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Miscellaneous - 100 JOHNNY CAKE STREET 4/30/2018 (2)
11 N c O � ry 00 00 a 9 8 A U e on O 00 z o o z� a U p U O N L U � � °; :r o u a] a O O o uozo 6 aAv�3awH w o 0 A u z �cn a � a �r O L V .� x b as O 0 6 O � A 3AB M R z o z° C ° E N of ar CQ k N Q� 00 i 13 35 obi obi A m 0 0 1 N O\ s3 'r 0 O a, a 9 8 A U N O 00 z o o z� d O N L °; :r o u a] a c o 6 aAv�3awH w 0 A z �cn z �r as A �^ M R z o z° C ° E N ar CQ k T ,C v .r � c i 13 35 obi obi A m 0 0 1 N O\ s3 'r 0 O a, a 9 8 U N O 00 z o o d O N L o u a] 6 w 0 A z �cn �r as A �^ M o z° E N ar CQ k � c o c F � a U a A a Q c � � 0 O un d a � � 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: When A. General Information filling out forms Commonwealth of Massachusetts on the computer, Title 5 Official Inspection Form r�'H�L1Hl�tPai�„ENT DOVER key to move your Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Johnnycake Street Neil Bateson use the return Property Address key. William O'Mara Bateson Enterprises Inc. Owner Owners Name Company Name information is required for every North Andover MA 01845 11/18/2016 page. Cityrrown 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. Important: When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor - do not Neil Bateson use the return Name of Inspector key. Bateson Enterprises Inc. � Company Name 111 Argilla Road Company Address Andover MA 01810 City/Town State Zip Code 978-475-4786 SI -15 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 F rther Evaluation by the Local Approving Authority C 11/18/2016 It or Si ature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Johnnycake Street Property Address William O'Mara Owner's Name North Andover Cityrrown B. Certification (cont.) MA 01845 11/18/2016 State Zip Code Date of Inspection 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: After permit from B.O.H., install new d -box, inspection from B.O.H., septic system now passes Title 5 Inspection B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 PUBLIC HEALTH DEPARTMENT Town of North Andover Community and Economic Development Division CERTIFICATE OF COMPLIANCE As of: 11/18/16 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Repair of D -box By: Todd Bateson At: 100 Johnnycake Street Map 107A Lot 0198 North Andover, MA 01845 this cert' e s ,1 not bq-c49 rued as a guarantee that the system will function satisfactorily. Michele Grant Public Health Agent 120 Main St., North Andover, Massachusetts 01845 Phone 918.688.9540 Fax 978.688.9542 Web www.northandoverma.gov North Andover Health Department Community and Economic Development Division LOCATION INFORMATION ADDRESS:Todd Batesonke St. nyca INSTALLER. DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: MAP: 107.A LOT: 0198 INSPECTIONS D -box inspection:�(' � DATE OF BED BOON DATE OF FINAL CONSTRUCTION INSPECTION:: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan E] Existing septic tank properly abandoned, Internal plumbing all to one building sewer Topography not appreciably altered Comments: SEPTIC TANK F1 Building sewer in continuous grade, on compacted firm base Ej n Cleanouts per plan Bottom of tank hole has 6" stone base El Weep hole plugged 1500 gallon tank has been installed El H-10 loading monolithic tank construction has been achieved by Water tightness of tank visual testing Inlet tee installed, centered under access port i� Application for Septic Disposal System Construction Permit — TOWN W N OF TODAY'S DATE NORTH ANDOVER, MA 01845 $ 250,00'—Full Repair Spb - Component Application is hereby made for a permit to: Construct a new onsite sewage disposal system* ❑ Repair or replace an existing on-site sewage disposalsystem* tom �ir or. replace an existing system component — What? A. Facility Information �00 :zi Address or Lot #—t Cityrrown A',. &-Q RECEIVED 2: *TYPE OF SEPT SYSTEM*: NOV 1 5 2016lb� ➢ ❑ Pump ravity (choose one) ***If pump system, attach copy of electrical permit to application*" TOWN OF NORTH ANDOVER ➢ ❑ Conventional System (pipe and stone system) HEALTH DEPARTMENT ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.) ➢ ❑ Pressure Distribution S.A.S. (No D -Box) ➢ ❑ Pressure Dosed (D -Box Present) S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES = (no further info. needed) NO = (installer must specify brand of filter before DWC issuance) W Zwtis the Make? What is Me Mode.&,' 2. Owner Information Name /e") �Q-e P\ A A Y C,4 hk S4 Address (if different from above) j . K-S-�— Cityrrown 3. Installer Information yLfal--- . C) Le `-/ 5— State Zip Code °lib' �L--%-i—Ayei-3 Telephone Number �A 40 5 Name Name of Comp 11 f AES ER RLLA OAD , INC. . ANDoV€R ;yin f3i Address A� M,4, do t i v Cityrrown 4. Designer Information Name Address Cityrrown State Zip Code Telephone Number (Cell Phone # if posAble please) Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 PAGE 2OF2 A. FacilityInformation continued.... S. Type'of Building; esidentialDwelling or ❑Commercial B. Agreement ODAY'S DATE $.250.66.,- Full Repair $125.00; -Component The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system.In accordance with the provtslons of Title 5 of the Env/ronmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place;the system In operation until a Certlflcate of Compliance has been lssu Is Boar of Health. / • Name Date Applicatio ppr y: (Board of Health Representat/ve) Namei� "l Date ApplicationZapp'roved. for the following reasons For Office Use OMv 1 . . Fee Attached? Yes No 2.- ProoetArmlager Obligation Foy A ed? Yes 3.; Puma Svstem? Ifsoi Attach co, jly ofElecr►� No 4. F6undad6&As Built.? (hew construction -ronl ; No (Same scale as approyedplan) Y� Yes S. FloorMws? (hew coristructlon' only). Ye No_ i pi(catfon'torp(sp03al Systerit'0611 traction Permft � Paae 2 of 2 Mc IN�'!'�•�Rp' �►•�,��'•�OBZ,iGAi'IorTs As die•Nqrffi Andoveric=cdaitu� frsjr iia tc atntcpi�srfps•theaeptic sy►stapa st: 0 1 � � fo�.thapmp�y o % of /LA (A-1>-_ (Aof ) Farpun b3 R*W to ditappbmdo of (rAul s name Abd dined Dated�/— rf.l 17o p� I vadett;tRlld the fomm*g► 60IL"tlow fot > ag+cmcut of ibis pm jccC 1. As the Inst Ber, I om.obl�pW to abu& sIIper its snd`Bosrd ofHes� � Fbm� t �et6om�ittg sap:�c Qa a vitae. . di* theiaatitaitIet;.Iph*off smy sadaS�a: I£homoosvt:e psojectms> tge� cr srny t b� ]IC9w -atble mY �in � and the spste n is nottegck theitem 6myJo the .6. F�att"ein thecc at �rt�ea•notbave m b�p�scti�t• . _ i>�fttspatt � �-ice, ct+c. As -6w Dive" cil0ki ba >itiiha�it�ed•m .8c d of Hest, amt: •iadpn. !um4ledgm& Must xz 'I�amlisr inusr baprt<fo�r t,iaapa, s ; 4 A6qW6Al'W4at: bewidsble to . - C- `ednad p.tb �►ork s�idzo.. -,.. • : • - - .. . toot bkm #o be "tte. 4. As tie sastslier,'I �d t!»tenly I= ►ptsfannc c'�il6srt�a�r) I jai rxed ia afot4piete t1Yg na of tiaRe sysdet�i idP M4- HwXw�l.Rd%�i..i....:.�..7..:.� i:. �.C-.r...:�it�a:..l ... rL'•�r.ti i�..`a:,.. - _ �._ „tr • _ ,i• L _ r._ COM , s: Dea!�lna�amt thrrt.a6ftiep�pes�tkrsara�dea cift�e lQrr �',6� iaeoc� - _ . . ' .1� la�Pe�i%a Qftbe"grad xad� fav a9seaL ' • . . - • , ' - ' AslorrbpBoutetGiotTeAltatarAzA`'vttaao�ulft d In#m&9 A dfft* l]4kvg , ftAes "W4 P=P .; fiber, reft,.ft wgffm l oaff . • Ide �..ifwTrl�t� �t����� .•.+wiw.r.P»�w�'�����[bsoiire .. Underd Wised Satptic.� - • • : C�v4 �l ���—�� � e Mc IN�'!'�•�Rp' �►•�,��'•�OBZ,iGAi'IorTs As die•Nqrffi Andoveric=cdaitu� frsjr iia tc atntcpi�srfps•theaeptic sy►stapa st: 0 1 � � fo�.thapmp�y o % of /LA (A-1>-_ (Aof ) Farpun b3 R*W to ditappbmdo of (rAul s name Abd dined Dated�/— rf.l 17o p� I vadett;tRlld the fomm*g► 60IL"tlow fot > ag+cmcut of ibis pm jccC 1. As the Inst Ber, I om.obl�pW to abu& sIIper its snd`Bosrd ofHes� � Fbm� t �et6om�ittg sap:�c Qa a vitae. . di* theiaatitaitIet;.Iph*off smy sadaS�a: I£homoosvt:e psojectms> tge� cr srny t b� ]IC9w -atble mY �in � and the spste n is nottegck theitem 6myJo the .6. F�att"ein thecc at �rt�ea•notbave m b�p�scti�t• . _ i>�fttspatt � �-ice, ct+c. As -6w Dive" cil0ki ba >itiiha�it�ed•m .8c d of Hest, amt: •iadpn. !um4ledgm& Must xz 'I�amlisr inusr baprt<fo�r t,iaapa, s ; 4 A6qW6Al'W4at: bewidsble to . - C- `ednad p.tb �►ork s�idzo.. -,.. • : • - - .. . toot bkm #o be "tte. 4. As tie sastslier,'I �d t!»tenly I= ►ptsfannc c'�il6srt�a�r) I jai rxed ia afot4piete t1Yg na of tiaRe sysdet�i idP M4- HwXw�l.Rd%�i..i....:.�..7..:.� i:. �.C-.r...:�it�a:..l ... rL'•�r.ti i�..`a:,.. - _ �._ „tr • _ ,i• L _ r._ COM , s: Dea!�lna�amt thrrt.a6ftiep�pes�tkrsara�dea cift�e lQrr �',6� iaeoc� - _ . . ' .1� la�Pe�i%a Qftbe"grad xad� fav a9seaL ' • . . - • , ' - ' AslorrbpBoutetGiotTeAltatarAzA`'vttaao�ulft d In#m&9 A dfft* l]4kvg , ftAes "W4 P=P .; fiber, reft,.ft wgffm l oaff . • Ide �..ifwTrl�t� �t����� .•.+wiw.r.P»�w�'�����[bsoiire .. Underd Wised Satptic.� - • • : C�v4 �l ���—�� Commonwealth of Massachusetts 94mgmg� 1�9Ilk Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Johnnycake Street Property Address William O'Mara Owner Owner's Name information is North Andover MA 01845 11/8/2016 required for every page. Cityrrown State Zip Code Date of Inspection Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. -Q 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. DECEIVE® A. General Information Inspector: Neil Bateson NOV 15 2016 TOWN OF NORTH ANDOVER Name of Inspector V4 1WU Bateson Enterprises Inc. Company Name 111 Arailla Road Company Address Andover MA Citylrown State 978-475-4786 SI -15 Telephone Number License Number B. Certification 01810 Zip Code 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 Zr Conditionally Passes ❑ Fails ❑ Need . Further Evaluation by the Local Approving Authority c. 11/8/2016 Inspector Signat Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner -and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc - rev. 6116 Tine 5 Q'ficial Inspection Form: Subsurface Sewage Disposal System - Page 1 of 17 m Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Johnnycake Street Property Address William O'Mara Owner's Name North Andover Cityfrown B. Certification (cont.) MA 01845 11/8/2016 State Zip Code Date of Inspection 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): t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Johnnycake Street Property Address William O'Mara Owner Owner's Name information is required for every North Andover MA 01845 11/8/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): ❑ 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 FIND( Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Johnnycake Street Property Address William O'Mara Owner's Name North Andover Cityrrown B. Certification (cont.) MA 01845 State Zip Code 11/8/2016 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D -box needs to be re 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 Y day flow t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Johnnycake Street Property Address William O'Mara Owner owners Name information is required for every North Andover MA 01845 11/8/2016 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No E]® 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. El® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. El® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Johnnycak Property Address William O'Mara Owner Owner's Name information is North Andover required for every page. Cityrrown Street C. Checklist V LQLc —FJ vvuc 11/8/2016 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 600 t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Johnnycake Street Property Address William O'Mara Owner Owner's Name information is North Andover MA 01845 11/8/2016 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? I ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage 9 ( Y 9 (gPd))� Yes Detail: Sump pump? ® Yes ❑ No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? ❑ Yes ❑ No ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc - rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Johnnycake Street Property Address William O'Mara Owner Owner's Name information is North Andover MA 01845 11/8/2016 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont:) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: Date Pumped last year, owner 1500 gallons Measured tank Inspect tank & tees ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ® Yes ❑ No ❑ Shared system'(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Johnnycake Street Property Address William O'Mara Owfler Owner's Name information is required for every North Andover MA 01845 11/8/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Tank was replaced 2004, info at B.O.H., D -box & trenches 31 years old, 10/8/1985, as built plan Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: ® cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: 1.6 feet feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" Cast iron through wall, 3" PVC in house, no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal If tank is metal, list age: ❑ Yes ® No 0.6 feet ❑ fiberglass ❑ polyethylene ❑ other (explain) years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x5'x4' Sludge depth: 1" t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Johnnycake Street Property Address William O'Mara Owner Owner's Name information is required for every North Andover MA 01845 page. City/Town State Zip Code D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 11/8/2016 Date of Inspection 32" 2" 8" 13" Tape measure 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 ok. Depth of liquid at outlet invert. No evidence of leakage. Inlet cover has riser 3" deep. Pumed septic tank. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness ❑ fiberglass Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: feet ❑ polyethylene ❑ other (explain): Date t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Johnnycake Street Property Address William O'Mara Owner Owner's Name information is North Andover required for every page. Cityrrown MA 01845 State Zip Code 11/8/2016 Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins.doc - rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Johnnycake Street Property Address William O'Mara Owner Owner's Name information is North Andover MA 01845 11/8/2016 required for every page. Cityrrown 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.): D -box badly corroded needs to be replaced. D -box cover broken, replaced it. Evidence of solid carryover, pumped d -box to clean. No evidence of leakage. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts ti Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Johnnycake Street Property Address William O'Mara Owner Owner's Name information is required for every North Andover MA 01845 11/8/2016 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: 2 trenches 65' ®-- - __.-leaching- trenches__..__......_._..._ _ ._ .. _.---number;iength: - long ❑ leaching fields number, dimensions: ❑ 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 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 ❑ No t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Johnnycake Street Property Address William O'Mara Owner's Name North Andover MA 01845 11/8/2016 Cityrrown D. System Information (cont.) State Zip Code Date of Inspection Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts up Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Johnnycake Street Property Address William O'Mara Owner Owner's Name information is required for every North Andover MA 01845 page. Citylrown State Zip Code 11/8/2016 Date of Inspection Q. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately G � Parc�n D��-- S�� ,j2- (� a8`R a�36` 1-314 3,6, ( ,6,( t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Foran - Not for Voluntary Assessments 100 Johnnycake Street Property Address William O'Mara Owner Owners Name information is North Andover required for every. page. Cityrrown D. System Information (cont.) Site Exam: { ® Check Slope ® Surface water ® Check cellar ® Shallow wells MA 01845 State Zip Code 11/8/2016 Date of Inspection Estimated depth to high ground water: 4 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: 5/10/1984 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Design plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: As per test pit data on design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc - rev. 6/16 Title 5 Official Inspection Foran: Subsurface Sewage Disposal System - Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Street MA 01845 11/8/2016 State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc • rev. 6/16 Title 5 Official Inspection Form; Subsurface Sewage Disposal System • Page 17 of 17 100 Johnnycak Property Address William O'Mara Owner Owner's Name information is required for every North Andover page. Citylrown Street MA 01845 11/8/2016 State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc • rev. 6/16 Title 5 Official Inspection Form; Subsurface Sewage Disposal System • Page 17 of 17 y Summary Record Card generated on 111712016 2:25:50 PM by Karen Hanlon Town of North Andover Tax Map # 210-107.A-0198-0000.0 Parcel Id 18024 100 JOHNNY CAKE STREET WILLIAM OMARA JR MARIE OMARA 100 JOHNNY CAKE STREET NORTH ANDOVER, MA 01845 . Page 1 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1 Acres FY 2017 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until WILLIAM OMARA JR Owner MARIE OMARA 100 JOHNNY CAKE STREET NORTH ANDOVER, MA 01845 CARROLL, CHARLES Previous Customer Inactive 7/15/2004 100 JOHNNY CAKE STREET N. ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 13245.0 -100 JOHNNY CAKE STREET Last Billing Date 9/12/2016 2100182 02 Cycle 02 Active UB Services Maint. Account No. 2100182 Service Code' Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 464.50 /1 UB Meter Maintenance Account No. 2100182 Serial No Status Location Brand Type Size YTD Cons 36207190 a Active ERT HH b Badger w Water 0.63 0.63 1307 Date Reading Code Consumption Posted Date Variance 8/2/2016 1336 .Actual 90 9/21/2016 350% .5/3/2016 1246 aActual 20 6/21/2016 -8% 2/2/20.16 1226 a Actual 22 3/28/2016 -64% 11/2/2015 1204 aActual 59 12/30/2015 18% 8/4/2015. 1145 a Actual 51 9/14/2015 138% 5/4/2015 1094 a Actual 21 6/22/2015 -2% 2/3/2015 1073 a Actual 22 3/20/2015 -60% 11/3/2014 1051 aActual 56 12/15/2014 -39% 8/1/2014 995 aActual 86 9/11/2014 282% 5/5/2014 909 a Actual 23 6/12/2014 2% 2/4/2014 886 a Actual 24 3/17/2014 -48% 10/31/2013 862 a Actual 44 12/20/2013 -21% 8/1/2013 818 aActual 56 9/18/2013 94% 5/1/2013 762 aActual 26 6/18/2013 -10% 2/7/2013 736 a Actual 35 3/13/2013 -50% 10/30/2012 701 a Actual 62 12/13/2012 -28% 8/2/2012 639 a Actual 89 9/26/2012 172% 5/2/2012 550 a Actual 32 6/20/2012 -11% 2/2/2012 518 a Actual 37 3/14/2012 -35% 11/1/2011 481 a Actual 56 12/15/2011 -50% 8/1/2011 425 a Actual 110 9/14/2011 251% 5/2/2011 315 a Actual 30 6/13/2011 -1% 2/4/2011 285 a Actual 33 3/15/2011 -59% 11/1/2010 252 aActual 76 12/13/2010 -31% Commonwealth of Massachusetts City/Town of . System Pumping. Record Form 4 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 forrim 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/ Right front of house, Left/ Right rear of house, Left/ right side of house, Left/ Right side of building, Left / Right front of building, Left / Right rear of building, Under deck cityfrown A)-�- (� State Zip 2. System Owner. Name Address (if different from location) Cityfrown State Zip Code Telephone Number> s t , B. Puimping 1. Date of Pumping rd 3. Type -of system: ❑ ❑ Other (describe): pa{e 2. Quantity Pumped Cesspool(s) eptic Tank Gallons 1 ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yeas E_K0 If yes, was it cleaned? ❑ Yes ❑ Na' 5. Condition of System: A-0 r A�aJ )� � 6. System Pumped By: 7. Neil. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company contents -were disposed: t5form4.doa 06/03 - System Pumping Record • Page 1 of 1 North Andover Health Department fommunity and Economic Development Division 11/15/16 Address: 100 Johnnycake Street All North Andover Residents with Septic Systems and Garbage Disposals Please note that due to a recent review of a Title 5 Report, your property has been identified as maintaining a working garbage disposal that is being used in conjunction with a septic system. The Health Department is concerned for the longevity of your septic system. Garbage disposals are never recommended where septic systems are used, but if they are installed, the system must be specifically designed to handle the waste from them; your system can not handle the waste as designed. Please note that continued use of this disposal could quickly cause a pre -mature failure of your septic system, resulting in a large expenditure to replace it. The North Andover Health Department recommends that you remove it from your home as soon as possible. Some information regarding regular maintenance of your septic system is attached. Please call the Health Department at 978.688.9540 if you have any questions, or e-mail your questions to: healthdeptgnorthandoverma. gov. Thank you for taking the time to consider the impact that your current setup has on your septic system and the environment. FanSincely, aGrasse, CE Director of Public Health 120 Main Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web http://www.northandoverma.gov Commonwealth of Massachusetts RECE TED u City/Town of a System Pumping Record � S Z I11 Form 4 TOWN OF NORTH ANDOVER G.,M Sq J'y 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 front of house, right front of hous side of ho , right side of house, Left rear of house, right rear of house, left side of building, right rear of building, under deck. City/Town State 2. System Owner. Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ Zip Code StaSCD6, �r Zip Code Telephone Number 2. QuantityPumped. DateG Ilons Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ' ❑ Yes ❑ No 5. Conditio of System: 6. System Pumped By: Neil J. Bateson Name Bateson Enterprises Inc. Company 7. Loc n where contents were disposed: G.L.S. Waste Wa er n Signature F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts M City/Town of System Pumping Record, 2 6 2007 Form 4IAN �DDVER DEP has provided this form for use by local Boards of Healt'li:'EThe-System Pumping Record must be submitted to the ocal Board of Health or other approving authority. A. Facility Information Important: When filling out 1. Syst m Location: forms the ,i( computer, use C.J only the tab key Address to move your (� I^ cursor - do not use theretum cityrrown Statel Zip Code key. 2. System Owner: Name Address (if different fromaocation) CityfrownState Zip Cade Telephone Number / B. Pumping Record 1. Date- of Pum_Ping 2: Quantity' Date ty Pumped: Gallons 3. Type of system: ❑ Gesspool(s) .�ic Tank- ❑ Tight.Tank ❑ Other (describe*)! 4. Effluent Tee Filter present? ❑ Yes B If yes, was it cleaned? ❑ Yes `❑ No 5. Condition of System: Commonwealth of Massachusetts City/Town of System Pumping Record �Form 4 5 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 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. VQ re9rn 1. System Location: I -5� cs -- --- I o o City/Town 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Date Zip Code State _t� (� r ; e6Ktf Telephone Number 2. Quantity Pumped: l� Gallons Cesspool(s) ErSeptic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes No 5. Condition oSystem: r lj�� 91 If yes, was it cleaned? ❑ Yes ❑ No System r-j2 ,�y: Name �---� Vehicle License Number Company 7. Location ere cont w L, S 0 Ou Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Town of North Andover Office of the health Department Community Development and Services Division 27 Charles Street North Andover, Massachusetts 01845 Susan Y. Sawyer, RENS/RS Public Health Director 978.688.9540 - Phone 978.688.9542 - Fax CE1�7IFICA�IE OFCO�I�LIA�VCE As of: Apfil231 2004 ,This is to cert that the individualsu6surface dmposa(system repaired (,Y" - lank 12epfacement Only by Todd Oateson at 100 Yohnnycake Street North Andover 9KA 01845 has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover 0oard of %earth regulations. The Issuance of this certifwate shall not 6e construed as a guarantee that the system will function satisfactorily. Sdan ,: Sawyer, XE,,i PuRic Yfealth Director BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Commonwealth of Massachusetts Board Of Health North Andover Disposal Works Construction Permit Permission is hereby granted Todd Bateson to (Repair) an Individual Sewage Disposal System.�� Q/) y at No 100 JOHNNY CAKE STREET Map -Block -Lot 107.A- 0198 - Permit No BHP -2004-0348 FEE $250.00 -------------- as shown on the application for Disposal Works Construction Permit No. BHP -2004-034 Dated April_ 06,_ 2004 Issued On: Apr -06-2004 Board Of -HA ' Commonwealth of Massachusetts Map -Block -Lot 107.A- 0198 - Board Of Health -- ---------- -- ------- North Andover e" Certificate of Compliance.',� THIS IS TO CERTIFY,That the Individual Sewage Dispnal Sy tem (Repair) by Todd Bateson -- Installer at No 100 JOHNNY CAKE STRE&T' - ---- --------- -- ----- .-- --- ---------------- -------------- has been installed in accordance-oith the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal -Works Construction Permit No. BHP -2004-034 _ Dated _._April 06,-2004 -------------------------------------------------------- ---- Printed On: Apr -06-2004 Board Of Health Town of North Andover ✓�0 Health Department�� Date: Location: (Indicate Address,if Residential, or ame of Business) le/ Check #: V✓ Type of Permit or License: (Circle) ➢ Animal $ ➢ Dumpster $ ➢ Food Service - Type: $ ➢ Funeral Directors $ ➢ Massage Establishment $ ➢ Massage Practice $ ➢ Offal (Septic) Hauler $ ➢ Recreational Camp $ ➢ SEPTIC PERMITS: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ Septic Disposal Works Cotistrru''ction (DW`) Septic Disposal Works ler�� ❑ ffis a $ ➢ Sun tanning $ ➢ Swimming Pool $ ➢ Tobacco m $ ➢ TrashlSolid Waste Hauler $ ➢ Well Construction $ e ➢ OTHER: (Indicate) A 012 Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: 4--f-�)_ L/ CURRENT INSTALLER'S LICENSE# LOCATION: LICENSED INSTA SIGNATURE: TELEPHONE ` ` ?/`' ot X0 CHECK ONE: REPAIR: �, NEW CONSTRUCTION: IF NEW CONSTRUCTION(, PLEASE ATTACH FOUNDATION AS -BUILT. xv`� Administrative Use Only � $ .00 Fee Attached? Yes 'No Foundation As -built? Yes No a Floor plans on file? �Xes No Approval Date: ,. INSTALLER PROJECT MANAGE NT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at �Qp �Kd �`' G ��-Q �� ` relative to the application of AO –& l� dated �"5'd L� for plans by dated with revisions dated I understand the following obligations for management of this project: an( 1. As the installer I am obligated to call for any and all inspections. If homeowner, contra( project manger, or any other person not associated with my company schedules an inspec 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 applic� inspections as indicated below. I understand that requesting an inspection,. with completion of the items in accordance with Tile 5 and the Board of Health Regulations r 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 d first. Installemust 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 verbal OK from engineer must be submitted to Board of Health, after which installer calls inspection time. Installer must be present for this inspection. With pump system all electri 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 on site. 3. As the installer I understand that persons or companies not associated with my company m not perform the work required by my company to complete the installation of the syst( identified in the attached application for installation. I further understand that work by othe unlicensed to installseptic systems in North Andover can constitute reasons for denial of t of my license in the Town of North Andover pl system, and/or revocation or suspension significant fines to all persons involved. 4. As the Installer I understand that I must be on site during the performance of the f011ow- construction steps: elevation of the excavation has been reached. a) Determination that the proper 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 oth components. 5. As the installer I understand that I am solely responsible for the installation of the system s per the approved plans. No instructions by the homeowner, general contractor, or any othi persons shall absolve me of this obligation. Septic Installer01 �d Date: l `5 —'2 Works Construction Permit # 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: 100 Johnnycake Street `;� TOWiV OF NORTH ANt?G',`� F _North Andover_ BOARD OF HEALTH Owner's Name: _Charles Carroll Owner's Address: _100 Johnnycake Street _ 7 _North Andover, MA 01845_ ,AUC! Date Date of Inspection: 4/23/2004_ i J Name of Inspector: Neil J. Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, Ma. 01810_ Telephone Number: _( 978 ) 4754786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: _4/23/2004_ 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., install new 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. Town of North Andover Office of the Health Department Community Development and Services Division 400 Osgood Street K� °inn° North Andover, Massachusetts 01845 4SSACHUSS I Michele E. Grant Board of .Health Inspector Date: January 19, 2005 To: Mrs. Joan Potter From: Michele E. Grant North Andover Health Inspector Re: 100 Johnny Cake Street Dear Mrs. Potter, Telephone (978) 688-9540 Fax (978) 688-9542 On the morning of January 19, 2005, we received your complaint regarding an unusual amount of water flowing through your yard, as well as the property next door to you, 150 Johnny Cake Street. As you know, at your request, DPW was dispatched to the site to take a Water Sample from the wet area of concern. The Water Sample indicated "No Fluoride". As a result of the findings, that would eliminate Town Water as being a problem, therefore eliminating a Septic System problem. A site inspection was conducted by the Board of Health as well as the Conservation Department on the afternoon of January 19, 2005. We were unable to determine exactly what was causing the problem. A review of the records was conducted and found that the Water Table is 18" below the surface. There weren't any Ground Wells in the area. The plans also indicate that the Johnny Cake neighborhood is historically in a high water table and in very close proximity to the Wetlands. This being the reason Conservation inspected the site as well. We definitely recommend you speak to the homeowners of 100 Johnny Cake Street. They may be unaware of the issues. It appears that this problem has been ongoing for sometime now. It is obvious that there is a serious water problem and is turning this into a dangerous situation. We encourage all parties to come together to find resolution to this issue and seek out the problem to rectify. We are completely baffled by the amount of water in this area. In conclusion, to The Health Department's investigation the information derived from these inspections, points towards Ground Water or an Underground Pipe as being a possible source. The location is on private property therefore it is not in the Town of North Andover's jurisdiction to continue any further investigation, unless new findings are discovered by a Private Drainage BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 IiEAL'1-11 688-9540 PLANNING 688-9535 Specialist. It would be appreciated by the Health Department to be informed of any findings so as The Health Department may identify any future problems in the area. Please, if you have any questions, call me at 978-688-9540 Sincerely, �< Michele E. Grant North Andover Health Inspector Cc: Jack Sullivan Department of Public Works Pamela Merrill Conservation Dept Susan Sawyer Public Health Director N Andover Health Dept. 27 Charles Street North Andover, MA 01845 Tel. 978-688-9540 Fax 978-688-9542 facsimile transmittal To: Daniel Potter Fax: 1-781-272-2531 From: S. Starr Date: 6/14/2002 Re: 140 Johnnycake septic Pages: 1 CC: A Riley 0 Urgent 0 For Review 0 Please Comment 0 Please Reply 0 Please Recycle Mr. Potter, It is a fact that with the design engineer 1 inspected your site yesterday. I left a message on your answering machine requesting a scaled plan showing the layout of your sprinkler system. This plan should show the linkage of all lines and the exact positioning of the sprinkler heads. I cannot make any further comments on your site until I review this plan. Kindly submit it to the Health Department at 27 Charles Street as soon as possible. Thank you. Town of North Andover Office of the Health Department Community Development and Services Division 400 Osgood Street North Andover, Massachusetts 01845 Michele E. Grant Board of Health Inspector Date: January 19, 2005 To: Mrs. Joan Potter From: Michele E. Grant North Andover Health Inspector Re: 100 Johnny Cake Street Telephone (978) 688-9540 Fax (978) 688-9542 Dear Mrs. Potter, 1`G�f1S P On the morningof J, Sv our complaint regarding an unusual amount of Iwo p g gwater flowing throug (�A- �erty next door to you, 150 Johnny Cake Street. As you know, ,i %I latched to the site to take a Water Sample from the wet area of cc J Icated "No Fluoride". As a result of the findings, that would eli. - problem, therefore eliminating a Septic System problem. A site inspection was conducted by the Board of Health as well as the Conservation Department on the afternoon of January 19, 2005. We were unable to determine exactly what was causing the problem. A review of the records was conducted and found that the Water Table is 18" below the surface. There weren't any Ground Wells in the area. The plans also indicate that the Johnny Cake neighborhood is historically in a high water table and in very close proximity to the Wetlands. This being the reason Conservation inspected the site as well. We definitely recommend you speak to the homeowners of 100 Johnny Cake Street. They may be unaware of the issues. It appears that this problem has been ongoing for sometime now. It is obvious that there is a serious water problem and is turning this into a dangerous situation. We encourage all parties to come together to find resolution to this issue and seek out the problem to rectify. We are completely baffled by the amount of water in this area. In conclusion, to The Health Department's investigation the information derived from these inspections, points towards Ground Water or an Underground Pipe as being a possible source. The location is on private property therefore it is not in the Town of North Andover's jurisdiction to continue any further investigation, unless new findings are discovered by a Private Drainage BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 IIEALTI1 688-9540 PLANNING 688-9535 Specialist. It would be appreciated by the Health Department to be informed of any findings so as The Health Department may identify any future problems in the area. Please, if you have any questions, call me at 978-688-9540 Sincerely, Michele E. Grant North Andover Health Inspector Cc: Jack Sullivan Department of Public Works Pamela Merrill Conservation Dept Susan Sawyer Public Health Director TOWINTOF NORTH Y DATE.60-0i SYSTEM PUMPING SYSTEM OWNER & ADDRESS SYS po )reL lq6 �Ohnoy CoKe_ ST No, Q/Vno vet j w a - DATE OF PUMPING: 'ER tl) LOCATION QUANTITY PUMPED:__,/5�� CESSPOOL: NO__" YES Septic Tank: NO----- YES__ NATURE OF SERVICE: ROUTINE '-- �EMERGENCY OBSERVATIONS: GOOD CONDITION L"'FU�LL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLID CARRYOVEROTHER EXPLAIN System Pumped by /I Ct o COMMENTS, CONTENTS TRANSFERRED TO ^ c>?o "/—//- J�/_ os ca.CG0.11o�= Crime S 7' wct R,, C V r Ala / `` o ' /(r (L6 I- SO L4:;,Ik SJ EG67v 7i( 1 i 4 S e/NF_ /73 So North Andover man buys Haverhill mansion BY ANITA PERKINS STAFF WRITER HAVERHILL — A gated mansion on the banks of the Merrimack River was sold for half the $3 million asking price. A North Andover man purchased the luxury home sitting on five acres of land, considered Haverhill's priciest row of real estate. The house belonged to the late James E. Ricci, founder of Refuse Diels, according to real estate records with the Salem Registry of Deeds. Janice Furey of the listing agency Prudential, Howe and Doherty, de- clined to comment on any part of the sale or the reason for the lower selling price. "It was a great house. It sold and it's gone," she said. Charles A. Carroll,100 Johnny Cake St., North Andover, became the new owner as of Feb. 2. The house, built by Ricci in 1987, was assessed for $1.5 mil- lion. Real estate taxes on the property are $14,415 per year. Carroll did not return a message left at his North Andover home yesterday. The 11 -room house sitting on 218,000 square feet of land with a. spectacular view of the Merrimack River was marketed around the world and fea- tured on the prestigious Sotheby's Web site. The estate at 459 E. Broad- way was sold by Erica P. Ricci Thibault. James Ricci died last year at 58. He helped develop the concept of waste - to -energy and opened a plant at 100 Recovery Way in Ward Hill in 1982. The plant was later sold to Ogden Martin Corp. and is now known as Co- vanta Energy. Board of Health North AnP_ve.r3Ha.ae. SEPTIC SISTEM INSTAL ATIOM CHECK LIST CNED DATE DI SAPPHOVED DAT --- easvnss FAIL OK 'EXUMUTION Old ?AIL 0* 1. Distance Tot a. Wetlands . b. Drains c.. Well. 2. Water mine Location 3. No .'PC Pipe 4. Sex sic Tank a. ..lees -_Length & To Clean Oat Cowers ' b. .,'anent Pipe to Tank On Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. AU, Lin©s ' Flowing Equal Amounts c. No Back Flow 6. Leach Meld or Trench a. IN mansions b. Stone Depth c: Capped Ends • d. Clean Double -Washed Stone 7. LF -tch Pits. a. Dimensions b. Stone Depth c.. Sp".sh'Pads d. Tees e. Cement Pipe to Pit - Both Sides f. ,lean Double Washed Stone 8. No Garbage Disposal 9. •Fir al Grading Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System c. Location -with Regard -to Perc Test d. Elevations e: Water Table ORDER OF CONDITIONS: LOT 10 SALEM STREET a. Notice of Intent of Forbes Realty Trust/Prepared by Christiansen Engineering, Inc.,/Dated July 1, 1985/Eight (8) pages. b. Plan titled„ "Subsurface Disposal System" Lot 10 Salem Street, North Andover, NIA/Prepared by Christiansen Engineering, Inc./Dated April 30, 1985, revised June 25, 1985/Two (2) sheets, (1 of 3 and 2 of 3). 13. The NACC has determined that the plans submitted under this filing, and also under filings for lots 8,9,11,12,13 and 14, contained certain inaccuracies which make it difficult for the NACC to evaluate the proposed work, (i. -e. inconsistent delineation of wetlands and buffer zones). Therefore, prior to any work being done on this lot, the following shall be submitted to the NACC for its approval. a. Revised plans, drawn accurately, and to scale, so that the NACC can match the plans for all the above mentioned lots in order to determine the overall wetlands configuration, flow direction, and size. b. Or, one plan, combining all lots, with wetlands and buffer zone delineated, as well as houses, drives, and associated appurtenances. c. and a plan and calculations, showing how the applicant intends to decrease, or maintain at zero, the rate of runoff, for this individual lot. t d. Or, rather than item 13c, the appliant- may provide an overall plan and calculations, showing lots 8 - 14 (inclusive), and those measures which will be imployed to maintain at zero, or decrease, the change in the rate of runoff for the entire area (lots 8 - 14 inclusive). 14. Upon receipt of the above required information, the NACC, if necessary, shall issue, within 21 days, additional conditions necessary to adequately protect adjacent wetland areas. 15. The provisions of this Order shall apply to and be binding upon the applicant, its employees, and all successors and assigns in interest or control. 16. Prior to the issuance of a Certificate of Compliance, the applicant shall submit a letter to the Conservation Commission from a registered professional engineer certifying that.the work is in compliance with the plans referenced above and the conditions stated above. 17. ?,,embers of the NACC shall have the right to enter upon and inspect the premises to evaluate compliance with this Order of Conditions. 18. Accepted engineering and construction standards and procedures shall be followed in the completion of the project. Health SUBSURFACE DISPOSAL DESIGN CHECK LOTS AP OVPR ED DATE It-/ g,5 DISAPPROVED DATE Provided: Reasons: �o �jt XPi' Title V FAIL. Reg 2.5 The submitted plan must show as a minimum: a) the lot to be served-area,dimensions lot #,abutters blocation and log deep observation Mea -distance to ties c location and results percolation tests-Ltetance to ties d design calculations & calculations shoxi.ig required leaching area (e) location and dimensions of system-in.clu6ing reserve area f) existing and proposed contours (g) location any wet areas Atbin 100' of se nage disposal system or disclaimer -check wetlands mapping (h) surface and subsurface drains within 10Cof sewage disposal system or disclaimer (i) location any drainage easements with' :.11*1 of sewage disposal system or disclaimer -Planning Board filer (j) known sources of water supply within 2001 of aewage disposal e system or disclaimer (k) location of any proposed well to serve lot -1001 from leaching facility (1) location of water lines on property -101 from leaching facility (m) location of benchmark (n) driveways (o) garbage disposals (p) no PVC to be used in construction (q) profile of system -elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and Other elevations (r) maximum ground water elevation in area sewage disposal systems (s) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Reg 6 Septic Tanks (a) capacities -150% of flog, water table, tens, depth of tees, access, pumping (b) cleanout (c) lot from cellar wall or inground swimmir; pool - (d) 250 from subsurface drains Reg 10.2 Distribution Boxes (a) slope greater 0.08 Reg 10.4 b) sump ` Town Of Nort .Ando aer Office of the Planning Department joy Community Development and Services 27 Charles .Street North Andover, Massachusetts 01845 Heidi Griffin Maiming Director D1V1Si?#P� I R 200 OCTA H": TOWN OF SYSTEM PUMPING RECORD DATE: 5 SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) L, -k+ S�'�, C�-- VCUG DATE OF PUMPING: QUANTITY PUMPED: CESSPOOL: NO c/ YES SEPTIC TANK: NO YES NATURE OF 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: CONTENTS TRANSFERRED TO. GALLONS Commonwealth of Massachusetts P,")Massachusetts System Pumping Record System Owner Date of Pumping: a'— �� qq Cesspool: No [-�� Yes [I System Pumped by: V4&44W System Location loo \16 �Av\,A/4 Quantity Pumped: (' � gallons Septic Tank: No [ ] License # Contents transferred to: Greater Lawrence Sanitary District Date: Inspector: Yes R -- Commonwealth of Massachusetts /—). &4—Massachusetts System Pumping Record System -Owner System Location ,DCO Date of Pumping: Quaiilily Pumped: DOW—/gallons Cesspool: No � Yes LI Septic Tank: No Yes �i---� System Pumped by: L erredda Sil&M,64a ,d License # Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: 2 2 I'3 _- E ' C�tnttltntl�r�Nl�b ul' �Iasrtlrbusell� .� , Mass viol His 8(1s • Sj'llellt'U�rnu � � , ar , A V4 Date or 1110tnIIII10 1'rr LJ fiat�ll� '1'dal t f.M 11eo ta-1 eS o ►'� Lleeaee 01 ' System 1'011iped Ilrs Cuuletils.ltm�slettetl Ir! �-�' 1 � -�'' , Dnle Illsplclul . 1 i✓ 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: _100 Johnnycake Street _^ - � {/-% North Andover_ i0 Bof t Y-�� Owner's Name: _Charles Carroll Owner's Address: _100 Johnnycake Street_ _ North Andover, MA 01845_ VAR 9 Date of Inspection: 3/10/2004_ 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 4ai&,,,,. Inspector's Signature Date: 3/10/2004_ 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: _100 Johnnycake Street- - North Andover — Owner: _Carroll_ Date of Inspection: _3/10/2004_ 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. Septic tank needs replaced, outlet tee badly corroded & tank leaking. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. Y_ 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: _100 Johnnycake Street- - North Andover— Owner: _Carroll_ Date of Inspection: 3/10/2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance _ _ "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _100 Johnnycake Street _ — North Andover— Owner: _Carroll _ Date of Inspection: 3/10/2004 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 1/2 day flow. _No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped No Any portion of the SAS, cesspool or privy is below high ground water elevation. No Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. No Any portion of a cesspool or privy is within a Zone 1 of a public well. _ _No Any portion of a cesspool or privy is within 50 feet of a private water supply well. _No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] _No_ (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either "yes" or "no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ _ the system is within 400 feet of a surface drinking water supply — the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: _100 Johnnycake Street- - North Andover— Owner: _Carroll_ Date of Inspection: 3/10/2004_ 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 ? No Has the system received normal flows in the previous two week period ? No Have large volumes of water been introduced to the system recently or as part of this inspection ? Yes_ _ Were as built plans of the system obtained and examined? (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 _Yes_ _ 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: 100 Johnnycake Street_ r North Andover— Owner: _Carroll_ Date of Inspection: 3/10/2004_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): _4_ Number of bedrooms (actual): _4_ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): _600_ Number of current residents: _2 Does residence have a garbage grinder (yes or no): Yes_ Is laundry on a separate sewage system (yes or no): _ No_ Laundry system inspected (yes or no): Seasonal use: (yes or no): _No_ Water meter readings: —Yes _ Sump pump (yes or no): Yes_ Last date of occupancy: _Dec. 25, 2003 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 2003, owner _ Was system pumped as part of the inspection (yes or no): _No _ If yes, volume pumped: 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: _19years old, 10/8/1985, As built plan _ Were sewage odors detected when arriving at the site (yes or no): _No Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _100 Johnnycake Street- - North Andover— Owner: _Carroll_ Date of Inspection: 3/10/2004_ BUILDING SEWER (locate on site plan) X Depth below grade: _24" Materials of construction: _ cast iron _X_40 PVC _other Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): _4" Cast iron thru wall. 3" PVC in house, no leaks visible SEPTIC TANK: X locate on site plan) Depth below grade: _12" Material of construction: f_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 2"_ Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: _2"_ Distance from top of scum to top of outlet tee or baffle: _N/A N/A = Tank leaking out. Distance from bottom of scum to bottom of outlet tee or baffle: 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 badly corroded. Evidence of septic tank leaking, liquid 8" below outlet invert. _ 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 l l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _100 Johnnycake Street- - North Andover— Owner: _Carroll_ Date of Inspection: 3/10/2004 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: _0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.):_ D -box level & distribution equal ,has flow levelers. No evidence of leakage out of d -box. No evidence of solid carryover _ PUMP CHAMBER: _ (locate on site plan) Pump in working order (yes or no): Alarm in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _100 Johnnycake Street- - North Andover— Owner: _Carroll_ Date of Inspection: —3/10/2004 _ 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: _X leaching trenches, number, length: —2 trenches 65' long_ leaching fields, number, dimensions: _ overflow cesspool, number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): _ 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 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _100 Johnnycake Street _ _ North Andover— Owner: _Carroll_ Date of Inspection: 3/10/2004_ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _100 Johnnycake Street _ North Andover— Owner: _Carroll_ Date of Inspection: _3/10/2004_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water _ 41 _ Please indicate (check) all methods used to determine the high ground water elevation: X Obtained from system design plans on record - If checked, date of design plan reviewed: _5/10/1984_ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: _ Checked with local excavators, installers- (attach documentation) Accessed USGS database -explain: _ _ You must describe how you established the high ground water elevation: Design plan_ ro d II w a fA � • ,OO.r � •.. � � . 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Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 100 Johnnycake Street, North Andover Owner: Carroll Date of Inspection: 3/10/2004 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Bateson Enterprises, Inc.