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HomeMy WebLinkAboutMiscellaneous - 120 HOLT ROAD 4/30/2018 (2) 120 HOLT ROAD ,- - -- -- -� J 21.0/034-0-0023-0000.0 6273 Town of North Andover HEALTH DEPARTMENT ,SS4CNU+t� f CHECK#: f73 DATE: 2. LOCATION: / Z-0 14z> l- H/O NAME: CONTRACTOR NAME.5�'vi A., o -�- L 4-n Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ BodyArt 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 $ 1 pTitle 5 Report $�� ❑ Other. (Indicate) $ Healt ' t Initials White-Applicant Yellow-Health Pink-Treasurer r 6273 Of,MOPTM ti S Town of North Andover HEALTH DEPARTMENT SACNUSf CHECK#: 1713 DATE: ���3 i L LOCATION: / Z o H/O NAME: CONTRACTOR NAME:_ viii c. /L-, V-+ I -.4- 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 $ T ❑ Other:(Indicate) $ Healtoefi-t-Initials White-Applicant Yellow-Health Pink-Treasurer Commonwealth of Massachusetts W Title 5 Official Inspection Form OCT 03 � 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments TowN of NALT H pep RANDOVpR 120 Holt Rod M a E M ,• N7 Property Address Joe Cristaldi Owner Owner's Name information is required for every North Andover MA 01845 9-25-2012 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael J. Wood use the return key. Name of Inspector Service Pumping and Drain Co., Inc. raa Company Name 5 Hallberg Park Company Address » North Reading MA 01864 City/Town State Zip Code 1-978-276-0217 5021 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 p P p P 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 b the Local Approving Authorit ❑ Y pp 9 Y _ _ 9 26 2012 Inspe is Signat a 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 120 Holt Road Property Address Joe Cristaldi Owner Owner's Name information is required for every North Andover MA 01845 9-25-2012 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 120 Holt Road Property Address Joe Cristaldi Owner Owner's Name information is required for every North Andover MA 01845 9-25-2012 page. City/Town 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 ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 Holt Road Property Address Joe Cristaldi Owner Owner's Name information is required for every North Andover MA 01845 9-25-2012 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) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5ppm, provided that no other failure crIteri a are triggered. A copy of the analysis must be attached to this form. 3. Other: D System Failure Criteria Applicable to All Systems: Y pp Y 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 El Z 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 /2 day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Holt Road Property Address Joe Cristaldi Owner Owner's Name information is required for every North Andover MA 01845 9-25-2012 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303 therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large 9 system considered a significant threat under Section E or failed under Section D shall upgrade the Y 9 p system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 Holt Road Property Address Joe Cristaldi Owner Owner's Name information is required for every North Andover MA 01845 9-25-2012 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins•11110 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 GSM ,•°'` 120 Holt Road Property Address Joe Cristaldi Owner Owner's Name information is required for every North Andover MA 01845 9-25-2012 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ❑ No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Garage Design flow(based on 310 CMR 15.203): unknown talions per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): unknown Grease trap present? ❑ Yes ® No Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Holt Road Property Address Joe Cristaldi Owner Owner's Name information is required for every North Andover MA 01845 9-25-2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: vacant since 2009 Date Other(describe below): General Information Pumping Records: Source of information: 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 f l ❑ 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): Septic tank, single leach pit t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Holt Road Property Address Joe Cristaldi Owner Owner's Name information is required for every North Andover MA 01845 9-25-2012 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: This system is original to the building and is approximately 45 years old according to the owner. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 32"feet Material of construction: ® cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): There are no visible signs of failure or leakage. Septic Tank (locate on site plan): Depth below grade: 2feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8'x4.5'x4' Sludge depth: 1" t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Holt Road Property Address Joe Cristaldi Owner Owner's Name information is required for every North Andover MA 01845 9-25-2012 page. CityTrown 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 >2 Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? tape measure/sludge judge I i Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): This system should be pumped yearly as part of a maintenance plan. There are no visible signs of failure or leakage. e t i Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 120 Holt Road Property Address Joe Cristaldi Owner Owner's Name information is required for every North Andover MA 01845 9-25-2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ 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 Commentsrm condition of al nswitches,( a and float etc): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Holt Road Property Address Joe Cristaldi Owner Owner's Name information is required for every North Andover MA 01845 9-25-2012 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 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): i Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 120 Holt Road Property Address Joe Cristaldi Owner Owner's Name information is required for every North Andover MA 01845 9-25-2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Stone is clean and dry at the bottom of the structure. There is no evidence of failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 120 Holt Road Property Address Joe Cristaldi Owner Owner's Name information is required for every North Andover MA 01845 9-25-2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Holt Road Property Address Joe Cristaldi Owner Owner's Name information is required for every North Andover MA 01845 9-25-2012 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 ?r O (faw,re2 AkCrAAbf_ t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Holt Road M Property Address Joe Cristaldi Owner Owner's Name information is North Andover MA 01845 9-25-2012 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: >8'feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: The bottom of the leach pit is clean and dry and is approximately 8' below grade. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM .' 120 Holt Road Property Address Joe Cristaldi Owner Owner's Name information is required for every North Andover MA 01845 9-25-2012 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 BORACZEK'S SEPTIC & DRAIN SERVICE 10 Belmont Avenue,Haverhill,MA 01830 (978)374-8803 & 1-(603)329-6005 CONUVONWEALTH OF MASSACHUSETTS N` iyp�veti,. ` MASSACHUSETTS i'AY 12 SYSTL,- I PUNIPING RECORD SYSTEM OWNER: c, SYSTEM LOCATIO/N: IZO h64 Ad P'A yds 7Z� 17s_ 1133 DATE OF PUMPING QUANTITY PUMPED•S LU GALLONS: 1 � I N Cess ol:No Yes � �ank: No Ye 1'O j SYSTEM PUNPEE SY:.BORAC?EK'SSEPTIC & DRA_INSERVIff Contents Transferred To: Z41 U10, DATE: INSPECTOR: i I � I Town of North Andover „oRT�j OFFICE OF ~�0 ,t o ,6'ti COMMUNITY DEVELOPMENT AND SERVICES A 27 Charles Street 4t North Andover, Massachusetts 01845 WILLIAM J. SCOTT 9SSACHu5�- Director (978)688-9531 Fax (978)688-9542 Establishment: Address: Teienhcne: Date: Person Saoken With:( A . Owner: W ��/"- On this day an inspection was made of your waste receptacle area. Your waste receptacle area was found �1e dirty and the cover of your waste receptacle was fou;' in good repair — in poor repair and kept closedy not kept closed. Other Comments: i I 410 . 600 Storage of Garbage and Rubbish - Garbage/Rubbish shall be stored in watertight receptacles with tight-fitting covers. Said receptacles and covers shall be of metal or other durable, rodent-proof material . 410 . 601 Collection of Garbage and Rubbish - The owner of any dwelling shall be responsible for the final collection or ultimate disposal or incineration of garbage and rubbish by means of a regular collection system approved by the Board of Health. f 410 . 602 Maintenance of areas free from Garbage and Rubbish (A) - The owner of any parcel of land, vacant or otherwise, shall -be responsible for maintaining such parcel of land in a clean and sanitary condition an''d free from garbage, rubbish or other refuse. The owner of such parcel of land shall correct any condition caused by or on such parcel or its appurtenance which affects the health or safety, and well-being of the occupants of and dwelling or of the general public. `Tsar C:�arcA Inscectof J .n.�.�n .gin.- . n n� nc _!moi 'ter_'/` )• ♦< r. �».rn.-- .r �.r ice.. ..c-.. r r [�o n: rn n. .. .. . ).l (1::C FORM 4-SYSTEM PUMPING RECORD" CURRIER SEPTIC & DRAIN SERVICE 107 FOREST STREET;MIDDLETON,MA 01949 (978)774-2772 COMMONWEALTH OF MASSACHUSETTS MASSACHUSETTS SYSTEM PUMPING CORD SYSTEM OWNER: SYSTEM LOCA ON: 'su etre 7� ,q 113 3 DATE OF PUMPING: QUANTITY PUMPED: �;2 50 GALLONS CESSPOOL: NO 0 YES F-1 SEPTIC T NO YES 0 SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE CONTENTS TRANSFERRED TO: DATE: /02410/1 INSPECTOR: �" THE COMMONWEALTH OF MASSACHUSETTS TOWN OF NORTH ANDOVER BOARD OF HEALTH Date:December 19, 1997 Permit#: 204-8D _ This is to certify that: SUTTON ST. TOWING,�120_Holt Rd North Andover, MA 01845 IS HEREBY GRANTED A DUMPSTER PERMIT This permit is granted in conformity with the statutes and ordinances relating thereto, and expires DECEMBER 31, 1998 unless sooner suspended or revoked. Gayton Osgood, Chairman Francis P. MacMillan, M.D., Member John S. Rizza, D.M.D., Member ' r ©� TOWN OF NORTH ANDOVER BOARD OF HEALTH- 30 SCHOOL STREET NORTH ANDOVER, MASSACHUSETTS 01845 TELEPHONE# (978) 688-9540 APPLICATION FOR DUMPSTER PERMIT PURSUANT TO SECTION 31A AND 31B OF CHAPTER III OF THE GENERAL LAWS, AND RULES AND REGULATIONS OF THE NORTH ANDOVER BOARD OF HEALTH DATE: I Application is hereby made for a permit ,to maintain a dumpster (s) on property located at 1� C� I-l o t'� ',,,,^^11 in accordance with the rules and regulations of the Board of Health. Number of Ownpsters: I Check use: ( ) Residential useC (� ommercial use ( ) 30 day temporary ( I Annual Name of applicant: Owner of property:_ L)Rr)S -N Telephone#: 5(-)$ Dumpster Company:—_ WIM Telephone#: Pick-Up Schedule: ` "uj�5c�u Trash Contractor: V3I m c'f '1,3N l.e Frequency of Pick-Up: I/ ' v� k On the bottom half of this form, please sketch an outline of property, showing the proposed location of the dumpster (s) . Give. distance from dumpster to other buildings and lot lines or boundaries. Use back side if additional space is needed. D Please return this application with a fee of $25.00 per establishment ($10 .00 for temporary permit) to Town of North Andover, Board of Health Office, Town Hall Annex, 146 Main Street, North Andover, M A 01845. Town of North Andover NORTH OFFICE OF 3�0g s��to ,e +O�L COMMUNITY DEVELOPMENT AND SERVICES A 30 School Street North Andover,Massachusetts 01845 Ssgc,Hus�tsh WILLIAM J. SCOTT Director November 1, 1997 To All North Andover Businesses : Re: 1998 Dumpster Permit Renewal Your current 1997 Dumpster Permit expires on December 31, 1997 . In order to renew this permit you must complete the enclosed application and return it along with twenty-five ($25) dollars permit fee per establishment, per calendar year (please note, this fee is per establishment, not per dumpster) . Applications and fee must be returned to the Board of Health Office, 30 School Street, North Andover, MA 01845 no later then December 8, 1997 . Please make check payable to the Town of North Andover. If you have any questions, please feel free to call the Board of Health Office at (508) 688-9540 . Sincerely, Sandra Starr, R.S . Health Administrator SS/cjp Enclosure i CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 TOWN OF NORTH ANDOVER BOARD OF HEALTH d 30 SCHOOL STREET NORTH ANDOVER, MASSACHUSETTS 01845 TELEPHONE# (978) 688-9540 APPLICATION FOR DUMPSTER PERMIT PURSUANT TO SECTION 31A AND 31B OF CHAPTER III OF THE GENERAL LAWS, AND RULES AND REGULATIONS OF THE_ NORTH ANDOVER BOARD .OF HEALTH DATE: W Application is hereby made for a permit to maintain a dimpster(s) on property located at 2. M A.tiv ST in accordance with the rules and regulations of the Board of Health. Number of Dumpsters: J� Check use: ( ) Residential use { Commercial use ( ) 30 day temporary ( ) Annual Name of applicant: VaA—(Aa P_j Owner of property: Pe ett IL V,%0A,4Ajco&Aj-- Telephone#: 6cd Dumpster Company: Telephone#: Pick-Up Schedule: oNt-Q- pec �u Trash Contractor: Frequency of Pick-Up: On the bottom half of this form, please sketch an outline of property, showing the proposed location of the dumpster (s) . Give distance from dumpster to other buildings and lot lines or boundaries. Use back side if additional space is needed. Tr%aAw"p6T&a] 8 Please return this application with a fee of $25.00 per establishment ($10.00 for temporary permit) to Town of North Andover, Board of Health Office, Town Hall Annex, 146 Main Street, North Andover, M A 01845. THE COMMONWEALTH OF MASSACHUSETTS TOWN OF NORTH ANDOVER o D BOARD OFHEALTH Date:DECEMBER 31,1996 Permit#: 0075-7 This is to certify that: SUTTON STREET TOWING,120 HOLT ROAD,NORTH ANDOVER,MA 01845 IS HEREBY GRANTED A DUMPSTER PERMIT This permit is granted in conformity with the statues and ordinances relating thereto, and expires DECEMBER 31,1997 unless sooner suspended or revoked. Gayton Osgood,Chairman Francis P. MacMillan,M.D.,Member John S.Rizza,D.M.D.,Member I TOWN OF NORTH ANDOVER \ BOARD OF HEALTH TOWN HALL ANNEX 146 MAIN STREET I NORTH ANDOVER, MASSACHUSETTS TELEPHONE# (508) 688-9540 APPLICATION FOR DUMPSTER PERMIT V PURSUANT TO SECTION 31A AND 31B OF CHAPTER III OF THE GENERAL LAWS, AND RULES AND REGULATIONS OF THE NORTH ANDOVER BOARD OF HEALTH DATE: Application is hereby made for a permit to maintain a dumpster(s) on property located at /,O H�LT a in accordance with the rules and regulations- of the Board of Health. Number of DumP stets. Q Check use: ( ) Residential use ( Commercial use ( ) 30 day temporary ( ) Annual Name of applicant: su l \ r` Owner of property: yG�+---eA� Telephone#: Dumpster Company: !u Telephone#: ci Pick-Up Schedule: In n'/ - o` 41-7 Trash Contractor: 5� Frequency of Pick-Up: On the bottom half of this form, please sketch an outline of property, showing the proposed location of the dumpster(s) . Give distance from dumpster to other buildings and lot lines or boundaries. Use back side if additional space is needed. 1 Please return this application with a fee of $25.00 per establishment ($10. 00 for temporary permit) to Town of North Andover, Board of Health Office, Town Hall Annex, 146 Main Street, North Andover, M A 01845.