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Home My WebLink AboutMiscellaneous - 115 VEST WAY 4/30/2018�F '0Rry qti �`� O0G m o � . g � - cHU`l� North Andover Health Department Community and Economic Development Division 06/27/2017 Address: 115 Vest Way All North Andover Residents with Septic Systems and Garbage Disposals Please note that due to a recent review of a Title 5 Report, your property has been identified as maintaining a working garbage disposal that is being used in conjunction with a septic system. The Health Department is concerned for the longevity of your septic system. Garbage disposals are never recommended where septic systems are used, but if they are installed, the system must be specifically designed to handle the waste from them; your system can not handle the waste as designed. Please note that continued use of this disposal could quickly cause a pre -mature failure of your septic system, resulting in a large expenditure to replace it. The North Andover Health Department recommends that you remove it from your home as soon as possible. Some information regarding regular maintenance of your septic system is attached. Please call the Health Department at 978.688.9540 if you have any questions, or e-mail your questions to: healthdept@northandoverma. goy. Thank you for taking the time to consider the impact that your current setup has on your septic system and the environment. Sincere , Brian LGrasse, CEHT Director of Public Health 120 Main Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web http://www.northandoverma.gov MEN Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. r� rtacn Commonwealth of Massachusetts 4, trih Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 115 VEST WAY Property Address DEREK MOUSSEAU Owner's Name N. ANDOVER MA 01845 06/14/17 City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered�iq�?p� way. Please see completeness checklist at the end of the form. A. General Information AU Inspector: JOHN SOUCY Name of Inspector SOUCY SEWER SERVICE INC Company Name 78 N BROADWAY Company Address SALEM City/Town 603-898-9339 Telephone Number B. Certification NH State 13397 License Number Zip Code H ANDpVFR DIE 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 F rther Evaluation by the Local Approving Authority 06/14/17 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 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.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 of 17 9 r ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 115 VEST WAY Property Address DEREK MOUSSEAU Owner Owner's Name information is N. ANDOVER required for every page. CitylTown B. Certification (cont.) MA 01845 06/14/17 State Zip Code Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 115 VEST WAY Property Address DEREK MOUSSEAU Owner Owner's Name information is N. ANDOVER required for every page. Cityrrown B. Certification (cont.) MA 01845 06/14/17 State Zip Code Date of Inspection ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ 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.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 4. 4�> Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 115 VEST WAY Property Address DEREK MOUSSEAU Owner's Name N. ANDOVER MA 01845 06/14/17 City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17 Mwm Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 115 VEST WAY Property Address DEREK MOUSSEAU Owner's Name N.ANDOVER Cityrrown B. Certification (cont.) Yes No MA 01845 State Zip Code 06/14/17 Date of Inspection ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 115 VEST WAY Property Address DEREK MOUSSEAU Owner Owner's Name information is N. ANDOVER MA 01845 06/14/17 required for every page. CityTrown 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 ® ❑ El Z ® ❑ El Z ® ❑ ® ❑ ® ❑ ® ❑ ® ❑ ® ❑ ® ❑ ® ❑ 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): 440 t5ins.doc • rev. 6/16 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 115 VEST WAY Property Address DEREK MOUSSEAU Owner Owner's Name information is N. ANDOVER required for every page. City/Town D. System Information Description: MA 01845 State Zip Code 06/14/17 Date of Inspection Number of current residents: 4 Does residence have a garbage grinder? (:Z Yes No Is laundry on a separate sewage system? (Include laundry system inspection es ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: RECOMMEND REMOVAL OF GARBAGE GRINDER. SEE ATTACHED METER READINGS. Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes ® No CURRENT Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins.doc - rev. 6/16 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 115 VEST WAY Property Address DEREK MOUSSEAU Owner Owner's Name information is N. ANDOVER MA required for every page. Cityrrown State D. System Information (cont.) Last date of occupancy/use: Other (describe below): 01845 06/14/17 Zip Code Date of Inspection Date General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: SOUCY SEWER SERVICE INC gallons NTENANCE & INSPECTION ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 115 VEST WAY Property Address DEREK MOUSSEAU Owner Owner's Name information is N. ANDOVER MA 01845 06/14/17 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): 6'+ Depth below grade: feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 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) 10.5'x 6' Dimensions: ❑ Yes ❑ No 2" Sludge depth: t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 115 VEST WAY Property Address DEREK MOUSSEAU Owner Owner's Name information is N. ANDOVER MA 01845 06/14/17 required for every page. CitylTown 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 39" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 7" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? TAPE & SLUDGE TOOL Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): BOTH TEES IN PLACE, TANK IS STRCTURALLY SOUND, NO APPARENT LEAKS, REMOVE GARBAGE GRINDER, PUMP TANK ANNUALLY. t5ins.doc - rev. 6/16 Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 115 VEST WAY Property Address DEREK MOUSSEAU Owner Owner's Name information is N. ANDOVER MA 01845 06/14/17 required for 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 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 Dimensions: Capacity: Design Flow: Alarm present: Alarm level: ❑ fiberglass ❑ polyethylene ❑ other (explain): gallons gallons per day ❑ Yes ❑ No 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.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 115 VEST WAY Property Address DEREK MOUSSEAU Owner Owner's Name information is N. ANDOVER required for every page. City/Town D. System Information (cont.) MA 01845 State Zip Code 06/14/17 Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Insp Subsurface Sewage Disposal System Fo M 115 VEST WAY ection Form rm - Not for Voluntary Assessments Property Address DEREK MOUSSEAU Owner Owner's Name information is required for every N. ANDOVER MA 01845 06/14/17 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: (4) 2'W X 1'D X 50'L ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): NO SIGNS OF HYDRAULIC FAILURE Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc • rev. 6116 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 N 115 VEST WAY Property Address DEREK MOUSSEAU Owner Owner's Name information is N. ANDOVER required for every page. Cityfrown MA 01845 06/14/17 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.doc - rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 115 VEST WAY Property Address DEREK MOUSSEAU Owner Owner's Name information is N. ANDOVER required for every page. City/Town t5ins.doc • rev. 6/16 MA 01845 State Zip Code 06/14/17 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 r:"; 1.� L11i1-LI A ( 33. 3 (LEACHING ANU1 � 1RENiJNE` I 1 COMMON_� —�RIVF -r= : I U),.;ATI;IN FI013 P,'II PLAN BY RI'KI rglN�KI ANU:ASSOL DAIL') N;14�3 2.GRAUES'V,FU FIELD ADJUSTED TV MATCH TOPO � AND DESIGN CRITERIA. r; 3.1 CERTIFY THAT THE'ioDS: ! /7AS INSTALLEUAS SHCMN I ANI: W1111 C.)NSIRUQI•)N � ?AAT RIALS AS SPT_,IFI Eb It i I IN 1 HE RELATED DESIGN. ! . EL_ VATIONS: TUI' 101IND: 171.7 OwLLLING -)I)T: 162.90 SEPTICTANK INLET' 101.'9 OUTLE T: 161-53 D -BOX INLET: 15991 OUTLET: 159.'6 ENUOF 1RENJH: + I > 159AG 1TE51_ a2' 154.75 . Ptm A 3: 151,51 04- 149.70 rPLAN OF AS BUIL CONDITIONS LO)T74A VE_ -7 VVA Y OW JER:JO-DEE RT UA1'.13/31103 SCALE:I°40 "YEPAREU BY: FLYNN JpSSOC. P.C, CIVIL, 6ANRARY aM CONSTP,UGTIGN ENGINEERS Plalslaw, New NairpsMre 0]665 P.O. am 559 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 115 VEST WAY Property Address DEREK MOUSSEAU Owner Owner's Name information is N required for every. ANDOVER MA 01845 page. City/Town State Zip Code D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells 06/14/17 Date of Inspection Estimated depth to high ground water: 4 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If h kddt fd i I wed' 8/31/83 AS BUILT ELEVATIONS c ec e, a e o esli gn p an reve 0 Date ® Observed site (abutting property/observation hole within 150 feet of SAS) EJ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: EXISTING SYSTEM INSTALLED AT EXISTING ORIGINAL GRADE. 4'- 5' OF FILL HAS BEEN ADDED. SYSTEM IS T- 4' ABOVE EXISTING WET AREA, OPPOSITE SIDE OF DRIVEWAY. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc • rev. 6/16 Tide 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 115 VEST WAY Property Address DEREK MOUSSEAU Owner Owner's Name information is required for every N. ANDOVER MA 01845 06/14/17 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information — Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 a ---S eWs rt's Sepik Service 0 Andover Sq* Q Waftm EIM Sqldc U Roto -Ram (978) 372.7471 a (978) 475.2593 ( 7 2 SSU >E i 58 South MmbaU Shv4 Brv#b4 MA 83835 _ r f— tn hm ....... Septic Yank Pumping and Cleaning 0 DW 0 Tone the Right Way" Not Responsible for Covers or Irrigation Systeme �&Valls■ Per: Services Rendered 0 -septic Tardc ❑ Dryweli • teeth, PitlOverflow ❑ D -Box O Pump Chamber o Grease Trap a Catch SaWn ❑ Port" Toffet O Odter W. ❑ tinder 1000 gallone Q 1000 gakft Q 1500 gallons ❑ 2000 gallm 0 3000 gallons. Q 4000 gallons 4 5000 gallons ❑ Offer Mise. t O Gigging Charge �`�• Q Q tAcat�rt � t3 Cart ❑ Service Call 0 E ❑ Labor Q © Waiting Time a Bn * oiggl V Charge Is Per }river Mian :r Cls... P. d -r. • Q Eliding High Q Khohen Sink (liquid levei)l Q $Vf ib /Shower o Full to Cover Q Vanity Q Excessive Sdids Q Fivor Drain Top / Q Vent Q Use No Powdered Soap .S"W Jet Q Heavy6rease Q Other _. ROM © Suggest Elootric B (h______ Q lion suiUon W. a Cetttloation: P/F e Reason: Pais Toitaf'Reruai Q Pump Bair ffle Q Repair O Chemical Treatment ❑ Other Description of worts j Recommerdatione Terms of Payment Vacuum Pumping Drain cleaning PAYMENT- DUE IN FULL Yr. Mwth Yr - Month UPON COMPLETION Terms & CondMoris I p Cah ❑ Check Q Credlt I , NotW rar "wit le kx dwrope briow curb dna. & 1.8% per -"1W* wN be atWVW W 40murss PW doe. 2, AN =wWrft"be npo W wat+in 4#bmm 4. Tho W40* sr aepree* ur pay aR poet d Cotte n. f VL/ 0 1 41,10. v� f nrr Description of worts j Recommerdatione Terms of Payment Vacuum Pumping Drain cleaning PAYMENT- DUE IN FULL Yr. Mwth Yr - Month UPON COMPLETION Terms & CondMoris I p Cah ❑ Check Q Credlt I , NotW rar "wit le kx dwrope briow curb dna. & 1.8% per -"1W* wN be atWVW W 40murss PW doe. 2, AN =wWrft"be npo W wat+in 4#bmm 4. Tho W40* sr aepree* ur pay aR poet d Cotte n. f VL/ 0 1 41,10. v� f nrr Summary Record Card generated on 6/12/2017 3:20:00 PM by Tara Hurley Page 1 ' Town of North Andover Type Size YTD Cons Tax Map # 210-104.6-0159-0000.0 a Active ERT HH Parcel Id 16481 w Water 0.63 0.63 770 115 VEST WAY Reading Code MOUSSEAU, DEREK Since Jan 2014 Posted Date Variance MOUSSEAU, ANGELA, M. 1053 a Actual 115 VEST WAY 20% NORTH ANDOVER, MA 1036 a Actual 01845 4/12/2017 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.53 Acres 9/7/2016 1003 FY 2017 107 10/24/2016 UB Mailing Index 6/13/2016 896 Name/Address Type Loan Number Active/Inact. From Until DEREK & ANGELA MOUSSEAU Owner 871 115 VEST WAY 15 4/22/2016 NORTH ANDOVER MA 01845 12/10/2015 856 GLIKLICH, SHAWN & TASHA Previous Customer Inactive 7/31/2006 1/20/2016 115 VEST WAY 9/9/2015 842 NORTH ANDOVER, MA 38 10/16/2015 01845 6/10/2015 804 MATTHEW & LAURA CHABOT Previous Customer Inactive 1/11/2013 7/24/2015 115 VEST WAY NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 17839.0 - 115 VEST WAY Last Billing Date 4/6/2017 3170504 03 Cycle 03 Active UB Services Maint. Account No. 3170504 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 53.20 /1 UB Meter Maintenance Account No. 3170504 Serial No Status Location Brand Type Size YTD Cons 29821488 a Active ERT HH b Badger w Water 0.63 0.63 770 Date Reading Code Consumption Posted Date Variance 6/8/2017 1053 a Actual 17 20% 3/9/2017 1036 a Actual 14 4/12/2017 -24% 12/9/2016 1022 aActual 19 1/23/2017 -84% 9/7/2016 1003 a Actual 107 10/24/2016 368% 6/13/2016 896 a Actual 25 8/2/2016 63% 3/11/2016 871 aActual 15 4/22/2016 7% 12/10/2015 856 aActual 14 1/20/2016 -64% 9/9/2015 842 a Actual 38 10/16/2015 63% 6/10/2015 804 a Actual 23 7/24/2015 28% 3/12/2015 781 a Actual 18 4/28/2015 33% 12/12/2014 763 aActual 14 1/15/2015 -46% 9/10/2014 749 a Actual 26 10/15/2014 32% 6/9/2014 723 a Actual 19 7/16/2014 25% 3/11/2014 704 aActual 15 4/11/2014 -10% 12/12/2013 689 aActual 17 1/17/2014 -3% 9/12/2013 672 a Actual 18 10/15/2013 8% 6/11/2013 654 aActual 16 7/24/2013 -4% 3/14/2013 638 a Actual 12 4/22/2013 -100% 1/9/2013 626 f Final Bill 0 1/9/2013 -100% 12/12/2012 626 aActual 18 1/9/2013 -9% ` Summary Record Card generated on 6/12/2017 3:20:00 PM by Tara Hurley Town of North Andover Tax Map # 210-1043-0159-0000.0 Parcel Id 16481 115 VEST WAY MOUSSEAU, DEREK Since Jan 2014 MOUSSEAU, ANGELA, M. 115 VEST WAY NORTH ANDOVER, MA 01845 Page 2 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.53 Acres Int/Pen Fee(s) Refunded Adjt. Abated Paid FY 2017 $5.15 ($97.46) 9/12/2012 608 a Actual 20 10/15/2012 4% 6/12/2012 588 a Actual 19 7/16/2012 -4% 3/13/2012 569 a Actual 20 4/14/2012 -2% 12/12/2011 549 aActual 20 1/17/2012 -22% 9/13/2011 529 a Actual 28 10/13/2011 25% 6/7/2011 501 a Actual 21 7/20/2011 27% 3/7/2011 480 a Actual 16 4/13/2011 -19% 12/8/2010 464 aActual 20 1/12/2011 -26% 9/9/2010 444 a Actual 28 10/15/2010 29% 6/8/2010 416 a Actual 21 7/15/2010 60% 3/10/2010 395 a Actual 13 4/14/2010 -24% 12/11/2009 382 aActual 18 1/12/2010 16% 9/8/2009 364 a Actual 15 10/15/2009 0% 6/9/2009 349 a Actual 14 7/20/2009 -33% 3/16/2009 335 a Actual 24 4/29/2009 71% 12/8/2008 311 aActual 13 1/20/2009 -25% 9/8/2008 298 a Actual 18 10/10/2008 20% 6/6/2008 280 a Actual 14 7/16/2008 1 % 3/10/2008 266 a Actual 14 4/11/2008 -31% 12/12/2007 252 aActual 22 1/22/2008 -20% 9/6/2007 230 a Actual 22 10/12/2007 26% 6/20/2007 208 a Actual 22 7/20/2007 46% 3/14/2007 186 a Actual 14 4/16/2007 -18% 12/13/2006 172 aActual 17 1/19/2007 -30% 9/13/2006 155 a Actual 13 10/20/2006 -39% 7/26/2006 142 f Final Bill 16 7/26/2006 194% 6/19/2006 126 a Actual 15 7/10/2006 13% 3/9/2006 111 a Actual 10 4/17/2006 -42% 12/22/2005 101 aActual 21 1/17/2006 -5% 9/20/2005 80 a Actual 20 10/14/2005 -3% 6/28/2005 60 a Actual 22 7/15/2005 30% 3/30/2005 38 m Manual estimate 20 4/5/2005 -44% 12/14/2004 18 aActual 18 1/14/2005 0% 10/22/2004 0 n New Meter 0 1/14/2005 0% 9/27/2004 2166 m Manual estimate 50 10/8/2004 18% 6/23/2004 2116 m Manual estimate 30 7/30/2004 154% 4/16/2004 2086 a Actual 21 5/17/2004 0% 12/17/2003 2065 n New Meter 0 12/17/2003 0% A/R Inquiry Sub System Account No. 3170504 Utility Billing Install Billed Adjt Bill Int/Pen Fee(s) Refunded Adjt. Abated Paid Balance 1 St $4,820.31 $5.15 ($97.46) $4,728.00 $0.00 Entry Date Install Trans Type Amount Balance Due Amount Billed Posted Flag 5/17/2004 Billed $55.30 $55.30 $55.30 Posted 5/26/2004 Payment ($55.30) $0.00 Posted 8/4/2004 Billed $89.72 $89.72 $89.72 Posted 8/17/2004 Payment ($89.72) $0.00 Posted 10/18/2004 Billed $194.93 $194.93 $194.93 Posted 11/3/2004 Adjustment ($97.46) $97.47 Posted 11/16/2004 Payment ($194.93) ($97.46) Posted 1/14/2005 Billed $58.22 ($39.24) $58.22 Posted 4/15/2005 Billed $63.82 $24.58 $63.82 Posted 4/27/2005 Payment ($24.58) $0.00 Posted �< Summary Record Card generated on 6/12/2017 3:20:02 PM by Tara Hurley Town of North Andover Tax Map # 210-104.6-0159-0000.0 Parcel Id 16481 115 VEST WAY MOUSSEAU, DEREK Since Jan 2014 MOUSSEAU, ANGELA, M. 115 VEST WAY NORTH ANDOVER, MA 01845 Page 3 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zonirl 1 Residential Size Total 1.53 Acres FY 2017 7/15/2005 Billed $72.68 $72.68 $72.68 Posted 7/25/2005 Payment ($72.68) $0.00 Posted 10/14/2005 Billed $75.62 $75.62 $75.62 Posted 10/27/2005 Payment ($75.62) $0.00 Posted 1/17/2006 Billed $80.08 $80.08 $80.08 Posted 2/6/2006 Payment ($80.08) $0.00 Posted 4/17/2006 Billed $41.72 $41.72 $41.72 Posted 5/1/2006 Payment ($41.72) $0.00 Posted 7/10/2006 Billed $58.67 $58.67 $58.67 Posted 7/26/2006 Billed $97.06 $155.73 $97.06 Posted 8/4/2006 Payment ($156.09) ($0.36) Posted 10/20/2006 Billed $48.51 $48.15 $48.51 Posted 11/30/2006 Interest $0.03 $48.18 Posted 11/30/2006 Interest $0.16 $48.34 Posted 11/30/2006 Payment ($48.15) $0.19 Posted 1/19/2007 Billed $61.03 $61.22 $61.03 Posted 2/23/2007 Interest $0.09 $61.31 Posted 2/23/2007 Interest $0.01 $61.32 Posted 2/23/2007 Payment ($61.23) $0.09 Posted 4/16/2007 Billed $51.64 $51.73 $51.64 Posted 7/20/2007 Billed $77.47 $129.20 $77.47 Posted 8/28/2007 Interest $1.97 $131.17 Posted 8/28/2007 Interest $0.34 $131.51 Posted 8/28/2007 Payment ($131.11) $0.40 Posted 10/12/2007 Billed $90.68 $91.08 $90.68 Posted 10/25/2007 Interest $0.01 $91.09 Posted 10/25/2007 Payment ($91.09) $0.00 Posted 1/22/2008 Billed $88.12 $88.12 $88.12 Posted 2/26/2008 Interest $0.01 $88.13 Posted 2/26/2008 Interest $0.12 $88.25 Posted 2/26/2008 Payment ($88.12) $0.13 Posted 4/11/2008 Billed $58.08 $58.21 $58.08 Posted 4/24/2008 Payment ($58.21) $0.00 Posted 7/16/2008 Billed $58.08 $58.08 $58.08 Posted 8/7/2008 Payment ($58.08) $0.00 Posted 10/10/2008 Billed $68.84 $68.84 $68.84 Posted 10/31/2008 Payment ($68.84) $0.00 Posted 1/20/2009 Billed $51.89 $51.89 $51.89 Posted 1/30/2009 Payment ($51.89) $0.00 Posted 4/29/2009 Billed $93.04 $93.04 $93.04 Posted 6/1/2009 Payment ($93.04) $0.00 Posted 7/20/2009 Billed $55.28 $55.28 $55.28 Posted 9/2/2009 Payment ($55.28) $0.00 Posted 10/15/2009 Billed $64.82 $64.82 $64.82 Posted 12/2/2009 Payment ($64.82) $0.00 Posted 1/12/2010 Billed $76.22 $76.22 $76.22 Posted 4/14/2010 Billed $57.22 $133.44 $57.22 Posted 4/28/2010 Interest $0.23 $133.67 Posted 4/28/2010 Interest $1.99 $135.66 Posted 4/28/2010 Payment ($136.13) ($0.47) Posted 7/15/2010 Billed $89.37 $88.90 $89.37 Posted 7/28/2010 Payment ($88.90) $0.00 Posted 10/15/2010 Billed $127.45 $127.45 $127.45 Posted 10/28/2010 Payment ($127.45) $0.00 Posted 1/12/2011 Billed $83.82 $83.82 $83.82 Posted 3/3/2011 Payment ($83.82) $0.00 Posted 4/13/2011 Billed $68.62 $68.62 $68.62 Posted 4/26/2011 Payment ($68.62) $0.00 Posted 7/20/2011 Billed $88.99 $88.99 $88.99 Posted 7/29/2011 Payment ($88.99) $0.00 Posted Summary Record Card generated on 6/12/2017 3:20:02 PM by Tara Hurley Page 4 Town of North Andover Tax Map # 210-1043-0159-0000.0 Parcel Id 16481 115 VEST WAY MOUSSEAU, DEREK Since Jan 2014 MOUSSEAU, ANGELA, M. 115 VEST WAY NORTH ANDOVER, MA 01845 Class Zoning2 Size Total FY 101 Single Family 1 Residential 1.53 Acres 2017 Property Type Zoning3 1 Residential 1 Residential 10/13/2011 Billed $125.53 $125.53 $125.53 Posted 11/1/2011 Payment ($125.53) $0.00 Posted 1/17/2012 Billed $83.82 $83.82 $83.82 Posted 1/30/2012 Payment ($83.82) $0.00 Posted 4/14/2012 Billed $83.82 $83.82 $83.82 Posted 4/30/2012 Payment ($83.82) $0.00 Posted 7/16/2012 Billed $80.02 $80.02 $80.02 Posted 7/25/2012 Payment ($80.02) $0.00 Posted 10/15/2012 Billed $83.82 $83.82 $83.82 Posted 10/23/2012 Payment ($83.82) $0.00 Posted 1/9/2013 Billed $119.04 $119.04 $42.82 Posted 1/15/2013 Payment ($119.04) $0.00 Posted 4/22/2013 Billed $53.42 $53.42 $53.42 Posted 5/9/2013 Payment ($53.42) $0.00 Posted 7/24/2013 Billed $68.62 $68.62 $68.62 Posted 7/29/2013 Payment ($68.62) $0.00 Posted 10/25/2013 Billed $76.22 $76.22 $76.22 Posted 11/14/2013 Payment ($76.22) $0.00 Posted 1/17/2014 Billed $72.42 $72.42 $72.42 Posted 2/24/2014 Interest $0.02 $72.44 Posted 2/24/2014 Interest $0.17 $72.61 Posted 2/24/2014 Payment ($72.42) $0.19 Posted 4/11/2014 Billed $64.82 $65.01 $64.82 Posted 4/22/2014 Payment ($65.02) ($0.01) Posted 7/16/2014 Billed $80.02 $80.01 $80.02 Posted 7/27/2014 Payment ($80.01) $0.00 Posted 10/15/2014 Billed $116.35 $116.35 $116.35 Posted 10/23/2014 Payment ($116.35) $0.00 Posted 1/15/2015 Billed $61.02 $61.02 $61.02 Posted 1/27/2015 Payment ($61.02) $0.00 Posted 4/28/2015 Billed $76.22 $76.22 $76.22 Posted 5/19/2015 Payment ($76.22) $0.00 Posted 7/24/2015 Billed $100.47 $100.47 $100.47 Posted 8/21/2015 Payment ($100.47) $0.00 Posted 10/16/2015 Billed $183.72 $183.72 $183.72 Posted 11/15/2015 Payment ($183.72) $0.00 Posted 1/20/2016 Billed $61.02 $61.02 $61.02 Posted 2/5/2016 Payment ($61.02) $0.00 Posted 4/22/2016 Billed $64.82 $64.82 $64.82 Posted 5/5/2016 Payment ($64.82) $0.00 Posted 8/2/2016 Billed $110.42 $110.42 $110.42 Posted 8/7/2016 Payment ($110.42) $0.00 Posted 10/24/2016 Billed $566.67 $566.67 $566.67 Posted 11/23/2016 Payment ($566.67) $0.00 Posted 1/23/2017 Billed $80.02 $80.02 $80.02 Posted 2/14/2017 Payment ($80.02) $0.00 Posted 4/12/2017 Billed $61.02 $61.02 $61.02 Posted 5/6/2017 Payment ($61.02) $0.00 Posted Founded in 1986 SOUCTS SEWER SERVICE, INC. 78 NORTH BROADWAY (Rt.28) SALEM, NH 03079 PHONE 603-898-9339 TITLE 5 DISCLOSURE June 16, 2017 Derek Mousseau Angela Mousseau 115 Vest Way N. Andover, MA 01845 On the above date and time, I made a visual inspection of the septic system at the above referenced property. Based upon my visual inspection, I certify that the septic is in proper working order as of the date and time of the inspection. This certification does not constitute a guarantee or warranty and because of the age and unpredictable characteristics of the septic system, it is+got to be interpreted as insuring that the system will continue to be in working order for any future period of time, no matter how brief. Owner further agrees to indemnify and hold harmless inspecting company from any liability #no costs incurred from the result of any third party reliance upon informati vided. John oucy Derek-Mousseau Presi ent/lnspector An ela Mou eau Note: Not valid without parties' signature. COMPLETE SEWER -SEPTIC SERVICE DATE OF S78 78 N. Broadway, Salem, NH 03079 (603) 898-9339 (800) 541-9379 www.soucysewer.com "WORKING FOR YOU AND THE ENVIRONMENT" If TIME F SERVICE l LIrU—v�� CUSTOMERNAME� STREET ADDRESS:-' �J _CITY:' GrZ STATE: PHON . 92f - �3s SPECIAL BILLING INSTRUCTIONS /�{ rcc, S -Q (,I C' < < rY'( S�-✓L C/ PUMPED ADDITIONAL GALLONS ® TANK LEVEL HIGH M CASH ® CHARGE CHECK BILL � u �r DESCRIPTION OF WORK COST TOTAL DIGGING ® VERY HEAVY SOLIDS 41 RESIDENTIAL COMMENTS II AGTERIA ADDED ® PUMP MORE OFTEN' M COMMERCIAL This is to acknowledge completion of the above work which has been done to my satisfaction. The company assumes no sibility for any damage made to sprinklers, lawn, bushes, driveway, curb or walkway. Any form of payment provided by the cust r const' tes a binding signature of this invoice and assumes all responsibility for payment in full, along with any collection or reas able attorne ees on outstanding b lances. Ib 1 D+e Customer Signature 4eefrm-- ignature f pORi// 79', 3 - E Town of North Andover �� HEALTH DEPARTMENT /5Lon A HECK #J(, DATE: U l LOCATION: V H/O NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal A 11 ❑ Body Art Establishment I $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: \ $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler , $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $! Title 5 Report i. ❑ Other: (Indicate) $ ealtW-A�gJk Initials White - Applicant Yellow - Health Pink - Treasurer r 7 NORTq 2/ F�t Q.r�- .,• Lp Town of North Andover HEALTH DEPARTMENT CMUSt� ,,��jj CHECK #:O� DATE: LOCATION: �A -U-) a H/O NAME:Lftuf o,,ChobcrL CONTRACTOR NAME: ,Tb &"o OJ Type of Permit or License: (Check box) $ 0 Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic -Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ 13 Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ff / Title 5 Report $ _8_.f`�')—( [I Other (Indicate) $ (b Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer } Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. 00 Commonwealth of Massachusetts Title 5 Official Inspection FormEllF Subsurface Sewage Disposal System Form - Not for Voluntary Assessmen acrt j � Laura Chabot Property Address 115 Vest Way Owner's Name North Andover City/Town HEALTH DEPARTMEN MA 01845 10/06/2012 State Zip Code Date of Inspection J D 2 l 1 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: John Souc Name of Inspector Soucy's Sewer Service, Inc. Company Name 78 N. Broadway Company Address Salem NH 03079 City/Town 603-898-9339 Telephone Number B. Certification State 13397 License Number Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® PasWq ❑ Conditionally Passes ❑ Fails ❑ �leedV Further EvaluatiW by the Local Approving Authority Signature 10/06/2012 Date ;1T,e system inspector shall submiio copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days f completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 =til= Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Laura Chabot Property Address 115 Vest Way Owner's Name North Andover MA 01845 10/06/2012 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: ® 1 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 Form: Subsurface Sewage Disposal System • Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Laura Chabot B. Certification (cont.) B) System Conditionally Passes (cont.): nnn 01845 Zip Code 10/06/2012 Date of Inspection ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 Property Address 115 Vest Way Owner Owner's Name information is required for every North Andover page. City/Town B. Certification (cont.) B) System Conditionally Passes (cont.): nnn 01845 Zip Code 10/06/2012 Date of Inspection ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Laura Chabot Property Address 115 Vest Way Owner's Name North Andover MA 01845 10/06/2012 City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 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 Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M Laura Chabot Property Address 115 Vest Way Owner Owner's Name information is required for every North Andover MA 01845 10/06/2012 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 Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Laura Chabot C. Checklist MA 01845 10/06/2012 State Zip Code Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® 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? n ❑ Was the site inspected for signs of break out? ® ❑ Property Address ® ❑ 115 Vest Way Owner Owner's Name information is required for every North Andover page. City/Town C. Checklist MA 01845 10/06/2012 State Zip Code Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® 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? n ❑ 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): 440 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 Laura Chabot Property Address 115 Vest Way Owner Owner's Name information is required for every North Andover MA 01845 10/06/2012 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: Garbage grinder should be removed. Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) 13 ® Yes ❑ No ❑ Yes ® No ❑ Yes ® No ❑ Yes ® No See Attached ❑ Yes ® No Current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No 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 ;M Laura Chabot D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: MA 01845 10/06/2012 General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Current Date Owner. Pumped 2008 1500 gallons Gage on truck Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy Date of Inspection ® Yes ❑ No ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Property Address 115 Vest Way Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: MA 01845 10/06/2012 General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Current Date Owner. Pumped 2008 1500 gallons Gage on truck Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy Date of Inspection ® Yes ❑ No ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins - 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 M Laura Chabot Property Address 115 Vest Way Owner Owner's Name information is North Andover required for every page. City/Town D. System Information (cont.) State Zip Code 10/06/2012 Date of Inspection Approximate age of all components, date installed (if known) and source of information: 1983 D box replaced in 2005 Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): 6' Depth below grade: feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below rade: 5 p g 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: 6'x10' Sludge depth: 3" t5ins • 11/10 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 G'M Laura Chabot SvO Property Address 115 Vest Way Owner Owner's Name information is required for every North Andover MA 01845 10/06/2012 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 38" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Tape and sludge tool Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Baffels in place. Pump tank every year. Install low flow water fixtures to conserve water. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: t5ins - 11/10 Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Laura Chabot Property Address 115 Vest Way Owner Owner's Name information is required for every North Andover page. Cityrrown MA 01845 10/06/2012 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: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM Laura Chabot D. System Information (cont.) MA 01845 State Zip Code 10/06/2012 Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): "D" box flow checked good. Pump Chamber (locate on site plan): Pumps in working order: Property Address Yes 115 Vest Way Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) MA 01845 State Zip Code 10/06/2012 Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): "D" box flow checked good. 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 u v Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4M Laura Chabot Property Address 115 Vest Way Owner Owner's Name information is North Andover required for every page. City/Town D. System Information (cont.) Type MA 01845 10/06/2012 State Zip Code Date of Inspection ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: (4) 2'x1'x50' ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No sions of Hvdraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17 dw, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Laura Chabot Property Address 115 Vest Way Owner Owner's Name information is required for every North Andover MA 01845 10/06/2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M Laura Chabot Property Address 115 Vest Way Owner Owner's Name information is required for every North Andover MA 01845 10/06/2012 . page. City/Town 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 1 t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Laura Chabot Property Address 115 Vest Way Owner Owner's Name information is North Andover required for every page. City/Town D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells In r ndwtr MA 01845 10/06/2012 4' Date of Inspection sIma a up o g g ou a e. feet Please indicate all methods used to determine the high ground water elevation: C: +i tdd tht h'i ❑ Obtained from system design plans on record I If checked, date of design plan reviewed: Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Dug hole w/auger in low drop off area, compensated elevation difference. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM Laura Chabot Property Address 115 Vest Way Owner Owner's Name information is required for every North Andover MA 01845 page. Cityrrown State Zip Code E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked 10/06/2012 Date of Inspection ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information — Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Town of North Andover 120 Main Street North Andover, MA 01845 (978)688-9550 MATTHEW & LAURA CHABOT 115 VEST WAY NORTH ANDOVER, MA 01845 NEW OFFICE HOURS PAYMENT ON • ' BEFORE Monday 8 - 4:30 05/14/2012 $83.82 Tues 8 - 6:00 $0.00 INTEREST AS OF 05/14/2012 Wed 8 - 4:30 ACCOUNT BILLING DATE Thu8 8 - 00 3170504 04/14/2012 Fri-12:0 Fri Billing Information: SERVICE DATES DUE DATE (978) 688-9550 12/12/2011-03/13/2012 05/14/2012 Reading Information: SERVICE ADDRESS (978) 688-9570 115 VEST WAY RETAIN THIS PORTION FOR YOUR RECORDS MOVING? PLEASE CALL (978) 688-9570 IN ADVANCE SERIAL # READINGS USAGE NB OF Current Type Date DAYS 29821488 569 Actual 03/13/2012 20 92 SERIAL # READINGS USAGE NB OF Previous Type Date DAYS 29821488 549 Actual 12/12/2011 20 90 29821488 529 Actual 09/13/2011 28 98 MESSAGES TRANSACTIONS THIS PERIOD AMOUNT PREVIOUS BALANCE $83.82 PAYMENTS THROUGH 04/05/2012 ($83.82) ADJUSTMENTS THROUGH 04/05/2012 $0.00 INTEREST AS OF 05/14/2012 $0.00 BALANCE FORWARD $0.00 CURRENT BILL DETAIL USAGEWNIT AMOUNT WATER USAGE 20 $76.00 ADMINISTRATIVE FEE $7.82 G7�kcv µ/iI/la 0 Sub -Total $83.82 TOTAL * NOTE * PAYMENTS SHOULD BE MADE: TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @ P.O. BOX 184, MEDFORD, MA 02155 WATER RATE: FIRST 20 UNITS @ $3.80 OVER 20 UNITS @ $5.55 Please note our office hours have SEWER RATE: FIRST 20 UNITS @ $5.83 OVER 20 UNITS @ $8.22 changed, effective 4/30. See above. Pay Online at BYPASS METER WATER RATE: ALL UNITS @ $5.55 www.townofnorthandover.com Please return this portion with your payment by 05/14/2012 Town of North Andover 120 Main Street 416731138 North Andover, MA 01845 (978)688-9550 Z01397-000001 If your address has changed, correct it below. MATTHEW & LAURA CHABOT 115 VEST WAY NORTH ANDOVER, MA 01845 Any amount which is not paid by due date will be subject to interest charges of 14% Per Year Billing Information: OFFICE HOURS (978)688-9550 Reading Information: Monday to Friday (978) 688-9570 8:30am to 4:30pm ACCOUNT BILLING DATE 3170504 04/14/2012 SERVICE ADDRESS 115 VEST WAY PLEASE PAY ON OR BEFORE 05/14/2012 $83.82 AMOUNT 1 / 1111111111111 1111 1 1111 . 111 1. ' �P, Town of North Andover 120 Main Street North Andover, MA 01845 (978) 688-9550 MATTHEW & LAURA CHABOT 115 VEST WAY NORTH ANDOVER, MA 01845 OFFICE HOURS PAYMENT ON • - BEFORE $125.53 02/17/2012 $83.82 Monday to Friday $0.00 INTEREST AS OF 02/17/2012 $0.00 _ 8:30am to 4:30pm __ACCOUNT BILLING DATE 3170504 01/1i/2012 Billing Information: SERVICE DATES DUE_ DATE (978) 688-9550 09/13/2011-12112/2011 02/17/2012 Reading Information: SERVICE ADDRESS (978) 688-9570 115 VEST WAY RETAIN THIS PORTION FOR YOUR RECORDS MOVING? PLEASE CALL (978) 688-9570 IN ADVANCE SERIAL # READINGS USAGE NB OF Current Type Date DAYS 29821488 549 Actuai 12/12/20i1 20 90 I SERIAL # READINGS USAGE NB OF Previous Type Date DAYS 29821488 529 Actual 09/13/2011 28 98 29821488 501 Actual 06/07/2011 21 92 MESSAGES TRANSACTIONS THIS PERIOD AMOUNT PREVIOUS BALANCE $125.53 PAYMENTS THROUGH 01/07/2012 ($125.53) ADJUSTMENTS THROUGH 01/07/2012 $0.00 INTEREST AS OF 02/17/2012 $0.00 BALANCE FORWARD $0.00 CURRENT BILL DETAIL USAGE/UNIT AMOUNT %A! AT[- VVI -%1 L.I \ U 1_% C_ 2_01 U.I�U ADMINISTRATIVE FEE $7.82 Sub -Total $83.82 TOTAL :i " NOTE " PAYMENTS SHOULD BE MADE: TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @ P.O. BOX 184, MEDFORD, MA 02155 WATER RATE: FIRST 20 UNITS @ $3.80 OVER 20 UNITS @ $5.55 SEWER RATE: FIRST 20 UNITS @ $5.83 OVER 20 UNITS @ $8.22 Pay Online at www.townofnorthandover.com BYPASS METER WATER RATE: ALL UNITS @ $5.55 Please return this portion with your payment by 0211712012 •.� Town of North Andover 120 Main Street 416731138 North Andover, MA 01845 (978) 688-9550 I111111IIIII IIIII IIIII IIAI IIIII IIIII IIIII IIIII IIII IIII Z01393-000001 If your address has changed, correct it below. MATTHEW & LAURA CHABOT 115 VEST WAY NORTH ANDOVER, MA 01845 Any amount which is not paid by due date will be subject to interest charges of 14% Per Year Billing Information: OFFICE HOURS (978)688-9550 Reading Information: Monday to Friday (978) 688-9570 8:30am to 4:30pm ACCOUNT BILLING DATE 3170504 01/17/2012 SERVICE ADDRESS 115 VEST WAY PLEASE PAY ON OR BEFORE 02/17/2012 1 $83.82 AMOUNT 041,67311382012000000000000031,705040403170504000000008382000 ' Town of North Andover 120 Main Street North Andover, MA 01845 (978)688-9550 MATTHEW & LAURA CHABOT 115 VEST WAY NORTH ANDOVER, MA 01845 OFFICE HOURS PAYMENT ON • ' BEFORE 11/12/2011 $125.53 Monday to Friday 8:30am to 4:30pm ACCOUNT _ BILLING DATE 3170504 10/13/2011 Billing Information: SERVICE DATES DUE DATE (978) 688-9550 06/07/2011-09/13/2011 11/12/201 Reading Information: SERVICE ADDRESS (978) 688-9570 115 VEST WAY TRANSACTIONS THIS PERIOD AMOUNT RETAIN THIS PORTION FOR YOUR RECORDS MOVING? PLEASE CALL (978) 688-9570 IN ADVANCE SERIAL # READINGS USAGE NB OF Current Type Date DAYS_ 29821488 529 Actual 09/13/2011 28 98 SERIAL # READINGS USAGE NB OF Previous Type Date DAYS 29821488 501 Actual 06/07/2011 21 92 29821488 480 Actual 03/07/2011 16 89 MESSAGES PREVIOUS BALANCE $88.99 PAYMENTS THROUGH 10/13/2011 ($88.99) ADJUSTMENTS THROUGH 10/13/2011 $0.00 INTEREST AS OF 11/12/2011 $0.00 BALANCE FORWARD $0.00 CURRENT BILL DETAIL USAGEWNIT AMOUNT WATER USAGE 28 $117.71 ADMINISTRATIVE FEE $7.82 ` / / Sub -Total $125.53 TOTAL " NOTE ' PAYMENTS SHOULD BE MADE: TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @ P.O. BOX 184, MEDFORD, MA 02155 WATER RATE: FIRST 20 UNITS @ $3.80 OVER 20 UNITS @ $5.55 Pay Online at SEWER RATE: FIRST 20 UNITS @ $5.83 OVER 20 UNITS @ $8.22 www.townofnorthandover.com BYPASS METER WATER RATE: ALL UNITS @ $5.55 Please return this portion with your payment by 1111212011 Town of North Andover 120 Main Street 416731138 North Andover, MA 01845 (978) 688-9550 Z01390-000001 If your address has changed, correct it below. MATTHEW & LAURA CHABOT 115 VEST WAY NORTH ANDOVER, MA 01845 Any amount which is not paid by due date will be subject to interest charges of 14% Per Year Billing Information: (978) 688-9550 Reading Information: (978) 688-9570 OFFICE HOURS Monday to Friday 8:30am to 4:30pm ACCOUNT 3170504 BILLING DATE 10/13/2011 SERVICE ADDRESS 115 VEST WAY PLEASE PAY ON OR BEFORE 11/12/2011 $125.53 AMOUNT 0416731138201,2000000000000031705040403170504000000012553007 Town of North Andover 120 Main Street North Andover, MA 01845 (978) 688-9550 MATTHEW & LAURA CHABOT 115 VEST WAY NORTH ANDOVER, MA 01845 OFFICE HOURS PAYMENT ON • ' BEFORE $68.62 08/19/2011 $88.99 Monday to Friday $0.00 INTEREST AS OF 08/19/2011 8:30am to 4:30pm F BILLING DATE 3170504 07/20/2011 Billing Information: SERVICE DATES DUE DATE (978) 688-9550 03/07/2011-06/07/2011 08/19/2011 Reading Information: SERVICE ADDRESS (978) 688-9570 115 VEST WAY RETAIN THIS PORTION FOR YOUR RECORDS MOVING? PLEASE CALL (978) 688-9570 IN ADVANCE SERIAL # READINGS USAGE NB OF r Current Type Date DAYS 1 29821488 501 Actual 06/07/2011 21 92 SERIAL # READINGS USAGE NB OF Previous Type Date DAYS 29821488 480 Actual 03/07/2011 16 89 29821488 464 Actual 12/08/2010 20 90 MESSAGES TRANSACTIONS THIS PERIOD AMOUNT PREVIOUS BALANCE $68.62 PAYMENTS THROUGH 07/20/2011 ($68.62) ADJUSTMENTS THROUGH 07/20/2011 $0.00 INTEREST AS OF 08/19/2011 $0.00 BALANCE FORWARD $0.00 CURRENT BILL DETAIL USAGE/UNIT AMOUNT WATER USAGE 21 $81.17 ADMINISTRATIVE FEE $7.82 Boit(. Sub -Total $88.99 TOTAL 100 ,:: •- * NOTE * PAYMENTS SHOULD BE MADE: TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @ P.O. BOX 184, MEDFORD, MA 02155 WATER RATE: FIRST 20 UNITS @ $3.80 OVER 20 UNITS @ $5.55 SEWER RATE: FIRST 20 UNITS @ $5.83 OVER 20 UNITS @ $8.22 BYPASS METER WATER RATE: ALL UNITS @ $5.55 Please return this portion with your payment by 0811912011 Any amount which is not paid by due date will be subject to interest charges of Town of North Andover 14% Per Year 120 Main Street 416731138 Billing Information: OFFICE HOURS North Andover, MA 01845 I'lll'II'l ll'll'IIII (II'I'I"I III'I I II �� Reading) Information: (978)688-9550 Monday to Friday . Z01386-000001 (978) 688-9570 8:30am to 4:30pm If your address has changed, correct it below. MATTHEW & LAURA CHABOT 115 VEST WAY NORTH ANDOVER, MA 01845 ACCOUNT I BILLING DATE 3170504 07/20/2011 SERVICE ADDRESS 115 VEST WAY PLEASE PAY ON OR BEFORE j 08/19/2011 $88.99 AMOUNT 04167311382011000000000000031705040403170504000000008899000 Town of North Andover 120 Main Street North Andover, MA 01845 (978) 688-9550 MATTHEW & LAURA CHABOT 115 VEST WAY NORTH ANDOVER, MA 01845 OFFICE HOURS PAYMENT ON • ' BEFORE 05/13/2011 $68.62 Monday to Friday 8:30am to 4:30pm ACCOUNT BILLING DATE 3170504 04/13/2011 Billing Information: SERVICE DATES DUE DATE (978) 688-9550 12/0812010-03/07/2011 05/13/2011 Reading Information: SERVICE ADDRESS (978) 688-9570 115 VEST WAY TRANSACTIONS THIS PERIOD AMOUNT RETAIN THIS PORTION FOR YOUR RECORDS MOVING? PLEASE CALL (978) 688-9570 IN ADVANCE SERIAL # READINGS USAGE NB OF Current Type Date DAYS 29821488 480 Actual 03/07/2011 16 89 SERIAL # READINGS USAGE NB OF Previous Type Date DAYS 29821488 464 Actual 12/08/2010 20 90 29821488 444 Actual 09/09/2010 28 93 MESSAGES PREVIOUS BALANCE $83.82 PAYMENTS THROUGH 04/13/2011 ($83.82) ADJUSTMENTS THROUGH 04/13/2011 $0.00 INTEREST AS OF 05/13/2011 $0.00 BALANCE FORWARD $0.00 CURRENT BILL DETAIL USAGE/UNIT AMOUNT WATER USAGE 16 $60.80 ADMINISTRATIVE FEE $7.82 �oA Sub -Total $68.62 TOTAL M. * NOTE * PAYMENTS SHOULD BE MADE: TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @ P.O. BOX 184, MEDFORD, MA 02155 WATER RATE: FIRST 20 UNITS @ $3.80 OVER 20 UNITS @ $5.55 SEWER RATE: FIRST 20 UNITS @ $5.83 OVER 20 UNITS @ $8.22 BYPASS METER WATER RATE: ALL UNITS @ $5.55 Please return this portion with your payment by 05/13/2011 Any amount which is not paid by due date will be subject to interest charges of gyp_ Town of North Andover 14% Per Year 120 Main Street 416731138 Billing Information: OFFICE HOURS North Andover, MA 01845 (978) 688-9550 (978) 688-9550 11111 11111 11111 11111 1111 1{ Reading Information: Monday to Friday Z01377-000001 (978) 688-9570 8:30am to 4:30pm If your address has changed, correct it below. MATTHEW & LAURA CHABOT 115 VEST WAY NORTH ANDOVER, MA 01845 ACCOUNT BILLING DATE 3170504 04/13/2011 SERVICE ADDRESS 115 VEST WAY PLEASE PAY ON OR BEFORE 05/13/2011 $68.62 AMOUNT Town of North Andover OFFICE HOURS PAYMENT ON • - BEFORE 120 •- 120 Main Street 03/07/2011 $83.82 North Andover, MA 01845 Monday to Friday (978) 688-9550 8:30am to 4:30pm ACCOUNT BILLING DATE 3170504 01/12/2011 Billing Information: SERVICE DATES DUE DATE MATTHEW & LAURA CHABOT (978) 688-9550 109/09/2010-12/08/2010 03/07/2011 115 VEST WAY Reading Information: SERVICE ADDRESS NORTH ANDOVER, MA 01845 (978) 688-9570 115 VEST WAY TRANSACTIONS THIS PERIOD AMOUNT PREVIOUS BALANCE $127.45 The Town is still experiencing a Water Drought. PAYMENTS THROUGH 01/12/2011 ($127.45) Call the Water Treatment Plant at 978-688-9574 for conservation kits information. ADJUSTMENTS THROUGH 01/12/2011 $0.00 RETAIN THIS PORTION FOR YOUR RECORDS INTEREST AS OF 03/07/2011 $0.00 MOVING? PLEASE CALL (978) 688-9570 IN ADVANCE BALANCE FORWARD $0.00 SERIAL # READINGS USAGE NB OF CURRENT BILL DETAIL USAGE/UNIT AMOUNT Current Type Date DAYS 29821488 464 Actual 12/08/2010 20 90 WATER USAGE 20 $76.00 ADMINISTRATIVE FEE $7.82 SERIAL # READINGS USAGE NB OF Previous Type Date DAYS Sub -Total $83.82 29821488 444 Actual 09/09/2010 28 93 f 29821466 416 Actual 06/08/2010 21 90 TOTAL MESSAGES *NOTE* PAYMENTS SHOULD BE MADE: TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @ P.O. BOX 184, MEDFORD, MA 02155 WATER RATE: FIRST 20 UNITS @ $3.80 OVER 20 UNITS @ $5.55 SEWER RATE: FIRST 20 UNITS @ $5.83 OVER 20 UNITS @ $8.22 (BYPASS METER WATER RATE: ALL UNITS @ $5.55 Please return this portion with your payment by 03/07/2011 Any amount which is not paid by due date will be subject to interest charges of n� Town of North Andover 14% Per Year 120 Main Street 416731138 Billing Information: OFFICE HOURS North Andover, MA 01845 11111 11111 11111 11111 11111 Jill 1111 Read9 ng'71,688-950 688-955 t 688-9550 on: Monday to Friday (978) 200870-000001 (978) 688-9570 8:30am to 4:30pm AACCOUNT BILLING DATE U l 3170504 01/12/2011 SERVICE ADDRESS 1 115 VEST WAY If your address has changed, correct it below. PLEASE PAY ON • - BEFORE MATTHEW & LAURA CHABOT 03/07/2011 $83.82 115 VEST WAY NORTH ANDOVER, MA 01845 AMOUNT - AID 04167311382011000000000000031705040403170504000000008382003 LETTER OF TRANSMITTAL tiORTh North Andover Health Department o� tLao �ti 400 Osgood Street A% e�`: •� _ _ '^`'b �oL North Andover, MA 01845 0 978.688.9540 - Phone 978.688.8476 - Fax '� �* cre :i.:«.cr healthdept(a'�townofnorthandover.com - E-mail �1 A0 raD '''♦��'�g www.townofnorthandover.com - Website Page of ss^CHUS� TO: Daniel Ottenheimer DATE: COMPANY: Mill River Consulting FROM: Pamela DelleChiaie, Health Dept. Assistant Phone: 1.800.377.3044 or 978.282.0014 77 4 r7 Fax: 978.282_-0012 Z4 -7 - SIGNED: We are sending you: oil Test OPlans or Review /7 Other U111 in below) These are transmitted as checked below: OFor Review and comment OAs Requested OAs Required OFor Your Use REMARKS: COPY TO: SIGNED: �C U COPY TO: P'o TOWN OF NORTH DOV' &j N°RrN Office of COMMUNITY DEVELOPMENT AND SERVICES o?°w'. HEALTH DEPARTMENT Is ~ ' 400 OSGOOD STREET " NORTH ANDOVER, MASSACHUSETTS 01845C,5 Susan Y. Sawyer, REHS, RS 978._ 6889540 — Phone Public Health Director REU„-A x688.876 — FAX healthde townofnorthandover.com < DEC I 5.to ofnorthandover.com APPLICATION F IL`�� C ON O R SO TES OWN `,F %IORTH ANDOVER DEPAR,rmENT DATE: / Z I l /D MAP & PARCEL: 4, AT • G � pr. LOCATION OF SOIL TESTS: C OWNER: Contact APPLICANT: ` i; f94C= Contact #: ADDRESS: 0 ENGINEER: 91 yll A fjE1Alk JZ- Alle, Contact #: 916 - (D $(e — 1-7 (oS CERTIFIED SOIL EVALUATOR:A0�401AI G 0 S(Dop_ JQ. �fiNyy> �C /ISG 7Dt? Intended Use of Land: Residential Subdivision Single Family Home Commercial Is This: Repair Testing: Undeveloped Lot Testing: Upgrade for Addition:_ In the Lake Cochichewick Watershed? Yes No x THE FOLLOWING MUST BE INCLUDED WITH THIS FORM ➢ Proof of land ownership (Tax bill, or letter from owner permitting test) ➢ 8.5"x Il "Plot Plan & Location of Testing (please indicate test nit sites on the elan )0- Fee of $425.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of $360.00 per lot for repairs or uuerades. GENERAL INFORMATION ➢ Only Certified Soil Evaluators may perform deep hole inspections. ➢ Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. ➢ At least two deep holes and two percolation tests are required for each septic system disposal area. ➢ Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. ➢ Full payment will be required for all additional tests within two weeks of testing. ➢ Within 45 days of testing, a scaled plan (no smaller than 1"-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). ➢ Within 60 days of testing soil evaluation forms shall be submitted. Please Do Not Write Below This Line N.A. Conservation Commission Apr Date: Signature of Conservation Agent: Date back to Health Department: (stamp in): lea � LA)/ N A-6 WET( /,N(. N' JARf AN"Ji'lYiI11-1W, Lj,"' AT I �) N F R:'W PLOI PLAN BY RFKIMIN-:'KI ANDASSOC DAI 1--') 8/19/,,33 2. GRA DESViRE FIELD ADJUSTED Ti` MATCH TOPO AND I)E:IGN CRITERIA, 3.1 CERTIFY THAT .,THE S -'-)DS. WAS INSTALLED AS SHOWN ANI) WI I H GONSI RUCJ ION MAT'= R I ALS, AS b Pc �I 1: 1 ED IN 11HE RELATED DESIGN, ELk.VATIONS- TOL' f -OI -IND: 171.7 DWELLING OUT. 162-90 SEPTICTANK: - INLET= 161.-79 OUTLET: 161-53 D -BOX 1HLET' 158.91 OUTLET: 158.'76 END OF TREN,-'H- -0 1 :- 15SAG ,;TFISI 2: 154.75 ptn 3- 151,51 d4 = 148.70 PLAN OF AS SUILI CONDITIONS LOT NA VES"I W A Y OWNER -'J0 -ULE RT DAT E.8/31/ 3 SCALE'.I--"40 PIAEPARED BY - ::LYNN Assoc. P. C, CIVIL, SANITARY and CONSTRUCTION ENGINEERS Plaistow, New Hampshire 03865 P.O. Box 569 I - I ::, LETTER OF TRANSMITTAL pORTH North Andover Health Department of 400 Osgood Street 3i* b! _ �. 'b o` North Andover, MA 01845 /o • ~ '-' p t 978.688.9540 - Phone 978.688.8476 - Fax A°A�Tao '�`�y(°� healthdept(atownofnorthandover.com - E-mail �SS�CHu`+E4 www.townofnorthandover.com - Website Page of TO: DATE: Daniel Ottenheimer /..2 COMPANY: FROM: Pamela DelleChiaie, Health Dept. Assistant Mill River Consulting SIGNED: Phone: 1.800.377.3044 or 978.282.0014 RE: // /l/ /� /t e Fax: 978.282..0012 We are sending you: U'' 'oil Test OPlans or Review L7 Other(fill in below) These are transmitted as checked below: OFor Review and comment OAs Requested OAs Required OFor Your Use REMARKS: COPY TO:z/ c� ¢ G��'7 COPY TO: SIGNED: l COPY TO: c' Toii,oNorth Andover Health Department Date. / Location: `le7--- i 1,1Jr �L�/4 (Indicate Address, if Residential, or Name of Business) Check #: 05-10 Type of Permit or License: (Circle) ➢ Animal $ ➢ Dumpster $ ➢ Food Service - Type: $ ➢ Funeral Directors $ ➢ Massage Establishment $ ➢ Massage Practice $ ➢ Offal (Septic) Hauler $ ➢ Recreational Camp $ ➢ SEPTIC PERMITS: a-- tic - Soil Testing $ 00 ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ➢ Sun tanning $ ➢ Swimming Pool $ ➢ Tobacco $ ➢ TrasIVSolid Waste Hauler $ ➢ Well Construction $ ➢ OTHER: (Indicate) Health Agent Initials 7 White - Applicant Yellow - Health Pink - Treasurer NEW ENGLAND ENGINEERING SERVICES, INC. Town of North Andover 115 Vest Way, North Andover, Soil testing * .w 10/27/2005 RECEIVED DEC o 2005 TOWN OF NORTH ANDOVER 8533 360.00 Checking - Banknorth 360.00 TOWN OF NORTH ANDOVER E NORT11 7 Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 49 400 OSGOOD STREET `ter a NORTH ANDOVER, MASSACHUSETTS 01845 �,SSAC11U5 t� Susan Y. Sawyer, REHS, RS 978,631440 – Phone Public Health Director R EC IV 688.8 76 – FAX APPLICATION FOR SOIL TE DATE: 1z 1110 s LOCATION OF SOIL TESTS: DEC 04*, pp5.to omo DWN OF NORTH ANDOVER HEAL7H DEPARTMENT MAP & PARCEL: 7 0 OWNER: SAw&/ Contact#: APPLICANT: S -¢'/L!= Contact #: .com ADDRESS: //!;' j/,40' -',5r 410�f/p ENGINEER: tn(1 h4JAKRJAJ( JVG. Contact #: 9 '16 – toa(o – l 7 (o¢, CERTIFIED SOIL EVALUATOR: &A0,+M1At C. 0000D_ ze. / Vfrrw 4 I&G T,Pt? Intended Use of Land: Residential Subdivision Single Family Home Commercial Is This: Repair Testing: Undeveloped Lot Testing: Upgrade for Addition:_ In the Lake Cochichewick Watershed? Yes THE FOLLOWING MUST BE INCLUDED WITH THIS FORM No X ➢ Proof of land ownership (Tax bill, or letter from owner permitting test) ➢ 8.5"x M"Plot Plan & Location of Testing (please indicate test nil sites on the nlan ➢ Fee of $425.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of $360.00 per lot for repairs or upgrades. GENERAL INFORMATION ➢ Only Certified Soil Evaluators may perform deep hole inspections. ➢ Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. ➢ At least two deep holes and two percolation tests are required for each septic system disposal area. ➢ Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. ➢ Full payment will be required for all additional tests within two weeks of testing. ➢ Within 45 days of testing, a scaled plan (no smaller than 1"-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). ➢ Within 60 days of testing soil evaluation forms shall be submitted. Please Do Not Write Below This Line N.A. Conservation Commission Approval Date{ Signature of Conservation Agent.. Date back to Health Department: (stamp in): N - I.h-OUNDARr AN':I')','F.LI_;PI_, LJ,;ATI`.')N FROM PL,01 PLAN 6Y R'F KIMIN=�K1 ANU.-ASSOC DAl F l)i 19,63 2_ GRADES V4 F RE FIELD ADJUSTED To MATCH TO PO AND DESIGN CRITERIA. 3.1 CERTIFY THAT -THE S:�DS: 'NAS INSTALLED AS SHOWN A,N[) Willi (;-.)N5lRU(,TI0N MATERIALS AS SPE�IFIED IN 1 HE RELATED DESIGN. Elk-VATIONS , TOP FOUND: 171.7 DWELLING OUT. 162.90 SE PT IC TANK = INLET= 161.78 OUTLE T: 161.53 ' D -BOX INLET = 158.91 OUTLET= 153:6 END OF TREN„H= I : 15SAG T15, 2: 154.75 RItS 3' 151.51 44 = 148.70 i PLAN of AS BU ILI CONDITIONS LOT 34AVESTWAY� OWNER-'JO-UEE RT DATE -.8/31A3 SCALE -.I'/40' P1ZEPAREU BY FLYNN Assoc. P.C.. CIVIL, SANITARY and CONSTRUCTION ENGINEERS Plaistow, New Hampshire 03865 — P.O. Box 569 Building Sketch Borrower Derek Moms= Property Address 115 Vest Way City Noah Andover Coiady Essex State MA Tp Code 01845 [ender Chrd Envoy Mortgage, Ltd. s Dining Kkchen Bath Laundry Room Room m ..,..... ti m Living Family /// Room Room m 44 44' First Floor Second Floor [1232 Sq R] [1232 Sq -R] 44' Form SKT.BLDSKI - `TOTAL" appraisal software by a Is mode, ino.-1-800-ALAMODE .rt RECEIVED ,C\ Commonwealth ®f Massachusetts MAY 112015 -_ CltyTC®w>n of North AndoverTOWN OF NORTH ANDOVER System Pumping Record HEALTH DEPARTMENT Form 4 k` DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same asthat provided T aeSys em Pumping ore /ng this form,. check with your Record mustbe submitted i:o local Board of Health to determine the form they um in date in the local Board of Health or other approving authority within 14 days from the p p 9 accordance with 310 CMR 15.351. A. Facility information important When 1. System Location: filing out forms Y 7 � on the computer, ' j jr Ve / J l A 14 use only the tab 77 key to move your Address Ma 01886 cursor- do not North Andover Zip Code use the return State C'fy/Town key. VQ 2. System Owner: [ \ Name V mrcn Address (if different from location) State Zip Code cityrown . Telephone Number B. Pumping Record 412-36L2. Quantity Pumped: Gallons 1. Date of Pumping Date ❑ Tight Tank E] Grease Trap 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If.yes, was it cleaned? El Yes ❑ No 5. Condition of System: 6. System Pumped By: t5form4.doc• 03/06 d Vehicle License Number tion wher ents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Signature of Receiving Facility Date Date System Pumping Record - Page 1 Commonwealth of. Massachusetts vs; L:k City/Town of No Andover - I'AY 4 2013 System Pumping Record w Form 4 DEP has provided this form for use by, local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out forms 1 on the computer, use only the tab System Location: key to move your Address cursor - do not No andover use the return City/Town key. 2. System Owner: ; Name c)U5-'�r-ll Address (if different from location) City/Town bi q�/' Ma State State Zip Code Zip Code Telep.tbone-Nur berms B. Pumping Record 1 . Date of Pumping 2. Quantity Pumped: t Date Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plarlt, 20 _ . Mill Bradford, Ma Q1835 Signature r "� Date Signature of Receiving Facility Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 Town of North Andover 120 Main Street North Andover, MA 01845 (978) 688-9550 MATTHEW & LAURA CHABOT 115 VEST WAY NORTH ANDOVER, MA 01845 OFFICE HOURS PAYMENT ON OR BEFORE READINGS 11/15/2010 $127.45 Monday to Friday Current Type 8:30am to 4:30pm ACCOUNT BILLING DATE 29821488 3170504 10/15/2010 Billing Information: SERVICE DATES DUE DATE i (978) 688-9550 06/08/2010-09/09/2010; 11115/2010 Reading Information: SERVICE ADDRESS (978) 688-9570 115 VEST WAY The Town is experiencing a Water Drought. Watch For information, visit web site, or call the Water Treatment Plant at 978 688-9574. RETAIN THIS PORTION FOR YOUR RECORDS MOVING? PLEASE CALL (978) 688-9570 IN ADVANCE SERIAL # READINGS USAGE NB OF Current Type Date DAYS 29821488 444 Actual 09/09/2010 28 93 SERIAL # READINGS USAGE NB OF Previous Type Date DAYS 29821488 416 Actual 06/08/2010 21 90 29821488 395 Actual 03/10/2010 13 89 MESSAGES TRANSACTIONS THIS PERIOD AMOUNT , PREVIOUS BALANCE $88.90 PAYMENTS THROUGH 10/15/2010 ($88.90) ADJUSTMENTS THROUGH 10/15/2010 $0.00 INTEREST AS OF 11/15/2010 $0.00 BALANCE FORWARD $0.00 CURRENT BILL DETAIL USAGE/UNIT AMOUNT WATER USAGE 28 $119.63 ADMINISTRATIVE FEE $7.82 Sub -Total TOTAL $127.45 1 " NOTE " PAYMENTS SHOULD BE MADE: TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @ P.O. BOX 184, MEDFORD, MA 02155 WATER -RATE: FIRST 20 UNITS @ $3.80 OVER 20 UNITS @ $5.55 SEWER RATE: FIRST 20 UNITS @ $5.83 OVER 20 -UNITS @ $8.22 BYPASS METER WATER RATE: ALL UNITS @ $5.55 Please return this portion with your payment by 1111512010 • n Town of North Andover 120 Main Street 416731138 (North Andover, 98) 88-9550 MA 01845 �� VIII IIIA 11111111111111 IN Z01372-000001 If your address has changed, correct it below. MATTHEW & LAURA CHABOT 115 VEST WAY NORTH ANDOVER, MA 01845 Any amount which is not paid by due date will be subject to interest charges of 14% Per Year Billing Information: OFFICE HOURS (978)688-9550 Reading Information: Monday to Friday (978) 688-9570 8:30am to 4:30pm ACCOUNT BILLINGDATE I 3170504 10/15/2010 SERVICE ADDRESS 115 VEST WAY PLEASE PAY ON OR BEFORE 11/15/2010 j $127.45 AMOUNT 04167311382011,000000000000031705040403170504000000012745009 t t NEW ENGLAND ENGINEERING SERVICES 1 INC January 4, 2006 Ms. Susan Sawyer North Andover Board of Health 400 Osgood Street North Andover, MA 01845 RE: TITLE V REPORT: 115 Vest Way North Andover, MA Dear Ms. Sawyer: SAN Y 1 2005 TR�Thi DFp�H ANDovi Enclosed is the Title 5 Report for the above referenced property. The system PASSES the inspection. If there are any questions please call me at my office, 686-1768. Sincerely, 9-2 /Jr. Benjamin C. Osgoo Certified Title 5 Inspector 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 I of 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 115 Vest Way North Andover, MA Owner's Name: Shawn & Tasha Glicklich Owner's Address: 115 Vest Way North Andover, MA Date of Inspection: December 22, 2005 Name of Inspector: (please print) Benjamin C. Osgood, Jr. Certified Title 5 Inspector Company Name: New England Engineering Services Inc. Mailing Address: 60 Beechwood Drive North Andover, MA 01845 Telephone Number: 978-686-1768 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of the on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15340 of Title 5 (3 10 CMR 15.000). The system: Inspector's Signature: asses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails l The system inspection shall submit a copy of this inspection report to the Approving Authority ( Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ""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. 2ofli OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 115 vest Way North Andover, MA Owner's Name: Shawn & Tasha Glicklich Date of Inspection: December 22, 2005 Inspection Summary: Check A, B, C, D or E/ALWAYS complete all of Section D A. System Passes: y E3 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: N 0 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 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: 3of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 115 Vest Way North Andover, MA Owner's Name: Shawn & Tasha Glicklich Date of Inspection: December 22, 2005 C. Further Evaluation is Required by the Board of Health: NO 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 (SAS) Soil Absorption System and the (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 the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organize 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 5ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 4of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 115 Vest Way North Andover, MA Owner's Name: Shawn & Tasha Glicklich Date of Inspection: December 22, 2005 D. System 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 overload or clogged SAS or cesspool. ✓ Static liquid level in the distribution box above outlet invert due to an overload or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow ri 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 r/ Any portion of a cesspool or privy is within a Zone 1 of a public well. r✓ 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and 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.) 1 I/ O (YaMo) 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 considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You mu dicate either "yes" or `no" to each of the following: (The followin—g-tTilqria apply to large systems in addition to the criteria above) Yes No The system is within %feeta ce drinking water su The system is within 200ary t urfac drinking water supply The system is located in a nip—sensitive ar tenor Wellhead Protection Area — IWPA) or a mapped Zone II of a public water su ell If you answered "ye5'rany question in Section E the system is considered a iigRificant threat, or answered "yes" in Section D above the large systwflias failed. The owner or operator of any large system considered a ificant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system own ould contact the appropriate regional office of the Department. 5of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 115 Vest Way North Andover, MA Owner's Name: Shawn & Tasha Glicklich Date of Inspection: December 22, 2005 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 V"' 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 an inspection ? V 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 sign of break out? located V Were all system components, excluding the SAS, on site? Were all the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the bales or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner ( and occupants if difference from owner) provided with information on the proper maintenance of the subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes No V Existing information. For example, a plan at the Board of Health. V Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] 6of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 115 Vest Way North Andover, MA Owner's Name: Shawn & Tasha Glicklich Date of Inspection: December 22, 2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design)_ Number of bedrooms (actual): DESIGN flow based in 310 CMR 15.203 ( for example: 110 gpd x # of bedrooms). �D O Number of current residents: 9 Does residence have a garbage grinder (yes or no):_ Is laundry on a separate sewage system (yes or no): N � [if yes separate inspection required] Laundry system inspected ( yes or no): Seasonal use: (yes or no): N O . Water meta readings, if available (last 2 years usage (gpd): /90 Sump Pump (yes or no): ti0 . *tip w ,�2 �Ns�AuE� �c�lzz��y Last date of occupancy LI t r e �T SE> �A)Fb2 l0 -rt-(E A-7 NOT vS COMIVIERCIAL/MUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sqft, etc Grease trap present (yes or no): Industrial waste holding tank present (yes or no): Non -sanitary waste discharged to the Title 5 system (yes or no) Water meta readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: (p ,j )h ,v o .N i✓ Was system pumped as part of the inspection (yes or 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) Tight tank Attached a copy of the DEP approval Other (describe): Approximate age of all components, date installed (if known) and source of information: fly — g d i Cl— D Rr(-E-r) e 131 [ 8_3 Were sewage odors detected wen arriving at the site (yes or no): 7of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 115 Vest Way North Andover, MA Owner's Name: Shawn & Tasha Glicklich Date of Inspection: December 22, 2005 BUILDING SEWER (locate on site plan) Depth below grader Materials of construction: ✓ cast iron 40 PVC other (explain) Distance from private water supply well or suction line: d4zz! Comments (on condition of joints, venting, evidence of leakage, etc.): P,f'E IN OK coN�t? ITloni kN afhScF SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction:Xconcrete metal fiberglass polyethylene Other (explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance (yes or no): (attach a copy of certificate) Dimensions: /S o 0 LL O ti s Sludge depth: G z Des ��cEs 1V6Pe 2711! flnf`r Distance from top of sludge to bottom of outlet tee or baffle: -kl D v r �a o Irl -L, C- ,vre }>I nr Jc. Scum thickness: © ?1 F? Pr V, Distance from top of scum to top of outlet tee or baffle: �k Distance from bottom of scum to bottom of outlet tee or baffle_. How were dimensions determined: ST7c K Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 'TANK IN ole co r9t1�n R�Sc%i2 t xts7-n1JFiZ 1N(,Ei r=n��. iZiS� (L 412> D 00e- 0J -T -L -t t EN D . ,vELA_.) S� 1-t lfo PL)C 0Jrt_FT- Tz5--Z-�7 41JD &-O--S OAf�L-E ep_pe'? P u j2.1ti G- I,us PEc -1-20N. GREASE TRAP: aW (locate on site plan) Depth below grade: Materials 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 sludge to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc. 8of11 - OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 115 Vest Way North Andover, MA Owner's Name: Shawn & Tasha Glicklich Date of Inspection: December 22, 2005 TIGHT OR HOLDING TANK:�j I P —(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Materials of construction: concrete metal fiberglass _polyethylene other (explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: D Comments ( note if box is level and distribution to outlets equal, any evidnence of solids carryover, any evidence of leakage into or out of box, etc.): w P csREP0-1 Obx 12EPc.R(r4p /9 < ev.5 jFG–CT)o.�_ Ac c� w0lz14, 1NsPcc- 8 THS –JD—A-, OlG l✓a 9 -TI -t A PUMP CHAMBER: N (locate on sire plan) Pumps in working order (yes or no) Alarms in working order (yes or no) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): 90f 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 115 Vest Way North Andover, MA Owner's Name: Shawn & Tasha Glicklich Date of Inspection: December 22, 2005 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required If SAS not located explain why TYPE leaching pits number leaching chambers, number leaching galleries number leaching trenches, number in length T2 e -c. K CS a . w i t7 e j t D e ' e- o /i (— leaching fields, number, dimensions: overflow cesspool, number: innovative/alterative system Type/name of technology: Comments ( note condition of soil, signs of hydraulic failure. Level of ponding, damp soil, condition of vegetation, etc) g e_ C c -E �� Dje�, fine A O� Sus7Pr✓I Sti v w cyve 26 D CESSPOOLS:�� (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth — top of liquid to inlet invert Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of Construction Indication of groundwater inflow (yes or no) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (locate on site plan) Material of construction: Dimensions: Depth of solids Comments (note condition of soil signs of hydraulic failure, level of ponding, condition of vegetation, etc. 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 115 Vest Way North Andover, MA Owner's Name: Shawn & Tasha Glicklich Date of Inspection: December 22, 2005 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. P RLig- 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Property Address: Owner's Name: Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells PART C SYSTEM INFORMATION (continued) 115 Vest Way North Andover, MA Shawn & Tasha Glicklich December 22, 2005 Estimated depth to ground water feet Please indicate (check) all methods used to determine the high ground water elevation: —_ Obtained from system design plans on record — If checked, date of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health — explain: Checked with local excavator, installers — (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: S 4 /0 c, us i cT N i✓ �> :.� A'$ z) u e G--20 U nJt- y.57-c-1 SIT OL- t> 02.t(7 -INA -L- G --RAD c,CyPrT)aN ,- J/q-kctN of � STf= , V I yi L LC 1-/ -7-c Fc c 7- c ki �t /,j A L- - ORL6�INAL 6-2+qD0� Sys77 nl vC-7-LjF? Ai2.E�l D/Z!C)�, UUVt:WMX .,, ' r ', rhe 'j' m �.l .n.'/fyy/ ecord"""' ll.� M M Dap. r1o0ded to m has p for use b 'b ml4id t61�9 IQCAI'Board of Health or other approyl 0 u by local Boards of He -A,-..Fac lilt -T y.lnfo tion go rt&n L only the W key Address to move YQLW retum., State Stem Nner" 7L. Name Mg I ZIP POI18 Record rr.,:, -7-Stale' ----------� e 9�v %�_ Telephone :-�o r .oats;of Pun 7 2, Pum U go rcj.17-: 7 ly ?7Z, pate ank Pumped: Z/7Z Gallo t1o.Tank CD Tight Tank Other (d'ei�db41# .. ...... , .. 4 ue.nt Tee F11te If yes, was it cleaned? 4 P? 14" cv, f 114 C� ") ; Wlij, `-d#Qsed; L-7 \4' d— ------------ ...... . . P Dat pJ/wtiV—e &/W0rms,htm#lnspect System PUMPIng Record - Pip 1 Town of North Andover Office of the Health Department Community Development and Services Division 400 OSGOOD STREET North Andover, Massachusetts 01845 Susan Y. Sawyer, REHS/RS Public Health Director f NORTH 7 o � �9SSA�NUS t� 978.688.9540 - Phone 978.688.8476 - Fax C�E�I FICA2E OAF C09W(DrIA9NC'�E As of.- January f:January 11, 2006 This is to cert that the individual su6surface drsposal system was a 1D-Bo.-1Replacement Completed d y: James Kellett At: 115 Vest Way NorthAndover, qi q 01845 Yfas 6een installed in accordance with the provisions of 7itfe v of the State Sanitary Code and with the North Andover Board of Yfealth regulations. 'The Issuance of this certificate shall not 6e construed as a guarantee that the system will function satisfactorily. �i �z-ti•-_,,•-rte...... _. Sus n `Y. Sawyer, j EAS/1I Tu6fic Ifealth Director BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEAL"fH 688-9510 PLANNING 688-9535 FA Town of North Andover Office of the Health Department Community Development and Services Division 400 OSGOOD STREET North Andover, Massachusetts 01845 Susan Y. Sawyer, REHS/ RS Public Health Director NORTh O.t��an Ya''•�•C CHU p 978.688.9540 - Phone 978.688.8476 - Fax CE1�1'�FIGA2E OF C09Y(I)rIA9VCE As of.- January fJanuary 11, 2006 7(is is to cert that the ind'viduafsu6surface disposafsystem was a 1D-Bo.X Weplacement Completed•dy: James XelCett At: 115 Vest Nay Noah Andover, WA 01845 Yfas been installed in accordance with the provisions of Title V of the State Sanitary Code and with the ,7Vonh Andover Board of YfeaCth regulations. The Issuance of this certificate shall not 6e construed as a guarantee that the system will function satisfactorily. fi Sus)n 7 Sawyer, ROYS/VI Tu61u.Ifealth Director BOARDOF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 TOWN OF NORTH ANDOVER Of NORTH Office of COMMUNITY DEVELOPMENT AND SERVICES o? •'�� ' '°°� HEALTH DEPARTMENT 400 OSGOOD STREET,.. NORTH ANDOVER, MASSACHUSETTS 01845 �'ss CHU t� Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX SEPTIC SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS:C MAP: LOT:_ INSTALLER: JJ _ DESIGNER: (� �J , 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: SELECT SYSTEM TYPE 1 1. GRAVITY DISTRIBUTION... L11 2. PRESSURE DISTRIBUTION... ❑ 3. PRESSURE DOSING... ❑ 4. HOLDING TANK... ❑ 5. ADVANCED TREATMENT... ❑ 6. OTHER... ❑ PUMP SYSTEM COMPONENT SUMMARY FROM PLAN 1. GALLON TANK = 2. LOADING OF SEPTIC TANK = 3. GALLON PUMP CHAMBER -- 4. 4. LOADING OF PUMP CHAMBER = 5. TYPE OF SAS = 6. DIMENSIONS AND DETAILS OF SAS: Comments: Page 1 of 4 TOWN OF NORTH ANDOVER E NORTH , Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 41 400 OSGOOD STREET",.��_ NORTH ANDOVER, MASSACHUSETTS 01845 Susan Y. Sawyer, REHS/RS Public Health Director SITE CONDITIONS 1. Existing septic tank properly abandoned... ❑ 2. Internal plumbing all to one building sewer... ❑ 3. Topography not appreciably altered... ❑ SEPTIC TANK 1. Bottom of tank hole has 6" stone base... ❑ 978.688.9540 — Phone 978.688.8476 — FAX 2. Weep hole plugged... ❑ 3. Tank has been installed (H-20) Tank Size: 1,500 2 -piece ... ❑ - H-40 4. Water tightness of tank has been achieved (Visual)... ❑ 5. Inlet tee installed, under access port... ❑ 6. Outlet tee (gas baffle or effluent filter) installed, under access port... ❑ 7. Cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present - Inches of Tank... ❑ 8. Hydraulic cement around inlet & outlet... ❑ ****Comments: **** PUMP CHAMBER - n/a 1. Bottom of tank hole has 6" stone base... ❑ 2. Weep hole plugged... ❑ 3. Pump Chamber Installed _Combo tank Gallons; (H-20) (Monolithic) 4. Inlet tee installed, under access port... ❑ 5. Pumps) installed on stable base... ❑ 6. Alarm Float Working... ❑ 7. Pump On/Off Float Working... ❑ 8. Total # of Floats... 9. Drain hole in pressure line... ❑ 10. Cover to within 6" of final grade installed over one access port... ❑ 11. Water tightness of tank has been achieved - Visual or Vacuum Test or Water held for 24 hours (circle) 12. Hydraulic cement around inlet & outlet... ❑ Comments: Page 2 of 4 TOWN OF NORTH ANDOVER t NORTH Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTIf DEPARTMENT x 400 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845Cµ„s Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX D -BOX _ / 1. Installed on stable stone base ... ld 2. Inlet tee (if pumped or >0.08'/foot)... ❑ 3. Hydraulic cement around inlet & outlets ... Lr� 4. Observed even distribution... 2' 5. Speed levelers provided (mqt*equired) ... Lk - Comments: SOIL ABSORPTION SYSTEM 1. Bottom of SAS excavated down to C Soil Layer, as provided on plan... El 2. Size of SAS excavated as per plan... ❑ 3. Title 5 sand installed, if specified on plan... ❑ 4. 3/4-1 1/2" double washed stone installed... ❑ 5. 1/8-1/2" (peastone) double washed stone installed 6. Laterals installed and ends connected to header (and vented if impervious material above) 7. Gravel -less disposal systems: type, number and location as per plan......... ❑ 8. Elevations of laterals installed as on approved plan... ❑ 9. 40 Mil HDPE barriers installed... ❑ 10. Retaining wall (boulder / concrete / timber / block) ... ❑ 11. Final cover as per plan ... ❑ *****Comments: ***** CONTROL PANEL 1. Alarm & Pump are on separate circuits... ❑ 2. Alarm sounds when float is tripped...... ❑ 3. Location of control panel: 4. Rated for exterior if placed outside... ❑ Comments: Page 3 of 4 f MORTh , tioo' Commonwealth of Massachusetts Map -Block -Lot �o� ...o .`• 104. B- 0159 - oF , Board of Health Permit No • •BHP :. North Andover -2005-0727 . o . P.I. FEE CHUst� F.I. $125.00 ---------------- Disposal Works Construction Permit Permission is hereby granted JAMES KELLETT to (Construct) an Individual Sewage Disposal System. -;� j - LJ Imp at No 115 VEST WAY as shown on the application for Disposal Works Construction Permit No. BHP -2005-072 Dated December 22, 2005 Issued On: Dec -22-2005 Board oeah lw 16W +`ow'M - Map -Block -Lot 0.. 104.B- •�tio Commonwealth of Massachusetts �+ : o' 104. B- 0159- Board 59-Board of Health North Andover �;s •••1e •r:� Certificate of Compliance ,I CHUst THIS IS TO CERTIFY..That the Individual Sewage Disposal System (Construct) by JAMES KELLETT - ----- Installer at No 115 VEST WAY has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. BHP -2005-072 Dated December 22, 2005 - - - Printed On: Dec -22-2005 Board of Health Towrt`of North Andover Health Department Date: 111o�oL e5_ Location: 115—` (Indicate Address, if Residential, or Name of Business) Check #: (O Type of Permit or License: (Circle) ➢ Animal $ ➢ Dumpster $ ➢ Food Service - Type: $ ➢ Funeral Directors $ ➢ Massage Establishment $ ➢ Massage Practice $ ➢ Offal (Septic) Hauler $ ➢ Recreational Camp $ ➢ SEPTIC PERMITS: v Septic - Soil Testing $ o Sept'c - Design Approval $ eptic Disposal Works Construction (DWC) $ aif:9: 0 Septic Disposal Works Installers (DWI) $ ➢ Sun tanning $ ➢ Swimming Pool $ ➢ Tobacco $ ➢ TrasIVSolid Waste Hauler $ ➢ Well Construction $ ➢ OTHER: (Indicate) 13*12 Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. ILS A If �enm Application for Septic Disposal System Construction Permit- TOWN OF "NORTH ANDOVER, MA 01845 Application is hereby made for a permit to: Fepair uct a new on-site sewage disposal system* or replace an existing on-site sewage disposal system* or replace an existing system component A. Facility Information Address or Lot # --p . A ndD v e r(-- City/Town 2.- *TYPE OF EPTIC SYSTEM*: ❑ Pump ETGravity (choose one) V*If pump system, attach copy of electrical permit to application*** nventional System (pipe and stone system) Ila Os - TODAY' DAT $ 250.00 — Full Repair $125.00 - Component ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D -Box Present) S.A.S. 2. Owner Information Name // r tlrs f- WA y Address (if different from above) N . /Qndo ✓C 3^-- City/Town State Zip Code Telephone Number 3. Installer Information Name , Name of Company Z-/,, h��l�' C ityfYown 4. Designer Information Name -- --- --- Address ----- — �----- --- City/Town State Zip Code Telephone Number (Cell Phone # if possible please) Name of Company ------- — - - ------ — ----- -- State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 Application for Septic Disposal System Construction Permit - TOWN OF 'NORTH AND0VF.R_ MA MR45 PAGE 2OF2 A. Facilitv Informati 5. Type of Building B. Agreement nued.... ential Dwelling or ❑Commercial TODAY'S DATE $ 250.00 — Full Repair $125.00 - Component The undersigned agrees to ensure the construction a e+rice 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 iss d by this Boarl of Health. Nar Date Application Approved By: (Board of Health Representative) Name Application Disapproved for the following reasons: For Office Use Only: L Fee Attacbed? 2. Project Manager Obligation Form Attacbed? Date Yes No Yes_ No 3. Pump S sy tem? If so, Attacb copy of Electrical Permit Yes_ No 4. Foundation As -Built? (new construction ronly): (Same scale as approved plan) S. Floor Plans? (new construction only): Yes_ No Yes_ No Application for Disposal System Construction Permit • Page 2 of 2 r • INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at l / sr f/ps t- WA Y off/;,, ffelleif dated dated with revisions dated relative to the application for plans by I understand the following obligations for management of this project: and 1. As the installer I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site 2. 4. when any work is being done. As the installer I must call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item three shall be applicable. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Tile 5 and the Board of Health Regulations may result in a $50.00 fine being levied against my company. a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final inspection – Engineer must first do their inspection for elevations, ties, etc. As -built or verbal OK from engineer must be submitted to Board of Health, after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade – Installer must request inspection when all grading is complete. Does not have to be on site. As the installer I understand that only I may perform the work (other than simple excavation) required to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation or suspension of my license to operate in the Town of North Andover; significant fines to all persons involved are also possible. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached. b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff or consultant. d) Installation of tank, D -box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersigned icensed Septic Installer �-�Date: llj— Board of Health - North An ver Haea. OK V SEPTIC SYSTEM nn INSTALLATICK CHECK LIST' LOT �� A \,��. S 4 DI PRN , AVATICK OK FAIL 1. Distance To: a. Wetlands b. gains c. Well 2. Water Line Location `3• No PPC Pipe it. Septic Tank a. _Tees -_Length & To Clean Out Covers. b. Cement Pipe to Tank On Both Sides of Tank 5. Distribution Box a. Covers k Box - No Cracks b. All Lines Flowing Equal Amounts C. No Back Flow Leach Field or Trench a. Dimensions b. Stone Depth c. Capped lads d. Clean Double Washed Stone ?. Leach Fits a./ash s b.epth C .Pads d.ePipe to Pit - Both Sides Clean Double Washed Stone 8. No Garbage Disposal 9. Final Grading Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System i c. Location with Regard -to Perc Test d. Elevations e: Water Table N Board of Health ---------------- APPROM DATE 7 Provided: ilk/ i SUBSURFACE DISPOSAL DMGN CHECK LIST DISAPPROM DATE Reasons: LOT f-34 N' 'I -S-r Title V FAIL Reg 2.5 The submitted plan must show as a miniMUM: 44 the lot to be served-area,dimensions lot #,abutters location and log deep observation hoies-distance to ties cation and results percolation tests -distance to ties sign calculations & calculations showing required leaching area location and dimensions of system -including reserve area f xisting and proposed contours g cation any, wet areas within 100' of sewage disposal system or disclaimer -check wetlands napping surface and subsurface drains vitnin 1001 of se -rage disposal System or disclaimer i} cation any drainage easements within 1001 of stege disposal system or disclair-er-Pl nning Board files J knees sources of -pater simply -within 2001 of stege disposal d system or disclaimer ( location o of sal proposed �ll_to _serve lot -1001 from. leaching facili cation of kater lines on property -101 from leaching facility — location of benchmark n drive -ways garbage disposals no PVC to be used in construction (q) profile of system -elevations of basement, plumb) pipe, septic tank, distribution box inlets and outlets, distribution field piping and 6tler elevations �mah�73mum ground wester elevation in area se -age dis_u�sal system S) plan mast; be prepared by a Professional Engineer or other professional authorized by lax to prepare such plans Reg 6 Septic . Twanks a) eapacitics-150 of flow, -meter table, tees, depth of tees, access, pumping cleanout 101 from cellar vrall or ingl ouDd s . -ng P001 (d) 251 from subsurface drains Reg 10.2 Distribution Faxes so�f pe greater than 0.08 Reg 10.4 I ) Mirp FAIL ! CK leg 15.1 15.4 15.8 3.7 1.4.1 14.3 14.4 U.6 14.7 lb.10 eg 9.1 9.6 i Leaching Pits Leaching pits are ferred where the installation is possible a) calculations f leaching area -minimum 500 eq ft ,b) spacing 0 surface a 2% (d) cover terial Ce) 21 ' x411 splash pad (f) a at elbow ( no bends in pipe from d -box to pipe Leaching Fields ,a) no greater th 20 minutes/inch b) area -minim' 900 sq ft ;c) constrnc on of Field `d) surf drainage 2 % ;e) 2 Brom cellar wall. or inground swimming pool Leachin Trenches a calcu3 aons of Ieaching area -min 500 sq ft 'b) spacing -4 ft min 6 ft with reserve between ,c) dimensions 4 constriction ;e) stone f) surface drainage 2% _ Doi ahi l l S10 e a) sTop�e y��to be shown) b) y/x X 150 = (to be shown) Pubs a) approval b) stand-by power I.- iv% SOIL PROFILE & PERCOLATION TEST DATA North Andoveri Mass. Street No Vel57 WA. --l( Lot No 34 Loc/Subdiv. Pland Owner �SP-�( C-0 Investigator Observer 1 A s SOIL PROFILE DATES 1.'Elev 2.Elev 3.Elev 4.Elev YEI..Lo � 6'JZ'Y r 0, 1 0 2 1T c s j 2 41 _I 4 5 5 6 6 E 1 2 3 4 5 0 Ties to Test Pits DATES Pit Number i 2 3 4 Start Saturation Soak -Minutes art Test-1Im Drop of 3" -Time Drop of 6" -Time M6ns.lst 3" drop � v Percolation , 8 8 8 8 W � 9 � 9 9 La. 10 . 10 10 Benchmark �� b`� Location Elevation Datum PERCO;,ATION TESTS DATES Pit Number i 2 3 4 Start Saturation Soak -Minutes art Test-1Im Drop of 3" -Time Drop of 6" -Time M6ns.lst 3" drop Mins.2nd " Drop Percolation Lor 3 3e3 L�2 - cr- 'Q�P �tfcV 'LAz3 Vz ,; �v>� .7V1L YPSVt`11-P. a rP.[it,NLl111y1y iL'.71 unin North Andover, Mass. Street No Lot No Loc/Subdiv. Pland OwnerLp Investigator_Observer SOIL PROFILE DATES 1.)Elev 2.Elev 3.Elev 4.Elev 0 0 0 0 1 2 3 4 Benchmark Elevation 5 6 7 8 9 10 DATES 1 2 3 4 5 6 7 8 9 10 Location Datum PERCOj ATION TESTS G,1 W-3 `71, I S'--5, 1 2 3 4 5 6 7 8 9 10 Tiies P Test est l Pit Number 1 2 4 Start Saturation CA ; Soak -Minutes i, �-3 ; 44 Start e , L1^ Drop of 3" -Time is-:1VV Drop of 6" -Time 1', 10 754 k t q-7 - M6ms.lst 3" drop FZ `ZZ _ Mins.2nd " Drop1 Percolation Lo COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 115 Vest Way bi Andover, MA 01845 Owner's Name: �r L7A �� iR. Owner's Address: Date of Inspection; Name of inspector. (please print) ERIC, LOARDSON Company Name: %mg -w; PFn Mailing Address: P.O. sox 5062 crme� to 02827 Telephone Number: AOt- 501 ?'k- toffs Oto CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper fimction 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: asses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fri , Inspector's Signature: Date: d 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 "has a design flow of I0,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. .g Page 2 of 1 ] OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE;DISPOSAL SYMM DAIWki ON FORM PART A CEIcKIMATIM (co awed) Property Address: 115 Vest Way N. Andover, Owner: Date of Inspection: 402600 Inspection Summary: Check AAC,D or E / ALWAYS complete all of Section D A*; I t . Sye asses: 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. Syste%oore ditionally Passes: Onsystem components as described in the "Conditional Pass" section need to be replaced or repaired. The s m, upon completion ofthe replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or no '11 (Y,N,ND) in the for the following statements. If `not determined' please explain. The septic tank ism andover 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial tration or afiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a mplying septic tank as approved by the Board of Health. *A metal septic tank will pass ins 'on if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 2 old is available. ND explain: Observation of sewage backup or breA 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 pWs)'am replaced obstruction is removed distribution box is elect or replaced ND explain: The system inquired pumping more than 4 times a year dui 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: Page 3 of 1 l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 115 Vest Way N Andover, MA 01845 Owner: Date of Inspection: C. Furtherfvaluation is Required by the Board of Health: Conditio exist which require father evaluation by the Board of Health in order to determine if the system is failing to protect%ublicealth, safety or the environment. 1. System willess Board of Health determines in accordance with 310 CMR 15.303(lxb) that the system is noning in a manner which will protect public health, safety and the environment: _ Cesspool or pn\y is within 50 feet of a surface water Cesspbol or privXis within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Bo of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner tfqt protects the public health, safety and environment: _ The system has a septic tank an it absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a ce water supply. The system has a septic tank and S S d the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS d\the SAS is within 50 fit of a private water supply well. The system has a septic tank and SAS and SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to de `- a distance ** ` d at a DEP certified laboratory, for coliform This system passes if the well water analysis, perf bacteria and volatile organic compounds indicates that well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is � to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis musbe ched to this form. 3. Other: Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGEPMS WAL SYSTEM INSPECTION FORM PART A CERTMCATION (cantinued) Property Address: 115 Vest Way 45 Owner: Date of inspection: 10-2"0 D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for aii inspections: Yes No _ _ ckup 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 — ogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or esspool _Xriquid depth in cesspool is less than 6" below invert or available volume is less than''/: day flow _ R44 .red pumping more than 4 times in the last year NOT due to clogged or obstructed p.pe(s). Number �6f times pumped i/^ Any portion of the SAS, cesspool or privy is below high ground water elevation. ,/ p portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface ,Anter supply. y portion of a cesspool or privy is within a Zone I of a public well. _ App+ portion of a cesspool or privy is within 50 feet of a private water supply well. _ _L -Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than '5 ppm, provided that no other failure criteria are triggered. A copy of thelanalysis must be attached to this form.] A(Yes/No) 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 convect the failure. E. Large Systems: To be considea large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 �• You must indica either "yes" or "no" to each of the following: (The following cri ' apply to large systems in addition to the criteria above) yes no _ the system is)rom . 400 feet of a surface drinking water supply _ — the system is withi\a* f a tributary to a surface drinking water supply _ ,the system is locategen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a publicly well If you have answered "yes" to any question 'n Section E the system is considered a significant threat, or answered "yes" in Section D above the large system failed. The owner or operator of any large system considered a significant threat under Section E or failed and Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the a op 'ate regional office of the Department. .. \ Page 5 of I l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 115 Vest Way N. Andover, MA 01845 Owner: Date of Inspection: 1 n -?R -nn Check if the following have been done. You most indicate `fires" or "no" as to each of the following: Yes o 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 ? z, 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 NIA) Was the facility or dwelling inspected for signs of sewage back up ? as ected for signs of break out ? r{ al m components, excluding the SAS, located on site ? ¢� ! 4v�¢. c�LtCla Iz _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected condition of the b es 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: Yes no _f Existing information. For example, a plan at the Board of Health. _ Determined in the field (if an of the failure criteria related to Part C is at issue approximation of distance _ y is unacceptable) [3 10 CMR 15.302(3)(b)j Page 6 of I l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY A9Sii�I'S SUBSURFACE SEWAGEvDISPOSAL SYSTEM IN XM --FORM PART C SYST M I11II018"TION Property Address: 115 Vest WayN. Andovei, MA 8 5 Owner: Date of Inspection: 10 X28-00 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CM )t 15203 (for example: 110 gpd x # of bedrooms): Number of current residents: �_ Does residence have a garbage grinderr no): Is laundry on a separate sewage system es or no): [if yes se nnft inspection required] Laundry system inspected: Seasonal use: (yes or no): Water meter readings, if available (last 2 years usage (gpd))::TU Sump Pump (yes or no):Q Last date of occupancy:C s1 Type of establishment: Design flow (based on 310 CW 15.203): gpd Basis of design flow (seats/pers sgftet Grease trap present (yes or no): Industrial waste holding tank prese (yes Non -sanitary waste discharged to the • I Water meter readings, if available: Last date of occupancy/use: OTHER (describe):. or no): _ e 5 system (yes or no): _ GENERAL INFORMATION Pumping Records Source of information: 1 QQ Was system pumped as part of the inspection (yes or no): O If yes, volume pumped: gallons — How was quantity pumped determined? Reason for pumping: TYPES c SYSTEM eptic 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, led (if known) and source of information: j 1, Lq E-11) Were sewage odors detected when arriving at the site (yes or no): Page 7 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 115 Vest Way 1845 Owner: Date of Inspection: 10-28-00 BUILDING SEWER (locate on site plan) 1 Depth below grade: Materials of construction: iron _40 PVC other (explain): Distance from private water supply well or suction line: Comments (on venting, SEPTIC TANK: ✓ (locate on site plan) etc.): 1 Depth below grade: Material of construction: _concrete metal fiberglass polyethylene _other{explain) If tank is metal list age: , Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) Dimensions: &;Q t".s oAteouS ov"AL Sludge depth: -S" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:I_� I I 1/ 0A(t+ s vs 0-*— t iK y - Distance from top of scum to top of outlet tee or baffle: & Distance from bottom of scum to bottom ofgydeti o;l IN: How were dimensions determined:: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels GREASE TRAP: Depth below grade: Material of construction: (explain):_ Dimensions: Scum thickness: on site plan) Distance from top of scum to top of Distance from bottom of scum to bo Date of last pumping: Comments (on pumping recommend as related to outlet invert, evidence c metal fiberglass ,polyethylene _other tee or baffle: f outlet tee or baffle: ,t and outlet tee or baffle condition, structural integrity, liquid Ievels etc.): Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 115 Vest Way N. 1845 Owner: Date of Inspection: 10-26-00 SOIL. ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: �S I leaching trenches, number, length: y leaching fields, number, dimensions: overflow cesspool, number: innovative/alternative system Typetname of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, CESSPOOLS: C. (cesspool must be pumped as part of inspection)(locate on site plan) Number andCO on: Depth — top of liquid to ' let invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: _ Indication of groundwater inf Comments (note condition of (yes or no): I , 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 failure, level of ponding, condition of vegetation, etc.): Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGEJDVW0&4L SYSTEM INSPECTION FORM PART C SYSTEMi`I3V 0RK4TM (continued) Property Address: 115 Vest Way N. 1845 Owner: Date of Inspection: 10-26-00 TIGHT or HOLDING TANK: (tank must be pumped at time of inspectionXlocate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity. gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: v/(ifpresent must be opened)(locate on site plan) Depth of liquid level above outlet invert: _ 1 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.): s Sy�'y''inS PUMP CHAMBER: (locate on site plan) Pumps in working order (y or no): Alarms in working order (yes o): Comments (note condition of p chamber, condition of pumps and appurtenances, etc.): Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSAWITS SUBSURFACE SEWAGEDISPOSAL SYSIM SON FORM PART C SYSTEAjE6VR ATXi(continved) Property Address: 115 Vest Way N. Andaver, MA 5 Owner: Date of Inspection: 10-2®-00 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent i benchmarks. Locate all wells pithin 100 feet. Locate where public water supply enters t ft _Q4, -44K erence landmarks or building. K Page I I of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 115 Vest Way N. Ai iduvei, MA Oi 845 Owner: Date of Inspection: 10-26-00 SITE ELh�jM Slope // Surface water Check cellar Shallow wells •� Estimated depth to ground water feet Please indicate (check) all methods used to determine the high ground water elevation: _ "Obtained from system design plans on record - if checked, date of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked with local excavators, installers- (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: NEW ENGLAND ENGINEERING INC North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT: 115 Vest Way, North Andover SERVICES July 14, 1999 Enclosed is a copy of the Title V report for the above referenced property. The systema� sses our inspection. If there are any questions please call me at my office, 686-1768. Sincerely oo Ben'a C. Os d Jr. Y.T. J g President OF X1 I� .1 Isis 33 WALKER ROAD -SUITE 23- NORTH ANDOVER, MA 01845 - (978) 686-1768-(888)359-7645- FAX (978) 685-1099 t COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY C0XE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Cortuniss;oner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION _ Property Address: Il$ Name of Owner 62/1*101 KSS Date of Inspection: (01-2611"Address of Owner: / /s 1��S�u�•¢ >/ N. 41VOW42 Name of Inspector: (Please Print) Benjamin (,. Osgood, Jr I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: New England Engineering Services Inc. Mang Address: 33 Walker Rd., Sui re 239 Nnrt-h Andover, MA 01845 Telephone Number: 978-686-1768 CERTIFICATION STATEMENT 1 certify that 1 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 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: _V Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: .,l Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)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 sbatl submit the report to the appropriate regional office of the Department of -Environmental Protection. The original should'be sent toZhe system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page I of 11 ij 11—ted on Recycled Pape, S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: %l � ✓�y W,4/ N' If Yvwltle Owner: 1 -WO; Date of Inspection: INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. _ 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 tank 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 complying septic tank as approved by the Board of Health. _ Sewage backup or breakout or high static 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). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping -more than fourlimes n yeardue to broken or obst, cted pipe(s). The'ystem Vvilhpess inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page 2of11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (contirxwed) Property Address: 115 IIPV 0%y, N ,fjr/dv Owner:,I�4� 7o�ttt'S Date of Inspeetion:�j�b,/�� 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 the environment. 11 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 WHICKYALL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVJBONMENT: Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than ..100 feet but 50 feet or more from a private water supply well, unless a 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 (approximation not valid). 3) OTHER revised 9/2/98 P2ge3ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: �1411,/ r N' Date of Inspection:��18/ D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described 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 Backup of -sewage into facili y or-e"tem component -due to an overloaded or -cogged SATSor,cesspoot. „— 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped T. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. 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 large systems in addition to the criteria above: The system serves a facility with a design flow of 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: Yes No the system is within 400 feet of a surface drinking water supply the system is -within 200 feet a eurtaoo drinlciwg vwter supply -- --- - — - the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone 11 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 inforgiation. i revised 9/2/98 P2ec4ofII , 1 , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 117 YtJ' 440Yj N' JfA'X"e Owner: CfOf>11 7V VCS Date of Inspection: ,/,Id ` Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following Yes No Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system compaoanU.I%&w&.b&an paarpod for-atJeast two we&" &r.&the'systam hasJx"nzacaiaiog+rrwal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with NIA. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non -sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. _ 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. The size and location of the Soil Absorption System orr the site has been determined based on: / V _ Existing information. For example, Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)) / The facility owner (and.occupar iu, if different from_owjaer).were,prauitted.with iafnunalion on ftiA improper maintensQC^ ^f SubSurface Disposal Systems. 13M NST LCft-Tfz-t:.T(��1�ctF � N SPEc�� I t4 1-1" Or C>—$0A 5,F_Fr-1C TA nck t nt5PELT W LTTt W►lt2 D revised 9/2/98 Page 5 of I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: j15 vkst w1dYJ N. 4At01We Owner: gVikon aDJ1J s Date of Inspection: �� FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.d./bedroom. Number of bedrooms (design):_ Number of bedrooms (actual): Total DESIGN flow Number of current residents.A Garbage grinder (yes or no):](_j Laundry (separate system) (yes or noA0 : If yes, separafeinspection required Laundry system inspected (yes or no) Seasonal use (yes or no):� Water meter readings, if available (last two year's usage (gpd): TC(tiN Sump Pump (yes or no): NO Last date of occupancy: LQM14r COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: qpd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non -sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last -date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information Q oz - 3 -1 System pumped as part of inspection: (yes or no)_ If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system lyes or no) (if yes, attach previous inspection records, ii any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed{if known) -end source o4-imomiation: _ ]jt)lL-T- J N 1119-,3 _• .. pei2 +5--oa 1 L- f Sewage odors detected when -arriving at the site: (yes or no) JN(O revised 9/2/98 P2ge6ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: t 15 v f' wqq( Owner: ( fam". yft)rdS Date of Inspection: 01249`) BUILDING SEWER: (Locate on site plan) Depth below grader Material of construction: _ cast iron _ 40 PVC _ other (explain) Distance fromprivatewater supply well or suction line �_ Diameter L Comments: (condition of joints, venting, evidence of fea"ge,-etc.) \ � % L-OCALS p (C I N F3frS EVAX 1 � SEPTIC TANK:_ (locate on site plan) Depth below grader Material of construction: _" concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Js.age.confirmed by Certificate of Compliance _ (Yes/No) Dimensions: nxw 4Wt-4NS Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: -- Scum thickness: LI" Distance from top of scum to top of outlet tee or baffle: — Distance from bottom of scum to bottom of outlet tee or baffle: — How dimensions were determined: MedcS,; •-r. _ 6Tt4Ic.. ak TA N A- T--: p e r P To TCI. c z' � �c L.ti S �'t c TlVD Comments: (recommendation for pumping, condition of inlet and outlet tees or -baffles, depth of liquid level in relation to outlet invert; structure"ntegrity, evidence of leakage, etc.) TANK &I U P IXF11Z Reis %G IZ 5 pl1GLt2 1 &Nb OC71^t--E-T TES I N S(�EC i'TUM fJ �1E.1'11 NC7 S GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (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, etc.) revised 9/2/98 Page 7ofII i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PARI C SYSTEM INFORMATION (continued) Property Address: 115 VO I N. #MOW Owner: CT1Nf M JQPC Date of fnspecbon: TIGHT OR HOLDING TANK: (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: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order: Yes _ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) gOX N� FAJND, Depth of liquid level above outlet invert:_ EXCAVA-Tiom OF 50y- wC"> 3E TDD o(3TtZUSlt1� Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) — PUMP CHAMBER:_W (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) revised 9/2/98 P2gr8orli SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Addir.: I 16 V i &T Owner: C -f- yr 'JoNis Date of Inspection: a,1 -'a SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, location may be approximated by non -intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: 4 Lii- cI+ T"-KCocS leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) Al2.E A OF 54Srfm "VieSt "OXXI9C.. LckvEK �f'NCN !CA`5<S FXOlftl' Ti -A- AN D I/Vy'>gft7*-J `21DAIE w&S "T/-CMC.fi DA-(zSE Awb CESSPOOLS: (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 (cesspool must be pumped as part of ins Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition efnregetation, etc.) PRIVY: NA (locate on site plan) Materjals of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (cortbrxwed) Property Address: 115 I��LSI WW, N• wwie Owner: QeAI+AM Date of knspec&n: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 5 revised 9/2/98 Page 10 Of II T?-' NLS} I I's -it SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:115 VEST LUH) Nr AhA 2 Owrw:4RAN4VA Date er Inspecoon:1Zgl qq NRCS Report name �Oi� sy �2ySSe X Cv-- Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 3 Feet %jC IO w eGL Trp n C %e S Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) pEslC#N �Ll4ros ( NDtcWrE- TMMC.ft S IL,T A-30(Ar— ex -ib ExtSI—rticer CTOPF-. 01S.Gle,. oft -I N4 lti 1,, eC-,}e3 Nle &' �)r=lam- L,('Q, e K(".)f;11) revised 9/2/98 Page 11 of 11 TOWN.(F NORTH ANDOVER SYSTEM PUMPING RECORD s u, SYSTEM OWNER & ADDRESS SYSTEM LOCATION ' (example: left front of house) '!Ix'��r �,}N�i{+l��ltay ,) •r• r Cr *�• it � ,.M l �,•. ,.+• r, :�., ... ..A.•��` DATE OF PUMPING: a 6 QUANTITY PUMPED tSO6 GALLONS CESSPOOL: N0 _ X YES_ SEPTIC TANK: NO _ YES r A k tg ,tl tit •+{�, e�IN OF SERVICE: - ROUTINE EMERGENCY _ t `,4!!�B girt t,Sr,: f{ pBSF,I�VATIONS:` t Ar rl"JFr r,r� �.x` ttp S t 1 GOOD CONDITION I FULL TO COVER HEAVY GREASE? BAFFLES IN PLACE �� ''.��'•;ti��. ROOTS�L. _L LEACHFIELD RUNBACK EXCESSIVE SOLIDS _ .— FLOODED SOLIDS CARRYOVER „ h OTHER (EXPLAIN) ! 5 ,.,w Gni ra SYSTEM PUMPED RV. ��i!{....2i�c .•4Jn t t t iA n, 'pI BOARD OF HEAU"I l �{1 qtr..#> . COM=NTS: ` b M1 :�t41'£Sialrkill�il•�.'f9 iCa� ! t ��', 3 M ... C k . (`i1 Y