNN0CO N•0 O C+)00 C -TN© 1 00.0Ll1r 1"ODM1 N M W ■ . . ■ . . ■ . ■ . . r . ■ H M1N T�OCOTrOLA©MSO©rCTNMO. i r r r r C NMMNNMNNN0NN MN7"M ". iy O cm C7 y = CC N �',ii• a; W O H DD N M r O M r LA r ©N L11 r 0 r ©(� � 5, OOCCZ a0©M�GGo N0 f, --a OW0NU1M10 Igal EC.4 W NMMMM4## LltLAUL U1LAC%040M1 � j JI �• _ N N N N N N N N N N N N N N N N N 0 PL 1 W i::::r; . W ;iv: M M1 OONM 1--00rLAT0N w� N #a0©MCON111M1Q#NO©00NLAN. O ,..i: o !:;, © NNMMMM L11Lt, U1LALF, %O+o40 � N N N N N N N N N N N N N N N N N CCO©©©©rrrrNNNrNNMM = 'MR-- 0.00o0Q00©©©©OOQ wi •��.; O I W v.vvvvvvavvavvvvv© V w r N N N N N N N N N N N N N N N N tn rM1©©©■ON©lrlrTO•rNMMaO Oth LLI N% .� Cn a x ui•",ij:: i [- j Z I N ©© © d© r Co CM C Co cm N M W LIJ OL Oz i'i"' ;iS "" I v D MML'7MC•immC17MmmMCCMCF) MM O t �' :!'WI ►.t I rNM#TNM#rNM� O�rNM# s CL sa I W i I I I I I I I /,`,,.:,iii I J G1©O©rrrrNNNNNMM MM �r N 0 W I } ©Qv©©DQ©©©OO©©©©© Ui 0>' W NNNNNNNNNNNNNNNNN U�LMCN-W 00,04-NM4Ln-0M1 W ��` \ :...... .. y 18 Q) dLl CD cn a� CL x '''�r�,�l: o` - o w arLM s . Z :::.. T•d ebi:T1•EO bT 1nC Town of North Andover, Massachusetts Form No. 3 ,40RTH DISPOSAL WORKS CONSTRUCTION PERMIT CH Applicant �00 Z"�2anllyl '9- 4 NAME ADDRESS TELEPHONE Site Location /'�� Permission is hereby granted to Construct ( ) or Repair ( -��n Individual Soil Absorption Sewage Disposal System as shown on the Desi wl— e D.W.C. No. N OF NORTH ANDOVER BOARD OF HEALTH Location Permit # Food Service $ Retail Food $ Limited Retail $ Seasonal $ Disposal Works Installers $ Disposal Works Construction/ -14 Soil Testing $ Design Approval Permit $ Dumpster Permit $ Burial Permit $ swimming Pool Permit $ Animal Permit $ Recreational Camp Permit $ Well Construction Permit: $ Funeral Directors Permit $ Massage Establishment License $ Massage Practice License $ Suntanning Establishment $ offal/Trash Hauler $ Other $ Z, v/ 7 U 2 - Health Agent White - Applicant Yellow - Dept. Pink - Treasurer m cw:c 0 Z a yr ro N W v U a ani 01-4 {� � aaZ H a C v .vi N I 0c o a � a Z `\ j} G 9 > r +� .i +) V U U R 4JN x 3 v ro �4 �4 o) 0 �40 a v ro 0 w 33H w IZ� a •H o U a a p 0) m ` 0 > o a +) a v v 0 N o w a 9 �� �4 �4 ri N �4a rn a •r+ r O v 10 ro ro ro v a) C +) 0 v v H_t •rl +� !!� v N N H G 1) r -i •r1 r-1 ro U ro 0) 0) \ CD 4-)0 0 o tr N ro ro v �+ ro (0 1-( u ro ro •r+ N a 04 + -+ a s� v N N 4-)ro v U l4 O ro N N rl N U S1 1 C N N c w 41 O v O v •r+ v r ri o v 3 v v ro ro w �-1 aL GL4 % rQ N ❑ ❑ N ❑ ❑ CQ a 3 (� N O O I r DATE ar INCOME TAX SOC. SEC. STATE TAX NET AMOUNT /7-y(D ✓2 /Z t o > UCS DATE INVOICE AMOUNT 53-7119/2113 BATESON ENTERPRISES, INC. 7 318 ANDOVER, MA. 01810 PH: (978) 475-1474 FAX: (978) 475-5451 i PAY // ' ' d DOLLARS TIME WK'D DATE ar INCOME TAX SOC. SEC. STATE TAX NET AMOUNT /7-y(D ✓2 /Z t o (A UCS DATE INVOICE AMOUNT 53-7119/2113 BATESON ENTERPRISES, INC. 7 318 ANDOVER, MA. 01810 PH: (978) 475-1474 FAX: (978) 475-5451 i PAY // ' ' d DOLLARS TIME WK'D DATE TO THE ORDER OF GROSS AMOUNT INCOME TAX SOC. SEC. STATE TAX NET AMOUNT /7-y(D ✓2 /Z t o c o UCS FIRST ESSEX BANK, F.S.B. LAWRENCE, MA 01840 11,00 7 3 L8111 1: 2 1 13 7 L 19 L1: 5811140 L 5 L, 4111 2Ill t APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: 0'^ J) 03 CURRENT INSTALLER'S LICENSE# ' LOCATION: /d r'o SS L) Iry LICENSED INSTALJ^- _o40 �r��-e5�!✓ SIGNATURE: CHECK ONE: TELEPHONE# M ?)`- a 70­�? REPAIR: NEW CONSTRUCTION: IF NEW CONSTRUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. j -V Na&✓AM+ �C $ &_+00 Fee Attached? Foundation As -built? Administrative Use Only Yes IJ No Yes No Floor plans on filet Yes AJ4- No_ Approval i Date:j,�o V INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at ,Zd relative to the application i of /0VV C 'dated for plans by and dated with revisions dated I understand the following obligations for management of this project: 1.. As the installer I am obligated to call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item two shall be applicable. 2. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection,. without completion of the items in accordance with Tile 5 and the Board of Health Regulations may result in a $50.00 fine being levied against my company. a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As -built or verbal OK from engineer must be submitted to Board of Health, after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade — Installer must request inspection when all grading is complete. Does not have to be on site. 3. As the installer I understand that persons or companies not associated with my company may not perform the work required by my company to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the, system, " and/or revocation or suspension of my license in the Town of North Andover plus significant fines to all persons involved. 4. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached. b) Inspection of the sand and stone to be used. C) Final inspection by Board of Health staff. d) Installation of tank; D -box, pipes, stone, vent, pump chamber, retaining wall and other components. 5. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Licensed Septic Installer Date: Disposal Works Construction Permit # a