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Miscellaneous - 104 COLONIAL AVENUE 4/30/2018 (2)
0 n O O N- C (D x.n'.t..p�tfi�l F •M' � �r f F }� i �„ 'i Y� � It It LOT•# MAP # 4 rr wig PARCEL # TSTREET,,I OONSTRUCTIO.N-APPROVOL, HAS PLAN REVIEW FEE.BEEN PAID?�/ ES NO PLAN APPROVAL: DATE APP. BY DESIGNER: PLAN DACE. a- 7 CONDITIONS WATER S PPLY: TOWN WELL WELL PERMI DRILLER.!.___.-•----- _.__.--.----...__._.__...._... 1' WELL TESTS.: CHEMICAL DA 1 E APPRUVED•-.-- _-.___- BACTERIA I UA t E. flPPRUVEI) BACTERIA II DATE APPRUVEI)-__._._- COMMENTS: FORM U APPROVAL': DATE ISSUED CONDITIONS: APPROVAL 1•U ISSUEYES NU BY FINAL APPROVAL:. YES ALL PERMITS PAID YES WELL CONSTRUCTION APPROVAL SEPTIC SYSTEM CONSTRUCTION APPROVAL YES OTHER ANY VARIANCE NEEDED FINAL BOARD OF HEALTH APPROVAL: NO NU NO NU YES NO DATE:......_........_..._ ....IIY:._. .. 'L G��L�LM_�NSIBL_�$_ T.I4Zl r:x; = +,: ,, r.• y>..:: ,i YES NO INSTALLER LICENSED? ?' - I S THE., .. _ REPAIR TYPE . OF }CONSTRUCTION : NEW No Y NEW CONSTRUCTION. CERTIFIED PLOT PLAN REVIEW NO ' ` CONDITIONS OF:.APPROVAL e4 s:. ri (FROM FORM U) .:. s NO ISSUANCE•OF DWC PERMIT INSTALLER: �; 1DWC PERMIT NO. — .. :. �' -BEGIN.INSPECTION ES -, EXCAVATION, NEEDED: EX .BY , PASSED CONSTRUCTION INSPECTIONS NEEDED: ';,;: ,•, .. .:::.' -.- YES s % - _ � > �� . �. AS BUILT PLAN SATISFACTflR�f, ' APPROVAL TO BACKFILL: DATE: ( 44 g BE_ �FINAL.GRADING APPROVAL: DATE ' FINAL CONSTRUCTION. APPROVAL: DATE: �l7 BY VEt.,,iT GBAGtf►+.��, -J rl�5kx,tf (Typ). C.,oLoui A L 1 .9ap GA L, fi AS BUILT PLAN OF SUBSURFACE DISPOSAL pTN 1 - pt `AO lyye of Permit or License: (Check box) Town of North Andover ❑ HEALTH DEPARTMENT CHECK #: F: d LOCA 72J9 H/O NAME: TT ` CONTRACTOR NAME:'6— Lh SX lyye 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 $ V V ❑ Other. (Indicate) $- (6 - Health C6- Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Owner Information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor . do not use the return key. V Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 104 Colonial Avenue Property Address William Powers Owner's Name North Andover City/Town MA 01845 State Zip Code RECEIVED JUL 2 8 2015 TOWN OF NORTH D R HEALTH DEPARTME�NT b f 7/16/2015 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information Inspector: Neil J. Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover MA 01810 C'Ityrrown State 978-475-4786 S 1 15 Telephone Number B. Certification License Number 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 ❑ Conditionally Passes ❑ Fails Ej Nee Fu her Evaluation by the Local Approving Authority i 7/16/2015 inspector's ig 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 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 Tide 5 Official Inspection Form: Subsurface Sewage Disposal System Page 1 of 17 Owner information is mquired-f& every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 104 Colonial Avenue Property Address William Powers Owner's Name North Andover City/Town B. Certification (cont.) MA 01845 7/16/2015 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 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 2 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 104 Colonial Avenue Property Address Owner William Powers 's information is OwnerName required for every North Andover MA 01845 page. CityrFown State 7/16/2015 Zip Code Date of Inspection B. Certification (cont.) t5ins • 3/13 ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if Pumps/alarms are repaired. (3) System Conditionally passes (cont.): ❑ Observation of sewage backup or breakout 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 (Exp1diri 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 d the system is failing to protect public health, safety or the environment. etermine if 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 Title 5 Official Inspection Fonn: 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 r 104 Colonial Avenue Property Addresn William Powers Owner owner's Name information is required for every North Andover page. City/Town t5ins • &13 B. Certification (cont.) MA 01845 7/16/2015 State Zip Code 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 aseptic 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 ❑ IZ 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 day flow Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Pape 4 of 17 Owner information is tegaited f6r evtry page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 104 Colonial Avenue Property Address William Powers Owner's Name North Andover u4rrown B. Certification (cont.) MA 01845 7/16/2016 State Zip Code Date of Inspection Yes No ❑ ® 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. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water 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 If 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 • 3113 Tide 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 A4� Owner information is required for every page. t5ins • 3H3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 104 Colonial Avenue Properly Address William Powers Owner's Name North Andover MA City/Town State C. Checklist 01845 7/16/2015 Zip Code 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? E] ® 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): Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 66-60 _ 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 104 Colonial Avenue Property Address William Powers Owner Owner's Name information is North Andover required for every page. City/Town D. System Information Description: Number of current residents: MA 01845 7/16/2015 State Zip Code Date of Inspection 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: 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? Gallons per day (gpd) 2 ❑ Yes ® No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ® No Yes ❑ Yes ® No Current Date ❑ Yes ❑ No ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins • 3/13 irtle 5 Official Inspection Forth: Subsurface Sewage Disposal pecti g poral System • Page 7 of 17 Owner information is required for every page. t5ins • 3l13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 104 Colonial Avenue Property Address William Powers owner's Name North Andover ctty/Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: MA 01845 State Zip Code General Information 2011, owner Date 7/16/2015 Date of Inspection Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Measured tank Reason for pumping: Type of System: Inspect tank & tees ® 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): 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 s " 104 Colonial Avenue Property Address William Powers Owner Owner's Name information is North Andover requited for every page. Citylrown D. System Information (cont.) MA State 01845 7/16/2.015 Zip Code Date of Inspection Approximate age of all components, date installed (if known) and source of information: 18 years old, 6/30/1997 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 1_3 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.): 4" PVC through wall, 3" PVC in house, no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 0.3 feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 10'x 5'x4' Sludge depth: 91 ❑ Yes ❑ No t5ins • W13 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 104 Colonial Avenue ri upcl ry r%aaress -- William Powers Owner Owner's Name information is �+ North Andover requited for every MA 01.845 7!16/2015 page. City/Town State Zip Code Date of Inspection U. 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? 33" 311 LA 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.): Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Grease Trak (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass 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: Teet ❑ polyethylene ❑ other (explain): Date t5ins • W 3 Title 6 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form . Net for Voluntary Assessments 104 Colonial Avenue. Property Address Owner William Powers 's information is ownerName requires for every North Andover page. Cityfrown D. System Information (cont.) MA 01845 7/16/2015 State Zip Code Date of Inspection 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 El metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: Alarm present: gallons per day ❑ Yes ❑ No Alarm level: Alarm in working order. ElYes ❑ 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 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 104 Colonial Avenue Property Address William Powers Owner's Name North Andover MA 01845 7/16/2015 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 2 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D -box level & distribution equal. Evidence of carryover, pumped d -box to clean. D -box cover broken, replaced it. 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 • 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 kv. I.- 104 Colonial Avenue Property Address William Powers Owner Owner's Name information is rewiredfiar every North Andover MA 01845 7/16/2015 . 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: ❑ overflow cesspool number: ri innovative/alternative system 3 trenches 62' long 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 • 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 VoluntaryAssessments 104 Colonial Avenue Property Address William Powers Owner Owner's Name information is regttlred for e=very North Andover MA 01£346 7/16/2015 page. City/Town 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 RT Owner information is required for every page. t5ins • 3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 104 Colonial A% Property Address William Powers Owner's Name North Andover MA CityrTown State D. System Information (cont.) 01845_ 7/16/2015 Zip Code Date of Inspection 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 segarateiv T108 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 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 104 Colonial Ai Property Address William Powers Owner's Name North Andover City/Town D. System Information (cont.) Site Exam: ® Check Slope ® Surface water MA 01845 State Zip Code ® Check cellar ® Shallow wells Estimated depth to high ground water: 4 feet 7/16/2015 Date of Inspection 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: 6/11/1993 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: Test pit data on design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3113 iille 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 104 Colonial Avenue Property Address William Powers Owner Owner's Name information is North Andover required for every page. Cityrrown MA 01845 State Zip Code E. Report Completeness Checklist 7/16/2015 Date of Inspection ® 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 - 3/13 Title 5 DtFlcial Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 Summary Record Card generated on 7/13/2015 2:20:35 PM by Karen Hanlon • Town of North Andover Tax Map # 210-1073-0139-0000.0 Parcel Id 18255 104 COLONIAL AVENUE WILLIAM POWERS 104 COLONIAL AVENUE NORTH ANDOVER, MA 01845 Page 1 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 0.6 Acres FY 2015 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until WILLIAM POWERS Owner 104 COLONIALAVENUE NORTH ANDOVER, MA 01845 GIUFFRIDA, BRIAN & SHARON Previous Customer Inactive 7/22/2009 104 COLONIAL AVE NORTH ANDOVER, MA 01845 JEAN FAMIGLIETTI Previous Customer Inactive 3/18/2010 104 COLONIALAVENUE NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 13306.0 - 104 COLONIAL AVENUE Last Billing Date 6/4/2015 2100033 02 Cycle 02 Active UB Services Maint. Account No. 2100033 Service Code Rate Charge Multiplier/Users MISCFEEADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 72.20 /1 UB Meter Maintenance Account No. 2100033 Serial No Status Location Brand Type Size YTD Cons 35644527 a Active ERT HH b Badger w Water 0.63 0.63 1313 Date Reading Code Consumption Posted Date Variance 5/1/2015 1323 aActual 19 6/22/2015 -8% 2/4/2015 1304 a Actual 22 3/20/2015 -78% 11/4/2014 1282 aActual 100 12/15/2014 -17% 8/5/2014 1182 aActual 112 9/11/2014 438% 5/12/2014 1070 a Actual 24 6/12/2014 polo 2/3/2014 1046 a Actual 23 3/17/2014 -76% 11/1/2013 1023 aActual 87 12/20/2013 -18% 8/7/2013 936 a Actual 114 9/18/2013 322% 5/7/2013 822 a Actual 27 6/18/2013 -2% 2/4/2013 795 a Actual 29 3/13/2013 -75% 10/30/2012 766 a Actual 109 12/13/2012 0% 8/1/2012 657 aActual 111 9/26/2012 202% 5/1/2012 546 aActual 36 6/20/2012 -6% 2/1/2012 510 a Actual 39 3/14/2012 -61% 11/1/2011 471 aActual 98 12/15/2011 -5% 8/3/2011 373 a Actual 105 9/14/2011 273% 5/3/2011 268 a Actual 26 6/13/2011 -1% 2/7/2011 242 a Actual 30 3/15/2011 -54% 11/2/2010 212 aActual 62 12/13/2010 -39% 8/2/2010 150 a Actual 99 9/13/2010 827% 5/5/2010 51 a Actual 6 6/9/2010 -28% 3/16/2010 45 f Final Bill 7 3/16/2010 8% Commonwealth City/Town of . of Massachusetts 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 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 ji�� , 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 Address Cfty/Town state Zip Code 2. System Owner. Name' Address (if ditmnt from locaffon) Cifyrrown B. Pumping 1. Date of Pumping 3. Type -of system: ❑ ❑ Other (describe): State Zip de 14+ Telephone Number Date 2. Quantity Pumped: Cesspool(s) eptic Tank L Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Ye„s 2 -No, If yes, was it cleaned? ❑ Yes ❑ No 5. Condition ofSystem- 6; ystem 6: System Pumped By.- Nell y: Neil. Bateson Name Bateson Enterprises Inc Company 7. Loca#QnAXbqm contents -were disposed: Waste Water F5821 Vehide License Number Date t5form4.doc- 06/03 1 System Pumping Record • Page 1 of 1 . O 3: '� ; "� a •_ � °L o w � a * Town of North Andover ,SSAcMUStt CHECK #: 0 LOCATION: H/O NAME: CONTRACT( 4199 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 w $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title.3ln-spector Title 5 Report $ $ �O ❑ Other: (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key v l� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 104 Colonial Avenue Property Address Brian Guiffrida Owner's Name North Andover Cityrrown MA 01845 State Zip Code C- 6/13/2009 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Neil J. Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover Ma Cityrrown State 978-475-4786 S115 Telephone Number B. Certification JUN 2 2 2009 License Number 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 ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority .i' 6/13/2009 Insp ct s Ignature 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 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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 4 Owner information is required for every page. A Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 104 Colonial Avenue Property Address Brian Guiffrida Owners Name North Andover City/Town B. Certification (cont.) MA 01845 6/13/2009 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 • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Owner information is required for every page. t5ins • 09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 104 Colonial Avenue Property Address Brian Guiffrida Owner's Name North Andover MA 01845 6/13/2009 CityTrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ ❑ ❑ broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ❑ Y ❑ Y ❑ Y ❑ N ❑ N ❑ N ❑ ❑ ❑ ND (Explain below): ND (Explain below): 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 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 104 Colonial Avenue Property Address Brian Guiffrida Owner's Name North Andover MA 01845 6/13/2009 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 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 '/z day flow t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 ❑ ® 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 Commonwealth of Massachusetts Title 5 official Inspection Form the system is within 400 feet of a surface drinking water supply Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ❑ 104 Colonial Avenue ❑ Property Address the system is located in a nitrogen sensitive area (Interim Wellhead Protection Brian Guiffrida Area — IWPA) or a mapped Zone II of a public water supply well Owner Owner's Name information is required for North Andover MA 01845 6/13/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water 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 • 09/08 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 104 Colonial Avenue Property Address Brian Guiffrida Owner Owner's Name information is required for North Andover every page. Cityrrown MA 01845 6/13/2009 State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ 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): 660 t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 6 of 17 • 1 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ., 104 Colonial Avenue Property Address Brian Guiffrida Owner Owner's Name information is required for North Andover MA 01845 6/13/2009 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (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? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 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 104 Colonial Avenue Property Address Brian Guiffrida Owner's Name North Andover Cityrrown D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: MA 01845 6/13/2009 State Zip Code Date of Inspection Date General Information Pumped last year, owner Was system pumped as part of the inspection? If yes, volume pumped: 1500 gallons How was quantity pumped determined? Measured tank. Reason for pumping: Inspect tank & tees Type of System: ® 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 - 09/08 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 M 104 Colonial Avenue Property Address Brian Guiffrida Owner Owner's Name information is required for North Andover MA 01845 6/13/2009 every 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: 12 Years old, 6/30/1997, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 1.3 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.): 4" PVC thru wall. 3" PVC in house. no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 3 feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 10'x 5'x 4' Sludge depth: 2 ❑ Yes ❑ No t5ins • 09/08 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 wM 104 Colonial Avenue Property Address Brian Guiffrida Owner Owner's Name information is required for North Andover MA 01845 6/13/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 25" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 19" How were dimensions determined? 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.): Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): t5ins - 09/08 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 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 ,M 104 Colonial Avenue Property Address Brian Guiffrida Owner information is required for every page. Owner's Name North Andover City/Town State 01845 Zip Code 6/13/2009 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 - 09/08 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 104 Colonial Avenue Property Address Brian Guiffrida Owner Owner's Name information is required for North Andover MA 01845 6/13/2009 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 level & distibution equal. No evidence of leakage. Evidence of light carryover, pumped d -box to clean. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 09108 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 wM 104 Colonial Avenue Property Address Brian Guiffrida Owner Owner's Name information is required for North Andover MA 01845 6/13/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) t5ins • 09/08 Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 3 trenches 62' 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 ❑ No 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 M 104 Colonial Avenue Property Address Brian Guiffrida Owner information is required for every page. Owner's Name North Andover MA 01845 6/13/2009 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins - 09/08 Title 5 Official Inspection Forth: 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 µ, 104 Colonial Avenue D. System Information (cont.) Site Exam: ® Property Address ® Brian Guiffrida Owner Owner's Name information is required for North Andover MA 01845 every page. Cityrrown State Zip Code D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 4 6/13/2009 Date of Inspection 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: 6/11/1993 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: As per design plan test pit data. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 104 Colonial Avenue Property Address Brian Guiffrida Owner Owner's Name information is required for North Andover MA 01845 6/13/2009 every page. City/Town 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 - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 Summary Record Card goneratedon &.1212009 2:46:52 PM by Karen Hanlon Page t Town of North Andover Tax Map # 210-1073-0139-0000.0 Parcel Id 18255 104 COLONIAL AVENUE_ GIUFFRIDA, BRIAN & SHARON 1.04 COLONIAL AVE NORTH ANDOVER, MA 01845 lass 101 Single Family Property Type 1 Residential Size Total 0.6 Acres -Y 2009 UB Mailina Index Name/Address GIUFFRIDA, BRIAN & SHARON 104 COLONIAL AVE NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Bldg Id. 13306.0 104 COLONIAL AVENUE 2100033 02 Cycle 02 UB Services Maint. Account No. 2100033 Service Code MISCFEE ADMIN FEE WTR WATER UB Meter Maintenance Account No. 2100033 Brand Serial No Status YTD Cons 41975368 a Active METE METE Date Reading 5/1/2009 3270 2/2/2009 3245 11/5/2008 3219 8/5/2008 3122 5/1/2008 3039 2/1/2008 3016 11/5/2007 2993 8/1/2007 2862 5/2/2007 2748 2/28/2007 2729 11/2/2006 2700 Trouble Code:03 6118/2008 8/21/2006 2647 Trouble Code:03 3114/2008 5/25/2006 2547 Trouble Code:03 1/15/2008 2/8/2006 2515 Trouble Code:03 9/14/2007 11/8/2005 2486 Trouble Code:03 6/22/2007 8/10/2005 2352 Trouble Code:03 3/2312007 51512005 2203 2/14/2005 2182 11 /18/2004 2056 8/10/2004 2021 Type Loan Number Active/tnact. From Payor Occupant Name Activelinactive Last. Billing_ Date 614/2009 Active Rate Charge Multiplier/Users 0.635/8 7.82 1l 01 ALL METER SIZE 92.60 /1 Until Location Brand Type Size YTD Cons E ENC RT METE METE w Water 0.630.63- 231 Code Consumption Posted Date Variance a Actual 25 6116/2009 -3% a Actual 26 3/16/2009 -72% a Actual 97 12/10/2008 22% a Actual 83 9/1212008 238% a Actual 23 6118/2008 -2% a Actual 23 3114/2008 -81% a Actual 131 1/15/2008 9% a Actual 114 9/14/2007 315% a Actual 19 6/22/2007 230 m Manual estimate 29 3/2312007 -66% a Actual 53 12/22/2006 -36%. a Actual 100• 9/1312006 276% a. Actual 32 6/20/2006 -4% a Actual 29. 3/13/2006 -79% a Actual 134 12/14/2005 -3% a Actual 149 9/12/2005 485% a Actual 21' 6/812005. -82%0 a Actual 126 3115/2005 309% m Manual estimate 35 12/17/2004 -77% a Actual 135 9/20/2004 345% a CO) I 1 1 I I i I O 0 a -------------------N vz 1 1 1 1 1 N 1 1 1 1 1 1 I 1 i W Utilities M 1 ' 0 , 1 1 (V _ ' 1 to I 1 � M -------- .,,,... 1 T------ M �) 1 L 1 1 f0 I (p 1 zn in V�BO 1 1 1 •-• , , apzo inr'. r 1 vz 1 1 1 1 1 N 1 1 1 1 1 1 I 1 i W TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTE ` . WNER & ADDRESS i9 6-27 SYSTEM LOCATION (example: left front of house) /MA - DATE C "UMPING: 1:9 —Z QUANTITY PUMPED /-wv GALLONS CESSP , NO /YES SEPTIC TANK: NO YES NATUP :'r SERVICE: ROUTINE EMERGENCY OBSER . MONS: OD CONDITION FULL TO COVER IVY GREASE BAFFLES IN PLACE OTS---- LEACHFIELD RUNBACK �ESSIVE SOLIDS YOVER OTHER (EXPLAIN) SYSTE ' ' "\4PED BY: COM'). 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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, left rear, left side of hous . R ght fro , right rear, right si of h use. Address Cityrrown State 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: 0 Zip Code Stated � _ Zip Telepphone.Number Date Quantity Pumped Cesspool(s) eptic Tank Ej Other (describe): 4. Effluent Tee Filter present? 0 Yes _— No t ��— Gallons [j Tight Tank If yes, was it cleaned? 0 Yes 0 No 5. Condition of S fi;✓m 6. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. L�ocation here contents were disposed: L.S.D Lowell Waste Water Of Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: 1 l CURRENT INSTALLER'S LICENSE# i LOCATION: LICENSED INSTALLER: SIGNATURE: TELEPHONE# Iry 6 � 4q (- cjqD q �,X. �SDe - qaq - T0'-7, /7 CHECK ONE: REPAIR: NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. $75.00 Fee Attached? AdIninistrative Use Only Yes No Foundation As -Built? Yes Approval No Oe.onJC �cAL� Date: S Z \ ACQ+,��� 1 f nY FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT _ _ & , R-..) �,w(-�R,o F} PHONE ft78 $21-{3 LOCATION: Assessor's Map Number PARCEL (3 SUBDIVISION LOT (S) STREET (01,604t*t, Avewac ST. NUMBER to ************************************OFFICIAL USE ONLY*********************************** RECOMMENDATIONS OF TOWN AGENTS: „v1V AU11RINIJ I KA VUR DATE APPROVED DATE REJECTED COMMENTS , vrrry rLA141=11 COMMENTS FOOD V_C INSF COMMENTS OR -HEALTH DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWERfWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197Im 0 1% VEST' -rR5,Qctf (rY P) Ca&oui A L I LVfE�eT 5&eYA_ 0 c, B = 157, LIZ S.-7. D -Esox Ou-r S .T E:"D 7-rl- o,L..D-Box r_u.b 7 Z+:,- 3 L1o,2' ! yq.s' — 1% VEST' -rR5,Qctf (rY P) Ca&oui A L I LVfE�eT 5&eYA_ 0 c, &Z6. = 157, LIZ S.-7. = 157, 3a Ou-r S .T = 157, 08 o,L..D-Box I iic,�T b = I S& . 37- i1.14 -nz 15-6, 3Z I U c.,F-T- E✓ D Cts 00 15uz) (�D 00 IEFuD (�SD = 1 s6 , 00 AS BUILT PLAN OF SUBSURFACE DISPOSAL LOCATED IN 1 W R i H A NDOVER, Imo'[ A. ,AS PREPARED FOR A.c. BU LDER S I NJc . DATE: Tut,., 30, 1T17 SCALE: .I "= qo Lo -r 19 COl OKII AL AV . MERRIMACK ENGINEERING 66 PARK STREET ANDOVER, MASSACHUSETTS 01810 i SYSTEM SERVICES 1 \oj, " I �eai,v,osC -I EASfMEuT I z.OT '*/9 I24,336 S,,C I= O.6046 AC . 160.57 � I I I I �D A / i0 J A 2`3g 4s E06E 0.- 7Z? F 7t% 7i/E QANE T.�qT THE �'�EYL.6tiC /3' lG"C',ITEO OA/ THEZOroff -%OW A .4.V0 ;rWT17T400GS t6i✓TGeAI IY/TN Me 7tN.-•✓ ' O/- .v0. 4.✓f06'eR Z4W/NB ,�E6VLAT•l�N.i . ArA4091,W Jfr44C.KP ovW4V STrPEC7^S �S fb.-TWRrm- CERT/fY Tii4IT TWAT pApire /.NW /f' Ot/OT L044MP AV T.YE fEACAW ,W~ ~T.•4.4O . ,er4. .jWaIVK OmS/ .0e,,W q CpMMt/A//Ty P.e".-Z *0 25"Gv98 GbJ9 C .4.4 6lt/93 RG. S � ii47-E PL or RL.4�t/ /N ��0. �NOo ✓E.Em ///A,SS^ . vie-"��ry fame 4SWUR �<. /11E.P.P/r�1m4Gt' E'.f/6•ct/EE.P�•l/6 SE.Pf�/�'ES G6 /P.WW .tT.rEET A.t/ODYE.� �JAS.£4GfU/SE7TS O/8/O Town of North Andover f NORTH OFFICE OF 3� 0.1 <<"`� ° •°oL COMMUNITY DEVELOPMENT AND SERVICES p 146 Main Street *, North Andover, Massachusetts 01845 -a Aria WILLIAM J. SCOTT Director March 4, 1997 Aurele Cormier A.C. Builders, Inc. 33 Walker Road North Andover, MA 01845 RE: Lot 19 Colonial Avenue Dear Mr. Cormier: This letter is to confirm that at their regularly scheduled meeting on February 27, 1997 the North Andover Board of Health granted a variance to Section 17.03 of the North Andover Minimum Requirements for the Subsurface Disposal of Sanitary Sewage to allow 9 feet between active trenches instead of 10 feet. A variance to Section 2.23 of the local regulations was also granted to allow 3.5 feet between the primary and reserve trenches. If you have any questions, please call the office at the number below. Sincerely, Sandra Starr, R.S. Health Administrator Cc: Les Godin, Merrimack Engineering File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS 66 PARK STREET • ANDOVER, MASSACHUSETTS 01810 • TEL. (508) 475-3555, 373-5721 • FAX (508) 475-1448 February 25, 1997 Town of North Andover Board of Health 146 Main Street North Andover, MA 01845 RE: Lot 19 Colonial Avenue Woodland Estates A.C. Builders, Inc. North Andover, Massachusetts Dear Board Members: Due to dimensional constraints and location of wetlands existing on the subject lot, we find it necessary to request the following variances to the Town of North Andover Board of Health minimum requirements for the subsurface disposal of sanitary sewage. 1. Regulation 2.23 so that the spacing between active and reserve trenches may be 3.5' as opposed to 4' as required. 2. Regulation 17.03 so that the spacing between active trenches may be 9' as opposed to 10' as required. The granting of these variances would allow the house to be placed closer to Colonial Avenue thereby providing a 50' house setback from the wetlands as required by the Town of North Andover Wetlands Protection By -Law. Please schedule this item for the next available meeting of the Board of Health and contact me should you have any questions or comments regarding the above. Very truly yours, MERRIMACK ENGINEERING SERVICES Les Godin Project Manager cd J I� J do o VS II \ r P4 W Lzl j � n", 66 W iWO4 fu WA A I� J No. FEE THE COMMONWEALTH OF MASSACHUSETTS )Ao, AaA,00ye7 (Z— , MASSACHUSETTS �yyfirafivn for is osttX gstem Coneitrurtion jJerntit Application is hereby made for a Permit to Construct ( tv or Repair ( ) an On-site Sewage Disposal System at: Location Address or Lot No. L6 -T 10, Owner's Na{�e, Address and Tel. No. kc, 931 LOCeS /f1G 1 Co 1. o) tt t �� V 331A)AL4GIZ ZO o Am no vGR r4h Installer's Name, Address, and Tel.No. Designer's Name, Address and Tel. No. �3 ler sA L-cy-t� "Y A l0FI t t- O YJ 1 A Type of Building: ' 11 Dwelling No. of Bedrooms Garbage Grinder (k6 Other Type of Building No. per Persons Showers ( ) Cafeteria ( ) Other Fixtures _ Design Flow Plan Date Title Description of Soil ", (!> gallons per day. Calculated daily flow U gallons. /-3-26. Number of sheets , 1T Revision Date lL 1-ty,-S n64 Il914 Nature of Repairs or Alterations (Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Application Approved by Application Disapproved for the following reasons Permit No. Date Issued Date Date THE COMMONWEALTH OF MASSACHUSETTS , MASSACHUSETTS (fPrtifirate of Compltttnee THIS IS TO CERTIFY, that the On-site Sewage Disposal System installed( ) or repaired/replaced ( ) on by for at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated . Use of this system is conditioned on compliance with the provisions set forth below: The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. This Certificate expires on DATE No. Inspector THE COMMONWEALTH OF MASSACHUSETTS , MASSACHUSETTS pisposal Sgstrm Cgonstrurtion ]Jtrmit Permission is hereby granted to to construct ( ) or repair ( ) an On-site Sewage System located at FEE and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within three years of the date below. DATE FORM 1255 Re, 3/95 A.M. SULKIN CO. - BOSTON. MA Approved by R/ PLAN REVIEW CHECKLIST ADDRESS/ �QZ61,j/� C- ENGINEER GENERAL �/ C// l/L- .-3 COPIES STAMP LOCUS �<TH ARROW `'/ SCALE �J CONTOURS `� PROFILE J SEC IT ON vl BENCH RK 6C SOIL & PERCS ELEVATIONS WETS. DISCLAIMER WELLS & WETS WATERSHED?DRIVEWA4— (Elev) WATER LINE FDN DRAIN SCH40 (-,� TESTS CURRENT?�_ SOIL EVAL SEPTIC TANK MIN 150OG 25' TO 6KLAR 4 D -BOX SIZE 17 INVERT DROP GARB. GRINDER (+200% EDF) MANHOLE c ---- # LINES 3 ELEV GW # COMPS. / C3 FIRST 2' LEVEL STATEMENT 1/� INLET 1�1, -,:5 G - OUTLET 1,G 4j = - /46 (2 " OR . 17 FT) / Jae' � /.�g, 40 , /�/cp TEE REQ' D? /9 LEACHING MIN 660 GPD?(� RESERVE AREA 4--� 4' FROM PRIMARY? --*" 2% SLOPE U1100' TO WETLANDS,--)(' 100' TO WELLS v 4' TO S.H.GW ✓ (5'>2M/IN) 35' TO FND & INTRCPTR DRAINS 325' TO SURFACE H2O SUPP2f 4' PERM. SOIL BELOW FACILITY—F? MIN 12" COVER FILL? (25' if above natural elev; 101if below) BREAKOUT MET? TRENCHES v MIN 660 gpd SLOPE (min .005 or 6"/100') l' SIDEWALL DIST. 3X EFF. W OR D (MIN 61) RESERVE BETWEEN TRENCHES? `/ IN FILL? ' MUST V Pik—BE 10' MIN.>�<"" 4" PEA STONE?L/ VENT? f-,� (>3COVER; LINES >50') BOT W" + SIDE IALI/ X LDNG , Q = TOT (L x W x #) (DxLx2x#) (G/ft2) Copyright © 1995 by S.L. SWfr FORK U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant11 fills out this section*****f*a*********** APPLICANT: A • C. Lijt(5 c, t�0 Phone 5-8350 LOCATION: Assessor's Map Number Parcel Subdivision _W00J land ESll1&5 Lot (s) I� Street CO toyi ll I ha St. Number 104 ************************Official Use Only************************ RECO ATIONY O 7/GENTS: Date Approved 441%_ Conservation Administrator Date Rejected Comments (rin l i_(2 Date Approved CZ Town Planner Date Rejected Comments Food Inspector -Health 4- ZQ Septic Inspector -Health Comments Date Approved Date Rejected Date Approved Date Rejected �s Public Works - sewer/water connections - driveway permit Fire De artment ��ti�v✓ �"'"��CJQ Received b3r Building Inspector Date Town of North Andover °f MORTIy 1 OFFICE OF 3?.t tioL COMMUNITY DEVELOPMENT AND SERVICES 146 Main Street 110 ' 2 North Andover, Massachusetts 01845 ....,o-•''t<y WILLIAM J. SCOTT Director July 1, 1996 Hayes Engineering 603 Salem Street Wakefield, MA 01880 Re: Lot #18 Colonial Drive Lot #19 Colonial Drive Lot #20 Colonial Drive To Whom it May Concern: This is to confirm that the Board of Health, at their regularly scheduled meeting on June 27, 1996, voted unanimously to grant the following variances: • To allow 91 feet to wetlands and 25 feet to a catch basin on Lot #18 Colonial Drive. • To allow 90 feet to wetlands on Lot #19 Colonial Drive. • To allow 85 feet to wetlands on Lot #20 Colonial Drive. If you have any questions, please do not hesitate to call the office. Sincerely, Sandra Starr, R.S., Health Administrator SS/cjp cc: Kathleen Bradley Colwell, Town Planner Michael Howard, Conservation Administrator Files BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 DATE 7 /�� Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER / SUBSURFACE DISPOSAL DESIGN REVIEW FEE_ 0 C PERMIT # �( DATE RECEIVED APPLICANT C / j - ASSESSOR'S MAP ADDRESS _333 A4 PARCEL # LOT # 117 S STREET ENGINEER /`�` cc ) � � ADDRESS U(/©l��'Z� PLAN DATE % �� / / REVISION DATE CONDITIONS OF APPROVAL: APPROVED DISAPPROVED ,D7� 1. 016 /Lrl SS/NEG 3. Z�ss 7" ;W- Sao ' a d r- 6.,/�-6/q6 HAYES ENGINEERING, INC. 603 SALEM STREET WAKEFIELD, MA 01880 NOA-0042 (617) 246-2800 REFER TO FILE # F?X (617) 246-7696 June 17, 1996 Board of Health Town Hall 120 Main Street North Andover, MA 01845 RE: Variance - Lots 18, 19 & 20 Woodland Estates, North Andover, MA Dear Members: N g�F\RQ OF �trL. Please accept this: letter as an applfcation for a variance from the North Andover Board of Health Regulations for the above-mentioned lots. We are requesting a variance from Section 4.18, which requires a distance of 100 feet between wetlands and the leaching facility or reserve area. We also are requesting a variance on Lot 18 for the distance between a subsurface drain and the leaching facility or reserve area. Please allow time or. the agenda at your next available meeting to discuss these issues. Very truly yours, Edward E. Stearns, P.L.S. Project Coordinator - - EES/dab Enclosures Town of North Andover Ot 40 oTH OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES o .. 146 Main Street North Andover, Massachusetts 01845 "SSgCHUSE` (508)688-9533 February 29, 1996 Hayes Engineering 603 Salem Street Wakefield, MA 01880 Re: Lot #19 Colonial Dr. To Whom it May Concern: This is to inform you that the proposed plans for the site referenced above have been disapproved for the following reasons: 1) Soil evaluation sheets missing. - 2) Soil tests out of date. 3) Less than 100 feet to wetlands. If you have any questions, please do not hesitate to call the. Board of Health Office at the number below. Sincerely, Sandra Starr, R.S. Health Administrator SS/cjp BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Julie Parrino D. Robert Nicetta Michael Howard Sandra Starr Kathleen Bradley Colwell W W Z O , O rJ`� ELU LU O Ol LL r J W J W 1 F- F- 2 O Z J a r-+ LU = O L Z 4. 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Q � Z � s _ ce N = L7 Cft Z to N V b c Q N W a W a O L W W > 0W a a U c O F' Q p cn s < Cie o O z o m Z 0 0 L z O Q U_ 0 � a c S3 Q Lu a� a i a rre �Oe I4.. ��s�� � •� Z C s '• I � oa � h U J C Ln � 1,L� � NM°l "*� bA Q vi LU I— LL- vi .iLU 0z O LU z o E a a 0 Ol LL -- LU J w w J w F- F- 2 ~ O Z • ] J Q � LU = O c C Z LL O Z O ce y bA N h v +� 1 W O m N N / Q U � Q JLn C� 'A ^ Q N w- CL J w L w W 0 4- W ¢ Q CU c O �. ce ce ) o QO � O O V Z J 11 Q w w aD sg U Z r 4� JER * f* 00 Z Q LL- cn W F— cJ 77L!/) 71-14L, _—_� U�o) — / -1A o -a8 -T'4-,5 /Z Z - 7'- IlVe � �� 0 z Z4 �- Zo -`IZ - -- —``�� s 1-71 144 -5,Lrk, Ste Lu a4 2, l Z.C:;, Ff-- -7, 7W 7o't- -i \NVV V W" icy– 662)t, Zo -`IZ - -- —``�� s 1-71 144 -5,Lrk, Ste Lu a4 2, l Z.C:;, Ff-- -7, 7W 7o't- -i \NVV V W" PATRICK J. DONOVAN ASSOCIATES, INC. Claim and eL.OSS . d'i.stments r P. O. BOX 110 WAKEFIELD, MA 01880 TEL. (781) 245-5540 - FAX (781) 245-7016 November 3, 1998 Building Commissioner City or Town Hall North Andover, MA 01845 Insured Property Address Insurer Policy Number Type of Loss Date of Loss Our File # : Brian J & Sharon K Giuffrida : 104 Colonial Avenue North Andover, MA 01845 : Preferred Mutual : PHOO100601891 : Explosion :10128/98 : WAP28937 Claim has been made involving loss, damage or destruction of the above -captioned property, which may either exceed $1,000 or cause Mass. Gen. Laws, Chapter 143, Section 6, to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 313 is appropriate, please direct it to the attention of the writer and include a reference to the captioned Insured, location, policy number, date of loss and file number. On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. r o�in Spa o Managing General Adjuster OF INDEPENDENT INSURINCE ADJUSTERS of Massachusetts Commonwealth of Massachusetts City/Town of a ° System Pumping RecordF ` Form 4 5 all G DEP has provided this form for use by local Boards of Health. Othe¢ T010 1 MRA M�Mk e information must be substantially the same as that provided here. �i 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: Le ht fro of ho 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 Address /612 Cityrrown 2. System Owner: Name Address (if different from location) Cityrrown B. Pumping Record State Zip Code Telephone Number 1. Date of Pumping Date 2. Quantity Pumped 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Other (describe): C �J Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes D No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition off' SKste - O� 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7.2;Eh)A- contents were disposed: Lowell Waste Water 0A F5821 Vehicle License Number Ce- E- ( Date t5form4.doc• 06103 System Pumping Record • Page 1 of 1