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Miscellaneous - 1010 JOHNSON STREET 4/30/2018
N u b o 0 0 V L z EnOz 64 g m 'm' o _ + m C1] L=J H t +14pTM , 7091 F=,• y • 09 Town of North Andover 'HEALTH DEPARTMENT ,SSACHUSt4 CHECK #:1](Pb DATE: LOCATION: 1v-&-mia-,- H/O NAME: f�x CONTRACTOR NAME:5MW 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 Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ Title 5 Report $ Other: (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Of. 0 TN 7091 . O Town of North Andover HEALTH DEPARTMENT / SSC U / CHECK #: DATE: LOCATION: Ah mn e H/O NAME: Lail, r CONTRACTOR NAME: 5mw ( E Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $- i '?� Title 5 Report $_ If �) C Other: (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer MEN Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. renin I r <)D, Commonwealth of Massachusetts l //,/W � Title 5 Official Inspection Forma Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1010 JOHNSON STREET Property Address PAULA COOKSON LAURIA Owner's Name N. ANDOVER City/Town MA 01845 04/21/2015 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. RECEIVED A. General Information Inspector: 8101 Ir1PITe11lf'1 Name of Inspector SOUCY'S SEWER SERVICE, INC. Company Name 78 NORTH BROADWAY Company Address SALEM City/Town 603-898-9339 Telephone Number B. Certification NH State 13397 License Number APR 2 7 2015 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 03079 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ N ed Further Evaluation by the Local Approving Authority i Signature V Date The system inspector shall subm4fa 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. t5ins • 3/13 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 1010 JOHNSON STREET Property Address PAULA COOKSON LAURIA Owner's Name N.ANDOVER CityfTown B. Certification (cont.) MA 01845 04/21/2015 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 se tic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, ex I its 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): STATIC LEVEL HALF WAY DOWN. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 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 1010 JOHNSON STREET Property Address PAULA COOKSON LAURIA Owner's Name N. ANDOVER MA 01845 04/21/2015 City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ® obstruction is removed ® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): ® 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 t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 1010 JOHNSON STREET Property Address PAULA COOKSON LAURIA Owner Owner's Name information is required for every N. ANDOVER MA 01845 04/21/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/ day flow t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 1010 JOHNSON STREET Property Address PAULA COOKSON LAURIA Owner Owner's Name nformation is equined for every N. ANDOVER MA 01845 04/21/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No El® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: E]® Any portion of the SAS, cesspool or privy is below high ground water elevation. El® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El® Any portion of a cesspool or privy is within a Zone 1 of a public well. El® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] i require ❑ ® 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. l5ins • 3/13 Title 5 Official Inspection Forth: 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 ,M 1010 JOHNSON STREET Property Address PAULA COOKSON LAURIA Owner Owner's Name quiretionis ed for every N. ANDOVER MA 01845 04/21/2015 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been donee, You must indicate "yes" or "no" as to each of the following: i require Yes No ® ❑ 11 0 El 0 ® ❑ ® ❑ ® ❑ ® ❑ ® ❑ ® ❑ ® ❑ ® ❑ 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): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 Yes No ® ❑ 11 0 El 0 ® ❑ ® ❑ ® ❑ ® ❑ ® ❑ ® ❑ ® ❑ ® ❑ 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): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1010 JOHNSON STREET Property Address PAULA COOKSON LAURIA Owner Owner's Name information is required for every N. ANDOVER MA 01845 04/21/2015 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: SEE ATTACHED Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: N ❑ Yes ® No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ® No ❑ Yes ® No 08/2014 Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1010 JOHNSON STREET Property Address PAULA COOKSON LAURIA Owner Owner's Name information is N. ANDOVER required for every page. City/Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: MA 01845 04/21/2015 State Zip Code Date of Inspection General Information Date Source of information: SOUCY'S SEWER SERVICE 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: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1010 JOHNSON STREET Property Address PAULA COOKSON LAURIA Owner Owner's Name information is N. ANDOVER required for every page. City/Town MA 01845 04/21/2015 State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1973 Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 16"feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): — Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal STATIC LEVEL APPROXIMATELY 28" 91 feet low -m=ono ❑ 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: Sludge depth ❑ Yes ❑ No t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1010 JOHNSON STREET Property Address PAULA COOKSON LAURIA Owner Owner's Name information is N. ANDOVER required for every page. Cityfrown t5ins • 3/13 State Zip Code 04/21/2015 Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 37" Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 22" Distance from bottom of scum to bottom of outlet tee or baffle 21 How were dimensions determined? TAPE AND SLUDGE TOOL Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK NEEDS REPLACEMENT 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 Title 5 Ofidat 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 �M 1010 JOHNSON STREET Property Address PAULA COOKSON LAURIA Owner Owner's Name information is required for every N. ANDOVER MA 01845 04/21/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): " Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 3/13 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 �M 1010 JOHNSON STREET D. System Information (cont.) MA 01845 04/21/2015 State Zip Code Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): BOX HIGHLY CORRODED, NEEDS REPLACEMENT. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Property Address PAULA COOKSON LAURIA Owner Owner's Name information is N. ANDOVER required for every page. CitylTown D. System Information (cont.) MA 01845 04/21/2015 State Zip Code Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): BOX HIGHLY CORRODED, NEEDS REPLACEMENT. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 1010 JOHNSON STREET Property Address PAULA COOKSON LAURIA Owner Owner's Name information is required for every N. ANDOVER MA 01845 04/21/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 900 SQ' ❑ 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.): NO SIGNS OF HYDRAULIC FAILURE Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1010 JOHNSON STREET Property Address PAULA COOKSON LAURIA Owner Owners Name information is required for every N.ANDOVER MA 01845 04/21/2015 page. Cityfrown 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.): t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1010 JOHNSON STREET Property Address PAULA COOKSON LAURIA Owner Owner's Name information is N. ANDOVER required for every page. City/Town MA 01845 State Zip Code 04/21/2015 Date of Inspection D. System Information (cont) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand -sketch in the area below ❑ drawing attached separately t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1010 JOHNSON STREET Property Address PAULA COOKSON LAURIA Owner Owner's Name information is N. ANDOVER required for every page. City/Town D. System Information (cont.) MA 01845 04/21/2015 State Zip Code Date of Inspection Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 6 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: ■ ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: DUG HOLE WITH AUGER IN REAR DROP OFF AREA. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1010 JOHNSON STREET Property Address PAULA COOKSON LAURIA Owner Owner's Name information is required for every N. ANDOVER MA 01845 page. City/Town State Zip Code E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked 04/21/2015 Date of Inspection ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information — Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 y Summary Record Card generated on 12/31/2014 10:38:38 AM by Karen Hanlon Town of North Andover Tax Map # 210-107.A-0137-0000.0 Parcel Id 17964 1010 JOHNSON STREET COOKSON, ROBERT W. 1010 JOHNSON STREET N. ANDOVER, MA 01846 Page 1 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.1 Acres FY 2015 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until COOKSON, ROBERT W. Payor 1010 JOHNSON STREET N. ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 13255.0 - 1010 JOHNSON STREET Last Billing Date 12/3/2014 2100311 02 Cycle 02 Active UB Services Maint. Account No. 2100311 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 3.80 A UB Meter Maintenance Account No. 2100311 Serial No Status Location Brand Type Size YTD Cons 13242722 a Active ERT HH METE METE w Water 0.63 0.63 275 Date Reading Code Consumption Posted Date Variance 11/3/2014 520 aActual 1 12/15/2014 -67%u 8/4/2014 519 aActual 3 9/11/2014 -22% 5/7/2014 516 aActual 4 6/12/2014 -40% 2/4/2014 512 a Actual 7 3/17/2014 31% 10/31/2013 505 aActual 5 12/20/2013 -26% 8/2/2013 500 a Actual 7 9/18/2013 -9% 5/1/2013 493 aActual 7 6/18/2013 0% 2/5/2013 486 a Actual 8 3/13/2013 -50% 10/31/2012 478 aActual 14 12/13/2012 22% 8/7/2012 464 a Actual 13 9/26/2012 105% 5/3/2012 451 a Actual 6 6/20/2012 -23% 2/2/2012 445 a Actual 8 3/14/2012 -40% 11/1/2011 437 aActual 13 12/15/2011 17% 8/2/2011 424 a Actual 11 9/14/2011 17%u 5/4/2011 413 a Actual 9 6/13/2011 47% 2/7/2011 404 aActual 7 3/15/2011 -78% 11/1/2010 397 aActual 29 12/13/2010 -14% 8/3/2010 368 a Actual 34 9/13/2010 240% 5/4/2010 334 a Actual 10 6/9/2010 -16% 2/2/2010 324 aActual 12 3/11/2010 6% 11/2/2009 312 aActual 11 12/11/2009 -12% 8/5/2009 301 aActual 13 9/11/2009 12%u 5/4/2009 288 a Actual 11 6/16/2009 5% 2/5/2009 277 a Actual 11 3/16/2009 11% 11/5/2008 266 aActual 10 12110/2008 -8% 8/4/2008 256 a Actual 11 9/12/2008 12% 5/2/2008 245 a Actual 9 6/18/2008 -16% 2/6/2008 236 a Actual 12 3/14/2008 -68% 11/2/2007 224 aActua1 36 1/15/2008 125% 10 i I � , I n ©g�eF•YA.T1�4,1.. 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S� 9 *i, �' - �''' 1 � "'� a .. r J,,�y .: -� ' s- S �-f ,:� 's -f k.: e� .Se "fir #.* r;. t � `y. t !t'° -'4' - e �,�•, �.yc �>'"�.+" R u 'F> � 7 �". ",� Y r �,.,. �� t *tom, .a �• faOr e rs t. rkc .Tt s `� it �� � • � t°-#. "f 'i`OD tN s r—c t �`t.f'".d''�•'�cke0-- 'rn�., r e,w.x-<r Al 41 IN r CONSERVATION DEPARTMENT Community Development Division September 13, 2006 Mr. Robert Cookson 1010 Johnson Street North Andover, MA 01845 RE: SITE INSPECTION -1010 Johnson Street, North Andover, MA Dear Mr. Cookson, This letter has been prepared to document my inspection on Monday, September 11, 2006 at the above -referenced property. The purpose of the inspection was to investigate the activities that were being conducted and to also identify the location of the adjacent wetland resource area. It is my understanding that you are building a retaining wall along the left side of your house where the walkout basement door is. You will do all the work, by hand. It was noted that dirt had been recently excavated and is stockpiled along the existing tree line. This is the only machine work that need to be done. Furthermore, it was determined that the wetland area is located about 85 -feet from the limit of work. As discussed, any work proposed within 100 -feet of a jurisdictional wetland resource area must be preceded by the appropriate application filing (whichever is appropriate) before the North Andover Conservation Commission (NACC), per MA Wetlands Protection Act-M.G.L. c.131, §40 and the North Andover Wetlands Bylaw (C.178 of the Code of North Andover). In addition, the NACC enforces a 25 -foot No Disturbance Zone and a 50 -foot No Build Zone from the edge of a wetland resource. Due to the proximity of the edge of the wetland and the limit of work, as well as the existing topography, this department will, not require. you to obtain a permit for the construction of the retaining wall. However, you will be required to install erosion control along the edge of work and soil stockpiling area to contain the material from migrating towards the resource area. The location of the erosion control was identified with you during our onsite meeting. Please feel free to contact me should you have any questions or would like to go over any items outlined in this letter. Thanking you in advance for your anticipated cooperation with this matter. Respectfully, Pamela A. Merrill Conservation Associate 1600 Osgood Street, Building 20, Suite 2-36, North Andover, Massachusetts 01845 Phone 978.688.9530 fox 978.688.9542 Web www. hitp://www.townofnorthandover.com/(onservel.htm L Q, Et .00 91FICK PAD f � 3 Rel c tR�6 I DECK 50too i�G FZ 00 EYP Form No. 4 Town of North Andover, Massachusetts BOARD OF HEALTH CERTIFICATE OF COMPLIANCE This is to certify that the Individual. Soil Absorption Sewage Disposal System constructed ( ) or repaired ( ) by '=-+ $- %. at (f C> cji<. 5 cs-VNJ SITE LOCATION has been installed in accordance with Board of Health Regulations as described in the Design Approval Site System Permit No. dated 19 The issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. BOARD OF HEALT ENGINEER r 140 Ali C4 VI llz� Zh SILL M' cu L P't M-1 "rO LIE r-*",*,� ic Ll 1104-- H 0 c lot. PIT ylvrt[r)' i�,jk~t.���,-�7►r� �= ~- oo IA r o N .�Ha,•.}...-;/?rr!L /tet..: �. JfijC ' (� Ar 1 rl•,II K✓�t�•1aOC%�-.�ti.C� 1 pk-u 1�7-1 � -E i I V tF*n[ /JOT E_: ltii- m owe 44( £ ✓I: .o,4.. -o✓ G t nf'/d J -e ": ,rte 'r o _� . 5'3. 14, CC P_),,rc cp•cr }uCL 7o EL f0 Z•/>;,. F,C c J$� !j,£rn..•vP .8�0. S7,*a r- otosC -rte 1 ry 13Yz rpt _ _ or J, ,� j 10114 �v / ��� � �.�A. ��� E'er, SOIL �F •� SA�,,by Sia rulz+l Y,0f> ftiCaL/�!`,os, %'ATE G•$+�,N�/<Sl j w4rzm I . I oo IA r o N .�Ha,•.}...-;/?rr!L /tet..: �. JfijC ' (� Ar 1 rl•,II K✓�t�•1aOC%�-.�ti.C� 1 pk-u 1�7-1 � -E i I V tF*n[ /JOT E_: ltii- m owe 44( £ ✓I: .o,4.. -o✓ G t nf'/d J -e ": ,rte 'r o _� . 5'3. 14, CC P_),,rc cp•cr }uCL 7o EL f0 Z•/>;,. F,C c J$� !j,£rn..•vP .8�0. S7,*a r- otosC -rte 1 ry 13Yz rpt _ _ or J, ,� j I is to jo(w5otv 11-1 N, 4 c o� NORrH qti � OCL �� fT `SSA C HUSH PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 5/18/15 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Repair of Tank and D -Box By: John DiVincenzo At: 1010 Johnson Street Map 107.A Lot 0137 North Andover, MA 01845 (suance of this certificate :loll not be construed as a guarantee that the system will function satisfactorily. Michele Grant Public Health Agent 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Commonwealth of Massachusetts . --- . City/Town of North Andover System Pumping Record Form .4 M DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important When filling out forms 1 on the computer, use only the tab key to move your cursor - do not use the return key. 2 System Location: �/�\ k(�\' Address V�'�-+�r,='�i� -- -• North Andover Cityrrown State System Owner: Name Address (if different from location) City/Town State ----------- JULRECEIVED 13 2015 TOWN Opp �WANDOVEK j jE. LTH DEpj RTt0ENT Zip Code Telephone Number B. Pumping Record 1. Date of Pumping pate Quantity Pumped: Gallons — 3. Type of system: ❑ Cesspool(s) N(Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: If yes, was it cleaned? ❑ Yes ❑ No 6. System Pumped By: Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts W City/Town of North Andover W° System Pumping Record Form 4 GSM Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. teb DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from tftin accordance with 310 CMR 15.351. A. Facility Information 1. System Location: Address North Andover TOWN OF NORTH ANDOVER HEALTH DEPARTMENT City/Town State Zip Code 2. System Owner: � t� Name Address (if different from location) City/Town State Telephone Number B. Pumping Record /57 1. Date of Pumping pg Date q/ , d uay p 2. Qu Pumped 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: H Zip Code Aa~()D Gallons ❑ Grease Trap If yes, was it cleaned? ❑ Yes ❑ No i Vehicle License Number 'Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant. 20 So. Mill Bradford. Ma 01835 Signature of Hauler Signature of Receiving Facility Date Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 Blackburn, Lisa From: paulaluria@comcast.net Sent: Wednesday, May 20, 2015 4:06 PM To: Blackburn, Lisa Subject: 1010 Johnson Street To Whom It May Concern, am Paula Cookson Luria, co-owner of the home at 1010 Johnson Street in North Andover, MA. Would you be so kind as to send the Certificate via email to me at paulaluria(aD-comcast.net. Would you also send the paper certificate to me at 63 Pratt Street in Lunenburg, MA 01462. Sincerely, Paula Cookson Luria i sw� V, North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 1010 Johnson St. MAP: LOT: INSTALLER: John DiVencenzo DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: I i INSPECTIONS r j I O 3D yl TANK INSPECTION: 111 ! (�( DATE OF BED BOTTOMINSPI DATE OF FINAL CONSTRUCT, DATE OF FINAL GRADE IN SPI i mvn SITE CONDITIONS � r n � i Comments: SEPTIC TANK ■❑ In plan I er Building sewer in continuous grade, on compacted firm base Cleanouts per plan Bottom of tank hole has 6" stone base Weep hole plugged 1500 gallon tank has been installed H-10 loading Monolithic tank construction Water tightness of tank has been achieved by visual testing Inlet tee installed, centered under access port V, North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 1010 Johnson St. MAP: LOT: INSTALLER: John DiVencenzo DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION:111 DATE OF BED BOTTO INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: SEPTIC TANK ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan [ Bottom of tank hone has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base Comments: CONTROL PANEL Comments: DISTRIBUTION -BOX Comments: ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Installed on stable stone base H-20 D -Box Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets Observed even distribution Speed levelers provided (not required) Schedule 40 PVC Pipe CO0OMDOw8altMassachusetts Map -Block -Lot 107.AO137 ----------------------- [][]F���/\�T�� BOARD ^ ^ Permit No oHp-201e*187 North Andover --------' P.|.FEE F.I. ----------------------- DISPOSAL ___�1us�oO_ ���� CONSTRUCTION ��|���K�� ~�'"~�" ~~~�"_.~~ ~~~~.~~~~� �~'~~.~~~~.~~~~_..-�~~ PERMIT Disposal System. u1No lUlUJ(}}{l�S(]�JSTl��ET �\� ^�_^��- ---�'—'----''—''-----'—''-----�\'°~----'^-'-'�"~,"-'°--_----.--________ uoehovwzootbuupp6uu1ioutorDiopoau|\foikxC0000ncioo9ennitINo. .13IlP'20157018 Dated --- Mayl2]0l5___ -- [F:1 _._------.-- Iaeued0u: Muy'|2'2Ol5 ARD OF HEALTH ............................................................................................ 1010 JOHNSON STREET Department: North Andover BOARD OF HEALTH ......................................................................................... Fee Type: DWC-Component Repair PERMIT ......................................................................................... Paid By: John DiVincenzo ......................................................................................... Received By: Lisa Blackburn ......................................................................................... DEPARTMENT'S COPY L..................................................................................................... .................................................................... Reference No: BHJ-2015-000022 ................................... Permit No: BHP -2015-0187 ................................... Account No: 1001001.1.5.0510.00 .................................... Receipt No: REC-2015-001534 .................................... Paid in Full On: Tue May 12,2015 .................................... Check No: 14321 ................................... Amount: $125.00 ................................... .. .. ... :::::*,: .......... j p10 R Y.y O A • / • SSA C HU`�E ' Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. rad �I ! Al TODAY' DATE $ 250.00 - Full Repair $125.00 - Component Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system" Repair or replace an existing on-site sewage disposal systep3p� Repair or replace an existing system component -What?t�- A. Facility X Informatioon-- // j 0 A.-) so � I� Address or Lot # City/Town 2.- *TYPE OF SE IC SYSTEM*: ➢ ❑ Pump Gravity (choose one) —If pump stem, attach copy of electrical permit to application— ➢ Conventional System (pipe and stone system) ➢ ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.) ➢ ❑ Pressure Distribution S.A.S. (No D -Box) ➢ ❑ Pressure Dosed (D -Box Present) S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter?. YES = (no further info. needed) NO = (installer must specify brand of filter before DWC issuance) What is the Make? What is the Model. 2. Owner Information Name Address (if different from above) City/Town Email address State Zip Code ephone Number 3. Installer Information Name Name / Name of Company C [� S"J G/ 7F hG�l 0M Dr, l %� Addre City/Town State Zip Code 779- �d.7-- 5�5)� Telephone Number (Cell Phone # ifpossible please) 4. Designer Information Name Name of Company Address City/Town State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 • Ft,�"Application for Septic Disposal System Construction Permit -TOWN OF TODAY'S DATE NORTH ANDOVER, MA 01845 $125.00 Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: Milesidenfial Dwelling or ❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Envir nmental Code, as well as the Local Subsurface Disposal Regulations for the Town of Norlb der, rider and that until a final Certificate of Compliance has been issued by thi B rd f H a h, a installed system is not approved. - J j2 me Date r Application Approved By: (Board of Health Representative) Name Date Application Disapproved for the following reasons: For Office Use Only: 1. Fee Attached.? 2. Project Manager Obligation Form Attached.? 3. Pump Sys tem? If so, Attach copv of Electrical Permit Applicant received copy of "Electrical Inspection Notes for Septic Systems" Handout. 4. Reviewed approvalletter, all paperwork received. S. Foundation As -Built. (new construction only): (Same scale as approved plan) Yes No Yes No Yes No Yes_ No Yes No Yes No 6. Floor Plans? (new construction only): Yes No Application for Disposal System Construction Permit • Page 2 of 2 .; SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer f r the construction for the septic system for the property at: 1016 hm n�,_ , (Address of septic system) For plans by Relative to the application of <=\/l✓+ y ����.! �leV (Installer's name) And dated Dated sl l L�-' o ay s ate With revisions dated I understand the following obligations for management of this project: (Engineer) rigina ate (Last revised date) 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner, contractor, project manager, or any other person not associated with my company schedules an inspection and the system is not ready, .then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that reauesting an inspection. without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or my company. a. Bottom of Bed — Generally, this is the first (15) inspection unless there is a retaining wall, which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection — Engineer must first do their inspection for elevations, ties, etc. As -built of verbal OK (or e-mail to: healthdel2t@to-,vnofnorthandover.com) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a 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. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation) and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the systern and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. 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 or consultant. d. Installation of tank, D -Box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. 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. Undersigned Licensed Septic Installer: (To y's ate) 6l� � � � 1 �l 1✓C' e �-' ame — Print) ,Fame — Signed) TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD D A 1 1:: � /01-6a S1 STEM OWNER & ADDRESS 66) 6J9 SYSTEM LOCATION (example: left front of house) OF PUMPING: QUANTITY PUMPED/iO,00 GALLONS CI'S SPUUL; NO YES SEPTIC TANK: NO YES L! NATURE OF SERVICE: ROUTINE V EMERGENCY 0BSERVATI0NS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: C'O.M.-NIENTS: CONTENTS TRANSFERRED TO: FULL TO COVER BAFFLES IN PLACE LEACI-IFIELD RUNBACK FLOODED OTHER (EXPLAIN) i r-/ :�` •moi �.►% �� ..• ,.i��-!; •: .P v�:�Qj:•1(•rin�gl?'c•• r• h"'jr fV� Ia � a imm ,� /n''Record ' SEP 0 8 2008 OFP h pfovldeC W; loft!, f c a f c y u T�GVfV OF --PAOMO`✓ER c C: f, u e ?• K.Ae TF—rDE G RTMENT ynf�orri�ca.',;C;1 - •,'.��. li llTl l r , � , , . , � /�dre1� (II dU(Iflnl fClT1 1�uUCn; Pumping Regord a',9 c• Pvnpinp 4. E` Ont To FIIIa(,pfo.w!? 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