HomeMy WebLinkAboutMiscellaneous - 120 GRAY STREET 4/30/2018 (2) 120 GRAY STREET
J 210/107.D-0120-0000.0
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MAP # /07P LOT #
PARCEL # STREET-- - . .._._._.._....._..._.__........
CQNSTRU.CTI.QN_APPRQVAL
HAS PLAN REVIEW FEE BEEN PAID? YES NO
PLAN APPROVAL: DATE jlleAPP. BY.___ _
DESIGNER: J�� �� 5 PLAN DATE.
CONDITIONS
WATER SUPPLY: TOWN WELL
WELLERMIT _ DRILLER._...___._._.__._._...._.._.._.._.__..._........... ..._...._.._.. .._......__.....
WELL TEST CHEMICAL DALE APPRUVED
BACTERIA I DA I E (IPPRUVED _....,,.
CTERIA II DATE APPRUVED._._._..____.._.___,__..__
COMMENTS:
FORM U APPROVAL': APPROVAL TO ISSUE YES NO
DATE ISSUED ll0 ___BY .__._.__._.__.. ._........_.
CONDITIONS:
FINAL APPROVAL:
ALL PERMITS PAID YES NO
WELL CONSTRUCTION APPROVAL YES NU
SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO
OTHER YES NO
ANY VARIANCE NEEDED YES / NU
FINAL BOARD OF HEALTH APPROVAL: DA TE:.,. ..,. `1:�,.,,BY:
'.a X r-•\,.•i � 1. f _ .h:,..a} •• .. ' e bf� #, \ 1 .e�C. 1 ,1�,. � ... -. F„
�+Qn, IS THE INSTALLER LICENSED? YES NO
CNTYPE OFCONSTRUCTION: W REPAIR
z NEW CONSTRUCTION: CERTIFIED PLOT PLAN ,REVIEW• YE NO
� x CONDITIONS OF..APPROVAL " YES NO
t
f,t '; Y + ` (FROM FORM U)
r r' ISSUANCE OF DWC PERMIT YES NO
DWC PERMIT N0. t ,INSTALLER:
BEGIN INSPECTION OES0:
.EXCAVATION . INSPECTION: : NEEDED:
PASSED / BY
CONSTRUCTION INSPECTIONS NEEDED:
AS BUILT PLAN SATISFACTORY:
+0 BACKFILL. DATE. /�S BY _-c
APPROVAL. T /J
>.FINAL . GRADING APPROVAL: DATE �� 9 BY
OVAL: DATE:/ X `�(� BY
.FINAL CONSTRUCTION APPR _
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Form No.4 {
Town of North Andover, Massachusetts
BOARD OF HEALTH
November 8 . 19 96
CERTIFICATE OF COMPLIANCE
This is to certify that "
the Individual Soil Absorption Sewage Disposal System constructed (X ) or repaired ( )
by Brian McKee a
INSTALLER
atree North Andover MA 01845
SITE LOCATION
has been installed in accordance with Board of Health Regulations as described in the Design
Approval Site System Permit No.122
dated May 25 . 19_25
S
The issuance of this certificate shall not be construed as a guarantee that the system will
function satisfactorily.
BOARD OF HEALTH
Town of North Andover, Massachusetts Form N°.2
NORrh BOARD OF HEALTH
•
o 3?'�' ' °° 19�_
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DESIGN APPROVAL FOR
SwCMUs t�
SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant ,Test No.
: Site Location
Reference Plans and Specs. a' • ��
ENGINEER DESIGN DATE
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
CHAIRMAN,BOARD OF HEALTH
v ,
: Fee _ Site System Permit No. 7
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APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
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DATE: CURRENT INSTALLER'S LICENSE#
LOCATION: #3 G 5 T
LICENSED INSTALLER: RI-1,401 Mcxe e
SIGNATURE: G TELEPHONE# 617 -
CHECK ONE:
REPAIR: NEW CONSTRUCTION:
IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT.
I
Administrative Use Only
$75.00 Fee Attached? Yes No
Foundation As-Built? Yes No /
Approval Date: ��h 7
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Town of North Andover, Massachusetts Form No.3
BOARD OF HEALTH
40RTH
Atio LA,D t 19—L—
O 9
IL
DISPOSAL WORKS CONSTRUCTION PERMIT
• ,SSACHUS*'
Applicant ��
NAME ADDRESS TELEPHONE
Site Location�4����nrr—.�'
: Permission is hereby granted to Construct ("or Repair ( ) an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No,
I
CHAIRMAN, BOARD OF HEALTH
Fee .�j , ) D.W.C. No. y
- ... ._. 4
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.,. - E ,1.•: ;
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Member (508) 682-1619
� PON 4
FAX: (508) 682-1083
R � ■
41Munwsva+ A
Donald F Johnston&Co.,Inc.
Builder&Contractor
114 Boston Street Don Johnston G.B.I.
No.Andover.MA 01845 p—;,—t
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BOSTON STREET CERTIFIED PLOT PLAN
(PUBLIC - WIDTH VARIES) LOCATED IN
S 3316'19"w 84.64' NORTH ANDOVER, MA.
SCALE:1"= 40' DATE: 7/25/96
SEPTIC 10/8/96
Scott L. Giles R.P.L.S.
50 Deer Meadow Road
�o North Andover, Mass.
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LOT 3 LOT 1
46,079 S.F.
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ExISI7,jjS38CN '
kn
CA
T o E FND
42' Lir '215.32
LOT41
LOT 2
N 10/8/96
TABLE OF ELEVATIONS
z OUT OF HSE.=212.02
IN TANK =211.33
OUT TANK =211.09
IN BOX =210.74
OUT BOX =210.63
o #1 END =209.91.
INV'N .s 2 B #2 END =209.92
G
15 -071 07,,W,T
10/8/96 S?' �r�
I HEREBY CERTIFY THAT I HAVE INSPECTED THE `" 7'
CONSTRUCTION OF THIS DISPOSAL SYSTEM AND
THAT THE CONSTRUCTION AND THE FINAL GRADING
HAS BEEN IN ACCORDANCE WITH THE DESIGNERS
INTENT AND THAT THE MATERIALS USED CONFORM
TO THE PLAN SPECIFICATIONS AND 310 CMR 15.00.
1 CERTIFY THAT OFFSETS SHOWN ARE FOR THE USE or
THE OFFSETS OF THE BUILDING INSPECTOR ONLY
SHOWN COMPLY AND SUCH USE IS FOR THE
WITH THE ZONINC. DETERMINATION OF ZONING
BY LAWS OF CONFORMITY OR NON-CONFORMITY 139
NORTH ANDOVER,MA. WHEN CONSTRUCTED.
WHEN BUILT. <«NO
7/26/96
10/8/96
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4. ti•� r
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_ NORT-
Town of dover
No. f
=4�
dover, Mass.,
COCHICHEWICK
A0RATED
BOARD OF HEALTH
FoodPERMIT
Septic System 6 �/
BUILDING INSPECTOR
THIS CERTIFIES THAT..................... ....�L............... ... .... . .. .... . ............ .................................... .................. Fo tion
.
has permission to erect......... . ........ buildin s on ........ .....
to be occupied as............... . ...eeCodes
........... .. ...... .................. ................................................................................ Chimney
provided that the person accepting it shall in every respect onform to the terms of the application on file in Final
this office, and to the provisions of and By-Laws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. 0dl°'
PERMIT EXPIRES IN 6 MONTHS Final
UNLESS CONSTRUCTIONS ARTS ELECTRICAL
/ SPEC OR
0
�........................... .................. ... .. .. . .... ......................................
ING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Display in a Conspicuous Place on the Premises — Do Not Remove Rough
Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector.
Burner
Street No.
Smoke Det.
FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: _/�a,�.9G� F dd ,�jfi�/ Phone
LOCATION: Assessor' s Map Number Parcel
Subdivision Lot(s)
i
Street �/�v,°S/ S'� �� St. Number iZO
************************Official Use Only************************
RECOMMENDATION OFITOWX AGENTS:
lf/
Date Approved
Conservation A,dpinis r/ator Date Rejected
/V7 P/� /, G' S`
Comments �n i vt.� 1�� G� ��
�) c r u,� Date Approved �2;2�
Town Planner Date Rejected
Comments /U c(s( d_),�,
i
Date Approved
Food Inspector-Health Date Rejected
i
_�,. C[ Date Approved
Septic Inspector-Health Date Rejected
Comments
Public Works - sewer/water connections
- driveway permitTTL-0 �q-2-5 �1
Fire Depar ment ��'�L oa ou e
tjrti/
Received by Buildin Inspector - Date
I
_ _ ___
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BOSTON STREET CERTIFIED PLOT PLAN
(PUBLIC - WIDTH VARIES)
� LOCATED IN
S 33016'19"W 84.64' NORTH ANDOVER, MA.
8CALE:lit= 40' DATE: 7/25/96
Scott L. Giles R.P.L.S.
50 Deer Meadow Road
opo North Andover, Mass.
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LOT 1
LOT 3
46,079 S.F.
AXI D o "°
SIT SSE FN
TDW
LOT 4 '
---- -- ,215.32
3 LOT 2
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G
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44 71S2,(pup ,
LIC _ S1,
Is8.07,
N v4pu8s)
I HEREBY CERTIFY THAT THE FOUNDATION
CONFORMS TO THE ZONING REGULATIONS
(DIMENSIONAL SETBACK REQUIREMENTS)
FOR THE TOWN OF NORTH ANDOVER, MA.
I CERTIFY THAT OFFSETS SHOWN ARE FOR THE USE �� 1K
THE OFFSETS OF THE BUILDING INSPECTOR ONLY
SHOWN COMPLY AND SUCH USE IS FOR THE
WITH THE ZONINC DETERMINATION OF ZONING $ •139M `
BY LAWS OF CONFORMITY OR NON-CONFORMITY �i�EC�sn"'
NORTH ANDOVER,MA. i LAMO
WHEN CONSTRUCTED.
WHEN BUILT. 7/26/96
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care
rW: R/
Bn%-.,.Q-..ITON STREET '
H��
84 .64 NOV - 61995.
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40$A
LOT 3 }
W 46,O79S, . 04 }
11111204.
204 — 06 I
- 8
Of 4 > 10
20
PR 7'0W 2/4Q
2 BUDDOSED 12
ANG
Al
214r \ _ _ •T 214 ADDITIONAL TEST PIT TO BE DUG
pTi AT TIME OF CONSTRUCTION.
216 -SE07174VV"o A 16
S VENTED
IP TOP AND SUB lO
EDGE RD. -- 1 �S8 Z ALL AROUND SYSTEM.
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BOARD OF HEALTH
41
9 120 MAIN STREET TEL. 682-6483
�9SSAcHusEt�y NORTH ANDOVER, MASS. 01845 Ext23
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July 6, 1995
Mr. Scott Giles
50 Deer Meadow Road
North Andover, MA 01845
Re: Lot #3 Gray Street
Dear Scott:
This is to inform you that the proposed plans for site
referenced above have been disapproved for the following reasons:
1) Soil tests not in system.
2) No P.E./R.S. stamp.
3) No water line.
4) No foundation drain outlet elevation.
1 5) No manhole to grade.
6) Tank requires three 20 inch manholes and gas
baffle.
7) Insufficient leach area.
8) Lines must be connected & vented.
If you have any questions, please do not hesitate to call the
Board of Health Office at the number above.
Sincerely,
Sandra Starr, R.S.
Health Administrator
SS/cjp
Town of North Andover, Massachusetts Form No. 1
NORTH A BOARD OF HEALTH
3�O�St`ED 6�'YOL ,
19
O a' io o,'v .. A
* °� ,TED Ew° 4LDRATEAPPLICATION FOR SITE TESTING/INSPECTION
PPp���J
1
.S'S
Applicant t �"
NAME ADDRESS TELEPHONE
Site Location " a
r"
Engineer
NAME ADDRESS TELEPHONE
Test/Inspection Date and Time
CHAIRMAN,BOARD OF HEALTH
Fee Test No.
S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No.
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PLAN REVIEW CHECKLIST
ADDRESS.�jT�3 (Ag �l �T ENGINEER
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GENERAL
3 COPIES STAMPX LOCUS (/ NORTH ARROW SCALE
CONTOURS PROFILE SECTION BENCHMARK SOIL &
PERCS ELEVATIONS WETS. DISCLAIMER �- � WELLS & WETS
WATERSHED?A DRIVEWAY ✓(Elev) WATER LINE , FDN DRAIN
_k
SCH40 (/ TESTS CURRENT? SOIL EVAL
SEPTIC TANK /
MIN 1500E C/' . 17 INVERT DROP // GARB. GRINDER(+200* EDF)
25 ' TO CELLAR (/ MANHOLE ELEV GW # COMPS.
D-BOX
SIZE # LINES FIRST 2 ' LEVEL STATEMENT
INLET /D -J - OUTLET L7-/ _ (2" OR . 17 FT) TEE REQ'D?AJD
(/LEACHING /
MIN 660 GPD? RESERVE AREAy 4 ' FROM PRIMARY? 6�- � 2% SLOPE
100 ' TO WETLANDS/ 100 ' TO WELLS 4 ' TO S.H.GW L—'- (5'>2M/IN)
35 ' TO FND & INTRCPTR DRAINS �� 325 ' TO SURFACE H2O SUPP `
4 ' PERM. SOIL BELOW FACILITY C/ MIN 12" COVER FILL? (25'
if above natural elev; 101if below) BREAKOUT MET?
TRENCHES ,
t� MIN 660 gpd/ SLOPE (min . 005 or 611/1001 ) SIDEWALL DIST. 3X EFF.
W OR D (MIN 6 ' ) RESERVE BETWEEN TRENCHES? 4----IN FILL? MUST
BE 10 ' MIN.L---'4" PEA STONE? VENT? (>3 ' COVER; LINES >501 )
BOT 3Zqj � + SIDE a 6 X LDNG TOT ajjO 46,!V
(L x W x #) (DxLx2x#) (G/ft2)
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Copyright 0 1995 by S.L.Starr 7627
DATE-7, 1iSheet of
BOARD OF HEALTH
TOWN OF NORTH ANDOVER
SUBSURFACE DISPOSAL DESIGN REVIEW
PERMITfY �
# �� �1 DATE RECEIVED
APPLICANT iV �JO lllJcSrON ASSESSOR'S MAP 7b
ADDRESS', PARCEL #
LOT # 8
ENGINEER 51f 0 A-61--CO STREET
ADDRESS '
PLAN DATE 6-1116 k5— REVISION DATE
CONDITIONS OF APPROVAL:
APPROVED
DISAPPROVED
7�vT� k0l— /A-)
ti0 LeJ/9TEz L .UC
4. itJO -�rdUIUD)97-/b")
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NEW ENGLAND ENGINEERING SERVICES
INC
RECEIVED
FEB 0 2 2005
TOWN - : . Ai\jDOVER
HEALTH DEPARTMENT
January 31,2005
North Andover Board of Health
Town Hall Annex
27 Charles Street
North Andover,MA 01845
RE: TITLE V REPORT: 120 Gray Street,North Andover, MA
Dear Sir or Madam:
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
Benja in C. Osg d,Jr., P.E.
Certified Title 5 inspector
60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: ►2-0 CLAN -s YLee i
Av(L Pi 14N i.>DJ P!L
Owner's Name: AN c� �� ,220 �- RECEIVED
Owner's Address: i Ao &p AR j s— C�^i
A!011 ?f R v P o,)f/L *v/1
Date of Inspections FEB 0. 2 2005
iName of Inspector.(pleaseprint) Benjamin
C. Osgood. Jr. TOWN OF NORTH ANDOVER
CompanyName:New England Engineering Services Inc. HEALTH DEPARTMENT
hURing Address:60 Beechwood Drive
North Andov , MA 0]845
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'
mspedion,The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.lam a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
1/ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: r- 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.
i
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,
I
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
! PART A
CERTIFICATION (confmued
Property Address: c2 o G-2 A�3 5y2 e7l�i
-A/Q 2TK Vr/J p oue/','
Owner. LV A t,)c!�, CL}22d l-L
Date of Inspection:
i
Inspection Summary: Check A B C D or E/ALWAYS complete all of Section D
A. System Passes:
S I have not found any information which indicates that any of the facture criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
IL System Conditionally Passes:
One or more system components as desar'bed in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the-Board of Health,will pass.
Answer yes,no or not determined(Y N M)in the for the following statements.If`knot determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is struct=Uy
unsound,exhn'bits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
-coasting tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipes)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstncted pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
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Page 3.of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 12o C iZ A- s i 2e e
Owner: 10 AA)c rl1-22�tee.
Date of Inspection: J
C. Further Evaluation is Required by the Board of Health:
Conditions Odst which require fiuther 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
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2.
Slistem 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 suppler.
i
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
— The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well:
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
Private water supply well".Method used to determine distance
"This system passes if the well water anal
ysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility attd
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.
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Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address, I zv =,
Owner: wA,vcN Gr3��2c9�i.
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You most in
dicate`5res or`ono to each of the following for all inspections:
Ye$ No
_ ✓ Backup of sewage into facility or system component due to overloaded or cloned 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 m the distribution box above outlet invert due to
an overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than V below invert or available volume is less than Y:day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructedn Number
of times pumped ply s)•
✓ 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.
17 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 mast be attached to this form.]
(YeslNo)The system fails,I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15303,therefore the system fails.The system owner should contactthe Board of
Health to determine what will be necessary to correct the failure.
F. 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
You indicate either"yes"or"no"to each of the following:
(The follo criteria apply to large systems in addition to the criteria above)
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yes no
the system is within feet of a surface drinking water y
the system is within 200 feet o a surface drinking water supply
the system is located in a en sensitive (Interim Wellhead Protection Area—IWPA)or a mapped
Zone 11 of a publ' er supply well
If you hay weed"yes"to any question in Section E the system nsidered a significant threat,or answered
`fires"' Section D above the large system has failed.The owner or open of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the tem m accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the D ent.
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Page 5 of l l
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:_ f A(> &-p-A4
No 0--TR Atil 7 Dy
Owner: &I Aur C,!J C' R a-v('Z-
Date of Inspection: ,I`� _
Check if the following have been done.You must indicate"yes"or"no!'as to each of the following:
Yes No
_ Pumping information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period?
— ✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(if they were not available note as N/A)
Was the facility or dwell'
— mg inspected for signs of sewage back up?
Was the site inspected for signs of break out?
J — 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 audition
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 Soll Absorption System(SAS)on the site has been determined based on:
Yes no
ZDdermined
Existing information.For example,a plan at the Board of Health.
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)]
II
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Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:_ ►2-0 Cr2 s.
o 0 0T1-t f nl D OJP/L
Owner: cti
Date of Inspection:_ 1.1
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 203(for example:110 gpd x#of bedrooms): 6-p D
Number of current residents:
Does residence have a garbage grinder(yes or no):APD
Is laundry on a separate sewage system(yes or no): :0('if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no):
.Water meter readings,if available(last 2 years usage(gpd)):
Sump Pump(ves or no):
Last date ofoc�� ✓r re a
COMMERCIAL/pNDUSMIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): and
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):—
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings,if available:
Last date of occupancy/use:
ETHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):pw
If yes,volume pumped: aallans--How was quantity pumped determined?
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)
_InnovativetAltemative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
—Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):
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Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_12� 61&1 -grge.c'i
NO/Llll /SND Oytlt
Owner: mAN c
Date of Inspection:
BUILDING SEWER(locate on site plan)
Depth below grade: /
Materials of construction:_cast iron /40 PVC_other lain
Distance from private water 1 well or suction line:
Pn supply
Commentsar
( condition ofjoints,venting,evidence of leakage,etc.):
SEPTIC TANK:_(locate on site plan)
Depth below grade: 3a"
Material of construction:—/ooncrete metal fiberglass_polyethylene
other(explak
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: t Sv 6 6*L-L 9 NS
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle-
Scum .33
thidmess; 3"
Distance from top of scum to top of outlet tee or baffle: 6
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: 4-1 EA 6y 2 c S c rL
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
lrr�nv'a N `))AJ sc i1' yo Py c i��s r ✓ Gray
_� �✓ J !0/1, tZ c O M D, I w s/-Ptq�I-[r.q-1O A o F 1,7,is E2 ib
tlI-f-HtN ( OF frlLHDG QuP/L U�L� O�Cit/it!G
GREASE TRAPA/A locate on site plan)
Depth below grade:_
Material of construction: concrete metal fiberglass polyethylene other
(explain):
Dimensions:
Scum thickness:
Distance from top of scrum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping-
Comments
umpingComments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_ i 20 &P-O:j s,2G-e
Owner. N C H 2 2o"-
Date of Inspection: , �s
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: 1Y _
Material of construction: concrete metal fiberglass_polyethylene other explain):
Dimensions:
Y aaLlons
Design Flow: aauo&&y
Alarm
present(yes or no
Alarm level: Alarm in working order(yes or no):
Date of last pumping-
Comments
umpingComments(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:
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.):
OX ,ni ON
s22 O� 0I2 CA22V OV4e4-, (1C-C0I'te-A/P ►nlsTAu.�,,�,v oJ�
i � % 70 / K,- , . SS 1/,l1R✓S, /G. J-�,f?-174 or
)3oA v3eLvw G-ko✓Nib I5 L4
PUMP CHAMBM-4,2- (locate on site plan).
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,
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Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: iso 6-P-R4 ;0_ee;
� /UD /y7k �!-ArDO✓?/lam
Owner: d AA) ew a4eo L4-
Date of Inspection;
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Ty
leaching pits,number:_
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length: a -EMA c k z 5 3 'L„,o jX 9eL,? X l�S G-
leaching fief number,dimensions:
�,
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
/42rH o� �LCu CkEc 5 S�yUw ccs
CESSPOOLS:A/A4 (cesspool must be pumped as part of inspec tion)0ocate 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:N�f (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.):
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4
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. Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
__Id[)
6-2R4 7n�e'
. �Vo 2T1r .4N o�es�
Owner: C 22v yL
Date of inspection:___ o
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.
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` Page 11 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address- /;Zo 67th 1�7-
&ee
o A .tQ
Owner:_ 1YANc�• C_4g Lo c
Date of Inspection: AVIP
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 9 feet
Please indicate(check)all methods used to determine the high ground water elevation:
—17 Obtained from system design plans on record-Hchecked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 fed of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers,-(attach documentation)
Accessed USGS database-explain:
You must descnbe how you established the hO ground water elevation:
0QIC�iNr41, D (nl�
AQFi4 0� sti�r�.► r 5 oni ,c� o.7—. 4
t�D�Cf1-
Insurance Adjustment Service, Inc.
139 Billerica Road Unit A-1
Chelmsford, MA 01824
(978) 256-3334
Fax (978) 256-3354
UNDER MASSACHUSETTS GENERAL LAWS CHAPTER 139 SECTION 3B
Date: April 10, 2007
TO: Board of Health/Building Inspector
RE: Insured: Eric &Monica Demers
Property Address: 120 Gray St.
No. Andover,MA 01845
Date of Loss: 3/21/2007
Policy Number: BP2433910
Type of Loss: Vandals shot the Insured's large window above front door.
File or Claim Number: 39602-tm
Claim has been made involving loss, damage or destruction of the above captioned property, which may either
exceed$1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6,to be applicable.
If any notice under Mass. Gen. Laws, Ch. 139, Sec. 38 is appropriate,please direct it to the attention of the
writer and include a reference to the captioned insured, locations, policy number, date of loss and claim or file
number.
Thank you for your cooperation.
Very Truly yours,
Tim Martino
Adjuster
Ext. 135