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Miscellaneous - 112 STONECLEAVE ROAD 4/30/2018
112 3TONECLEAvE RC3A(l North Andover Board of Assessors Public Access Page 1 of 1 at „ORT„ North Andover Board of Assessors O`t•�ao ga'�Q.O 3:e..t. ... ,•a OL 9 • 7 tamw "SSACHU roperty Record Card Click Seat To Return Parcel ID:210/104.B-0124-0000.0 FY:2011 Community:North Andover SKETCH PHOTO Click on Sketch to Enlarge Click on Photo to Enlaz e Search for Parcels �L Search for Sales Summary 3` h; Residence Detached Structure Condo 112 STONECLEAVE ROAD Commercial Location: 112 STONECLEAVE ROAD Owner Name: CHRISTOPHER M.&MARY E.LITSTER Owner Address: 112 STONECLEAVE ROAD City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood:7-7 Land Area: 1.01 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 2036 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 440,500 455,200 Building Value: 214,800 229,500 Land Value: 225,700 225,700 Market Land Value: 225,700 Chapter Land Value: LATEST SALE Sale Price: 390,500 Sale Date: 02/21/2002 Arms Length Sale Code: Y-YES-VALID Grantor: DAVID I.BRUSH Cert Doc: Book: 06682 Page: 0180 http://csc-ma.us/PROPAPP/display.do?linkld=1706958&town=NandoverPubAcc 8/24/2011 North Andover Board of Assessors Public Access Page 1 of 1 pOR71q !V o `h Andover er Board of Assessors f 4 MATCHING PARCELS SSACHpS� Click on a column title to sort data by that column Click Sea]To Retum 30 items found,displayinig,all items.1 Fiscal Year Parcel ID St.No. Street Owner Name STONECLEAVE ADAMS FAMILY REALTY TRUST, 2011 210/104.B-0 137-0000.0 0 ROAD RICHARD D.&JOANNE E.ADAMS, TRUSTEES Search for Parcels 2011 210/]04.B-0139-0000.0 0 STONECLEAVE ADAMS,GEORGE BLAKE,ADAMS, OAD BARBARAJ. Search for Sales 2011 210/104.B-0140-0000.0 0 ROAD CLEAVE ADR SRA JORGEBLAKE,ADAMS, 2011 210/104.B-0141-0000.0 0 STONECLEAVE ADAMS,GEORGE BLAKE,ADAMS, ROAD BARBARA J. 2011 210/105.C-0035-0000.0 10 ROS CLEAVE KIItBY CHRISTOPHER LAURIE S KIltBY 2011 210/105.C-0046-0000.0 11 STONECLEAVE NUTTER,HEATHER,NUTTER,STEVEN ROAD 2011 210/1 OS.C-0036-0000.0 26 STONECLEAVE TOWER,JOSEPH F III,PATRICIA M ROAD TOWER 2011 210/lOS.C-0045-0000.0 31 STONECLEAVE COUNTRY ROAD REALTY TRUST, ROAD KRISTINE A ACKLEY,TR 2011 210/105.C-0044-0000.0 37 STONECLEAVE MITTS,JOAN F, AD 2011 210/105.C-0037-0000.0 38 STONECLEAVE VELGUTH,CHARLES A,LOUISA G ROAD VELGUTH 2011 210/104.B-0 144-0000.0 43 STONECLEAVE LUN4PERT,STANLEY B,MARY ANN E ROAD LIMPERT 2011 210/104.B-01 19-0000.0 50 ROOAN CLEAVE ICHTON,MARILYN, 2011 210/]04.B-0143-0000.0 55 STONECLEAVE BARCLAY,BRUCE E,DOROTHY R ROAD BARCLAY 2011 210/104.B-0120-0000.0 62 ROAD STONECLEAVE BARRY,DOUGLAS J,PATRICIA M BARRY 2011 210/104.B-0 142-0000.0 67 STONECLEAVE PETRIE,PAUL E.,LAURENZA,THERESA ROAD M. 2011 210/]04.B-0121-0000.0 74 STONECLEAVE HALL,CLYDE M,JOAN P HALL ROAD 2011 210/104.B-01 24-0000.0 112 STONECLEAVE CHRISTOPHER M.&MARY E.LITSTER, ROAD 2011 210/104.B-0138-0000.0 114 STONECLEAVE ADAMS FAMILY REALTY TRUST, ROAD RICHARD D&JO-ANNE ADAMS,TRS 2011 210/104.B-0125-0000.0 124 STONECLEAVE PAPELL,MICHAEL W,NATALIE N ROAD PAPELL 2011 210/]04.B-0126-0000.0 136 STONECLEAVE DISE,JOHN B,SUSAN G DISE ROAD 2011 210/]04.B-0136-0000.0 141 SROM CLEAVE SASSO,SYLVIA, 2011 210/104.B-0127-0000.0 148 STONECLEAVE GRANT,JOHN J,JR,PATRICIA M GRANT ROAD 2011 210/]04.B-0135-0000.0 151 ROOAN CLEAVE VOGEL,BRIAN L,BARBARA G VOGEL 2011 210/104.B-0128-0000.0 162 STONECLEAVE BOOTHBY,STANTON R,SANDRA L ROAD BOOTHBY 2011 210/]04.B-0134-0000.0 163 STONECLEAVE STADLER FAMILY TRUST,WILLIAM& ROAD PATRICIA STADLER,TRS 2011 210/]04.B-0133-0000.0 175 STONECLEAVE DEPARI JR,RALPH R,MARY DEPARI ROAD 2011 210/104.B-0129-0000.0 178 STONECLEAVE BURBA REALTY TRUST,RANDALL S& ROAD PATRICIA,R S&P A BURBA,TRS 2011 210/104.B-0 132-0000.0 187 STONECLEAVE GAULD,ROGER E,NANCY L GAULD I ROAD 2011 210/104.B-0130-0000.0 192 STONECLEAVE GREELEY REALTY TRUST,JOHN& ROAD SUSAN GREELEY,TRUSTEES 2011 210/104.B-0131-0000.0 199 STOOD CLEAVE CORLISS,MICHAEL,CORLISS,DOREEN 30 items found,displaying all items.l http://csc-ma.us/PROPAPP/newSearch.do;j sessionid=0979475 CC219CC7FD957506052B... 8/24/2011 Commonwelfith•ot Massachusetts Title 5 Official Inspection orm L, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments er ry 112 Stonecleave Road b 6 Property Address Chris Lister Owner Owner's Name information is required for North Andover MA 01845 8/13/2011 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: A. General Information EC When filling out / forms on the r" computer,use 1. Inspector: r+. AUG 22 M1 only the tab key to move your Neil James Bateson cursor-do.+not I TOWN CIF NORTH A Alnr)�mo Name of Ins ector use the retum p HEALTH DEPARTMENT key. Bateson Enterprises Inc. Company Name - 111 Argilla Road Company Address Andover MA 01810 City/Town State Zip Code 978-475-4786 S115 Telephone Number License Number B. Certification I certify that Ihave 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 '1� Title 5(310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Nee s Further Evaluation by the Local Approving Authority 8/13/2011 pe 14Sionatur 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-11/10 Title 5 ficial Inspection form:Subsurface Sewage Disposal System•Page 1 of 17• ' CommonweWith•d Massachusetts P. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 112 Stonecleave Road Property Address Chris Lister Owner Owner's Name information is required for North Andover MA 01845 8/13/2011 every page. Cityrrown 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. 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 Forth: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 112 Stonecleave Road Property Address Chris Lister Owner Owner's Name information is required for North Andover MA 01845 8/13/2011 every page. 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 obstructedpipe(s)or due to a broken settled or uneven distribution box. System will � Y 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): ❑ 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 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 112 Stonecleave Road Property Address Chris Lister Owner Owner's Name information is required for North Andover MA 01845 8/13/2011 every page. Cityrrown state Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Healthand Public Water Supplier,( PP ,if any) determines that the system is functioning in a manner that protects th Y g p e 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 5ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Outlet tee in septic tank&d-box needs to be replaced D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y day flow 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 112 Stonecleave Road Property Address Chris Lister Owner Owner's Name information is required for North Andover MA 01845 8/13/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 112 Stonecleave Road Property Address Chris Lister Owner Owner's Name information is required for North Andover MA 01845 8/13/2011 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? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 .DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 600 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 112 Stonecleave Road Property Address Chris Lister Owner owner's Name information is required for North Andover MA 01845 8/13/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 5 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 On well water 9 ( Y 9 (gpd))� Detail: Well 70'to front of septic tank, 104'to d-box. Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 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 112 Stonecleave Road Property Address Chris Lister Owner Owner's Name information is North Andover MA 01845 8/13/2011 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped 2009, owner Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection f o the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•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 .'" 112 Stonecleave Road Property Address Chris Lister Owner Owner's Name information is required for North Andover MA 01845 8/13/2011 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 33 years old, 5/29/1978, as built plan. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.3 feet Material of construction: ® cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): 4"Cast iron thru wall, 3" PVC in house, no leaks visible Septic Tank(locate on site plan): Depth below grade: 1.3 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: Tx5'x4' Sludge depth: 2 t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 112 Stonecleave Road Property Address Chris Lister Owner Owner's Name information is required for North Andover MA 01845 8/13/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle N/A Scum thickness 2" Distance from top of scum to top of outlet tee or baffle N/A Corroded outlet tee Distance from bottom of scum to bottom of outlet tee or baffle N/A How were dimensions determined? Tape Measure Iim e Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert evidence of leakage,a, etc. :9 ) Outlet tee needs to be replaced. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): 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 t5ins•11110 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 112 Stonecleave Road Property Address Chris Lister Owner Owner's Name information is required for North Andover MA 01845 8/13/2011 every page. Cityrrown 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 Forth: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 112 Stonecleave Road Property Address Chris Lister Owner Owner's Name information is required for North Andover MA 01845 8/13/2011 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert -2" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box liquid level below all outlets. Evidence of leakage. D-box has corrosion holes. Evidence of carryover. D-box needs to be replaced. 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 M 112 Stonecleave Road Property Address Chris Lister Owner owner's Name information is North Andover MA 01845 8/13/2011 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 field 20'x 45' ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok.Vegetation ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments b 112 Stonecleave Road Property Address Chris Lister Owner owner's Name information is required for North Andover MA 01845 8/13/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 112 Stonecleave Road Property Address Chris Lister Owner Owner's.Name information is North Andover MA 01845 8/13/2011 required for - every page. Cityrrown 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 ❑ drawing attached separately i P it '411 t5ins•11110 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 112 Stonecleave Road Property Address Chris Lister Owner Owner's Name information is North Andover MA_ 01845 8/13/2011 required for - _ every page. City/rown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth t high pt o g ground water: >4 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: 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: Essex County Soil Map Y must ust describe how you established the high round water elevation: � 9 9 Essex County Soil Map, Sheet#37, Canton Soil , Water>6' Deep Before filingthis Inspection Report, please see Report Completeness Checklist on nextPa9 e. t5ins•11/10 Title 5 ficial Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 t r �: a \ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M yy< 112 Stonecleave Road Property Address Chris Lister Owner Owner's Name information is required for North Andover MA 01845 8/13/2011 every page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D(System Failure Criteria Applicable to All Systems)completed E System Information-Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17 1 r 1 7777-W t o N—L k. 1.31.91 E i t � � I 1 U i i V� f . Y( 1 PETER F. REILLY AFFILIATED WITH F.P. REILLY AND SONS, INC. 206 ANDOVER STREET, SUITE 11 ANDOVER, MA 01810 (978) 475-4370 SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART A - CERTIFICATION Property Address: 112 Stonecleave Road, North Andover, MA 01845 Name of Owner: Brush Address of Owner: same Name of Inspector: Peter F. Reilly (I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: F.P. Reilly & Sons Mailing Address: 136 Andover Street, Andover, MA 01810 Telephone Number: (978) 475-4370 / (978) 375-3750 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: ✓ Passes N/A Conditionally Passes N/A Needs Further Evaluation By the Local Approving Authority N/A Fails Inspector's Signature: Date: October 7, 2000 Peter F. Reilly The system inspector shall submit a copy of this inspection report to the approving authority within thirty (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 regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. NOTES AND COMMENTS e� ,y f ' f SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART A - CERTIFICATION (continued) Property Address: 112 Stonecleave Road, North Andover, MA Owner's Name: Brush Date of Inspection: 10/7/00 INSPECTION SUMMARY: A. SYSTEM PASSES: Check A, B, C or D ✓ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: System was functioning properly. B. SYSTEM CONDITIONALLY PASSES: N/A 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. Indicate yes, no, or not determined (Y, N, ND). Describe basis of determination in all instances. If "not determined", explain why not) N The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tan was installed within twenty(20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. N Sewage backup or breakout or static high water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health): N/A broken pipe(s) are replaced N/A obstruction is removed N/A distribution box is leveled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): N/A broken pipe(s) are replaced N/A obstruction is removed SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART A - CERTIFICATION (continued) Property Address: 112 Stonecleave Road, North Andover, MA Owner's Name: Brush Date of Inspection: 10/7/00 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 the public health, safety and environment. 1. SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: N/A Cesspool of privy is within 50 feet of a surface water N/A Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh. 2. SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: N/A The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. N/A The system has a septic tank and soil absorption and the SAS is within a Zone I of a public water supply well. N/A The system has a septic tank and soil absorption and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a water well water analysis 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. Method used to determine distance N/A (approximation not valid). 3. OTHER N/A ' L SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART A - CERTIFICATION (continued) Property Address: 112 Stonecleave Road, North Andover, MA Owner's Name: Brush Date of Inspection: 10/7/00 D. SYSTEM FAILS: You must indicate "Yes" or "No" to each of the following: N/A I have determined that the system violates one or more of the following failure conditions exist as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No No Backup of sewage into facility or system component due to an 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. N/A Liquid depth in cesspool <6" below invert or available volume <% day flow. No required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: none No Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. N/A Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. N/A Any portion of a cesspool or privy is within a Zone I of a private water supply well. N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well. N/A 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You Must indicate either "Yes" or "No" to each of the following: The following criteria apply to a large system in addition to the criteria above. N/A The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: N/A The system is within 400 feet of a surface drinking water supply N/A The system is within 200 feet of a tributary to a surface drinking water supply N/A The system is located in a nitrogen sensitive area (Interim Wellhead Area (IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2)• Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART B - CHECKLIST Property Address: 112 Stonecleave Road, North Andover, MA Owner's Name: Brush Date of Inspection: 10/7/00 Check if the following have been done. You must indicate either "Yes" or "No" as to each of the following: Yes No Yes Pumping information was requested of the owner, occupant and Board of Health. Yes None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. Yes As built plans have been obtained and examined. Note they are not available with N/A. Yes The facility or dwelling was inspected for signs of sewage backup. Yes The system does not receive non-sanitary or industrial waste flow. Yes The site was inspected for signs of breakout. Yes All system components, excluding the SAS, have been located on the site. Yes The septic tank manholes were uncovered, opened and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. Yes Existing information (Example: Plan at BOH). N/A Determined in the field if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable [1 5.302(3)(b)). SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION Property Address: 112 Stonecleave Road, North Andover, MA Owner's Name: Brush Date of Inspection: 10/7/00 FLOW CONDITIONS RESIDENTIAL: Design Flow: unknown Number of bedrooms (design): unknown Number of bedrooms (actual): 4 Total Design Flow: unknown Number of Current residents: 4 Garbage grinder (yes or no): no Laundry (separate system) (yes or no): no; if yes, separate inspection required Laundry system inspected (yes or no): N/A Seasonal use (yes or no): no Water meter readings, if available (last two years usage (gpd): about 250 gpd past 2 years Sump Pump (yes or no): no Last date of occupancy: current COMMERCIAL/INDUSTRIAL: Type of Establishment: N/A Design Flow gpd (based on 15.203): N/A Basis of Design Flow: N/A Grease trap present (yes or no): N/A Industrial waste holding tank present (yes or no): N/A Non-sanitary waste discharged to the Title 5 system (yes or no): N/A Water meter readings, if available: N/A Last date of occupancy: N/A OTHER: (Describe) N/A Last date of occupancy: N/A GENERAL INFORMATION PUMPING RECORDS and source of information: last pumping: 7/99 according to BOH records System pumped as part of inspection (yes or no): no if yes, volume pumped: N/A gallons Reason for pumping: N/A TYPE OF SYSTEM ✓ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy NO Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other (explain) SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 112 Stonecleave Road, North Andover, MA Owner's Name: Brush Date of Inspection: 10/7/00 APPROXIMATE AGE of all components, date installed (if known) and source of information: Original system installed in 1977 Sewage odors detected when arriving at the site (yes or no) NO BUILDING SEWER: (locate on site plan) Depth below grade: about 18"-20" material of construction: ✓ cast iron 40 PVC other (explain) Distance from private water supply well or suction line N/A Diameter: 4" Comments: Condition of joints, venting, evidence of leakage, etc.) Building sewer was watertight and appeared sound at foundation. SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 16"-18" material of construction: ✓ concrete metal Fiberglass Polyethylene other (explain) If tank is metal, list age N/A Is age confirmed by Certificate of Compliance N/A (Yes/No) Dimensions: rectangular - 1,500 gallons <1" sludge depth 28" distance from top of sludge to bottom of outlet tee or baffle <1" scum thickness 7" distance from top of scum to top of outlet tee or baffle 16" distance from bottom of scum to bottom of outlet tee or baffle How dimensions were determined: measurement / estimation Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc.) Tank was watertight and appeared to be functioning properly. GREASE TRAP: N/A (locate on site plan) Depth below grade: material of construction: concrete metal FRP other (explain) Dimensions: N/A scum thickness N/A distance from top of scum to top of outlet tee or baffle N/A distance from bottom of scum to bottom of outlet tee or baffle Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc.) N/A SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 112 Stonecleave Road, North Andover, MA Owner's Name: Brush Date of Inspection: 10/7/00 TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to, or at time of inspection) (locate on site plan) Depth below grade: material of construction: concrete metal Fiberglass Polyethylene other (explain) Dimensions: N/A Capacity: N/A gallons per day Design Flow: N/A gallons per day Alarm Present: N/A Alarm level: N/A Alarm in working order N/A (Yes or No) Date of Previous Pumping: N/A Date of previous pumping: N/A Comments: (condition of inlet tee, condition of alarm and float switches, etc.) N/A DISTRIBUTION BOX: ✓ (locate on site plan) 0" depth of liquid above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc.) The d-box was level and functioning properly. No solids carryover evident. PUMP CHAMBER: N/A (locate on site plan) N/A Pumps in working order (Yes or No) N/A Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) N/A SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 112 Stonecleave Road, North Andover, MA Owner's Name: Brush Date of Inspection: 10/7/00 SOIL ABSORPTION SYSTEM (SAS): ✓ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: not applicable Type leaching pits and number N/A leaching chambers and number N/A leaching galleries and number N/A leaching trenches, number, length N/A leaching fields, number, dimensions 1 field , 4 lines, 20' x 45' per "as-built" plan overflow cesspool, number N/A alternative system (name of technology) N/A Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) Soils over leaching area were good, no evidence of breakout. CESSPOOLS: N/A (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 (cesspool must be pumped as part of inspection) N/A Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc.) not applicable PRIVY: N/A (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, recommendations for maintenance or repairs, etc.) not applicable SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 112 Stonecleave Road, North Andover, MA Owner's Name: Brush Date of Inspection: 10/7/00 SKETCH OF SEWAGE DISPOSAL SYSTEM: indicate at least two permanent references, landmarks, or benchmarks locate where public water system enters house locate all wells within 100' N/A we¢tY 2 hekJ� . 8 oak Scrn. ti, 0 Zb sus r r . 45 ' SEPTIC TANK TIES: A to Inlet (1) 817" B to Inlet $17" A to Center (C) N/A B to Center N/A A to Outlet (0) 9'4" B to Outlet 14'9" C to Outlet 17'2" D-BOX TIES: A to Box 2816" B to Box 4214" C to Box 3410" D to Box 5610" NOTE: The system is in the rear yard. The "A" point is the corner of the screened porch closest to the tank. The "C" point is the oak tree closest to the septic tank. The "D" point is the far rear corner of the house at the garage. Could not swing the "D" point to the tank as the porch was in the way. SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 112 Stonecleave Road, North Andover, MA Owner's Name: Brush Date of Inspection: 10/7/00 NRCS Report Name N/A Soil Type N/A Typical depth to groundwater N/A USGS Date website visited 4/29/00 Observation Wells checked Wilmington Groundwater depth: Shallow Moderate ✓ Deep SITE EXAM Slope level in area of system Surface water none observed Check Cellar dry Shallow wells none observed Estimated Depth to Groundwater > 1 ' (below bottom of SAS) Indicate all methods used to determine High Groundwater Elevation: Y Obtained from Design Plans on record Y Observation of Site (abutting property, observation hole, basement sump, etc.) Y Determined from local conditions Y Check with Local BOH N Check FEMA Maps Y Check pumping records Y Check local excavators, installers N Use USGS Data Describe how you established the High Groundwater Elevation.* Design plan, local records and grade changes and soil conditions indicate no groundwater in the SAS. *Inspector's Note: Soil Evaluation is the currently recognized method for determining or establishing the high groundwater elevation. Since I am not a licensed or certified soil evaluator, I am not qualified to determine or establish the high groundwater elevation beyond the public information available, such as recent design plans of the site or the nearby area. My estimation of the high groundwater elevation is based on a due diligence effort to obtain all available information both on and off the site and my experience as a certified subsurface disposal system inspector. (see attached Disclaimer) DISCLAIMER This passing septic inspection under Massachusetts Title V is in no way a guaranty or warranty of the inspected septic system. The inspection is a "snapshot in time" and does not constitute a complete assessment of the quality or potential longevity of the septic system. The pass/fail criteria are specific and outlined in detail in this report. Under the limited criteria of a Title V inspection, it is impossible to determine how long any septic system will last. The inspector made a diligent effort to certify the septic system based on the criteria required under Title V. Under Massachusetts Title V, soil evaluation is the accepted method of determining the high groundwater elevation. This inspector is not a certified soil evaluator and is therefore not qualified under Title V to determine or establish the high groundwater elevation. The method used to estimate the high groundwater for this inspection was based on the public records and methods of observation described on the previous page. Groundwater levels can vary greatly from season to season, year to year and soil evaluation is considered the most reliable method of groundwater determination under Title V. Peter F. Reilly Inspector October 7, 2000 Commonwealth of Massachusetts City/Town of RECEIVED System Pimping Record JUN 2 3 2014 Form 4 TOWN OF NORTH ANDOVER DEP has provided this form for use-by local Boards of Health. Other fo s-rfi'WAM IIA& h�'e information must be substantially the same as that provided here. Before using.this form,check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/Right front of house, Left ear of hou , Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address City/Town State Zip Code 2. System Owner. LA Name Address(if different from location) Citylrown State Telephone Number 1, r B. Pumping Record A: 1. Date of Pumping Pumped: Date 2. Quantity Pud. Gallons 3. Type of system: ❑ Cesspool(s) aleptic Tank El Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes 2rNo If yes, was it cleaned? ❑ Yes ❑ No; 5. Condition f 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc- Company ncCompany 7. Loca' contents were disposed: Lowell Waste Water C� Sign HauiwU Date t5fbrm4.doe-06/03 System Pumping Record•Page 1 of 1 � Commonwealth of Massachusetts .V r= N City/Town of REC���°-��' System Pumping Record OCT 3 'JAR -1H AN()OVERForm 4 TO'NFALTH DEP RT iE DEP has provided this form for use by local Boards of Heal Otherfia s may be used, but the information must be,substantially the same as that provided here. Before using this form,check with your local Board of Health tq determine the form they use. The System Pumping Record must be submitted to the local Board of Health or-other approving authority. A. Facility Information 1. System Location: Ceft side of i ht side of house, Left front of house, Right front of house, Left rear of house, Ig t rear of house. Left rear of building. Right rear of building. Address r �D Cityfrown 1 State C Zip Code 2. System Owner: Name Address(f different from location) City/Town State ' Zip fCode >,g 7 Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑- If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: ` t� A0 IF l 6. System Pumped By: Neil Bateson F5821 Name . Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: .L.S.D Lowell Waste Water Signature of Hauler Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of MassachusettsMormsmay D City/Town of System Pumping Record 08 Form 4 DOVER , ENT DEP has provided this form for use by local Boards of Healte used, but the information must be substantially the same as that provided here. Before using this form,check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System LOCatiqll: ' forms on the computer, use only the tab key Address to move your cursor-do not Cityfrown State Zip Code use the return key. 2. 2. System Owner: kA Name 11 Address(if different from location) CityrTown Stat � �' {�p Code �Jy Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Er'�tic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes Deo If yes,was it cleaned? ❑ Yes ❑ No 5. Condition System- LA 6. Systqn Pumped Name Vehicle License Number Company 7. Location re contents wer sposed: -c3 . Signaturef of aul Date t5fonm4.doc•06/03 System Pumping Record.Page 1 of 1 Commonwealth.of Massachusetts RECEIVED,,," City/Town of I System Pumping Record JUN 12 2006 . Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health.. The System Pumping Record must be submitted to the:local Board of Health or other approving authority. . A. Facility Information Important: When filling out 1. System Location: forms the computer,use only the tab key Address to move your cursor-do not i use the return Qityfrown State Zip Code key. 2. System Owner: Name Address(if different from location) Cityfrown Stat Zi Code Telephone Number B. Pumping Record 1- Date.of PumpingDate 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank- ❑ TightTank ❑ Other(describe): 4: Effluent Tee Filter present? ❑ Yes Q-1q0 If yes, was it cleaned? ❑ Yes ❑ No 5. Conditio of System: 6. System Pumped By :Name Vehicle License Number Company . .. T Locaf where contents wer osed: e -� Si. atur .of auler Date http://www.mass.g. ep/ at /a pprovals✓t5forms.htm#insP ect t5form4.doc•06/03 System,Rumping Record•Page 1 of t - . .�, t►N OF NORTH'ANDOVER�' SYSTEM PUMPING RECORD 3f'STEM OWNER & ADDRESS ,. SYSTEM LOCATION 1 (example: left front of bouse)144 . iia S OF _...._ vA"f-E OF PUMPeNC: QUANTITY PUM P E-0G.�L L CJ v, .,�� ::i:aal'UUL: n0 -�,�-- YES_ SEPTIC TANK: NO YES a 11� " NATURE OFSERYICE; ROUTINE. „ EMERGENCY ul,sr:RVATION& s GOOD C011 D.ITIM FULL TO COYER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUM3ACK. EXCESSIVE$QLiDS , FLOODED SOLIDS CARRYOYER .R;HRR (EXPLAIN) �1'�'I'EM PUMPCI� QY: , .' •`'.. ' -1 , CUNI"II:NTS: c UN7'IsN'!'S' TRANS'lrERRSO TO: r TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example: left front of house) u-5 IJP'` ck r(14 slb(e DATE OF PUMPING: QUANTITY PUMPED 10&0 GALLONS CESSPOOL: NO V YES SEPTIC TANK: NO YES_ L/ NATURE OF SERVICE: ROUTINE t-,,/EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: COMMENTS: CONTENTS TRANSFERRED TO: - ,S 1 Commonwealth of Massachusetts Massachusetts System Pumping Record System Owner System Location 1� l l c�- Sly de� Date of Pumping: �U� --� Quantity Pumped: ��?J gallons Cesspool: No Septic Tank: No L_J Yes System Pumped by: Fetrejea Sii&+'tpaa License# Contents transferrred to : Greater Lawrence Sanitary District Date: _ Inspector: _„_ .DOVER/ ©FN QESH V�VF TC , FLEA r. 0 It, AtJG FOR 14- SYSTEM PUN Pr\G e$Aao 0 � X995 Commonwealth of Massachusetts Massachusetts System Pumping Record }'stem Uwner System Location Date of Pumping: ( � S� Quantity Pumped: �CMvgallons Cesspool: No Yes ❑ Septic Tank: No ❑ Yes i System Pumped by: � License #: Contents transferred to: ' Date Inspector i "°R$" Commonwealth of Massachusetts Map-Block-Lot 104.60124 BOARD OF HEALTH Permit No ` North Andover BHP-2011-0772 4 ^ , s 4i'b+:.��•:'i , FEE Ss�cmu $125.00 ----------------------- DISPOSAL WORKS CONISTRUCTIONI PERMIT Permission is hereby granted Todd Bateson to(Repair-DISTRIBUTION BOX ONLY)an Individual Sewage Disposal System. at No 112 STONECLEAVE ROAD as shown on the application for Disposal Works Construction Permit No. BHP-2011-077 Dated August_22,_20 11 ------------- Issued On:Aug-22-2011 - --------------------------------------------------------------------------------- 1 'POR 7"*,�,o Applicgtion for Septic Disposal System �,' °cTODAY'S BATE AConstruction Permit—,TOWN OF .f ORTH ANDOVER, MA 01845 $250.00—Full Repair $125.00-Component 5,C Important~ Application is hereby made for a permit to: forms o thout ❑Construct a new on-site sewage disposal system* computer,use ❑Re air or replace an existing on-site sewage disposal system* only the tab key to move your epair or replace an existing system component—What? cursor-do not use the return key. A. Facility Information C�1^►��'S Address or Lot# F' fO1y�G L4,4✓ City/?own1, �� 2.-*TYPE OF SEPTIC SYSTEM*: ❑Pump 9,Travity(choose one) ?onv pump system,attach copy of electrical permit to applijation*** entional System(pipe and stone system) i ❑Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system. El Pressure Distribution S.A.S.(No D-Box)(Attach Draft Maintenance Agreement) ❑Pressure Dosed(D-Box Present)S.A.S. 2. Owner Information /n Name _f 1 � off- S l��✓-� G�P v..� � f , Address(if different from above) Cdylt own State Zip Code Telephone Number 3. Installer Information JJ BATE'S0N ENTERPRIS Name nn Name of Company ILLA ROAD L �0% MA 01810 Address '^ City/Town State Zip Code Telephone Number(Cef/Phone##possfb a please) 4. Designer Information Name / Name of Company Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for o'sposal System Construction Permit Page 1 of 2 Opp �,rc or`iH Application..for Septic Disposal System — TODAY'S DATE ` p Construction Permit * TOWN. OF "�'^, . :� $.250.00-Full Repair '�4R.•�^� ORTH ANDOVER, MA 01845 $125.00,-Component PAGE 2OF2 A. Facility.Information continued.... 5. _TYPe of Bui[din qesdential Dwelling or 0 Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the 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 issued his Board of Health. Z Name Date Application troved By: ( and of Health Representative) Name Date Application Disapproved for the following reasons: For Office Use Only: L Fee Attached. Yes No 2. ProjectMaaager Obligation Form Attached. Yes No 3. Pump System? Ifso;Attach copv ofElectrical Permit Yes No 4. Foundation As-Built, (new construction ronly); Yes No (Same scale as approved plan) .5 Floor Plans?(new construction only). Yes_ No Appi1cation for Mposal System Construction Permit•Page 2 of 2 SEPTIC SYSTEM.'INSTALLER PROJECT MANAGEMENT OBLIGATIONS r As the North Andover licensed.installer for the construction for the septic system-for.the property at: (Address of septic system) Fbr plans by (En e ) Relative to the application of (installer's name) And dated (Ungtnal dat Dated �1 o s ate With revisions dated (Last revised date) 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 khans 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 shill..be,applicable. 3.4 As the installer, I atm••required to.have.the necessary.work completed prior:to the applicable inspections as indicated belowi I:understand that requesting'an inspection,without completion:of the items in accordance with Title 5 and'the Board of Health Regulations may.resukiin a$50:00 fine beitig.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 doiielrst. The:installermust request the inspection but does not have to be present. b. Final.-Construct on.Inspeetion—Engineer must first:do their inspection for elevations;ties,etc. As-built of verbal OK(or e-mail to:.healthdelittownofriorthandover.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 Gtade Installer must request inspection when. 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 ofmy license to operate in the Town of North Andover. significant fines to all persons involved are also possilile 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. A Inspection ofthe'sand and stone to be used. c. Final inspection by Board ofHealth staffor consultant. d. Installation..of tank,D Box;pipes,stone, vent,pump chamber,tetairug wall and other components. 6. As the installer.I understand that I anti solely responsible for the installation of the system as per the aplgoved pilins. No instructions by the homeowner general contractor,-or any, other persons shallabsolve me of plus obligation. Undersigned Licensed Septic Installer: (Today's Date). �' J9- ame:— Print v rt � S�gTIEDt�6 • TED P. North Andover Health Department �© Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NO S LOCATION INFORMATION ADDRESS: j/� MAP: LOT: INSTALLER. DESIGNER: �� sQ/� PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: zoo, 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 ❑ Building sewer in continuous grade, on compacted firm base ❑ 4 Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ gallon tank has been installed loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by testing ❑ Inlet tee installed, centered under access port /Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of final grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ 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 ❑ Watertightness of tank has been achieved by testing ❑ Comments: Hydraulic cement around inlet & outlet CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement Comments: E] Alarm signal located inside: basement DISTRIBUTION-BOX Installed on stable stone base E 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) Comments: D L r 4-C rn Y �• C rLu1 s -n 1 ru -� ���v Qfs�; Z I I • S�.CfT:ED7� 7671. North Andover Health Department Community Development Division Date: August 9,2011 Chris Litster 112 Stonecleave Road North Andover,MA 01845 Re: Application for 14 x 20 addition at 112 Stonecleave Road Dear: Mr. Litster, — —7-:: -Your-applicationfor-a building additiors was-reviewed-by-the Health Departrrient on-A-ug-ast 9-- - 2011. Unfortunately,the application cannot be approved by the Health Department for the following reasons found in red: 1. x Missing information - only a partial floor plan was submitted. Also note that the septic plan used in the application is different than the 2000 Title V. Verification of locations are needed to scale with the addition on the same plan. Information on the past Title V inspection can be found in the Health Dept. file. 2. x Passing Title 5 inspection of septic system required (system installed in 1978) 3. ❑ Location of structure not acceptable 4. ❑ Undersized septic system To address the problem(sl: If#1 is checked,please supply: a. A floor plan of the existing home and proposed addition-please label all rooms (second floor is not included with plan) b. Draw in the project on the As-built at the Health Dept. showing house, septic system and proposed project in scale(this can be done in the Health Dept) If#2 is checked: 112 Stonecleve Road August 9, 2011 a. Have the septic system inspected by a certified Title 5 inspector to determine whether it is operating properly: A list of licensed inspectors can be found at http://www.townofnorthandover.com/Pages/NAndoverMA Health/permitsandreg_s b. Tie-in to municipal sewer If#3 is checked: NO—unless room count appears no increase. a. Relocate the project • If#4 is checked: Please feel free to call the Health Office at 978-688-9540 with any questions you may have. Sincerely, Su Sawyer Public Health Director Cc: Building Department File — -- ----------------- --- - - 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com LOT 23A 43958 s.{=, j - � >�i�"PD-QTIOt�I SI{Oiv�) n1 C _ Lor 24 , Lo-r 22 4orW 1. \ 1 , 1 2 N 38•o 11-97 JI q � m I I o 1 - 0 : QN` �O o L-c� S{{oW� lS S1�03Ecsi Td ZE91F�IcTloJg FOUR SEASONS ASSOCIATES,INC. 375 Common St. Iaarence.14aBe. 01010 Talophonel (617) L83_%?l NOTE: THIS IS NOT A SURVEY AND SHOULD BE USED FOR MORTGAGES PURPOSES ONLY.DO NOT USE OFFSETS FOR ESTABLISHING LOT LINES.FOR THE EREC- TION OF FENCES OR CONSTRUCTION PURPOSES.IF BUILDINGS SHOWN LESS THAN ONE FOOT FROM THE BOUNDARY LINES,IT IS ADVISED TO MAKE SURVEY TO VERIFY THESE MEASUREMENTS. 1 HEREBY CERTIFY THAT 1 HAVE EXAMINED THE PREMISES.AND ALL BUILDINGS.EASEMENTS AND ENCROACHMENTS ARE LOCATED ON THE GROUND AS SHOWN. 1 FURTHER CERTIFY THAT THE BUILDINGS CONFORMED TO THE ZONING LAWS AND AMENDMENTS OF Mo.AQLOVER..WHEN CON. STRUCTED.1 FURTHER CERTIFY THAT THIS PROPERTY IB 40T LOCATED IN THE ESTABLISHED FLOOD HAZARD AREA. BUYER BuRsfi a,,�vIa TO THOOMIDWr,IErZ'> FEDEP—AL 5AVIOG5 $.._1oAu 1460C�i10 �� A"Aof Af��.r�c AND TITLE INSURERS �° LE yes BOOK: 2032 � o H. PAGE: I3 MORTGAGE INSPECTION PLAN " HOLZH No.1817817 � PLAN NO.: 7814 t G LOCATED A o`s�rCIS?irP�o�� SCALE: �'I=t1 o{ CO'` Il2�TC.t�E�Lii1�'d rG`><,D , 1G, riL;' �ovj—=2, �+\� /SNA( DATE: TLS X57 TO BE USED FOR MORTGAGE PURPOSES ONLY