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HomeMy WebLinkAboutMiscellaneous - 10 CROSSBOW LANE 4/30/2018 (2)s- Lot & Street *f ' Map/Parcel CONSTRUCTION APPROVAL Has plan review fee been paid: YES NO Plan Approval: Date: Designer: Conditions: Water Supply: Town Well Well Permit: Driller: Well Tests: Chemical Bacteria I Bacteria II Plumbing Sign -Off: Comments: Approved by: Plan Date: Date Approved Date Approved Date Approved Wiring Sign -off: Permit# Form "U" Approval: Approval to Issue: YES NO Date Issued By: Conditions: Final Approval: 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: CONDITIONS: Is the installer licensed? Type of Construction: New Construction: Issuance of DWC permit: DWC Permit Paid? DWC Permit # Begin Inspection: xcavation Inspection: Veeded: 'assed: ;onstruction Inspection: Deeded: \s Built Plan Satisfactory: 'ES: ipproval of Backfill: 'inal Grading Approval M( Ilk 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 Date: Date: inal Construction Approval: :ertificate of Compliance: 0 Installer: M 0 Date: By: Approval: Date: YES NO Gf NORTq 1M 5378 F = 9 Town of North Andover HEALTH DEPARTMENT ,SSACHUSt4 CHECK #: -- DATE: LOCATION: H/O NAil�'�.� p� 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 $ , —6v. 06 ❑ Other: (Indicate) I FAZ � * Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer ti 5 3/ E NORTH 1 Fi ��.r • 09 Town of North Andover HEALTH DEPARTMENT $ACMUSf CHECK #:ac u DATE: LOCATION: H/O NA CONTRA T� 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 5 pector $ itle 5 Report $U`� ❑ Other: (Indicate) Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer C Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assess ent s N" -5 toll 10 CROSBOW LANE TOWN 01: NMOTIJ AMMA Property Address HTRP'-- RI CHRISTOPHER AND KATHERINE TODOSCO Owner's Name NORTH ANDOVER City/Town MA 01845 State Zip Code 3/28/11 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. Important: I A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your I do Benjamin C. Osgood, Jr. cursor - not use the return Name of Inspector key. none Company Name 16 Hillside Avenue, Unit 3 Company Address Amesbury MA 01913 Cityrrown State Zip Code 978-834-6585 870 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 3/29/11 Inspect s 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. U ' t 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. Cityrrown State Zip Code B. Ge -1 iiCation (con It. 3/28/11 Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): 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. Cityrrown State Zip Code Date of Inspection B. Ge ��� iVatI (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 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. Citylfown State Zip Code Date of Inspection B. _.apt- _ atiOn (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or ❑ ® clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow 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. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ 0 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ M Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water duality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this forma ❑ 0 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 0 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 'vee 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. Commonwealth of Massachusetts . Title 5 Official Inspection Form of 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 C. Checklist 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 N/A) ❑ 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? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 Not }available DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 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. CitylTown State Zip Code Date of Inspection D. System information Description: i Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes 2 No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes 'Z No Laundry system inspected? ❑ Yes 0 No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: DCaURRENT Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): y (gpd) Gallons per da 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: 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 I Owner's Name information is required for NORTH ANDOVER MA 01845 3/28/11 every page. City/Town State Zip Code Date of Inspection ' D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Date Source of information: May 2010 per BOH records Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: 0 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 UTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 CROSBOW LANE Owner information is required for every page. Property Address CHRISTOPHER AND KATHERINE TODOSCO Owner's Name NORTH ANDOVER Cityfrown D. System Information (Cont.) MA 01845 State Zip Code 3/28/11 Date of Inspection Approximate age of all components, date installed (if known) and source of information: 27 Years old per Owner Were sewage odors detected when arriving at the site? El Yes ® No Building Sewer (locate on site plan): 15" Depth below grade: 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.): PIDe OK in basement Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 0.25 feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 1500 Gallons < Sludge depth: 2" ❑ 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 Owner's Name information is required for NORTH ANDOVER every page. Cityrrown MA 01845 State Zip Code 3/28/11 Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 2811 Scum thickness 0" Distance from top of scum to top of outlet tee or !baffle 611 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 iinvert, evidence of leakage, etc.): Tank in good condition. PVC tee in good condition Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Commonwealth of Massachusetts ID T1 J 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 Owner's Name information is required for NORTH ANDOVER every page. City/Town MA 01845 State Zip Code 3/28/11 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 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 gwner's Name NORTH ANDOVER MA 01845 3/28/11 City/Town State Zip Code Date of Inspection D. System Information (cont Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert a 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: Alarms in working order: ❑ Yes ❑ No ❑ 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 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 (coat.) 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 Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Commonwealth of Massachusetts IBRTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 CROSBOW LANE UVE 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 (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.): 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. CitylTown 3/28/11 state Zip Code Date of inspection D. System information (Cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below [j drawing attached separateiv �I DrsTAso &s �^ TA"jv, 2 — TA" V-, Z 1,5 � 1- 06Dri 43.3 )t G. Of IQ HovSr- y I" ROO i TA N K D--�3o� Zo t _ ---------7 a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 CROSBOW LANE Owner information is required for every page. Property Address CHRISTOPHER AND KATHERINE TODOSCO Owner's Name NORTH ANDOVER MA 01845 3/28/11 Cityrrown State Zip Code _Date of Inspection D. System Information (cont.) Site Exam: ® I Check Slope Surface water ® Check cellar ® Shallow wells Estimated de th to hi h round water 5 p g g feet Please indicate all methods used to determine the high ground water elevation: p 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. Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 CROSBOW LANE Property Address CHRISTOPHER AND KATHERINE TODOSCO Owner Owner's Name information is I 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 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 Commonwealth of Massachusetts - -�"�" " new City/Town of t .`, @ 2013 _ System Pumping Record NORTH AND4VE OWN OF NORTH ANDOVER Form 4 HEALTH DEPARTMENT DEP has provided this form fqr use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out 1. System Location: / forms the Q��JJJ11 computer, use only the tab keyAddr ss to move your (/,/� '� ` — 3 � _ Zip Code cursor - do not City own State use the return key. 2. System Owner: Name �° Address (if diffeeent front cation State Zip Code CItylTown Telephone Number B. Pumping Record J `_ -%-3 2. Quantity Pumped: on 1. Date of Pumping 5 -ie Galt 3. Type of system: ❑ Cesspool(s) Septic.Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yeso(No if yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 11// 6. System Pumped By: Name Vehicle License Number ompany 7. Location where contents were disposed: 5i t uter nature of Recei ng Facility 15form4•doc• 03106 Date.. -- --- --- -- Date System Pumping Record • Page t of t 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 C Email - ndellechiaieotownofnorthandover.com '16 Website hM://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 Commonwealth of Massachusetts`s `City/Town of 25 91 - System Pumping Record MY ?010 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 side e, Rlght side of house, Left front of house, Right front of house, Left rear. of house l ht rear of nous . Left rear of building. Right rear of building. Address cityrrown State Zip Code 2. System Owner: co Name Address (if different from location) city/rown Sia ip Code Telephone Number B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Date Cesspool(s) 2. Quantity Pumped 0-8ept!16Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: i VI"o 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc _ I Company 7. Location where contents were disposed: �.L.D A Lowell Waste Water F5821 Vehicle License Number ggjatute of Haug Date i t6form4.doc• 06/03 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. Commonwealth of Massachusetts City/Town of System Pumping Record ��� ���� u $ FOnYi 4 T av�c� �� rir�ts �I t�t��efc3v�_ hF4AOL i'r 1�cY Afi I I�JEN �„ - DEP has provided this form for use by local Boards of Health. other fortis 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 \ Cilyy/romm ( State Zip Code 2. System Owner: Name Address (ff different from location) Cityrrown stateDIS&-- t7Code Telephone Number T B. Pumping Record Q --Z) %- /,�; 1. Date of Pumping Bate 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) epfic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 2j"N`o If yes, was it cleaned? ❑ Yes ❑ No 6. Condition of System: 8. System Pumped BY: Name Vehicle License Number Company 7. Locatio ere contents ndisposed: ,L-<;�, Date t6fomn4.doc• 003 System Pumping Record • Page 1 of 1 TOWN OF SYSTEM DATE: & b SYSTEM OWNER & ADDRESS ���tSeo �o Cr ossWw Lvk G RECORD RECEI ED MAY 2 5 2005 TOWN OF NORThi ,010OVER HEALTH DEPARTMENT YSTEM LOCATION, (example: left front of house) It. � bact o � 6ut Sre, DATE OF PUMPING:;LIQ _ QUANTTPY PUMPED : ! p G ONS CESSPOOL: NO YESSEPTIC 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(EXPLAIli) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TR►NSFEx aD To: G.L.S.D__.V_ Rowell Waste Town of North Andover Office of the Health Department Community Development and Services Division 27 Charles Street North Andover, Massachusetts 02845 Sandra Starr . Pubiic 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 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 se tis€actorily. r . LaGrasse Board of Health inspector BOARD OF APPEALS 688.954I BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688.9540 PLANNING 688.9535 x TRANSMISSION VERIFICATION REPORT DATE,TIME FAX NO./NAME DURATION PAGE(S) RESULT MODE NorAAndover Health. Department 1600 Osgood Street Building 20, Suite 2.86 North Andover, MA 01845 978.688.4540 - Phone 978.688.8476 — Fax healtlideptD-townofaorthandover coin - E-mail www.town0northandaver.tom •Website TIME : 07/13/2907 16:32 NAME : HEALTH FAX : 9786888476 TEL : 9786888476 SER.# : 000B4J120960 07/13 16:28 813102559826 02:03:33 OK STANDARD ECM Letter of Transmittal [-Page_/ of fROM: If. %o cry W6 furs sending yov: O CORY Gfieffer ON= 0 dther1fi//in helow) These aro transmitted as chocked below: A f.74*mwdw paW > > 174 R*aw ➢ L'l�orRe vandmmn t ➢ 17WA04 d ➢ Urwrvu-& COPY Department Assistant > O rrot a*gfvr q"Hi North Andover Health Department 16000 sgood Street Building 20, Suite 2-36 North Andover, MA 01845 978.688.9540 - Phone 918.688.8476 — Fax heaithdeitC&-townofnorthandover.com • E•mali www.townofnorthandover.com • Website Letter of Transmittal Page of /,5-� o•,�iLI10 is .NOo _ ' Y*l ��9_ ca��«�w«« 4� T0: � t� D ..2.�� DATE: � / COMPANY: FROM: Pamela DelleChiale, Health Department Assistant Phone: "7 moi/ • / �s o� RE: ��.�2�� . Fax: O • o f b 5-' We are sending you: O Copy of Letter O Plans O Other ffill in below) These are transmitted as checked below: I 30. L7AWmWx#o&d ➢ L7As&pMW To: LAo4Pvmi ➢ L7AwA xews dmwmwt SIGNED: ➢ LAW&a w*for ➢ Osvr't ahsra0 t. 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 CFERTIFICATTON Property Address: 10 Crossbow Lane 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 I Bateson Company Name: Bateson Enterprises Inc._ Naffing Address: _111 Argiila 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: 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 DEL') 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 -box & outlet tee in septic tank, inspection from B.O.H., septic system now passes Title S 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 �*A1s`• 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 ArgiKe Road_ _Andover, Ma. 01810 Telephone Number: ( 978 ) 475.4786 i CERTIFICATION STATEMENT I certify that I have personalty 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 h 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 some or different conditions of use. i 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 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). 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 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 10 Crossbow Lane- -North ane_North Andover Owner: Holmberg_ Date of Inspectlon: _7/$/2003 i C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine ifthe 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. I _ 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. _ Ike 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: i Page 4 of 1 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: 7/812003_ 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 i 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, �I No Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. NoAny portion of a cesspool or privy is within a Zone 1 of a public well. No7 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 100000 gpd to 15,000 gpd. You must indicate either "yes" or `%d" 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 i the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area -- IWPA) or a mapped Zone Il of a public water supply well If you have answered' des" 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 Check if the followin have been done. You must indicate ` es" 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 ? N/A _ Were as built plans of the system obtained and examined? (If they were not available note as NIA) 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 ? I 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 NMA _ 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)(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: HoImbergSeero Date of Inspection: 7/8/2003 FLOW 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: _S _ 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 COMMERCIiAL/INDUSTRUL 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_fflllans -- 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 Page 7 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Crossbow Lane — North North Andover_ Owner: Holmberg, Date of Inspection: Y 2003_ BUILDING SEWER (Iocate on site plan) X I 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: JOL 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 NIA = Outlet tee corroded off in septic tank Distance from bottom of scum to bottom of outlet tee or baffle: _NIA" 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_ L 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.): DI,STRMUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: --111— Comments 1"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 PI7MP 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 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 of Inspection:7/8/2003 SOH, ABSORPTION SYSTEM (SAS): 1 (locate on site plan, excavation not required) i If SAS not located explain why: Ty 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/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, eta): Soil oL Vegetation oL No sign of ponding to surface. _ ESSPOOIS: (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 fiffure, level of ponding, condition of vegetation, etc.): PRIVY: (locate on site plan) I Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page l0 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 Inspectlon: 7/811003_ 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 - 4314" B to 1= 2715" B to 2 = 34'5" B to D -Boa = 46' 45' 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 ISO 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 >b Feet Deep._ Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service 1 l i Argilla Road Andover, Mass. 01810 j Tide 5 Inspection Report Property Address: 10 Crossbow 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. Ne' 34Bas.on& Bateson Enterprises, Inc. • f `• :ii:pc= :g ::ir•';;il�W1. F�- 0 73 ®M ion M®M M �ppj Microsoft �¢:t' ti .i3i:• Citi MNM LA s} NO. 9NNhLAat" MOO rO N W •Lt LA �d 49 t* h r h h r M !t N Jr .0 a N N +O "a pppp N LA r M 0 r LA U)MGOlrhroohh®.D 10 I NNLAr r e- r r h V� c�t 000000U. 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C*2 gat..gca t ••1 1 MC"3Mt*l0MMc+7 MC700 MMPI O rNM,7rrNCo V"CY r� CsrNM �! 1 LtJ 1 I 1 I rI CIS i I I 1 I I MI V s--' � f U 1010--ragg©©mQ04 C9 f 0 m©mmQl....bmvgm'Qmm a NNNNNCVNtVNNCVNNNNNN rl LA�ohOe7lOtNMsfU% L' r Ill - - .. � 3:' • � � ;; .;S IF� • . ,ti. _ Li,l .. ,••, • Js$ �` •O LIZ lil t-j"kI, i ei►i ; T T- co bT 1 n DelleChiaie, Pamela From: Osgood, Benjamin C. [BOsgood@Pennoni.com] Sent: Sunday, March 27, 20118:56 AM To: DelleChiaie, Pamela Subject: 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. Engineer 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://www.pennoni.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.sec.state.ma.us/ore/preidx.htm. Please consider the environment before printing this email. Commonwealth of Massachusetts City/Town of MAY 2 5 20i0 " � o a W 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 side se, Right side of house, Left front of house, Right front of house, Left rear of house ight rear of hoes . Left rear of building. Right rear of building. Address Co City/Town 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: State Zip Code Date ❑ Cesspool(s) ❑ Other (describe): Stateip Code Telephone Number 2. Quantity Pumped �ptic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition �of^System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: G. LiD n /, Lowell Waste Water Of F5821 Vehicle License Number Date t5form4.doc° 06/03 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. Commonwealth of Massachusetts City/Town of SEP o g 2008 System Pumping Record Form 4 TOWN OF NORP RTMEOT R HEALTH Dc 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:r� Address 'to City/Town Sttatee 2. System Owner: Name Address (if different from location) Tap Code City/Town State�'7 '� Z Code SCP&- 6 3- Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 13 No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. Systerp PiAmped By: Name Vehicle license Number Company 7. Locatio ere cont disposed: Sian re oVAa Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 TOWN OF SYSTEM DATE: SYSTEM OWNER & ADDRESS 0jf�co 60�6610 RECEIVED MAY 2 5 2005 TOWN OF NORTH HANDOVER HEALTH DEPARTMENT SYSTEM LOCATION (example: left front of house) -4 back 01 6LAS--e, DATE OF PUMPING: C QUANTITY PUMPED : 0 UGAL ONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE'OE SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONUNTS TRANSFERRED TO: G.L.S.D Lowell Waste Town of North Andover, kORTH of" I �1ti Office of the Health Department Community Development and Services Division 27 Charles Street North Andover, Massachusetts 0184.5 "SS,CHUSE�` 'Sandra Starr Telephone (978) 688-9540 Public Health Director Fax (978) 688-9542 TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE i 8/15/2003 This is to certify that Outlet Tee and Distribution Box constructed () or repaired (X) by Todd Bateson i at 10 Crossbow Lane i 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. VLaGrasse Board of Health Inspector i BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEAL-TH 688-9540 PLANNING 688-9535 TRANSMISSION VERIFICATION REPORT TIME 07/1312007 16:32 NAME HEALTH FAX 9786888476 TEL 9786888476 SER.# 000B4J120960 DATE,TIME 07113 16:28 FAX NO./NAME 813102559826 DURATION 00:03:33 PAGE S? 12 RESULT Olt: MODE STANDARD ECM North Andover_ Health Department 1600 Osgood Street Suilding� 20, Suite 2-36 North Andover, MA 01845 08.688.9S40 - Phone 978.688.8476 — Fax healthdeatotownofnorthandover.com - E,mail www.townofnorthandover.co - m Website 1 Letter of Transmittal Page —Z _ of p lift r �[ Re are sending you: 17 Copy of letter 0Pans 17Other (fill io below) These are transmitted as checked below: % 04*wwyar ➢ 47l ar4PvW > L7,QsRagl ➢ L7krv�,dmmn A aw ibow > ©rwYow-& Y 17ftz&# _. wear qvvMf > L7& a*,lr&t DATE: COMPANY:/ FROM: PAmein DelleChiaie, Wealth Department Assistant Phone: /• / RE: Fax: Re are sending you: 17 Copy of letter 0Pans 17Other (fill io below) These are transmitted as checked below: % 04*wwyar ➢ 47l ar4PvW > L7,QsRagl ➢ L7krv�,dmmn A aw ibow > ©rwYow-& Y 17ftz&# _. wear qvvMf > L7& a*,lr&t 0 North' Andover Health Department 1600 Osgood Street Building 20, Suite 2-36 North Andover, MA 01845 j 978.688.9540 - Phone 978.688.8476 — Fax healthdeptC&-townofnorthandover.com - E-mail www.townofnorthandover.com - Website Letter of Transmittal Page / of 1`5' g VkORT#t O�,�i�eo esq�'O F T0: DATE: 17 7' // & D /- / COMPANY: FROM: Pamela DelleChiaie, Health Department Assistant Phone: "1 / /• /�` RE: Ile Fax: �/O O%�J` ` l U� l0 We are sending you. O Copy of Letter O Plans O Other tfill in below) These are transmitted as checked below: ➢ agpproveidasNotaal ➢ atJsR ➢ a�Rd ➢ orar4a►ovd ➢ ararRe&*W daM7"ff ➢ arar rarrilm ➢ alPat" q*sfnr *PTW ➢ aSubait cad V;Nfbr&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 CERTIFICATION Property Address: _10 Crossbow Lane_ 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: ( 978 ) 4754786 � AUG 2 2 2003 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 � I/;AJInspector'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. Notes and Comments: After permit from B.O.H., installation of d -box & 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 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 if 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. I L1 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 I 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: 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 j 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 j 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 '/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.] I 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 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 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 North Andover Owner: Holmberg_ Date of Inspection: _7/8/2003_ 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 ? 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 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)] i 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 CONEVIERCIALANDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): P -pd 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 _k_'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): _ I 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 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: 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.): I 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 lin working order (yes or no): _ Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): _ Page,0 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, olmberg-_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/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. _ 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_ I SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Ato1=12'7" Ato2=19'9" A to D -Box = 43'4" 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 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. 4 Nei J. Ba son Bateson Enterprises, Inc. Cl EO trT inc 170 soft 401917"� 7(m micro f j o X 0N0.TLA4-.7NOra0 NNItiLt1O•M' y J MODb �N aIM-T.01-N r-N1�.TM all / rbtir�M1rb.©.Np ,0or U)M r. 64 y' W.. M W O©©©Oa©©L11 Ln LA Lrta I� tititi N w a©aa a 000000LA0 C•CNC,6. p U aL6 f� I ©aaarrrTLl1L11LALA0000LA ! J' W I. . . . . I 1 / / I / ■ ©©ao©va©©�-a©a©©© W 0 F- ; r MNC+O�U) UjCDNN©CaN.O I CC M GD CO T N a a' Ln C. © LA r T CD N N M W . . . . 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No. ",&// N OF NORTH ANDOVER BOARD OF HEALTH Location- 150 Permit # Food Service $ Retail Food $ Limited Retail $ Seasonal $ Disposal works Installers $ Disposal Works Constructionz-,4 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 $ 1,�w45 7026 Health Agent White - Applicant Yellow - Dept. Pink Treasurer Mr. N o� D x 0 �'• a Z1 a N ILN x N .o o O \ °i� Z A J4 -1Q) � a r. W° N v O u Q)i N r H M a r4 o 4 N 0 Q -4 3 P m 9 X > �� rj� U U A +.) N x ! a) ro � N 0) 0 N -H 0 H H � v ro U w -� o Q) 3 3 0 N � o � ro -) �+ +J ro � � •-+ a a s4 a s� � +� •� N � tT N > 0 rx +� a a) v o N Q w a ro 0 v o ro ro ro a) a) a; 4-) o a) v E+ i rl O O O ro 14 ro a) N ro ro ro S + ro 10 ro N a 04 a H rZ F �4 U 14 O 41 rg ro N N N F� �4 •4 •� U r G N N C W G 0 v O Q) a) r+ H 0 (1) �j �:l 3 z v a) ro ro :� W +1 a a w a a N Q 2 w Q Q m w FC a 3 w z N O O m 77 DATE TO THE ORDER OF GROSS INCOME SOC. I STATE NET AMOUNT WK'D AMOUNT TAX SEC. TAX a`�r-,13 z /0. — 17-a r\ A DATE INVOICE AMOUNT 53-7119/2113 BATESON ENTERPRISES, INC. ANDOVER, MA. 01810 7318 PH: (978) 475-1474 FAX: (978) 475-5451 PAYDOLLARS TIME DATE TO THE ORDER OF GROSS INCOME SOC. I STATE NET AMOUNT WK'D AMOUNT TAX SEC. TAX a`�r-,13 z /0. — 17-a I —l— 1 IWN FIRST ESSEX BANK, F.S.B. I AVtlnrKirr MA MRAn 1110073 L 8 111 1: 2 111 13 7 1 L9 1111: S 13 11, 1, 0 L5L, Loll 2 P NIP APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: CURRENT INSTALLER'S LICENSE# LOCATION: �d t'o 5.5 �,•v LICENSED INSTAL.£: o .2so`✓ SIGNATURE: CHECK ONE: TELEPHONE# REPAIR: NEW CONSTRUCTION: IF NEW CONSTRUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. AM + Administrative Use Only $196-00 Fee Attached? Yes V No Foundation As -built? Yes 4,J� No Floor plans on files Yes N� No Approval y- Date: �� otc INSTALLER PROJECT MANAGEMENT OBLIGATIONS i As the North Andover licensed installer for the construction of the septic system for the property ..relative to the application of IOVV% 4 0S : '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 fust 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