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Miscellaneous - 119 GRANVILLE LANE 4/30/2018 (2)
119 GRANVILLE LANE /4NL- 210/106.0-0057-0000.0 I 1 P a r4 4 Lot & Street119 Map/Parcel 106e, CONSTRUCTION APPROVAL Has plan review fee been paid YES NO Permit# Plan Approval: Date: ZZ Approved by: Designer: 666.0 Plan Date: Conditions: Water Supply: To Well Well Permit: Driller: Well Tests: Chemical Date Approved Bacteria I ate Approved Bacteria II Da Approved Plumbing Sign-Off: iring Sign-off: Comments: Form "U" Approval: Approval to Issue: YES NO Date Issued By: Conditions: Final Approval: All Permits Paid? YES NO Well Construction Approval? YES NO Septic System Construction Approval? YES NO Certification? YES NO Other? YES NO Any Variance Needed? YES NO FINAL BOARD QF, ALTH APPROVAL: DATE: MuVU APPROVED BY: r 1 _ v SEPTIC SYSTEM INSTALLATION CONDITIONS: Is the installer licensed? YES NO Type of Construction: NEW R€PAI New Construction: Certified Plot Plan Review YES Floor Plan Review YES NO Conditions of Approval from Form U YES NO Issuance of DWC permit: YES NO DWC Permit Paid? YES NO DWC Permit# // 9Installer: : Begin Inspection: YES NO Excavation Inspection: Needed: Passed: By: Construction Inspection: Needed: As Built Plan Satisfactory: YES: Ne rhalg(k Approval of Backfill: Date: By: v Final Grading Approval: Date: J-�A A By: ,- Final Construction Approval: Date: By: J Certificate of Compliance: Approval: Date: _ O`NORTH,� 7103 • Town of North Andover ,; HEALTH DEPARTMENT ,SSACHU`�tt w CHECK#: 5b5 DATE: I LOCATION: H/O NAME: CONTRACTOR NAME: Type of Permit or License:(Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ Title 5 Report $--*',.A-- ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage DisposaLSystem Form-Not for Voluntary Assessments P),qo rty A d rVI Owner l' 0 (-(Z0 A-e ifformation is es me _ required for do _ every page. rTowrf State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the and of the form. ImportantC`EIVED When filling out A. General Information RE forms on the MAY 0 4 2015 computer,use 1. Inspector. - only the tab key i to move your r 15 �,_ O y 'TOWN OF NORTH ANDOVER a cursor-do not Name of Inspector ff x HEALTH DEPARTMENT use key. return C nu ; L Company Name Company Address 1°Q'D City/To" State / Zip Code Teleph ne Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the I-oval Approving Authority Irlapedoertignature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This Inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•03113 Title 5 Offidal Ir[nspection Form Subsurfooe Sewage Disposal System•Pape 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 yMe L � Property Address i Owner Information is Owner's Name required for every page. Cityrrown State Zip Code Date of.Inspection B. Certification (cont.) Inspection Summary: Check A,B,C�D or E/always complete all of Section D A) System Passes: [ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: �PviC' C o� "o (� B)System Conditionally Passes: I ❑ 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"br"not determined"(Y, N, ND)for th following statyements. If"not determined, " please explain. The septic tank is metal and over 20 years old'or the sep ' tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or a titration or tank failure is imminent. System will pass inspection if the existing tank is replaced wi a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it i structurally sound, not leaking and if a Certificate of Compliance indicating that the tank,is less an 20 years old is available. ❑ Y ❑ N ❑ ND; xplain below): I I Title 5 official inspection Form Subsurface Sewage Disposal System•Page 2 of 17 t5ins•03113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Addre s Owner Owner's Name Information is required for every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.); ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N/F—] (Explain Explain below): ❑ obstruction is removed! 11Y El below): distribution box is leveled or replaced 11Y ❑ NExplain below): , i ❑ The System required pumping more th 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with a roval of the Board of Health): ❑ broken pipe(s)are reply .d ❑ Y El El ND (Explain below): ❑ obstruction is remov ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist whichrequire further evaluation by the Board of Health in order to determine if the system is failing to protect public health, sa!surface the environment. 1. System will pass unless Board of Healthmines in accordance with 310 CMR 15.303(1)(b)that the system is not functi ia manner which will protect public health, safety and the environment: ❑ Cesspool or privy is with/ithin ir 0 feet of a water ❑ Cesspool or privy is 50 feet of a bordering vegetated wetland or a salt march t5ins-03/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1� Property Add Owner Information is Owner's Name required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) deterimes that the system 1s functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)an a SAS is within 100 feet of a surface water supply or tributary to a surface water pply. ❑ The system has a septic tank and SAS and the SAS is within Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is ithin 50 feet of a private water supply well. i ❑ The system has a septic tank and SAS and the S 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 wat/analyerformed at a DEP certified laboratory,for coliform bacteria indicates absent and thepremonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no otheria are triggered. A copy of the analysis must be attached to this form. 3. Other: I i D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No'"'to each of the following p g for all inspections: i — Yes No i ❑ Er Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Cr' 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 W or cesspool ❑�i ❑ Liquid depth:in cesspool is less than 6" below invert,or available volume is less than % day flow t5ins"03113 Title 5 Official Inspection Forth Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments rL vnVI � �. � Property Address Owner Information is Owner's Name required for every page. CitylTown State Zip Code Date of Inspection i B. Certification (cont.) i Yes No ❑ 12' Required pumping more than 4 times in the last year NOT due to clogged or obstructed pi I e(s). Number of times pumped: ❑ Z Any portion of the SAS, Cesspool or privy is below high ground water elevation. ❑ Q� Any portion of celsspool 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. ❑ QT Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Q' 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 passe's 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.] ❑ This system is a cesspool serving a facility with a design flow of 2000gpd- 2"" 10,000gpd. El 2"" 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 ai 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"<ib " " f th following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feekiing water supply ❑ ❑ the system is within 2 feeta surface drinking water supply ❑ ❑ theZ ed in a nitrea (Interim Wellhead Protection Armapped Zone II of a public water supply well If you have answered "ystion in Section E the system is condidered a significant threat, or answered "yes" in Sethe large system has failed. The owner or operator of any large system considered ignificant 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-03/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Ins'-pection Form Subsurface Sewage Disposa System Form - Not for Voluntary Assessments I� 'Y Property Add ss p rtY Owner Information is Owner's Name required for _ every page. City[Town State Zip Code Date of Inspection i C Checklist i Check if the following have been tlone. You must indicate"yes"or"no"as to each of the following: Yes No i I ❑ Pumping information was provided by the owner, occupant, or Board of Health i ❑ 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? I ❑ Q� 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) Er ❑ 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 differe nt from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? This size and location of the Soil Absorption System (SAS) on the site has been determii ed based on: ❑ Existing information. For example, a plan at the Board of Health. 2 ❑ Determined iii 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)] i D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): (Sins•03113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 6 or 17 Commonwealth of Massachusetts Title 5 Official lhI spection Form Subsurface Sewage Dispos, I System Form-Not for Voluntary Assessments o 1 �Y Property Address Owner Information is Owner's Name required for _ every page. City/Town state Zip Code Date of Inspection D. System Information Description: / I i Number of current residents: Does residence have a garbage grinder? ❑ Yes 12r No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes El/No Laundry system inspected? f' ❑ Yes ❑ No i Seasonaluse? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: ' l Sump pump? ❑ Yes �Nci Last date of occupancy: '4DaL'— Commercial/industrial Flow Conditions:. Type of Establishment: Design flow(based on 310 CMR'i15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft.,e .): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank presen . ❑ Yes ❑ No Non-sanitary waste discharg/t' e Title 5 system? Yes 11No Water meter readings, if ava t5ins•03/13 Tide 5 Official inspection Form subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inpection Form Subsurface Sewage Disposal System form -Not for Voluntary Assessments o IIf { Vl Property Addregs i Owner Owner's Name Information is required for every page. City/Town State Zip Code Date of Inspection i D. System Information (coat.) Last date of occupancy/use: Date Other(describe below): i 17 I r I General Information i Pumping Records: Source of information: U Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped detert'nined? Reason for pumping: Type of System: l� 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/Alternlative 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)i Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 8 of 17 t5ins-03113 Commonwealth of Massachusetts Title 5 Official Inspection Form ` Subsurface Sewage Disposal System (Form - Not for Voluntary Assessments a 1 1-(� L P party Address Owner Owner's Name Information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all compone ts, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes E�No Building Sewer(locate on site plan): Depth below grade: 3, feet Material of construction: d 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.): Ok i Septic Tank locate on site plan is �C°C 25 S Depth below grade: feet Material of construction: la concrete ❑ metal ❑ fiberglass polyethylene ❑ other(explain) I I i If tank is metal, list age: ` years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: �-� D �' 0 X �—X Il Sludge depth t5ins•03113 Title 5 Official Inspection Forth Subsurface sewage Disposal System•Pape 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ' R Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I Property Address i Owner Information is Owner's Name required for every page. City/Town State Zip Code Date of Inspection I D. System Information (corit.) Septic Tank (cont.) nn Distance from top of sludge to bottom of outlet tee or baffle I _ Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? SI U C, e- Zj o( � Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, Evidence of leakage, etc.): i �c � t'r� l I e)�r�-p e r- 0`�7�r c��'►✓1 G ��U � '" IU b Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑Xfliblass ❑ polyethylene ❑ other(explain) i Dimensions: Scum thickness Distance from top of scuo top of outlet tee or baffle Distance from botto of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•03/73 ?ttie 5 Offldat 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 a Property Address I Owner Owner's Name Information is required for every page. City/Town State Zip Code Date of Inspection I I D. System Information (co!nt.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I I Tight or Holding Tank(tank must!be pumpe at time of inspection) (locate on site plan): i Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ pol hylene ❑ other(explain) I Dimensions: Capacity: g ons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No I Alarm level: ! Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of ala/and at switches, etc.): i I *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Title 5 Official Inspection Forth Subsurface Sewage Disposal System•Page 11 of 17 t5ins-03113 i Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a Property Address Owner Owner's Name Information is required for every page. City/Town State Zip Code Date of Inspection I D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet iILert 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.): i I v.P ��roy\��S P�-P✓�`�oly '1M11i11v✓�� e-A YY o V-e _LJ 0 5 ✓I 5 6 kA 5 0 rc A r �2 O�r V -P 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.): i I C, 0J Soil Absorption System (SAS)(locate on site plan, excav n not required): i If SAS not located, explain why: i i Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 12 of 17 t5ins-03113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Dis sal S stem Form- Not for Voluntary Assessments wo V Property Address Owner Owner's Name Information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (coat.) Type: ❑ leaching pits number: ❑ leaching chambers) number: I ❑ leaching galleries number: ❑ leaching trenches ' number, length: ❑ leaching fields C7�0� number, dimensions: d C S ❑ overflow cesspool number: ❑ innovative/alternatite system Type/name of;tech ology: Comments (note condition of soil signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): V) di y-aY-e � � X - o r Qyl Wa rj -;316 45 a ; kyd ► i1 VIIC — 41 )DY C Isle 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 I Materials of construction Indication of groundwater infl w ❑ Yes ❑ No t5ins•03113 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 41.,e�AllreV I Owner Owner's Name Information is required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (co;nt.) i Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I i I I i i Privy (locate on site plan): Materials of construction: Dimensions I Depth of solids Comments (note condition of soil, signs of h raulic failure, level of ponding, condition of vegetation, etc.): i I I Title 5 Official Inspection Form Subsurface Sewage Disposal S�stem•Pape 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 0i lie tj <"w� Property Address Owner Owner's Name Information is required for every page. City/Town State Zip Code Date of Inspection I. 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 Ithe building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately i I I f� P c I,b i I Title 5 Official Inspection Form Subsurface Sewage Disposal System Page 15 of 17 t5ins-03/13 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal ystem Form -Not for Voluntary Assessments 1 Property Addregs Owner Information is Owner's Name required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ! ❑ Shallow wells Estimated depth to high ground water: -2, - Q feet Please indicate all methods used,to determine the high ground water elevation: FM Obtained from system design plans on record If checked, date of design plan reviewed: C� d Mare- Observed eObserved site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: I I ❑ Checked with local excavators, installers-(attach documentation) i ❑ Accessed USG,$database-explain: i You must describe how you established the high ground water elevation: i Before filling this Inspection Report, please see Report Completeness Checklist on next page. Title s omcial Inspection Form Subsurface Sewage DN)wal Systern•Pape 16 of 17 tSins•03113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments A V i L j� Property Address Owner Owner's Name Information is required for every page. City/Town State Zip Code Date of Inspection i E. Report Completeness Checklist Inspection Summary:A, B, C, D,or E checked Q� Inspection Summary,D (System Failure Criteria Applicable to All Systems)completed Er System Information - Estimatetl depth to high groundwater lJ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i I I i TNe 5 Official Inspection Form Subsurface Sewage Disposal System•Pape 17 of 17 NEW ENGLAND ENGINEERING SERVICES INC TURIN I OF N rqi H AQOVE-R/ BOARD�F 4 MAR 2 6 2003 L March 24, 2003 North Andover Award of Health Town Hall Annex 27 Charles Street North Andover,MA 01845 RE: TITLE V REPORT: 119 Granville Lane,North Andover,MA Dear Sirs: Enclosed is a copy of the Title V report for the above referenced property. The system PASSED our inspection. If there are any questions please call me at my office,686-1768. Sincerely Benjamin CO. Osg Jr. 60 BEECHWOOD DRIVE-NORTH ANDOVER, MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 e � l COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION Sr TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 11q 6-2AN,j,d(c L rn)E Doan{ AAj z> OyC.a, 1-i#+ Owner's Name: >_¢./yj Ia A g R s m oss C/! Owner's Address: l 1 G C-a A-N 0,1,L(-7, LOtAiC No a 4 Date of Inspection: L y o Name of Inspector:(please print)_Benjamin C. Osgood, Jr. CompanyName:New England Engineering Services Inc. Mailing Address:60 Beechwood Drive, North Andover, ILA 01801845 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 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: V/ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 5j;2 o The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ""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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: i l q G-2(+Iu o f llc I.-.Ansi N o�ynl A-,,)7 n,-)E R Owner: C f2 n1 W t►A- Date of Inspection: 3 i 2`11 a 3 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, 11 pass. Answer yes,no or t determined(Y,N,ND)in the for the following.statements.If"not d ermined"please explain. The septic tank is in and over 20 years old*or the septic tank(whether or not)is structurally unsound,exhibits substantial' tration or exfiltration or tank failure is immin .System will pass inspection if the existing tank is replaced with a plying septic tank as approved by the d of Health. *A metal septic tank will pass in ion if it is structurally sound,not ledking and if a Certificate of Compliance indicating that the tank is less than 20 s old is available. / ND explain: Observation of sewage ba or break orzgh water level in a distribution x due to broken r wag backup t th distr hon bo d o 0 obstructed pipe(s)or due to a broken,settled or un distribution box.System will pass inspection if(with approval of Board of Health): f` brok ipe(s)are r aced obi ction is removed distribution box is level r replaced ND explain: ,X The system r d pumping more than 4 times a year due to bro en or obstructed pipe(s).The system will pass inspection if( approval of the Board of Health): �. broken pipe(s)are replaced obstruction is removed ND explain: 5 ! Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: n Q. G-24AJQj1c LAN6- /Vo dLTI-� AN �ore✓L Nt Owner: 2A 5 n o s s e v Date of Inspection: 3 zy C. Further Evaluation is Required by the Board of Health: Conditions exist which require fiuiher evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. I 1 System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b)that-the f tem is not functioning in a manner which will protect public health,safety and the environment: I or privy is within 50 feet of a surface water f C 1 or privy is within 50 feet of a bordering vegetated wetland or a salt marshy f � 2. .System will fail unless a Board of Health(and Public Water Supp ,if any)determines that the system is functioning in a man er that protects the public health,safety and environment: _ The system has a septic d soil absorption system(SA,S5I and the SAS is within 100 feet of a surface water supply or tributary to surface water supply. _ The system has a septic tank and S and the SAS i within a Zone 1 of a public water supply. _ The system has a septic tank and SAS an thy AS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS ani the AS is less than 100 feet but 50 feet or more from a private water supply well".Method determ' distance "This system passes if the well analysis,per a DEP certified laboratory,for coliform bacteria and volatile organic ounds indicates twe is free from pollution from that facility and the presence of ammonia nitren and nitrate nitrogen is equal t or less than 5 ppm,provided that no other failure criteria are triggere.A copy of the analysis must be attach to this form. 3. Other:/ n i Page 4 of 11 OFFICIAL INSPECTION FORINT—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A j CERTIFICATION(continued) Property Address: jig C -fzjj, o,111 /1/0-(LTJ-( R'i r7 atJc%( ,t,4K Owner: �=tz,►n�.J ussEti Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or`5no"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 V1 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool v Liquid depth in cesspool is less than 6"below invert or available volume is less than%z day flow —�f 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] �,_(YesJNo)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. You must in a either"yes"or`4io"to each of the following: (The following crit apply to large systems in addition to the criteria above) yes no _ the system is within 400 f a surface drinking water supply _ the system is within 200 feet of a tri to a surfa g water supply the system is located in�nitrogi area erim Wellhead Protection Area—IWPA)or a mapped Zone II of a public wat If you have answer.rd"yes o any question in Section E the system i\Wered a significant threat,or answered "yes"in iofi D above the large system has failed.The owner or operator of any large system considered a isgaifi6fit 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. r Page 5 of 11 k OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:_I f It ftA)0 1 iVc dL T R�t�pu�2. 41A Owner: ) (LrZMIAJjq (Z r4srn�SsCN Date of Inspection: 3)z`i 1, Check if the following have been done.You must indicate'yes"or"no"as to each of the following: i 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? -ZHas the system received normal flows in the previous two week period? f Have large volumes of water been introduced to the system recently or as part of this inspection? ZWere 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: Yes no Existing information.For example,a plan at the Board of Health. — -LZ'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)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: of &R oW i, he- L flAJe �ya�2Ti( Anupc„ie2 4,/4 Owner: C f2M t,u 1#+ 12'_' M 05S E"V Date of Inspection: 312 Lj/a-`3 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_ Number of bedrooms(actual):_ DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):_IJ Y© Number of current residents: ? Does residence have a garbage grinder(yes or no): ,i o Is laundry on a separate sewage system(yes or no):No [if yes separate inspection required] Laundry system inspected(yes or no). Seasonal use:(yes or no):,&0 Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):_A/p Last date of occupancy yo - sy t_?._..---..-------- - - -- -- -- ------ ----- -------- ----- - --- .. COMMERCIAIJINDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203). gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):— Industrial waste holding tank present(yes or no):T Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: h gar(L D Was system pumped as part of the inspection(yes or no):,jLV If yes,volume pumped: gallons-How was quantity pumped determined? Reasonfor 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/Altemative technology.Attach a copy of the cement operation and maintenance contract(to be obtained from system owner) _Tight tank —Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: -?%z �2F'?-(Zs Were sewage odors detected when arriving at the site(yes or no): V0 Page 7 of 11 i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: !)R Cs-(z Hn)u+ j,- 1._AN F V O 217-e ,+AJD ouC-2 Owner: C u w I t2-.45=-rnvS5c iv Date of Inspection: 3 Z c3 BUILDING SEWER(locate on site plan) Depth below grade: 36 Materials of construction: cast iron _40 PVC other(explain): Distance from private water supply well or suction line: nes$ Comments(on condition of joints,venting,evidence of leakage,etc.): P t- BCHWT) wflt._t_s , A J C)2:� SEPTIC TANK:—(locate on site plan) Depth below grade:9 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: /67j.>Q G-Aj_c.o,vs Sludge depth. a" Distance from top of sludge to bottom of outlet tee or baffle: 3 6 Scum thickness: y" 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: ` How were dimensions determined: ,14 cA.s ,,z 5-Ilr cc Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7WAIA t,v 6-00P c0D i—o 6,,L/. 5CK Yo Pdc CSS I/,3 6-00-0 La�k��/7t7d1_ krcc',u t"1> 2Ls FRJ 7tz. w c' Y/A.- 6 " OF e'2"W F r1 f/i(. -7 iw/< GREASE TRAPxI440ocate on site plan) Depth below grade:— Material of construction:_concrete_metal_fiberglass_polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): I Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: aq &-a gA1y,(.t >~RNE _Al o 9-ni 4w Do pea- AAA Owner: J�2 i►l I A11;1 2►4s M V-CS 6 t/ Date of Inspection: 3i 2 y%0 3 TIGHT or HOLDING TANK:/v'if(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: Gallons Design Flow: �allons/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: O.. 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.): 60_7c ) PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): � Alarms in working order(yes or no): Lies Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Pomp HA44RE12 IAJ' oEgeq CQ1A' -f7aAv Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: jig "&y v:L t—E L Rnj E yoaT1Y �Ni7r7ue�Il �,4 Owner: �-2 w ti+ (LAS rn�ss L-qtr Date of Inspection: a y 3 3 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: _Teaching fields,number,dimensions: Ci c K f"GL p q ., .5 overflow cesspool,number: innovativetalternative system Typelname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): CESSPOOLS-.AL?4 (cesspool must be pumped as part of inspectionxlocate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): i Page 10 of 11 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: j cj G d2,AN U f LL i L-RNe5- Ivo a.,)-x A--Aj Owner: -2na 2AsY»,jss EN Date of Inspection: Zj -,yj0.3 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. I 7, ( 14 r 1 2-� I i Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Jfrt GfL4n3u c�E L RrvE Owner: r-9M IN119 IM S.i OSSEN Date of Inspection: zy/0 SITE EXAM Slope j Surface water Rea,Z �a2 p S' b-s 1-C N► Check cellar „v,, f,q: '/1, ,..o Shallow wells Estimated depth to ground water fo 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 mast describe how you established the high ground water elevation: P 175 'OewE A e 71113 1 r S D tc -jryz- wrt E-Al S<�s 77e,-.4 s D91 c C19 yMD� Ian c��R7L�2 -� ` t3r�az,. SUsTEM I Commonwealth of Massachusetts North Andover, Massachusetts System Pumping Record RECEIVED System Owner& Address: William and Michelle Phillips 119 Granville Lane TOWN OF NORTH ANDOVER North Andover, MA HEALTH DEPARTMENT Location of system: Front Date of Pumping: February 4, 2010 Type of system: Septic Gallons Pumped: 1500 gallons System pumped by: Service Pumping& Drain Co., Inc. 5 Hallberg Park North Reading, Ma License#: BHP-2010-0359,0373,0374,0375,0376,0377,0378 Contents transferred to: Greater Lawrence Sanitary District Date: February 4 20'{fls � . . Pumping Techncian: .P©`` This is PROPRIETARY and CONFIDENTIAL information that may be used only by the Board of Health for regulatory purposes TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE: 10/05/00 This is to certify that the individual subsurface disposal system constructed () or repaired (X) by Tom Sawyer at 119 Granville Lane has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Board of Health Inspector V I Co monwealth of Massachusetts orth Andover, Massachusetts System Pumping Record System Owner & address: William Phillips 119 Grandville Lane North Andover, MA Location of system: Front yard OCT 0 5 2004 Date of Pumping: September 17,2004 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Type of system: Septic Tank Gallons Pumped: 1500 gallons System pumped by: Service Pumping&Drain Co., Inc. License #: BHP-2004-0004 Contents transferred to: Greater Lawrence Sanitary District Date:September 17,2004 Pumping Technician:PD This is PROPRIETARY and CONFIDENTIAL information that may be used only by the Board of Health for regulatory purposes i i Commonwealth of Massachusetts North Andover,Massachusetts System Pumping Record System Owner& address: Norman & Ermina Rasmussen 119 Granville Lane No. Andover Location of system: Front yard Date of Pumping: September 16, 2002 Type of system: Septic Tank Gallons Pumped: 1500 gallons System pumped by: Service Pumping &Drain Co., Inc. License #: 109-20H Contents transferred to: Lawrence Treatment Plant Date; September 16,2002 Pumping Technician M.W. This is PROPRIETARY and CONFIDENTIAL information that may be used only by the Board of Health for regulatory purposes � t4yo �� ` �. Aug-10-00 10:51A Paul D. Turbide,. PE/PLS 978-465-0313 P.01 Facsimile Cover Sheet To: SANDRA STARR Company: NORTH ANDOVER BOH Phone: 978-688-9540 Fax: 978-688-9542 From: Paul D. Turbide Company: Port Engineering Associates, Inc.. Phone: (978) 465-8594 Fax: (978) 465-0313 Date August 10, 2000 Pages Including This Cover Page: 2 Comments: Sandy, Enclosed is my review of 119 Granville Lane System Upgrade Thanks, Paul Turbide Aug-10-00 10: 51A Paul D. Turbide, PE/PLS 978-465-0313 P.02 August 8,2000 Sandra Starr North Andover Board of Health Administrator Office of Community Development and Services 30 School St. North Andover,MA 01845 RE: Title V review for 119 Granville Lane System Upgrade Dear Sandra, I Enclosed find our review of the"Checklist for North Andover Septic System Plans"for the septic system upgrade at the above-mentioned site. The following is a list of technical deficiencies that Port Engineering has found. u Buoyancy calculations are not provided for either the septic tank or pump chamber, which both appear to be 2 feet into the water table by scale. See 310 CMR 15.221 (8)- v The existing septic tank is not shown on the plan as required be 310 CMR 15.220(4xm). If you have any questions or comments please feel free to contact us. I For fort Engineering Associates, Inc SIT Paul D. Turbide,PElPLS PORTit I �NGINEEGING Civil Engineers& Land Surveyors One Barris Street Newburyport,MA 11»50 (978)465-8594 11 Server KNAMP2884\Granville 119-00Aug08.doc AS-BUILT CHECKLIST LOT NUMBER, STREET NAME ASSESSORS MAP &PARCEL NUMBER LOT LINES &LOCATION OF DWELLINGS LOCATIONS &DIMENSIONS OF SYSTEM, INCLUDING RESERVE TIES TO LOT LINES &DWELLING, WELLS a. FROM SEPTIC TANK b. FROM LEACH AREA LOCATIONS OF DEEP HOLES &PERC TESTS ✓ ELEVATIONS OF DISPOSAL SYSTEM 'f TOP OF FDN ELEVATION LOCATIONS OF WELLS, DRAINS, WATERCOURSES / WITHIN 150' OF SYSTEM y A ELECTRIC LINES CABLE LOCATION OF WATER, GAS, , 1O DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK&D-BOX ORIGINAL STAMP & SIGNATURE V' IMPERVIOUS AREAS - DRIVEWAYS, ETC. NORTH ARROW �/ LOCATION&ELEVATIONS OF BENCHMARK USED Address/l? C.044V W- IV- _ Title of File Page of Date File Open: Date file closed: Doc Document/Action Title Date of Refer to other Purpose of Documernt/Action and notes. action Document/ document/ Num. Action Department Board of Appeals — Board of Health — Planniing Board — Conser�atiion Commission — Building Department i��. ".c -.. .. � `•c�wt'`�,,t``. -?•;:. .;:ate cwt�•rt:•s;:."�:;�::,.�,._ � • }� .SG• n .•'�.. 77 1 t TOIYVN- OF NORTH ANDOVER SEWAG DISPOSAL S).STENI I_,ST:ALLA-TION CERTIFICATION The unser sismed here:v certiiv that the S ewaLc Disposal System i. consu<<ctr�d; recaired V by located at I q 5- Gft.AtJy��r-� HAj N- /SAV Dov t=_iZ_--- was installed in conformance with the ;`1o:tit Andover Board of Ho ith a-fproved plan, Svstem Design Penrit = , dated With an accroved design flow of gallons per day The matera:s used-? were in conformarc–t ,-Ir t those specined on the approved- plan; the system was installed in' accordar:ce %��ith the previsions of 3110 CNIR 15.000, Title 5 and local rezalations, and the final Qradir. adrees substantially with the approved plan. Ail .work ;s accurate:v represented :)c the As-built Adch has been submitted to the'Board c:Health. Bed inspection date: q1 Z a __ �• D ,s.1'/1-_. Engineer R:ares.en:ative y RICHARD Final inspection crate: /0 — C -- TANGARDtree. Represen[at:ve O/Si .off p `.�G Instiiec: ���� �' °��SSD�T L Date: _�! –Z7_•Z01J� Cesium, Engineer: Date: ��IwleC� -- `t t - �4 i i y INSPECTION CHECKLIST FOR SEPTIC SYSTEMS Yes NO Initials A. Bottom of Bed 1. Excavation to proper depth 2. With trenches,sides of excavation are beneath B horizon 3. Edge of excavation specified distance from foundation,etc. Comments: -Fa. B. Retaining Wall 1. Wall height and width as specified 2. Waterproofed 3. Wall minimum 10'to leaching facility 4. Wall meets specifications of plan Comments: C. Building Sewer 1. Pipe diameter minimum 4" 2. Schedule 40 pipe 3. Watertight joints 4. Inlet to tank cemented `1 5. Slope minimum 0.01 or 1/8"per foot minimum 6. Pipe properly set on compact firm base 7. Pipe laid on continuous grade in straight line 8. Cleanouts precede all change in alignment and grade 9. Manholes at any 90°change 10. 10' minimum offset to water line Comments: D. Septic Tank 1. Level 2. 1,500 gal minimum 3. Gas baffle present on outlet >� l ' 4. Manhole to grade 5. Manholes over center and each tee q__1� /2 / 6. 3-20"manholes 7. Inlet tee minimum 12"under invert J� 8. Outlet tee minimum 14"under invert 9. Outlet line cemented 10. Air space 3"above tees 11. 2"-3"drop from inlet to outlet 12. Pipe set ill' 13. Compact base with 6"of 1/4"crushed stone under tank 14. Tank is watertight Comments: a Yes NO E. Pump Chamber 1. If separate from tank,compact base with 6"of 1/4"stone underneath 2. Minimum 2"pipe to d-box if gravity system 3. 20"access manhole t� 4. Tank level t/ 5. Watertight 6. Tank size agrees with plan specification 1/ 7. Manhole to grade l/ 8. Check valve and bleeder hole present 9.. Alarm in building on separate circuit 10. Alarm functions 11. Manual operating switch ✓.� 12. Pump delivers liquid to d-box Comments: F. Distribution Box 1. D-box level 2. Minimum 0.17'(2")drop from inlet to outlet �/� 3. Minimum 6"sump A 4. Outlet pipes show equal distribution ✓ ,�,J 5. Compact base with 6"of stone beneath box 6. Box is watertight 7. All lines cemented with hydraulic cement 8. Schedule 40 pipe Comments: G. Soil Absorption system I. All stone double-washed-'/4"- 1 %2" <�/2 -pea stone �- Bucket test done? 2. Minimum 27of pea stone above distribution lines J/ 3. Minimum 6"stone beneath pipe 4. Distribution lines capped or connected together 5. Grading meets 3:1 slope 6. Minimum of 9"of fill graded over system 7. Toe of slope stops minimum 5' from edge of property; if not,then swale. ��' Comments: H. Leach Trenches 1. Minimum 2 trenches 2. Length of trenches agree with plan. (Max. length 100') 3. Width of trenches agree with plan-Minimum 2';maximum-4'. 4. Vent present if<50 feet or specified 5. Distance between trenches minimum 4' and maximum of 6' 6. Minimum distance between trenches 10' 7. Pipe slope minimum 0.005 or 6"per 100' 8. Depth of trenches below outlet invert minimum of 6". A 4 Yes NO j 9. Pipes set on stable base. Comments: 1. Leach Field 1. Maximum length of field 100' 2. Pipe slope minimum 0.005 or 6"per 100' 3. Separation between pipe 6'maximum 4. Pipes connected at end 5. Separation between adjacent fields 10'minimum /0 6. Pipes set on stable base v� 7. Maximum 4' separation from edge of field to first line 8. Minimum two distribution lines 9. Maximum perc rate 20 mpi Comments: I Leaching Pits 1. Minimum inlet pipe 4" 2. Pits of concrete 3. Sidewall between 12"and 48"wide 4. Access manholes on each pit 5. Pipes cemented with hydraulic cement Comments: K. Final Grade 1. Slope over soil absorption system minimum 0.02 2. All system components covered by at least 9"soil ter' 3. Cover soil free of stones larger than 6" 4. Grading slopes away from dwelling (/ 5. No areas over system that may pond — NORTN Town Of North Andover �= a-�`` � oma William,/. Scott Community Development & Services Director lliam 27 Charles Street (978)688-9531 North Andover, Massachusetts 01845 �ASSNCHUS Fax 978-688-9542 Board of August 22, 2000 Appeals (978)688-9541 Ben Osgood, Jr. Building New England Engineering Department 60 Beechwood Drive (978)688-9545 No. Andover, NIA 01845 Conservation Department Re: 119 Granville Lane (978)688-9530 Health Dear Ben: Department (978)688-9540 This is to inform you that the revised septic system plans dated 08/14/00 for the site referenced above has been approved. Public Health Nurse (978)688-9543 any If Y you havequestions, please do not hesitate to call the Board of Health Office at 978-688-9540. Planning Sincerely, Department (978)688-9535 p,�j Sandra Starr,R.S., C.H.O. Health Director SS/smc cc: Taylor File Aug-22-00 09:47A Paul D. Turbide, PE/PLS 978-465-0313 P.02 August 22, 2000 Sandra Starr North Andover Board of Health Administrator Office of Community Development and Services 30 School St. North Andover, MA 01845 RE. Tide V Review for 119 Granville Lane Revision Dear Sandra, I find that the design plan with a revision date of August 14, 2000 adequately addresses the concerns outlined in my P Su report dated August 8 2000. If you have any questions or comments please feel free to contact us. For Port Engineering Associates, Inc Paul D. Turbide, PE/PLS P011Titi ENGINEERING Civil Engineers& Land Surveyors One Harris Street Newburyport,MA 01950 (978)465-8594 \iserver\pinabh12884\Granvi ll a 119rev.doc Aug-22-00 09:47A Paul D. Turbide, PE/PLS 978-465-0313 P.Ol I Facsimile Cover Sheet To: SANDRA STARR Company: NORTH ANDOVER BOH Phone: 978-688-9540 Fax: 978-688-9542 From: Paul D. Turbide Company: Port Engineering Associates, Inc. Phone: (978) 465-8594 Fax: (978) 465-0313 Date August 22, 2000 Pages Including This Cover Page: 2 Comments: Sandy, Enclosed is my review.of 119 Granville Lane Revision Thanks, PORT Paul Turbide ENGI�EERI�G Civil Engineers& Land Surveyors One Harris Street Newburyport,MA 01950 (978)465-8594 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PE'�tiIIT � i DATE: ..Se:1r-, Q, :2co® CTj=i tT D, tSTALLER'S LICEi`+SE� lig-0 LOCATION: LQ &ro_rJuoile I-0�"ie LICEiZSED D, +STALLER: SIGNATURE: 44 TELEPHONE4 17940S_-5-113 CHECK ONE: REP. : NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOLiYDATION AS-BUILT. Administrative Use Only . ed? Yes v No S75.00 Fe.. Attac`t Foundation As-Buiit? Yes No Floor Plans? Yes No Approval Date: nL �, sr7 FORM 11 - SOIL EVALUATOR FORM Page I of 3 No. Date: Commonwealth of Massachusetts 46;� , Massachusetts Soil SdUAMOLAssessment for On-site &W= Disvosd- Perfomed By: ... ......4 ....... Date: Witnessed BY: ......... .....71 ....................................................................................................... ..... ......... ...... L=Won Addm$Or owws"am tAf Aftw. Tclqkm I FPO New Construction ❑ Repair .Office RevleW Published Soil Survey Available: No ❑ Yes Year Publishedap �/............. Publication Scale �010-�O oi M Unit Drainage Class Limitations ...................... ....................................... Surficial Geologic Report Available: No Q Yes ❑ Year Published Publication Scale GeologicMaterial (Map Unit) ...............................I................................................................................ .......................... Landform .............I.............................I..................I....................................................................................................................... Flood Insurance Rate Map: Above 500 year flood boundary No Elyes El/ Within 500 year flood boundary No 0 Yes Within 100 year flood boundary No 0Yes ❑ Wetland Area: National Wetland Inventory Map (map unit) .............................................................. ....................... . Wetlands Conservancy Program Map(map unit) ............................................................................................ Current Water Resource Conditions(USGS): Month Range :Above Normal ZINormal DBelcwNormal 13 Other References Reviewed: DEP APPROVED FORM-12107195 VUL. a FORM 11 - SOIL EVALUATOR FOUNT Page Z of 3 Location Address or Lot NO. On-site Review A Deep Mole Number Da4. . �lr. Time:� ��i� WeatherCLDy Location (identify on site plan) � �,1 ,,.L�� �...�.,,,.. ,w..�......�...�,.. ...... Land Use Slope (%) Surface Stones :, x..:.. . ...., .... . .... . . Landform Position on landscape (sketch on the back) ... ,"�. ., Distances from: Open Water Body, f Q0eet Drainage way oG feet Possible Wet Arek, ieet Property Line /`r.... feet Drinking Water Well ., N. . feet Other w�... .,..,A.,.,,.,.,- DEEP OBSERVATION HOLE LOG" Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(inches) (USDA) (Munsell) Mottling (Structure,Stones,Boulders,Consistency, % Gravel) J� 75 4-4' VP 4!9- 52:> Y� 3/8 0;- Parent Material{geologic) 77 le- Depthto5odrock. Death to groundwater, Standing Water in the Hole: � ✓� � 4 9 _ � Weeping from Pit Face; N Estimated Seasonal High Ground Water: DEP APPROVED FORM-12!07193 FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. /�� 4�, e, /ud, ,�lijJp� On--,W—e Revie Deep Hole Number .... .,. Date:. . a Time: '� o • ✓7 � ... ... Weather C Z T Location (i tify on site plan) .. .. .:.,,...�........ � , Land Use Slope {%) Surface„Stones Vegetation .. .... .... . ` J.... ww.,,.,.,. x. . Landform - Position -Position on landscape (sketch on the back) Distances from: Open Water Body- 42feet Drainage wa, 45!9� feet Possible Wet Area `4�-'70 feet Property Line 2O feet Drinking Water Well feet Other .. DEEP OBSERVATION HOLE LOG* Depth from Soil Horizon Soil Texture So;l Color Soil Other Surface(Inches) (USDA) (Munsell) Mottling (Structure,Stones,Boulders,Consistency, % Gravel) y,�'`'� , dC� /x'79 Parent Material(geologic) 4� i '" DepthtoSedrock: Depth to Groundwater: Standing Water in the Hole:,�✓" Weeping from Pit Face: W Estimated Seasonal High Ground Water: DEP APPROVED FORM-12/07/95 FORM II - SOIL EVALUATOR FORM Page 3 of 3 Location Address or Lot No. Determination for easonal High Water T_ able Meehod tJsed: ❑ Depth observed standing in observation hole............... . inches ❑ Depth weeping from side of observation h le........... .... inches d Depth to soil mottles —k'"- inches ';0"-j ❑ Ground water adjustment ................... feet Index Well Number .................. Reading Date Index well level Adjustment factor................... Adjusted ground water level ...................................... .. ... Depth of Naturally Qccurring Pervious Material Does at least four feet of naturally occurring pervious materialexist in��II areas observed throughout the area proposed for the soil absorption system? -�� If not, what is the depth of naturally occurring pervious material? Certification I certify that on (date) I have passed the soil evaluator examination approved by the 0epp rtment of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature Z4 �� - Date DRP APPROVED FORM•1210710S NEW ENGLAND ENGINEERING SERVICES INC August 15, 2000 Sandra Starr, Administrator North Andover Health Department Town Hall Annex 27 Charles Street North Andover, MA 01845 Re: 119 Granville Lane,North Andover, Septic system design Dear Sandra: Enclosed are five copies of revised plans for the above referenced property. This plan has the following revisions: 1. The existing septic tank has been shown and labeled. 2. The septic tank detail and pump station detail have had a reference to Addendum 1 added. Addendum 1 is the Buoyancy Calculations for the pump chamber and septic tank. Addendum 1 is enclosed with this letter. If you have any questions please do not hesitate to contact this office. Sincerely, 62 Benjamin C. Osgood r.,EIT President TC'tea �F �az E fa y 1 Aus r 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 NEW ENGLAND ENGINEERING SERVICES INC ADENDUM #1 BUOYANCY CALCULATIONS 119 GRANVILLE LANE, PUMP CHAMBER BOUYANCY CALCULATIONS: WEIGHT OF TANK = 8,000 lbs. WEIGHT OF SOIL OVER TANK = (8.0' x 5.2 x 2.0) x 110 lbs/cu ft= 9,152 lbs. ESHGW ELEV. = 94.11 BOTTOM OF TANK ELEV. = 90.42 WEIGHT OF WATER DISPLACED = (96" x 62" x 45") / 1728 (cu in. — cu ft.) x 62.4 lbs/ cu ft. = 9,672 lbs. TOTAL WEIGHT OF TANK & SOIL = 8,000 + 9,152 = 17,152 lbs. WEIGHT OF WATER DISPLACED = 9,672 lbs. WEIGHT OF TANK & SOIL IS GREATER THAN WEIGHT OF WATER DISPLACED. SEPTIC TANK BUOYANCY CALCULATIONS: WEIGHT OF TANK = 10,680 lbs. WEIGHT OF SOIL OVER TANK = (10.5' x 5.66' x 1.5') x 110 lbs/cu ft= 9,805 lbs. GROUNDWATER ELEV. = 94.11 BOTTOM OF TANK ELEV. = 90.77 WEIGHT OF WATER DISPLACED = (126" x 68" x 41") / 1728 (cu in. — cu ft.) x 62.4 lbs/ cu ft. = 12,685 lbs. TOTAL WEIGHT OF TANK & SOIL = 10,680 + 9,805 = 20,485 lbs. WEIGHT OF WATER DISPLACED = 12,685 lbs. L WEIGHT OF TANK & SOIL IS GREATER THAN WEIGHT OF WATER DISPLACED. SN OFgy � A i iz RIr<,A-n N '\ TANG.' ;D y A FF�S�ONALrENG` � 60 BEECHWOOD DRIVE-NORTH ANDOVER, MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at nra gd jJ(f J at_ relative to the application of 4 iJ%a M dated "Y -' tZ,20ogv for plans by E- Er-k11U'ixpd dated_0jV,2—VW with revisions dated I understand and agree to the following obligations for management of this project: 1. As the installer I am obligated to 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 two shall be applicable . 2. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection,without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against 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 BOH,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. 3. As the installer I understand that persons or companies not associated with my company may not perform the work required by my company 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 in the Town of North Andover plus significant fines to all persons involved. 4. As the Installer I understand that I must be on site during the performance of the following constriction 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. d) installation of tank,D-box,pipes,stone,vent,pump chamber,retaining wall and other components. 5. 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 Lice ed Septic Installer Date: Cry 0- 70o'D 11, fir, 1 fi 1 V�i6 nr7 l } fe/'i�4-e- /5¢?,rt,-. G- �. i+ Town of North Andover, Massachusetts Form No.2 f NORTp BOARD OF HEALTH o•t"S.y + OAC/ o � F w P ty�7k,� • °-"-���--►'++ DESIGN APPROVAL FOR ss"CHUsf` SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM • Applicant G t Test No. : Site Location / Reference Plans and Specs. 511 io 1 6 • ENGINEER OATE Permission is granted for an individual soil absorption sewage disposal syst m to be installed in accordance with regulations of Board of Health. CHAIRMAN,BOARD OF HEALTH i Fee Site System Permit No. / " ti BOARD OF HEALTH TE*,M&9540 ' NORTH ANDOVER, MASS. 01845 TESTS APR 4 �0 APPLICATION FOR SOIL 00 ,,, N' DATE: 'jI �`I I°� LOCATION OF SOIL TESTS: 1\� 1-.✓� ti' r1 ti'De✓erg `' �1 .r Assessor's map & parcel number: OWNER: TEL. NO.: ADDRESS: I lel rw e ]r-►h A•/1 n®v�'�i W, ENGLAND Ei�t�c=t'}�c�n ENGINEER: eVLu ,<-ey =i.•� _ L. NO.: c7Z ? - 6� C�-I � '15? CERTIFIED SOIL EVALUATOR: Intended use of land: residential subdivision, single family home, commercial Repair testing Undeveloped lot testing N. A. Conservation Commission Approval: «� r 5 Q THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) 2. Plot plan 3. Fee of 2� 75.00 per lot for new construction. This covers the minimum 0 two p holes and two percolation tests required for each disposal area. Fee of J_ p repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections: 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. 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). . 7. Within 60 days of testing soil evaluation forms shall be submitted. Town of North Andover, Massachusetts Form No. 1 NORTH ��• BOARD OF HEALTH �.., APPLICATION FOR SITE TESTING/INSPECTION ATED ��SSACHUs���h Applicant N ME ADDRESS TELEPHONE Site Location 1 J Engineer NA9E ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee � Test No. %.-J S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH ; 32O��t`ED OL O p 19 �RAORgrEo PPPy y* APPLICATION FOR SITE TESTING/INSPECTION �SSACHUS�S Applicant - NAME ADDRESS TELEPHONE Site Location ' r Engineer NAME ADDRESS TELEPHONE Test/I nspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. rl BOARD OF HEALTH TEL. 688-9540 NORTH ANDOVER, MASS. 01845 APPLICATION FOR SOIL TESTS DATE: 1-I ►`I�°� 1..� N - AN©o✓e� 1�� LOCATION OF SOIL TESTS: Assessor's map & parcel number:- OWNER: TEL. NO.: ADDRESS: 1 lq Ch i✓�� e 1-v\ N AA. 01- ENGINEER: 1qzu " EL. NO.: CERTIFIED SOIL EVALUATOR: OS9r, �� (zc.I��.Q G Intended use of land: residential subdivision, single family home, commercial Repair testing Undeveloped lot testing N. A. Conservation Commission Approval: THE FOLLOWING MUST,BE INCLUDED WITH THIS FORM: 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) 2. Plot plan 3. Fee of 2� 75.00 per lot for new construction. This covers t Fee he minimum 7$ 5.00 per of for and two percolation tests required for each disposal area repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks) shall be s plan (no smaller than 1ubmitted to 6. Within 45 days of testing, a scaled the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. 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V - c 11 I 1j) in I I 1 QV4Zs © /� 1 �II: II_I E1J\ - •�, "� �' III U , Vic: to Q LL1 <( u) III t"1 -1 ? tl_ I-- II.I LI1 U_-1 U_J UJ UI U.i �; U.I 111 lU LI) Z Z 1- 71- i c i o N.S a/J _ 431q y /i9,q `S V - 1 i K el — Commonwealth of Massachusetts North Andover,Massachusetts RECEIVED System Pumping Record NOV 1 System Owner& address: 6 205 William Phillips TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 119 Granville Lane North Andover,MA Location of system: Front Date of Pumping: October 27, 2005 Type of system: Septic Tank Gallons Pumped: 1500 Gallon(s) System pumped by: Service Pumping&Drain Co., Inc. License #: BHP-2004-0977 Contents transferred to: Greater Lawrence Sanitary District Date tG+ab r 27, o , mpi hrricia ., This is PROPRIETARY and CONFIDENTIAL information that may be used only by the Board of Health for regulatory purposes RECEIVED,, MAY 14 2008 Cha".of ff T WN OF NORTH ANDOVER MA StWn Pumping ftword - F4 Rl .� aer.ids sysm�q t► r A.- idbt�+ct-t+� � A. Far. -OTt� z --- _ I caft Telephone I�r,her soo z. Qntrty Pum : Sege flank rqw To* . UWk*mTsqFftrpMenj7 Yes NO tf xes..was t moaned? Y. -5: icor► m: A. Syftm-PUMPO By 7: Liman where aontmta vmra -- i Commonwealth of Massachusetts North Andover, Massachusetts System Pumping Record System Owner & address: Michelle Phillips RECEIVED 119 Granville Lane North Andover, MA AUG 0 3 2009 TOWN OF NORTH ANDOVER Location of system: Front HEALTH DEPARTMENT Date of Pumping: July 27, 2009 Type of system: Septic Gallons Pumped: 1500 gallons System pumped by: Service Pumping& Drain Co., Inc. 5 Hallberg Park North Reading, MA License#: BHP 2007 0728, 0725, 0727, 0722, 0724, 0726 Contents transferred to: Greater Lawrence Sanitary District Date; July 27, 2009 Pumping Technician: PK This is PROPRIETARY and CONFIDENTIAL information that may be used only by the Board of Health for regulatory purposes