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Miscellaneous - 120 CARLTON LANE 4/30/2018 (2)
120CA 77N 210110 �f 6.0-0097-0000.0 - _ I � ii ' =51 ) I84 91 Acs . l 0 42' II 4S" �LEVAT(0NS FIFE /-,T FouNpA?70N WALL /5520 )ANK WLEr -zs , 5" TANK OUTLET s, ,S� DisT 30x �nILEi- -� /57, IS" C ELT ON LANE DIsr Sox our4Er o, Pl PE AT' 9A/l- 0 T �3ED --� L �n ..;..mom• ,,•< Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 120 Carlton lane Property Address Jan Micklo Owner Owner's Name information is required for North Andover MA 01845 8/8/2016 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information RECEIVED When filling out forms on the AUG computer,use 1. Inspector: 15 2016 only the tab key to move your Neil J. Bateson TOWN OF NORTH ANDOVER cursor-do not Name of InspectorDEPRARTMENT use the return key. Bateson Enterprises Inc. Company Name VS-19 -A 111 Argilla Road Company Address Andover MA 01810 'eQ/D Cityfrown State Zip Code 978-475-4786 S115 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs further Evaluation by the Local Approving Authority 8/8/2016 Inspe or' Signature U 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 120 Carlton lane Property Address Jan Micklo Owner Owner's Name information is required for North Andover MA 01845 8/8/2016 every page. Cityfrown 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: After permit from B.O.H., install new septic tank, new outlet pipe to d-box, new d-box&inspection from B.O.H., septic system now passes Title 5 Inspection 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-3/13 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 120 Carlton Lane Property Address Jan Micklo Owner Owner's Name information is required for North Andover MA 01845 8/8/2016 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately P o . 4� la A4_0 � a - t � t�tr ❑-- a�H t� t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17 r • ���i`�n 1�' • PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division F CERTIFICATE OF COMPLIANCE 4 As of: 8/8/16 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Repair of Tank, D-Box, tank to D-box By: Todd Bateson At: 120 Carlton Lane Map 106.0 Lot 0097 -x (� Nofth Andover, MA 01845 The sua ce of this cerin—) ze s all`not be construed as a guarantee that the system will function satisfactorily. { I .. x Michele Grant Public Health Agent 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 918.688.9540 Fax 918.688.8416 Web www.lownofnorthandover.com • North Andover Health Department (ommunity and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 120 Carlton Lane MAP: 106.0 LOT: 0097 INSTALLER: Todd Bateson DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS Tank, D-Box, pipe from tank to D-box INSPECTION: 8/8/16 DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Contractor reports any changes to design plan Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑/ Cleanouts per plan [� Bottom of tank hole has 6" stone base Weep hole plugged 1500 gallon tank has been installed H-10 loading Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Con men�tU: )tj t r4a 44V�"�L L) S h - c7��� -t� v'enl f PUMP CHAMBER ;I s ,� ��ti �.e.p�i s��- Crx S�I rove ocv�q ❑ Bottom of tank hole h 6" stone base S m a ❑ Weep hole plugged �U- �p-s C� ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading 1 ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Watertightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet I Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX Installed on stable stone base H-20 D-Box Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets Observed even distribution �� Speed levelers provided (not required) 0 Schedule 40 PVC Pipe F `I Comments: • tY Commonwealth of Massachusetts Map-Block-Lot BOARD OF HEALTH Permit No North Andover -BHP-2016-0235------------- --------- FEE $175.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd Bateson - - - - ----------------------------------------------------------------------------------------- to(Repair)an Individual Sewage Disposal System. at No 120 CARLTON LANE -----------_- as shown on the application for Disposal Works Construction Permit No. BHP-2016-02 D July 27,2016 ---------- -d L �' t ------------------------- - Issued On:Jul-27-2016 BOARD OF HEALTH i Application for Septic disposal Systeme F TODAY'S DATE Construction Permit -TOWN OF $250.00-Full Repair NORTH ANDOVER, MA 0185 $125.00-Component Important: Application is hereby made for a permit to: When filling out ❑Construct a new on-site sewage disposal system= forms on the computer,use ❑Repair or replace an existing onsite sewage disposal system* only the tab key pair or replace an existing system component-What? ^�� I)._� �- to move your P£F e F-«_ cursor-do not use the return A. Facility Information key. /dO.. 1A, tsl-MNIFED III Address or Lot# C'tyrrow' V/ 14t TOWN OF NORTH ANDOVER 2.-*TYPE OF SEPTIC SYSTEM*: HEp,�TH DEPA TMENT�C� ➢ ❑ Pump Gravity(choose one) '�F� xV *"If pump syst attach copy of electrical permit to application '�1� ➢ onventional System(pipe and stone system) ➢ ❑Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system.) ➢ Pressure Distribution S.A.S.(No D-Box) ➢ ❑Pressure Dosed(D-Box Present)S.A.S. ➢ ❑Does the system require an effluent filter? Yes Na If yes,does plan specify make and model of filter? YES=(no further info. needed) NO=(installer must specify brand of filter before D WC issuance) 1 WhatistheMake? WhatistheModckj' 2. Owner Information �-$N / ; 1 10 Name Address(if different from above) s- om__ At�� CitylTown State Zip Code ?2?- 6 ,3- Gya'L Telephone Number 3. Installer Information Name _ Name of ComOUTESON ENTERPRISES,INC. /( / At I(� Address L ANDOVER,MA 01810 A-Q Iti/.gy i Yr/o CitylTown State Zip Code C/7V Fl/s—d`Io3 Telephone Number(Cell Phone#►fpossible please) 4. Designer Information Name Name of Company Address CitylTown State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit.Page 1 of 2 UA . AP;plication for Septic D sposalvstem cTODAM DATE Monstruction Permit --'- NOF " ORTH ANDOVER MA 01845 $.z5o,00 T Full Repair ��u5 `' x'1 OO-Compon'ent PAGE 2 OF 2 A. FaeitityInformation continued.... S. T -Pe•of Building: SKeisldentlal,Dwellfng or[]Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system In accordance with the provisions of Title 5 of the . Environmental Code,as well as the Local Subsuifte Disposal Regulations for the Town of North Andover,and hot to place the system In operation untli a Certlflcate of Compliance has been Issued b Is Board of Health. Name We plication App By: (Board of Heath Representative) Namev Date Applil DIsapprovfogy tVeowing real ns:' r For Office.Use Only: 1 .'FeeAttached?: Yes V No 2.- Protect Manager Obligation Form Atta d.� Yes_ No ' 3.: Pum,pSvstem? Ifso) b f 1 rt'. �'es_ No 4. Foundation As Built?(hew construction ronly), es_ No (Same scale as spproyed plan) 5. FloorPlans?thew construction only). No Applfc tion{or•p(sposal 4ystem-:c6n*ucaori Permft pace 2 if SEMCSY$TMi-DTA'W- AM'MP=i4diT11, r:PBLiGb'TIt3M As @ic•NqAAu&Ym liomcd3tisailles��e�at3ut:lic�'f6t•theaeptYc eyrttr�pa fc�r thaprraprrty� otupdc ) { •FAQs Om b9 C Aed dated Dsted '9 �lt t With MvIdD u dated • . . revtacd � I uadetQtttad the fono ing oblfgatiow fot mmugement of Shia pr4eco 1. As the fastaUer,I wn.obsligaW iv obWa sOpenwib snd•Boud of =kh nppsoved plaaaot to �pet6oaufag aap:aa�c a�a a site:. Z. At f}►e ;I t. It ani►optRsdbs : IEho ooansca �ojece or,uQ o*apwoft twtisWI&my any •aa bgmd� tt and the apataa is no of Y ftp detect atLh tic�tble. � ' • x tp 9 xo theaP io�a ntit ,' - r• J—�;" ,t*il .I" p - Olkharc is ar`rctg1,ych ahba betaecdostea•ntat have to b4preset , ' -� t �a•tiztep�anfarnaf.�,et+�. .. • o va+t OR'(os amyl txr tha engineer must ba t ibh9tfcd•to aha-8oard"ofHeabib a #: €vs ii 3issprecifpn.dme, Iasmlter itiust baptat b f+er t ,inape at, orb qtr. ! deet tt at be a able m • . ' •eawdp�p•tb�ka�d. .tao .. •�' •' : . . -.. ,' •_ C. phud, , ft*pee amat rats `iaapectioa�vhe 'i 11 d S ecunplttc: IustA]Ier does not . •-have#o beo�te.. :, .. .� . , -: :. 4. As•tlte fastallm-I undid that Daly ay p e l c�otlra't aa►s ),fnci 1 i mired m aotgptete tlig of the syatcgii #titatedspplttlaa: , Hugh Ang6m- ft faorddcid1�f tht—,Xsadl XA A. wall 5.. eioadltet;�I imdent�ad I mai%e•a ffit parommce of Ae fa"caost oa. a Deatfamt tbat.�p�perrl��a c�f�e e�te�,at�ar,l�•bcro t+arcbed- . . - fa &PPeeitmafftb amaimgla4aerokwed a •FiIIs1.taapeeo'ara6p8o�fat.�TeAltfrerl�tircaasunAa�� - . • . - d Iia�l t d 't ank,D-- egg p r,�tQar,sroat pfimpobdib& rdalb*Wafmd oilier . tS. Aa tlt i p t # ,:for$r_ t�lt�den-�f the s'atem y.r�+!�,r s ' . ����� �A tw�nTMi��f�s� �[wr �._•n_.�t.__sttn�•Qt'triV ef, t��!- �_ bd� • t1SC0�3Mf�i�'IOfL "'� . _ - ■w�` �� - 1 Unded£�t�ued Sapdt:.I� - . .•(fo$ I�te�:, ����-�G Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments RECEIVED 120 Carlton Lane Property Address INib Jan Micklo Owner Owners Name TOWN OF "I rl ANI.Jv I information is requiredAndover MA 01845 7/8&4W DEPARTM ki-W required for every page. Cityfrown State Zip Code Date of Inspectio Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Neil J. Bateson use the return Name of Inspector key. Bateson Enterprises Inc. >a5 Company Name 111 Argilla Road Company Address Andover MA 01810 City/Town State Zip Code 978-475-4786 S 1 15 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ eels Further Evaluation by the Local Approving Authority 7/8/2016 Inspector's Signat 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•3113 -Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 1 Commonwealth of Massachusetts . - - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 120 Carlton Lane Property Address Jan Micklo Owner Owner's Name information is required for every North Andover MA 01.845 7/8/2016 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ® Y ❑ N ❑ ND(Explain below): Tank leaking out, needs to be replaced. t5ins•3113 Title 5 Ofriclal 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 120 Carlton Lane Property Address Jan Micklo Owner Owner's Name information is required for every North Andover MA 01845 7/8/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ 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-3113 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 120 Carlton Lane Property Address Jan Micklo Owner Owner's Name information is North Andover MA 01845 7/8/2016 required for every page. Cq 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: i **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: Septic tank, outlet pipe to d-box&d-box needs o be replaced. i i 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 1/2 day flow t5ins-3113 Tide 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 120 Carlton Lane Property Address Jan Micklo Owner Owner's Name information is required for every North Andover MA 01845 7/8/2016 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. [Phis 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•3113 Tile 5 Oficial Inspection Form:Subsurface Sewage Dlsposel System•Page 5 of 17 Commonwealth of Massachusetts .ta Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 120 Carlton Lane Property Address Jan Micklo Owner owner's Name information is required for every North Andover MA 01845 7/8/2016 page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health j ❑ ® 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? ® El available 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 ® F-1 information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 600 t5ins-3113 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 120 Carlton Lane Property Address Jan Micklo Owner owner's Name information is required for every North Andover MA 01845 7/8/2016 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Yes 9 ( Y 9 (9p ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 120 Carlton Lane Property Address Jan Micklo Owner Owner's Name information is required for every North Andover MA . 01845 7/8/2016 page. C4rrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped 2014, owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Titie 5 Official Inspection Fomr.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 " 120 Carlton Lane Property Address Jan Micklo Owner Owner's Name information is required for every North Andover MA 01845 7/8/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 32 year old, 11/20/1984, final inspection from B.O.H. No date on as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ®cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4"Cast Iron through wall, 3"PVC in house, no leaks visible I Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: I ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) i If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10' x 5'x4' Sludge depth: 2 }Sins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 N Commonwealth of Massachusetts Title 5 Official Inspection Form fAr Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Y 120 Carlton Lane Property Address Jan Micklo Owner Owner's Name information is required for every North Andover MA 01845 7/8/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle N/A Scum thickness 1" Distance from top of scum to top of outlet tee or baffle N/A=tank leaking Distance from bottom of scum to bottom of outlet tee or baffle N/A How were dimensions determined? Tape measure 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 half full of liquid, evidence of leaking , needs to be replaced. Outlet pipe to d-box broken in many locations, needs to be replace to d-box. i Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete El metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle i Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form'Subsurface Sewage Disposal System•Page 10 of 17 C4 Commonwealth of Massachusetts - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 120 Carlton Lane Property Address Jan Micklo Owner Owner's Name information is required for every North Andover MA 01845 7/8/2016 page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): " Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal P 9 poral System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w r 120 Carlton Lane Property Address Jan Micklo _ Owner Owner's Name information is required for every North Andover MA 01845 7/8/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 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 badly corroded needs to be replaced. Evidence of leakage, has corrosion holes. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts • A MO . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 120 Carlton Lane Property Address Jan Micklo Owner owner's Name information is required for every North Andover MA 01845 7/8/2016 page. City/Town State Zip Code Date of Inspection D. System Information(cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 field 30'x45' ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 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 120 Carlton Lane Property Address Jan Micklo Owner Owner's Name information is required for every North Andover MA 01845 7/8/2016 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.): i 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 120 Carlton Lane Property Address Jan Micklo Owner Owner's Name information is required for every North Andover MA 01845 7/8/2016 page. Citylrown 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 g O D-2 Y- a =t3 � �h D G,, a t5ins•3113 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 " 120 Carlton Lane Property Address Jan Micklo Owner Owner's Name information is required for every North Andover MA 01845 7/8/2016 page. C4fTown 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: >4 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date 981 Date ❑ Observed site(abutting propertylobservation hole within 150 feet of SAS) ® Checked with local Board of Health explain: Design plan ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Test pit data on design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 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 r 120 Carlton Lane Property Address Jan Micklo Owner Owner's Name information is required for every North Andover MA 01845 7/8/2016 page. Chy/Town State Zip Code Date of Inspection E. Report Completeness Checklist i 0 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 t5in3•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Summary Record Card generated on 6/20/2016 11:59:51 AM by Karen Hanlon Page 1 Town of North Andover Tax Map # 210-106.C-0097-0000.0 Parcel Id 17732 120 CARLTON LANE MICKLO, GREGORY&JAN 120 CARLTON LANE N. ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.18 Acres FY 2016 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until MICKLO,GREGORY&JAN Payor 120 CARLTON LANE N.ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 14198.0-120 CARLTON LANE Last Billing Date 6/14/2016 2100190 02 Cycle 02 Active UB Services Maint. Account No.2100190 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 45.60 /1 UB Meter Maintenance Account No.2100190 Serial No Status Location Brand Type Size YTD Cons 13242558 a Active ERT HH METE METE w Water 0.63 0.63 871 Date Reading Code Consumption Posted Date Variance 514/2016 1387 aActual 12 6/21/2016 9% 2/2/2016 1375 a Actual 11 3/28/2016 -51% 11/2/2015 1364 aActual 22 12/30/2015 -14% 8/4/2015 1342 a Actual 26 9/14/2015 11% 5/4/2015 1316 a Actual 23 6/22/2015 -13% 213!2015 1293 a Actual 27 3/20/2015 10% 1113/2014 1266 a Actual 25 12/15/2014 6% 8/1!2014 1241 a Actual 22 911112014 -2% 5/5/2014 1219 a Actual 23 6/12/2014 -15% 2/4/2014 1196 a Actual 29 3117/2014 10% 10/31/2013 1167 aActual 25 12/20/2013 1% 8/1/2013 1142 a Actual 25 9/1812013 -13% 5/1/2013 1117 aActual 26 6/18/2013 -8% 2/7/2013 1091 a Actual 34 3/13/2013 -2% 10/30/2012 1057 a Actual 31 12/13/2012 0% 8/2/2012 1026 a Actual 32 9/26/2012 8% 5/212012 994 a Actual 29 6/20/2012 -3% 2/2/2012 965 a Actual 31 3/14/2012 5% 11/1/2011 934 aActual 29 12/15/2011 -8% 8/2/2011 905 a Actual 32 9/14/2011 4% 5/212011 873 a Actual 29 6/13/2011 9% 2/4/2011 844 a Actual 29 3/15/2011 -5% 11/1/2010 815 aActual 29 12/13/2010 -10% 8/3/2010 786 a Actual 33 9/13/2010 17% 5/3/2010 753 a Actual 28 6/9/2010 -18% 2/1/2010 725 a Actual 34 3/11/2010 6% 11/2/2009 691 aActual 32 12/11/2009 11% 8/3/2009 659 a Actual 28 9/1112009 23% 5/7/2009 631 a Actual 24 6/16/2009 -12% boa2'Q 01 nealui SEPTIC SISTEK North AndDYeT'iH£►DD• /'C/I_"Ml �INSTA?�•ATICK CHBC$ LIST LOT`. (�cl —P M DATE DISA.PPROM AVATIC�I OK FAIL SIL OK = ---- -— f' 1. Distance Tot `,w a. Wetlands b. Drains c.. Well 2. Water Line Location 3• , No PVC Pipe 4. Septic Tank a. _Tees -_Length & To Clean Oat Covers. b. Cement Pipe to Tank Ca Both Sides of Tank 'S. Distribution Box a. Covers .& Box - No Cracks b. All Lines Flo Amg Equal Amounts c. No Back Floe 6. Leach Field or Trench a. Dimensions b. Stone Depth c. Capped Lids d. Clean Double Washed Stone 7. Leach Pits a. Dimensions b. Stone Depth c. Splash Pads d. Tees e. Cement Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. No Garbage Disposal 9. Final Grafi Inspection 10. Barricading ,Covered System - L 11. As Built Submitted �J-1sL a. Lot Location b. Dimensions of System c. Location with Regard_to Pere Test d. Elevations e: Water Table r 30� g�� d 02 AA1 I,CY'th ^L�rcr, �ss 7-1 i - •, �d ij� SURFACE DIEPO , DMIGN CHM ST LOT l' APPROVED HATE DISAPPROVED DATE _. Provid?d: __._.___... Reasons: R - Tf tle Reg �.5 The submitted plan must show as a minimum: a) the lot to be served-area,dimensions lot #,abutters b location and log deep observation hoes-distance to ties location and results percolation tests-distance to ties design calculations & calculations showing required leaching area location and dimensions of system-including neserve area Ll existing and proposed contours j g) location any rat areas vAthin 1001 of sewage disposal system or t disclaimer-check wetlands mapping h) surface and subsurface drains within 200' of sewage disposal system or disclaimer i) location any drainage easements within 1001 of sevmge disposal system or disclalrer-Planning Board files Q) knom sources of tster supply within 2001 of sewage disposal system or disclaimer W location of aw proposed well to serve lot-1001 from leaching facility (1) location of water lines on property-101 from leaching facility m) location of benchmark u) driveways garbage disposals i (p) no PVC to be used in construction 1 L,.-"(q) profile of system-elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and 0tler elevations _ v ) maxim= ground nater elevation in area sewage disposal system (s) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Reg 6 / 5 tic Tanks # (a) capac t es- 5O% of flow, water table, tees, depth of tees, faccess., pumping h)' cleanout c) 10t from cellar wall or inground swimming pool ? 9((d) 251 from subsurface drains Reg 10.2 Distribution Boxes a) s ope greater ME 0.08 Reg 10.4 8b) sump Submyfacer Dosign. Check List PaF:e 2 FAIL 0K Leaching Pits Leaching pits are preferred where the installation is possible Reg 11.2 a) calculations-of leaching area-ad nirmum 500 sq ft 11.4 b) spacing; 11.10 csurface drainage lid 11.11 Idj 'cov6r material e) A x21x41" splash pad tee at elbow g) no bends in pipe from d-lox to pipe Leac Fields Reg 15.1 a) no greater than 20 minutes/inch area-minimum 900 sq ft 15.4 construction of field 15.8 surface drainage 2 % 3.7 e) 20t from cellar wall or inground emimm ng pool Leaching Tneack6s -- Reg 14.1 a) c of-Teaching area-min 500 sq ft 14.3 b) spacin ft min 6 ft with reserve between 14.4 c) one 14.6 d) c traction 14.7 e) e 14.10 f) surface drainage 2% Dovnh� Sl e Pa) s o /Y x =�to be shown) b) /0,/ 150 (to be shown) Reg 9.1 a) *sd-by 9.6 b) power " tv. it Address �D 4::-' 4 Title of File Page of Date File Open: nate ffle closed: [D oc Document/Action Title Date of Refer to other Purpose of Document/Action and notes; action Document/ document/ — fdum. Action -Department Board of Appeals — Board of Health Planning Board _ Conserv�atiion Commission — Building Departmertr fi Conubonwealth of Massachusetts Massachusetts System Pumping Record System Owner System Location �© 1 ,)CD G" Lam. Date of Pumping: �-r ��� �✓ Quantity Pumped: j,5 gallons Cesspool: Not Yes Septic Tank: No Yes System Pumped by: Fettedert License# Contents transrerrred to : Greater Lawrence Sanitary District Date: Inspector AIS 6 t'�mit.�ui� �nfil�of M�esaacbu8e1t8 f, `�;Massucl�usetl� necord SYRICIIi(hvnd— ---- _ Syetelo Lucnllutl C ^ALJ nlio��e Date of 111111111111g: B ettd1• IJ Yeb Cemspo d: Nu ik SysleW himped by: Vdemort Kt`¢ lead N.iCC118d - L"ut�leuts t�n�isfe�tted (u : gre�ler LbHr�ntid getuiti�ry ltlslri� i TOWN OF o SYSTEM' PUMPING RECORD DATE: " ��" SYSTEM OWNER&ADDRESS SYSTEM LOCATION n� I (example:left front of house) �-o (0'(�- Ly\ DATE OF PUMPING: Q QUANTITY PUMPED : I c,�d C7 GALLONS CESSPOOL: NO YES PTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: r CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste