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HomeMy WebLinkAboutMiscellaneous - 105 CARLTON LANE 4/30/2018 (2)North Andover Board of Assessors Public Access t NORTI/ it .•nu. ...,. • °c Click Seal To Return Search for Parcels Search for Sales Summary Residence Detached Structure Condo Commercial Page 1 of 1 • North Andover Board of Assessors Location: 105 CARLTON LANE Owner Name: WANG, ZIN BARNUM, MICHA Owner Address: 105 CARLTON LANE City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 7 - 7 Land Area: 1.00 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 3196 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 647,700 670,000 Building Value: 422,900 445,200 Land Value: 224,800 224,800 Market Land Value: 224,800 Chapter Land Value: 11 http://csc-ma.us/PROPAPP/display.do?linkld=1465524&town=NandoverPubAcc 4/2/2009 P Safety Insurance P.O. Box 55098 Boston MA 02205 617-951-0600 October 12, 2016 Building Commissioner or Inspector of Buildings Fire Department or Arson Squad Board of Health or Board of Selectman City Hall NORTH ANDOVER, MA 01845 Insured: PETER CORDARO and EMILY CORDARO Property Address: 105 CARLTON LANE, NORTH ANDOVER MA Policy Number: HMA0348880 Claim Number: BOS00072014 Date of Loss: 10/9/2016 Notice of Loss Under M.G.L. c. 139,§ 3B This communication shall serve as written notice pursuant to M.G.L. c. 139, § 3B that [Safety Insurance Company] ("Safety") has received a claim involving loss, damage or destruction to a building or other structure at the above -referenced address which may either: (1) meet or exceed $1,000; or (2) cause the condition or the building or other structure to render M.G.L. c. 143, § 6 applicable. In accordance with M.G.L. c. 139, § 313, if the city or town intends to initiate proceedings designed to perfect a lien under Section 313, M.G.L. c. 143, § 9 or M.G.L. c. 111, § 127B, please notify Safety of the same by certified mail. Kindly forward such notice to my attention, at the address indicated above, and include with such notice a reference to the above-described insured, property address, policy number and claim number. If you have any questions regarding this notice, please feel free to contact me directly at 617-951-0600, extension 5015. Sincerely, Pete Najarian Claim Examiner PUBLIC HEALTH DEPARTMENT Town of North Andover {ommunity Development Division Certificate of Compliance As of.• .7 1y 31, 2012 This is to certify that a SA`ISTACTO T IMPECrIION Was completed for the: Caceret andInsta>f'ation o�an M-20 Ois�6ution Box_, Wain Line c� Inlet Tee Tor an Ore ;Site Wastewater"VaWsaC� By: warren (Peace at: 105 Cad,on .Gane Parcel ID :210/106.0-0086-0000.0 Wortfi.Andover, MA 01845 2 -ie Issuance of this certificate shall not 6e construed as a guarantee that the On -Site Sewage Disposal System will function satisfactorily. SusA T Sawyer, (Pu6lic Wealth Vii. 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com k North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: /D � MAP: LOT: INSTALLER: DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS9 L a TANK INSPECTION: /��� Z DATE OF BED BOTTOM INSPECTION: 7G 3,,11 DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned % ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK Q Building sewer in continuous grade, on compacted firm base _ �n- ❑----'Boffom of tank hole has 6" stone base __ G --Weep role plugged ----� ga loci -tank has been installed loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by testing ❑ Inlet tee installed, centered under access port Comments: PUMP CHAMBER Comments: CONTROL PANEL Comments: DISTRIBUTION -BOX Comments: k ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of final grade installed over one access port ❑ Hydraulic cement around inlet & outlet ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ gallon Pump Chamber installed ❑ 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) P ILFD 6y6 . Commonwealth of Massachusetts Map 106.00O086086Lot _ BOARD OF HEALTH Permit No North Andover BHP -2012-0694 P. FEE F.I. $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Warren Pearce Jr. to (Repair -D -BOX; MAIN LINE; INLET TEE) an Individual Sewage Disposal System. at No 105 CARLTON LANE as shown on the application for Disposal Works Construction Permit No. BHP -2012-069 Dated --- July 24, 2012 1--------------- Issued On: Jul -24-2012F HELTH t 0 R • y�ORTh i O.t ��o ,�r 1•G Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. ICI Application for Septic Disposal System '✓� (Construction Permit - TOWN OF TODAY'S DATE NORTH ANDOVERMA 01845 $ 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 system* (� Repair or replace an existing system component — What?7�� A. Facilitv Information -- Address or Lot # City/rbwn TOWN F�O�RTHANDO 2.- *TYPE OF SEPTIC SYSTEM*: HEALTH DEPARTMENT ❑ Pump ❑ Gravity (choose one) ***If pump system, 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) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D -Box Present) S.A.S. 2. Owner Information P1 i GVVa \tea Name Address (if different from above) City/Town 3. Installer Information Na 6 4 ` e��L Address �j )Q A _ <1nfora/Ww � 4. Designe Name Address Cityfrown State(I 7 ?I Code a ` /E7 � 0 � Telephone Number Name of Company O( IC 6 q State q Zip Code Number (Cell Phone # if possible please) Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit - Page 1 of 2 pORTN' Application for Septic Disposal System TODAY'S DATE �y� Construction Permit -TOWN OF $ 250.00 — Full Repair $125.00 - Component PAGE .2 OF 2 A. Facility Information continued.... 5. Type of Building: �sidential Dwelling or nCommercial 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 Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation until a Certificate of Compliance has been is ued by this Boar of Health. c� Name Date Application In : (Board of Health Representative -- ZA 7i 1 Name Date A icatig Disapproved for the following reasons: For Office Use Only: Application for Disposal System Construction Permit • Page 2 of 2 1. Fee Attached. Yes 2. Project Manager Obligation Form Attached? Yes No 3. Pump Sys tem? If so, Attach coy ofElectrical PettnitYes No 4. Foundation As -Built? (new construction ronly): Ye No (Satre scale as approved plan) /j I 6 6 5. 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 for the construction for the septic system for the property at: . � 0 �D_ Ca�_ 4� (_,� " r^�_� (Address of septic system) For plans by Relative to the application of (00'� E22Q C..Q (Installer's name)�And dated Dated 7— al — 1 T o ay s ate With revisions dated I understand the following obligations for management of this project: (Engineer) ngina ate (Last revised date) 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans pdor 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 requesting 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 (1'� 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: healthdept@townofnorthandover.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 system 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: 7 ) (Today's Date) (Name —Print) (Name —Signed) Owner information is required for every page. Commbnwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 CARLTON LANE, NORTH ANDOVER, MA 01845 Property Address MICHA S. BARNUM Owner's Name NORTH ANDOVER MA 01845 JULY 11, 2012 Cityrrown 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below) DISTRIBUTION BOX CORRODED -RECOMMEND REPLACEMENT. MAIN LINE GOING INTO SEPTIC TANK IS BREACHED - FLOW ENTERING NEAR SIDEWALL OF TANK AND NOT THROUGH LINE AND INLET TEE. RECOMMEND REPAIR/REPLACEMENT OF CAST IRON MAIN LINE AND RECONNECTION OF INLET TEE ❑ 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form J Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 CARLTON LANE, NORTH ANDOVER, MA 01845 !� 6 Property Address MICHA S. BARNUM Owner Owner's Name information is required for NORTH ANDOVER MA 01845 JULY 11, 2012 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. A. General Information 1. Inspector: STACEY J. ABATO Name of Inspector RAGGS, INC. Company Name P.O. BOX 1027 Company Address CONCORD MA Citylrown State 978-369-1100 S14046 Telephone Number B. Certification JUL 20 2012 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT License Number 01742 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 9"Ohl /0:6 w�7 Z012 Inspector's Signatu Ue 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 • 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 i r ' Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments p° 105 CARLTON LANE, NORTH ANDOVER, MA 01845 Property Address MICHA S. BARNUM Owner information is required for every page. Owner's Name NORTH ANDOVER City/Town B. Certification (cont.) MO n1RdF JIQIC &IP �Wuc JULY 11, 2012 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: 13) 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 CARLTON LANE, NORTH ANDOVER, MA 01845 Property Address MICHA S. BARNUM Owner Owner's Name information is required for NORTH ANDOVER MA 01845 JULY 11, 2012 every page. City/Town 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): DISTRIBUTION BOX CORRODED -RECOMMEND REPLACEMENT, MAIN LINE GOING INTO SEPTIC TANK IS BREACHED - FLOW ENTERING NEAR SIDEWALL OF TANK AND NOT THROUGH LINE AND INLET TEE. RECOMMEND REPAIR/REPLACEMENT OF CAST IRON MAIN LINE AND RECONNECTION OF INLET TEE ❑ 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 R 1 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 105 CARLTON LANE, NORTH ANDOVER, MA 01845 Property Address MICHA S. BARNUM Owner Owner's Name information is required for NORTH ANDOVER MA 01845 JULY 11, 2012 every 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 'h day flow t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Insp Subsurface Sewage Disposal System Fo M 105 CARLTON LANE, NORTH ANDOVER, Property Address MICHA S. BARNUM Owner Owner's Name information is required for NORTH ANDOVER every page. City/Town B. Certification (cont.) Yes No ection Form rm - Not for Voluntary Assessments MA 01845 MA 01845 JULY 11, 2012 State Zip Code Date of Inspection ❑ ® 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 • 11110 Title 5 Official Inspection Farm: 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 105 CARLTON LANE, NORTH ANDOVER, MA 01845 Property Address MICHA S. BARNUM Owner Owner's Name information is required for NORTH ANDOVER MA 01845 JULY 11, 2012 every page. Cityrrown 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? 1:1 ® 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): 4 X150=600 t5ins - 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 Commonwealth of Massachusetts u v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 CARLTON LANE, NORTH ANDOVER, MA 01845 Property Address MICHA S. BARNUM Owner Owner's Name information is required for NORTH ANDOVER MA 01845 JULY 11, 2012 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1-2 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)): 165.99 AVGGPD Detail: 5/3/10-5/2/12; 162 UNITS=16,200 CF 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: Gallons per day (gpd) ❑ Yes ® No OCCUPIED Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No l5ins • 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 105 CARLTON LANE, NORTH ANDOVER, MA 01845 Property Address MICHA S. BARNUM Owner information is required for every page. Owner's Name NORTH ANDOVER MA 01845 JULY 11, 2012 Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other (describe below): General Information Pumping Records: LAST SERVICED 4/4/09 PER OWNER & RECORD Source of Information. Was system pumped as part of the inspection? If yes, volume pumped: 1,500 gallons How was quantity pumped determined? FIELD ESTIMATE Reason for pumping: Type of System: ® Yes ❑ No MAINTENANCE & TANK & TEE INSPECTION ® 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): 15ins • 11/10 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 105 CARLTON LANE, NORTH ANDOVER, MA 01845 Property Address MICHA S. BARNUM_ Owner Owner's Name information is required for NORTH ANDOVER MA 01845 JULY 11, 2012 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: AS -BUILT PLAN DATED 12/23/82 ON FILE AT BOH; OUTLET TEE/BAFFLE REPAIR 5/03 BOH RECORD Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 2 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.): NOT VISIBLE; OK; YES -FLOW IS ENTERING INTO TANK NEAR/AT SIDEWALL OF TANK AND IS NOT FLOWING THROUGH THE INLET TEE. RECOMMEND INVESTIGATION OF THE MAIN LINE (HAND EXCAVATION OUTSIDE TANK TO DETERMINE EXTENT OF MAIN LINE DETERIORATION AND REPLACEMENT OF LINE GOING INTO TANK. THE PVC INLET TEE IN THE SEPTIC TANK SHOULD BE RECONNECTED. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 1 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: 7" ❑ Yes ❑ No t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 105 CARLTON LANE, NORTH ANDOVER, MA 01845 Property Address MICHA S. BARNUM Owner information is required for every page. t5ins - 11/10 Owner's Name NORTH ANDOVER City/Town D. System Information (cont.) Septic Tank (cont.) MA 01845 JULY 11, 2012 State Zip Code Date of Inspection 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? 27" 1" 6" 14" FIELD ESTIMATE Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): RECOMMEND ANNUAL PUMPING; INLET AND OUTLET TEES INTACT; TANK APPEARED STRUCTURALLY SOUND AT TIME OF INSPECTION; LIQUID LEVEL AT OUTLET INVERT; SEE NOTE ABOVE REGARDING MAIN LINE -THERE IS FLOW COMING IN AT/NEAR THE SIDEWALL OF THE TANK. IT APPEARS THAT THE MAIN LINE IS BREACHED. CARE SHOULD BE TAKEN TO ENSURE WATERTIGHT CONNECTION AROUND THE MAIN LINE GOING INTO TANK WHEN REPAIR IS DONE. THE TANK DID NOT APPEAR TO BE EXCESSIVELY CORRODED; CONCRETE APPEARED SOUND. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): 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 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 CARLTON LANE, NORTH ANDOVER, MA 01845 Property Address MICHA S. BARNUM Owner's Name NORTH ANDOVER MA 01845 JULY 11, 2012 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 - 11/10 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 105 CARLTON LANE, NORTH ANDOVER, MA 01845 Property Address MICHA S. BARNUM Owner information is required for every page. Owner's Name NORTH ANDOVER City/Town D. System Information (cont.) MA 01845 JULY 11, 2012 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 APPEARED LEVEL WITH EQUAL DISTRIBUTION TO OUTLETS; LIGHT CARRYOVER -BOX CORRODED WITH COVER STARTING TO CRACK ALONG CENTERLINE- LEAKAGE POSSIBLE - RECOMMEND REPLACEMENT OF DISTRIBUTION BOX AND COVER 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 - 11/10 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 105 CARLTON LANE, NORTH ANDOVER, MA 01845 Property Address MICHA S. BARNUM Owner Owner's Name information is required for NORTH ANDOVER MA 01845 JULY 11, 2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits ❑ leaching chambers ❑ leaching galleries ❑ leaching trenches ® leaching fields number: number: number: number, length: number, dimensions: 1 FIELD; 25'X 56' RECORD ❑ 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.): LOAM: NO SIGNS OF HYDRAULIC FAILURE OR PONDING ABOVE GROUND; DRY; GRASS 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 • 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 -- Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 CARLTON LANE, NORTH ANDOVER, MA 01845 Property Address MICHA S. BARNUM Owner's Name NORTH ANDOVER MA 01845 JULY 11, 2012 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts AM . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 CARLTON LANE, NORTH ANDOVER, MA 01845 Property Address MICHA S. BARNUM Owner Owner's Name information is required for NORTH ANDOVER MA 01845 JULY 11, 2012 every page. City/Tcwn State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below Carlton Lane I_klt"u S CAI-2— c 4— Water Line , Garage 4 Bedroom Dwelling 105 Carlton Lane North Andover, MA 01845 DECK A B C D Septic Tank O O� .. .......................... As-built E !/Distribution Box ;Dimensions ::A-C = 14'-3' 14'-4" Leaching Field 'A-D = 20'-11" _ f B-D=12'-7" y� �41P Wry ::A-E = 21'-5" :B-E = 21'-10" by p ....................... I t5ins - 11110 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 105 CARLTON LANE, NORTH ANDOVER, MA 01845 Property Address MICHA S. BARNUM Owner Owner's Name information is required for NORTH ANDOVER MA 01845 JULY 11, 2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells 4' _ Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: /Z/ S Obtained from system design plans on record If checked, date of design plan reviewed: 3/3181 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 CHECKED CELLAR -DRY - NO SUMP PUMP. CHECKED SOIL LOGS ON RECORD PLAN ON FILE AT BOARD OF HEALTH AND PRIOR INSPECTION REPORTS. SYSTEM DESIGNED AND INSTALLED IN ACCORDANCE WITH TITLE 5 (1978) CODE WHICH REQUIRED A MINIMUM FOUR FOOT OFFSET BETWEEN THE BOTTOM OF THE SYSTEM AND GROUNDWATER. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins - 11110 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 105 CARLTON LANE, NORTH ANDOVER, MA 01845 Property Address MICHA S. BARNUM Owner information is required for every page. Owner's Name NORTH ANDOVER City/Town MA 01845 JULY 11, 2012 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 • 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 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. r ISI rerun Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Asses: 105 Carlton Lane Property Address Micah Barnum & Xin Owner's Name North Andover City/Town MA 01845 State Zip Code RECEIVED entsAPR 0 7 2009 TOWNOF-ORTH TOTER ME 04/04/2009 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. C* 4 A. General Information 1. Inspector: Pat Leclerc Name of Inspector AP Title 5 Inspections Company Name 668 South Main Street Company Address Bradford City(Town (978) 662-5111 Telephone Number B. Certification MA State N/A License Number 0'1835 Zip Code 0 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 Furth r Evaluation by the Local Approving Authority April 7, 2009 Inspector's Signature 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. Barnum - DEP INSPECTION FORM.doc - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Carlton Lane Property Address Micah Barnum & Xin Wang Owner's Name North Andover MA 01845 04/04/2008 City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally*Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ 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. ND Explain: ❑ 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): C FE broken pipe(s) are replaced obstruction is removed Bamum - DEP INSPECTION FORM.doc • 08106 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Carlton Lane Property Address Micah Barnum & Xin Wang Owner Owner's Name information is required for North Andover MA 01845 04/04/2008 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ . The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. eamum - DEP INSPECTION FORM.doc • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Carlton Lane Property Address Micah Barnum & Xin Wang Owner's Name North Andover MA 01845 04/04/2008 City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont): ❑ 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 El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool 1:1 ® Liquid depth in cesspool is less than 6" below invert or available volume is less than'/ day flow E] ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Bamum - DEP INSPECTION FORM.doc - 08/06 Title 5 Offical Inspection Form: Subsurface Sewage Disposal System - Page 4 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Carlton Lane Property Address Micah Barnum & Xin Wang Owner's Name North Andover MA 01845 04/04/2008 CityrFown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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. Bamum - DEP INSPECTION FORM.doc • 08/06 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 5 of 15 Commonwealth of Massachusetts i Title 5 Official Inspection Form ry Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' 105 Carlton Lane Property Address Micah Barnum & Xin Wang Owner Owners Name information is required for North Andover MA 01845 04/04/2008 every page. City/Town 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? 11 ® 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? ® 11 the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? information 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)] Barnum - DEP INSPECTION FORM.doc • 08/06 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Carlton Lane Property Address Micah Barnum & Xin Wang Owner Owner's Name information is required for North Andover MA 01845 04/04/2008 every page. Cityrrown State Zip Code Date of Inspection 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): Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonaluse? Water meter readings, if available (last 2 years usage (gpd)): Sump pump? Last date of occupancy: Commercialllndustrial Flow Conditions: Type of Establishment: NIA Design flow (based on 310 CMR 15.203): NIA Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): N/A Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: N/A Last date of occupancy/use: N/A Date Other(describe): N/A 4 600 ❑ Yes ® No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes No 121,100 gal or 165.90 ood ❑ Yes ® No Occupied Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Barnum - DEP INSPECTION FORM.doc • 05/06 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 7 of 15 Title 5 Official Inspection Form Subsurface Sewage Disposal System Commonwealth of Massachusetts 105 Carlton Lane Form - Not for Voluntary Assessments Property Address Micah Bamum & Xin Wang Owner Owner's Name information is required for North Andover MA 01845 04/04/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Pumped August or September 2008 Was system pumped as part of the inspection? ® Yes L] No If yes, volume pumped: 1500 gallons gallons How was quantity pumped determined? Tank measurents Reason for pumping: To inspect inlet and outlet Tees/Baffles Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy El 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) 11 Tight tank. Attach a copy of the DEP approval. E] Other (describe): Approximate age of all components, date installed (if known) and source of information: Svstem installed 11/23/1982 Were sewage odors detected when arriving at the site? El Yes ® No i, Bamum . DEP INSPECTION FORM.tloc - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 15 D. System Information (cont.) General Information Pumping Records: Source of information: Pumped August or September 2008 Was system pumped as part of the inspection? ® Yes L] No If yes, volume pumped: 1500 gallons gallons How was quantity pumped determined? Tank measurents Reason for pumping: To inspect inlet and outlet Tees/Baffles Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy El 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) 11 Tight tank. Attach a copy of the DEP approval. E] Other (describe): Approximate age of all components, date installed (if known) and source of information: Svstem installed 11/23/1982 Were sewage odors detected when arriving at the site? El Yes ® No i, Bamum . DEP INSPECTION FORM.tloc - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 15 Commonwealth of Massachusetts t Title 5 Official Inspection Form i r x Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Carlton Lane Property Address Micah Barnum & Xin Wang Owner Owner's Name information is required for North Andover MA 01845 04/04/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer (locate on site plan): Depth below grade: 2.0 feet 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 1.0 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) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: Sludge depth: 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? 2 inches thick 21 inches 0 inches N/A N/A Tape measured Barnum - DEP INSPECTION FORM.doc • 06/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form r sl Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Carlton Lane Property Address Micah Barnum & Xin Wang Owner Owner's Name information is required for North Andover MA 01845 04/04/2008 every page. City[rown 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.): During the pumping of the tank, no evidence was found that any infiltration is occurring. The inlet and outlet tees/baffles were inspected and found to be in good condition. The structural integrity of the tank and tees/baffles were good. Grease Trap (locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): N/A Dimensions: NIA Scum thickness NIA Distance from top of scum to top of outlet tee or baffle NIA Distance from bottom of scum to bottom of outlet tee or baffle NIA Date of last pumping: NIA Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): N/A Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NIA Material of construction: ❑ concrete ❑ metal N/A ❑ fiberglass ❑ polyethylene ❑ other (explain): Bamum - DEP INSPECTION FORM.doc • 08/06 Tifle 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewaae Disnosal Svstem Form - Not for Voluntary Assessments I�MVI" 105 Carlton Lane Owner information is required for every page. Property Address Micah Barnum & Xin Owner's Name North Andover CityrFown MA 01845 State Zip Code 04/04/2008 Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: N/A Capacity: N/A gallons Design Flow: N/A gallons per day Alarm present: ❑ Yes ❑ No Alarm level: N/A Alarm in working order: ❑ Yes ❑ No Date of last pumping: N/A Date Comments (condition of alarm and float switches, etc.): N/A Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 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.): The distribution box was level and distribution to outlets was equal. There was no evidence of leakage into or out of D -Box. Pipes in and out of D -Box were in good condition. Water was introduced to septic tank and flow to each pipe was even. No carry-over into D -Box Pump Chamber (locate on site plan): Pumps in working order: Alarms in working order: ❑ Yes ❑ No ❑ Yes ❑ No Barnum - DEP INSPECTION FORM.doc - 08106 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 15 Commonwealth of Massachusetts I - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c % 105 Carlton Lane Property Address Micah Barnum & Xin Wang Owner Owner's Name information is required for North Andover MA 01845 04/04/2008 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1, 23'X 56' ❑ 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 condition was good. No odors detected and no signs of hydraulic failure. The vegetation condition was normal. aamum - DEP INSPECTION FORM.doc • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 15 41 Commonwealth of Massachusetts 5 Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Carlton Lane MA 01845 State Zip Code 04/04/2008 Date of Inspection D. System Information (cont.) Property Address Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Micah Barnum & Xin Owner Owner's Name information is required for North Andover every page. Cityrrown MA 01845 State Zip Code 04/04/2008 Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth — top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A Privy (locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A Bamum - DEP INSPECTION FORM.doc • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Carlton Lane Property Address Micah Barnum & Xin Wang Owner Owner's Name information is required for North Andover MA 01845 04/04/2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Carlton Lane �-- Water Line 3 a� Garage 4 Bedroom Dwelling 105 Carlton Lane North Andover, MA 01845 DECK A B O �O 4 --Septic Tank As -built E t,Distribution Box '.Dimensions A -C = 14'-3' B -C = 14'-4" Leaching Field `A -D = 20'-11" B -D = 12'-7" A-E = 21'-5" ::B-E = 21'-10" Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form r ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Carlton Lane Property Address Micah Barnum & Xin Wang Owner Owner's Name information is required for North Andover MA 01845 04/04/2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to ground water: 4 feet below bottom of SAS 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: 03/03/1981 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: The high ground water elevation was determined to be 4 feet below soil absorption system. This information was obtained from the Plan of Subsurface Disposal System. Bamum - DEP INSPECTION FORM.doc - 08106 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 15 Town of North Andover Office of the Health Department Community Development and Services Division 27 Charles Street North Andover, Massachusetts 01845 Sandra Starr Public Health Director TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE 05"3 f pOR7k � Q filo rb*'` 40 ' ��ssacKus a`� Telephone (978) 688-9540 Fax (978) 688-9542 This is to certify that the individual subsurface disposal system components (Outlet Tee and Baffle) were constructed () or repaired (X) by Neil Bateson at 105 Carlton Lane have been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. *rian LaGrasse Health Inspector BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 COMMONWEALTH OF MASSACHUSETTS lax Z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a DEPARTMENT OF ENVIRONMENTAL PROTECTION a 7 �0 TITLE 5 OFFICIAL INSPECTION FORM — NOT, FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: _105 Carlton Lane_ _North Andover_ Owner's Name: Philip Giantris_ Owner's Address: 105 Carlton Lane North Andover, MA 01845_ Date of Inspection: 5/2/2003_ Name of Inspector: Neil J. Bateson Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, Ma. 01810_ Telephone Number: _( 978 ) 475-4786 G MAY I ?nnQ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fail Inspector's Signature.4i ate: _5/2/2003_ The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments: After permit from B.O.H., install new outlet tee with gas baffle in septic tank, inspection from B.O.A., septic system now passes Title 5 Inspection. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. COMMONWEALTH OF MASSACHUSETTS m F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION r ,a APR 1 8 2003 TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: _105 Carlton Lane_ _North Andover Owner's Name: Phillip Giantris_ _ Owner's Address: _105 Carlton Lane_ North Andover, MA 01845_ Date of Inspection: 4/1/2003_ Name of Inspector: _Neil J. Bateson Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, Ma. 01810 Telephone Number: _( 978 ) 475-4786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: Passes _X_ Conditionally Passes Needs Further Evaluation by the Local Approving Authority 4Fa _a�_ Inspector's Signature: Date: _4/1/2003&V_ The system inspector shall sumy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 1Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 105 Carlton lane _North Andover— Owner: Giantris Date of Inspection: _4/1/2003_ Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: X� One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Outlet tee in septic tank. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. _N_ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: _N_ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain: NThe system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will p— ass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _105 Carlton Lane North Andover_ Owner: Giantris Date of Inspection: 4/1/2003 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _105 Carlton Lane_ North Andover— Owner: Giantris Date of Inspection: _4!1/2003_ D. System Failure Criteria applicable to all systems: You must indicate `yes" or `ho" to each of the following for all inspections: Yes No _No_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool No Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool —No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _No_ Liquid depth in cesspool is less than 6" below invert or available volume is less than %2 day flow T _No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _No_ Any portion of the SAS, cesspool or privy is below high groundwater elevation. _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. No Any portion of a cesspool or privy is within a Zone 1 of a public well. _No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. —No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as T described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either "yes" or `ono" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _ _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: _105 Carlton Lane_ _North Andover— Owner: Giantris Date of Inspection: 4/1/2003_ Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No Yes _ Pumping information was provided by the owner, occupant, or Board of Health _No Were any of the system components pumped out in the previous two weeks ? _Yes _ Has the system received normal flows in the previous two week period ? No_ Have large volumes of water been introduced to the system recently or as part of this inspection ? Yes Were as built plans of the system obtained and examined? (If they were not available note as N/A) Yes _ Was the facility or dwelling inspected for signs of sewage back up ? Yes_ _ Was the site inspected for signs of break out ? _Yes_ _ Were all system components, excluding the SAS, located on site ? _Yes_ _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? _Yes_ _ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no _Yes _ Existing information. For example, a plan at the Board of Health. _No_ Determined in the field (if any of the failure criteria related to Part Cis at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: _105 Carlton Lane_ North Andover– Owner: Giantris Date of Inspection: _4/1/2003_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): —4_ Number of bedrooms (actual): _4_ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): _600_ Number of current residents: 1 Does residence have a garbage_grinder (yes or no): _No Is laundry on a separate sewage system (yes or no): _No [if yes separate inspection required] Laundry system inspected (yes or no): Seasonal use: (yes or no): _No_ Water meter readings: Yes_ Sump pump (yes or no): _No_ Last date of occupancy: — Current-C OMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sqft,etc.): Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): _ Non -sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: _Pumped two years ago, owner Was system pumped as part of the inspection (yes or no): Yes_ If yes, volume pumped: _1500___gallons -- How was quantity pumped determined? _Measured tank._ Reason for pumping: _Inspect tank & tees TYPE OF SYSTEM X Septic tank, distribution box, soil absorption system _ Single cesspool Overflow cesspool T_ Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Altemative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank _ Attach a copy of the DEP approval Other (describe): Approximate age of all components, date installed (if known) and source of information: 21 years old. 11/23/1982 As built plan Were sewage odors detected when arriving at the site (yes or no): _No_ Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _105 Carlton Lane_ North Andover Owner: Giantris Andover- Owner: of Inspection: 4/1/2003_ BUILDING SEWER (locate on site plan) X Depth below grade: 24" Materials of construction: -X-cast iron -X-40 PVC other (explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): _4" cast rion thru wall. 3" PVC in house. No leaks. SEPTIC TANK: X locate on site plan) Depth below grade: —12" Material of construction: _X_concrete _metal _fiberglass __polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance (yes or no): _(attach a copy of certificate) Dimensions: 10' x 5' x4' Sludge depth 6"_ Distance from top of sludge to bottom of outlet tee or baffle: _N/A_ Scum thickness: _611 _ Distance from top of scum to top of outlet tee or baffle: N/A_ NIA = outlet tee off on septic tank. Distance from bottom of scum to bottom of outlet tee or baffle: _N/A How were dimensions determined: _Subtract scum & sludge depth to tee length. _ 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 corroded off. No evidence of leakage. Depth of liquid at outlet invert. _ GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: concrete metal _fiberglass polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _105 Carlton Lane_ North Andover— Owner: Giantris Date of Inspection: 4/1'/2003 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: _0_ Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): _D -box level & distribution equal. No evidence of leakage. Evidence of carryover, pumped d -box to clean. _ PUMP CHAMBER: (locate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _105 Carlton Lane_ North Andover— Owner: Giantris Date of Inspection: —4/l/2003— SOIL ABSORPTION SYSTEM (SAS): _X (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: leaching trenches, number, length: X leaching fields, number, dimensions: —1 field 23' x 56'_ overflow cesspool, number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): —Soil ok, Vegetation ok. No sign of ponding to surface. CESSPOOLS: _ (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth — top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _105 Carlton Lane_ _North Andover— Owner: Giantris Date of Inspection: _4/1/2003_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 4_ feet Please indicate (check) all methods used to determine the high ground water elevation: X_ Obtained from system design plans on record -'If checked, date of design plan reviewed: _3/3/1981 _ _ 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._ NUMBER 1288 Town of North Andover, Massachusetts Form No. 3 NORTH BOARD OF HEALTH 3a ° ♦ OL Q a O p �..o��'`� DISPOSAL WORKS CONSTRUCTION PERMIT ,SSICHUSEt I Applicant e�lJ� �� ����° / � �✓�� %� Site Location "^' �� �<�iPi��L✓�i� 'L""'v"` Permission is hereby granted to Construct ( ) or Repair (-r-an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN, BOAP.60F HEALTH Fee V / 1 COMMONWEALTH OF MASSACHUSETTS North Andover Board of Health GIANTRIS, PHILIP D & D SALLY GIANTRIS ------------------------------------------- ------ 1.NAME 105 CARLTON LANE ------------------------------------------------ ------------------------------------------- ADDRESS IS HEREBY GRANTED A PERMIT Disposal Works Construction D.W.C. No. 4Q ae This permit is granted in conformity with the Statutes and ordinances relating thereto, and expires ---------------August 15, 2003 --------------- unless sooner suspended or revoked. ------------------------------- April 15, 2003 -------- ---------------------- FEE $175.00 Board Of Health APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: —�� 3 CURRENT INSTALLER'S LICENSE# LOCATION: LICENSED INSTAro � �feSo,✓ SIGNATURE: ff` TELEPHONE# \77yJ R:57 --"7i3 CHECK ONE: REPAIR: L1___1" NEW CONSTRUCTION: 0al"_ F 44-0-- 6e�llj( IF NEW CONSTRUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. ,4,1175.00 Fee Attached? Foundation As -built? Floor plans on file? Administrative Use Only Yes 1'� No Yes No Yes No Approval Date: INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at �� C��/�i✓ %�" - relative to the application of t,49 Bg45,4v/ dated q'y' °3 for plans by and dated with revisions dated I understand the following obligations for management of this project: 1. As the installer I am obligated to 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 manger, 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 requesting an inspection, without completion of the items in accordance with Tile 5 and the Board of Health Regulations may result in a $50.00 fine being levied against my company. a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As -built or verbal OK from engineer must be submitted to Board of Health, after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade - Installer must request inspection when all grading is complete. Does not have to be on site. 4. As the installer I understand that only I may perform the work (other than simple excavation) required to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation or suspension of my license 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. Indr,icensed Septic Installer Disposal Works Construction Permit 4 TO: NORTH ANDOVER, MASS. June 17 19 83 BOARD OF HEALTH FROM: DESIGN ENGINEER Re: Soil Absorption Sewage Disposal System This is to certify that I have inspected the construction materials of said disposal system at Lot 31 Carlton Lane Site Location North Andover, Mass. The grades and construction materials.�specified in my plans and specifications dated May 11 �9�a _Built December 23 1982 P �- 0 Reg . P �,,M , En�j'Thee %lRjeg . Sanitarian ,. c , S i YtYlt� FORM U - IDT 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, ****************Applicant fills out this section***************** APPLICANT: __(�4$Il_� P O : Gl'f�1tT�o►c Phone LOCATION: Assessor's Map Number J0 6G Parcel cgC� Subdivision QLW- -(.Ttm F"Ms I' Lot(s) 3 Street Q° AlLt,mtA CA'I`{St. Number O S ************************Official Use Only************************ OMMENNDATIONS OF TOWN AGF.N'PS Date Approved Conservation Administrator Date Rejected • Comments Date Approved Town Planner Date Rejected Comments Date Approved/Ql/Q/97 �ealth Agent Date Rejected Comments Public Works - sewer/water connections driveway permit Fire Department ' Received by Building Inspector Date 11 tio:f. FM OK TPtSTALLATICI COY LIS; 4k Reaunst J/ LOT j '1 � CAA16tWO) 1. Distance Tot a. Wetlands ,.� b. Drains /. c. Well / 2. Water Line Location 3. No PVC Pipe - 'i"oTM,�: l�. Septic Tank �ti uoT ►� a.... -Tess --Length &. To Clean -Oat Corers. �._ b. Cement Pipe to Tank -- on Both Sides of Tank /.� ► I' +!� . 5. Distribution Box a. .,Covers & Box.- No Cracks !' b. All Lines Flossing Equal Amounts c. No Back Flow / 6.- Leach Field or Trench a. Dimensions b. Stone Depth c. Capped lads d. Clean Double Washed Stone 7. Leach Pits a. Dimensions b. Stone/Depth c. Splash Pads d. Teas e Zement Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. No Garbage Disposal 9, Final Grading Inspection � fzs�83 10. Barricading Covered System 11. As Built Submitted ^ a. Lot Location b. Dimensions of System c. Location with Regard -to Pere Test d. Elevations e: Water Table i Board of Health North Andover,Mass APPROVED Provideds FACE DISPOSAL DESIGN CHECK LIST LOT DISAPPROVED DATE Reasons: Title V FAIL Ob Reg 2.5 The submitted plan must show as a minimum: a) the lot to be seared-area,dimensions lot #sabutters ✓ b location and log deep observation hoes -distance to ties v c location and results percolation tests -distance to ties design calculations k calculations showing required leaching area ✓ (e) location and dimensions of system -including eeserve area 77(f) existing and proposed contours ✓(g) location any wet areas within 1001 of sewage disposal system or disclaimer -check wetlands mapping (h)surface and subsurface drains within 100' of sewage disposal system or disclaimer ---~ (i) location any drainage easements within 1001 of sewage disposal system or disclaimer -Planning Board files (3) known sources of water supply within 2001 of sewage disposal e system or disclaimer — 1(k) location of any proposed well to serve lot -1001 from leaching facility ✓ (1) location of water lines on property -101 from leaching facility ✓ (m) location of benchmark (n) driveways (o) garbage disposals --(p) no PVC to be used in construction (q) profile of system -elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and Other elevations ✓ (r) maximum ground water elevation in area sewage disposal system ✓(s) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Reg 6 I S tic Tanks W'0':'0 (a) capacities -150$ of flow, water table, tees, depth of tees, access, puaping (b) cleanout ✓ (c) 101 from cellar wall or inground swiaming pool - (d) 251 from subsurface drains Reg 10.2 Distribution Boxes ✓ (a) slope greia—ter—MW 0.08 Reg 10.4 ✓ b) sump 1A