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Home My WebLink AboutMiscellaneous - 110 OLYMPIC LANE 4/30/2018 (2) f 110 OLYMPIC LANE - 210/106.6-0121-0000.0 G North Andover Board of Assessors Public Access Page 1 of 1 s Ton o€Nor#h Arkdover IE7 pORYy - g6�ww{�>•Z7.r . c Assessors C'f _ of,Y� e 11'O of- .'�i`sse.S.rf.ors Pro e P rty &�cNus� Record Card Return to the Home page click on logo Parcel ID:210/106.13-0121-0000.0 Community: North Andover SKETCH PHOTO New Search Click on Sketch to Enlarge Sales o P 1"ct u r Summary Residence Available Detached Structure Condo Commercial Comparable Sales Location: 110 OLYMPIC LANE Owner Name: LIFE ESTATE TO: PAULA VON KUMMER VON KUMMER,JUDITH&ANDERSON, PENELOPE Owner Address: 110 OLYMPIC LANE City:NORTH ANDOVER State:MA ZIP: 01845 Neighborhood: 7-7 Land Area: 1.01 acres Use Code: 101 -SNGL-FAM-RES Total Finished Area: 3304 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 638,200 587,400 Building Value: 401,600 372,200 Land Value. 236,600 215,200 Market Land Value:236,600 Chapter Land Value: LATEST SALE Sale Price:0 Sale Date: 07/25/2005 Arms Length Sale Code: A-NO-FAMILY Grantor:VON KUMMER,PAULA Cert Doc: Book:9661 Page:309 E 1 I �I I I i http://csc-ma.us/NandoverPubAcc/jsp/Home.jsp?Page=3&Linkld=991125 8/13/2007 Vf Commonwealth of Maa$achuaeta Title 5 Official Inspection Farm a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 119plympic Ln. N. Andover, MA Property Address Vankummer, Paula Owner Owner's Name Informrequired tion is North Andover MA 01845 7118/07 _ required Par _... .........-- - eve page. CitylTown ---'---- —........actl..— ry g State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. t Whenfl�linuin g out A. General Information w. When forme on the computer,use 1. Inspector: only the tab key to move your ,Jose h Delahunt cursor-do not --------� ..._._ use the return Name Of Inspector key. -Delahunty Septic Service Company Name ^Q 248 Danville Rd. Company Address Fremont, NH NH 03044 rte„ 6t—at-e---_ _ .._..... .. CitylTown zip code 603 895 6305 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 6(310 CMR 15.000)-The system: [9 Passes ® Conditionally Passes ® Fails ❑ Needs Further valuati the Local Approving Authority I 7121107 ctor's Signature Date _.... The system inspector shall mit 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. ***'PThis 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. Title 5 oamputer rorm.doc•O$M Ttee 5 orrmai inspection Form:$up*urrece Sewage Di$ppgei 9yetem.pap•t Of 15 TO 39k1d [-AS :6I1d3S Ail-I IHy-131 S069-S69-6.09 9T:07 !00,?,'5L/PLS Septic System Information 110 OLYMPIC LANE J� Printed On: Thursday,August 09,,?_00 System ID: BHS-2002-1191 General System Information Latest Permit Information Calcaluted Design Flow. Test Pits Septic Tank Disposal Trench Design Flow. One Two Capacity: Number: Design Flow Provided. Minutes per inch: Width: Width: Total Flow. Depth: Length: Length: Seasonal. No No Depth to Water: Diameter: Leaching: Grinder: No No Soil Type: Depth: Laundry: No No Inspections: Inspected: Expires: Inspector: Status: 07/21/2007 Joseph Delahunty Passes Comments: Title 5 Title 5 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Page 1 of 1 ( i Of CORTF( Town of North Andover HEALTH DEPARTMENT ' ,SSACHUStt CHECK#: _ � DATE: LOCATION: H/O NAME: CONTRACTOR NAME:�yiJ-2 �> G Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors '$ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ '. ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ t ❑ Well Construction $ y SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title e55Inspector $ EL,fitle 5 Report $ � ❑ Other:(Indicate) $ 2546 �- Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer Commonwealth of Massachusetts N W Title 5 Official Inspection Form ��'�1�' _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 110 Olympic Ln. N. Andover, MA Property Address Vankummer, Paula Owner Owner's Name information is required for North Andover MA 01845 7/18/07 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. Important: When filling out A. General Information forms on the RECEIVEDcomputer, use 1. Inspector: only the tab key to move your Joseph Delahunt cursor-do not Name of Inspector use the return key. Delahunty Septic Service IWEP,lTti_ ANDOVER Company Name DEPARTMENT rae 248 Danville Rd. -- Company Address Fremont, NH NH 03044 City/Town State Zip Code 603 895 6305 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 7/21/07 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. Title 5 computer form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 110 Olympic Ln. N. Andover, MA Property Address Vankummer, Paula Owner Owner's Name information is required for North Andover MA 01845 7/18/07 every page. 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: Check baffle when tank is pumped, recommend every 2 years or yearly with heavy use. 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): ❑ broken pipe(s) are replaced ❑ obstruction is removed Title 5 computer form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 I T • Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 Olympic Ln. N. Andover, MA Property Address Vankummer, Paula Owner Owner's Name information is required for North Andover MA 01845 7/18/07 every page. City/Town 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. Title 5 computer form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 • Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 Olympic Ln. N. Andover, MA Property Address Vankummer, Paula Owner Owner's Name information is required for North Andover MA 01845 7/18/07 every page. 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 ❑ ® 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 Y2 day flow ❑ ® 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. Title 5 computer form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 ' Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 Olympic Ln. N. Andover, MA Property Address Vankummer, Paula Owner Owner's Name information is required for North Andover MA 01845 7/18/07 every page. CityfFown 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 2000 d- ❑ ® 9 Y 9 9P 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 ❑ El 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. Title 5 computer form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 Olympic Ln. N. Andover, MA Property Address Vankummer, Paula Owner Owner's Name information is required for North Andover MA 01845 7/18/07 every page. CitylTown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] Title 5 computer form.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 ' Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 Olympic Ln. N. Andover, MA Property Address Vankummer, Paula Owner Owner's Name information is required for North Andover MA 01845 7/18/07 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 600 gpd Number of current residents: 1 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage attached 9 ( Y 9 (gpd)) Sump pump? ® Yes ❑ No Last date of occupancy: currentDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): Title 5 computer form.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 Olympic Ln. N. Andover, MA Property Address Vankummer, Paula Owner Owner's Name information is required for North Andover MA 01845 7/18/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: BOH Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: 1000 according to plans and BOH info gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: original 1980 Were sewage odors detected when arriving at the site? ❑ Yes ® No Title 5 computer form.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 Olympic Ln. N. Andover, MA Property Address Vankummer, Paula Owner Owner's Name information is required for North Andover MA 01845 7/18/07 every page. City/Town State Zip Code Date of Inspection I I D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2 feet 4 inches at tank 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.): none Septic Tank(locate on site plan): Depth below grade: 1 foot 8 inches feet Material of construction: ® concrete ❑ metal ❑ 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: 8' x 5' with operating level of 47' Sludge depth: 7 inches Distance from top of sludge to bottom of outlet tee or baffle 25 inches Scum thickness 1 inch Distance from top of scum to top of outlet tee or baffle 5 inches Distance from bottom of scum to bottom of outlet tee or baffle 19 inches How were dimensions determined? Calabrated rod, tape measure Title 5 computer form.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 '1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 Olympic Ln. N. Andover, MA Property Address Vankummer, Paula Owner Owner's Name information is required for North Andover MA 01845 7/18/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert evidence of a leaks etc.): :) Outlet baffle to be inspected after every pump, some cement rot on top portion of baffle. Pump tank every 2 years or every year with heavy use. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete metal fiberglass❑ ❑ polyethylene other ex Iain 9 ❑ ❑ (explain): ) Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 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): Title 5 computer form.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 • Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 Olympic Ln. N. Andover, MA Property Address Vankummer, Paula Owner Owner's Name information is required for North Andover MA 01845 7/18/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert At inverts 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.): none Pump Chamber(locate on site ) Ian : P Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Title 5 computer form.doc•08/06 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 110 Olympic Ln. N. Andover MA Property Address Vankummer, Paula Owner Owner's Name information is required for North Andover MA 01845 7/18/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: i I i Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 20 x 55 ❑ 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.): Title 5 computer form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 110 Olympic Ln. N. Andover, MA Property Address Vankummer, Paula Owner Owner's Name information is required for North Andover MA 01845 7/18/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on siteplan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Title 5 computer form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 w • Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 Olympic Ln. N. Andover, MA Property Address Vankummer, Paula Owner Owner's Name information is required for North Andover MA 01845 7/18/07 every page. City/Town State Zip Code Date of Inspection I D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to ground water: 6 feet plus, see plans on file 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: Jan. 1979 Date ❑ Observed siteabuttin r site (abutting p operty/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Plan on file ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Plans on file. Title 5 computer form.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 • Commonwealth of Massachusetts H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 Olympic Ln. N. Andover, MA Property Address Vankummer, Paula Owner Owner's Name information is� required for North Andover MA 01845 7/18/07 every page. City/Town State Zip Code Date of Inspection D. System y m 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. X 0 C c,ver Coves Title 5 computer form.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 y Summary Record Card generated or,7/18/2007 111:48:54 AM by Lisa Warren Page 1 • Town of North Andover Tax Map # 210-1063-0121-0000.0 110 OLYMPIC LANE VON KUMMER, FERDINAND G. 110 OLYMPIC LANE N. ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 1.01 Acres FY 2007 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until VON KUMMER, FERDINAND G. Payor 110 OLYMPIC LANE N.ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/inactive Bldg Id. 17521.0-110 OLYMPIC LANE Last Billing Date 7/13/2007 3170191 03 Cycle 03 Active UB Services Maint. Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 21.91 /1 UB Meter Maintenance Serial No Status Location Brand Type Size YTD Cons 0025176428 a Active ENC RT ? w Water 0.63 0.63 0 Date Reading Code Consumption Posted Date Variance 6/15/2007 2558 a Actual 7 7/20/2007 18% 3/15/2007 2551 m Manual estimate 6 4/16/2007 -9% 12/12/2006 2545 a Actual 6 1/19/2007 -51% 9/18/2006 2539 a Actual 13 10/20/2006 13% 6/19/2006 2526 a Actual 13 7/10/2006 60% 3/8/2006 2513 a Actual 6 4/17/2006 21% 12/22/2005 2507 a Actual 6 1/17/2006 -38% 9/21/2005 2501 a Actual 9 10/14/2005 69% 6/27/2005 2492 a Actual 6 7/15/2005 -23% 3/22/2005 2486 a Actual 8 4/5/2005 2% 12/13/2004 2478 a Actual 7 1/14/2005 -43% 9/16/2004 2471 a Actual 12 10/8/2004 90% 6/22/2004 2459 a Actual 5 7/30/2004 -8% 4/15/2004 2454 a Actual 10 5/17/2004 0% 12/12/2003 2444 n New Meter 0 12/12/2003 0% %, a.rd of Malth North Anc�averaM$as. - .•'SEPTIC SZST�i INSTALLATICK CF,.IDCK LIST LOT �6 Q 1 ' OVID DATE DISAPPtZU�T AVATICN OK FAIL , -70 FAIL CK / 1. Instance Tot ��✓✓✓�/ a. Wetlands b. Drains Well 2. Water Line Location ; i 3• No PPC Pipe �. Septic Tank a*--- Tees -_Length Ec To Clean Out Covers. f/ b. Cement Pipe to Tank - On Both Sides of Tank- t 5. Distribution Box a. Covers &_ Box - No Cracks b. All Lines Flowing Equal Amounts c. No Back Flow 6. Leach Field or Trench a. Dimensions - b. Stone Depth c. Capped ids °i d. Clean Double Washed Stone Leach Pits�,�� # a. Dimen ons f b. Ston Depth 0 sh Pads d. - T s { e. Cent Pipe to Pit - Both Sides. '. f. Clean Double Washed Stone No Garbage Disposal g. -Find Grading Inspection 10: Barricading Covered System 11. As Built Submitted, - a. Lot Location: b. .Dimensions of System c. Location with Regard-to Pere Test y = d. Elevations e: Water Table .. E 1 ` 4 DISPO"AL SYSTEM CHK LINT . NORTH ANDOVER BOARD OF HEALTH APr_. OV ED rD,10E PROVIDED DISAPPROVED DATE TIME REASON Title 5 Reg. 2. 5 Fail OK The submitted plan must show as a minumum: (a) the lot to be served (area,dimensions ,l.ot //,abutters) (Planning Board files) (b) location and log of deep observation holes-distance to ties ( ) location and results of percolation tests-distance to ties (d) design calculations & calculations showing required leaching area (e) location and dimensions sf system (including reserve area) existing and proposed contours g) location of any wet areas within 100' of the sewage disposal system ordisclaimer (check wetlands mapping) (h) surface and subsurface drains within 100' of sewage disposal system or disclaimer (i) location of any drainage easements within 100' of sewage disposal system or disclaimer (planning board files) (j ) known sources of water supply within 200' of sewage disposal system or disclaimer Y(k) location of any proposed well to serve the lot (100' from leaching facility) (Fl) location of water lines on property (10' from. leaching facilities) (/m) location of benchmark (,n) driveways Ll/ o) garbage disposers %�p) no PVC is to be used in construction � (q) a profile of the system (elevations of basement , plumbe pipe septic tank, distribution box inlets and outlet-s, distribution field piping and any other elevations) (r) maximum ground water elevation in area of sewage dispoti system ( s) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Septic Tanks Reg. 6 Capacities - 150% of flow, water table , tees , depth of tees , access , purnping, (�bCleanout c) 10' from cellar wall or inground swimming pool (d) 25' from subsurface drains North Andover Subsurface disposal syatem Check list = Page 2 � 7ail OK p1stribution Boxes Reg.10.2aSlope great er than 0.08 Reg.10.4 (b) Sump Leaching pits Leaching pits are pre rred where the installation -is ' possible Reg.11 .2 (a) Calculat ' ns of leaching area (minimum 500 S.F. ) Reg.11 .4 (b) Spacing/ Reg.11 .1 (c) Surf ''e drainage 2% Reg.11 .11 d Cov r Smaterial ` A e e -1 bo fa S k �C Leaching Fields Reg.15.1a) RiGreater than 20 minutes/inch Reg.15.1 b) Area (.minimum_.900 S.F. ) Reg.15.4 �- Construction of field Reg.15.8 d) Surface drainage 2% Reg. 3.7 (e) 20' from- cellar wall or inground swimming pool Leaching Trenches Reg.14.1 (a Calcul/drainage tiof .leaching area (min. 500 S.F.) Reg.14. 3 (b Spaci . min. 6 ft. with reserve between) Reg.14.4 (c Dimen 14. 5 Reg.14.6 (d Const Reg.14.7 (e� Stone Reg.14.1 (f) Surf2% Downhill Slope Slope y/ to be shown) �a� by/x X 1 0 = to be shown) Pumps Reg. 9.1 (a) App oval Reg. 9.6 (b) St nd-by power TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD n JAN ' 62003 DATE: 1119h SYSTEM OWNER&ADDRESS SYSTEM LOCATION (example: left front of house) W . DATE OF PUMPING: D QUANTITY PUMPED GALLONS i CESSPOOL: NO. YES SEPTIC TANK: NO YES . ..._ , NATURE OF SERVICE, ROUT INE I� � EMERGENCY OBSERVATIONS:_. ;; f GOOD CONDITIONFULL TO COVER HEAVY GREASE BAFFLES IN PLACE .ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) � QJLtJ' SYSTEM PUMPED COMMENTS: CONTENTS TRANSFERRED TO: N �N p � -rk. 1 Q � �L s t � ►Sa.o 1NY_PIPE ZE.. �� o► z Q6 V I L-r SAVPIPE,OUTOF Tr`�w 166t1cl - - —S V Vit. A�C,E `� ='jc ►L iNV_ O$' ( I blv PIrpt= dUT 0.pbox tco a 6. l 0-7.32 �N TNS a� � � ►Y� V SS•t3 To c�' ta�ci+d CL. 'CN AG.'F V PtxtS"f titati�•. F 4 rZ titEo TWA t"�c.Es W M '4� At�S,d - V t•., D.f�iD R�C��U4 Pr �btJ 0<F '(AX C>V-CN P t.1 MQS t. t P, o ir- VQ Lai �t2AhLK GC7t=t_1IQA'S � AS5vCtA.TES .s � .Gf • .� it r!C�tNt:E�25� At2c.�-t[T'�.GTS AN C>'C)%4f . 1 • �d 1 , { r r' I I - • it r NG i�• ° l, v� f�'3 ji r 3 u L-T NV PIPE– OUT OF H5E --- — -- - KI v PIPE i NTO Il ,r.iv PIPE INTO D.BOX —___-�'- !73 C 3 t4y 91 DE AUT - ,N�1 • �;}' ,�� _ ,T - ' �• ,J Sco,�E � " - 4 I� Dom,-� E- d - ' ' - ��t �.f\iDGr/E=.t2 ��• rbc �� ^•; �� ' . F ;