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HomeMy WebLinkAboutMiscellaneous - 124 STONECLEAVE ROAD 4/30/2018 (2) `F'4 CTO1NIFCI FAVF RnAQ oad o g ra�� NorthAndoverBoardofAssessors PublicAccess Page 1 of 1 It Kor+ry Town of North A kdover Of A-Ssessors. �483acwull' TZ Property Return to the Home page click on logo Record Card Parcel ID:210/104.11-0125-0000.0 Community:North Andover New Search SKETCH PHOTO Click on Sketch to Enlarge Click on Photo to Enlarge Sales ; o Summary Residence y Detached Structure Condo Commercial Comparable Sales =ti 124 STONECLEAVE ROAO Location: 124 STONECLEAVE ROAD Owner Name: PAPELL,MICHAEL W NATALIE N PAPELL Owner Address: 124 STONECLEAVE ROAD City:NORTH ANDOVER State:MA ZIP:01845 Neighborhood:7-7 Land Area: 1.01 acres Use Code: 101 -SNGL-FAM-RES Total Finished Area:1998 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 515,500 538,600 Building Value: 290,700 302,000 Land Value: 224,800 236,600 Market Land Value:224,800 Chapter Land Value: LATEST SALE Sale Price:360,000 Sale Date:04/04/2000 Arms Length Sale Code:Y-YES-VALID Grantor:HEIFETZ,ALLAN Cert Doc: Book:05718 Page:0119 http://csc-ma.us/NandoverPubAcc/jsp/Home.jsp?Page=3&Linkld=1180314 4/16/2008 I OWNER: BENCHMARK: LOT 22A MICHAEL & NATALIE PAPELL NAIL SET IN 10" OAK 44,031 S.F.f 124 STONECLEAVE ROAD ELEVATION = 100.00' NORTH ANDOVER, MA 01845 (ASSUMED DATUM) 1.4'f ABOVE GROUND 0 W � Lo " ����� NEW 1,500 GALLON CONCRETE r MONOLITHIC SEPTIC TANK W/ f V ��.• TEES & OUTLET GAS BAFFLE Z Zft�� COVERS TO FINISHED GRADE EX 20' X 45' SEPTIC LEACHING BED WITH LOCATION TAKEN FROMI IAS-BUILT PLAN BY JOSEPH 13ARBAGALLO DATED 9/24/78 0 32' 0 259 ' 3.7 0 EX. D-BOX 0 \ 10.3' W/ NEW COVER A0.1 10' MIN. PIPING FROM HOUSE 42.0' 0 0 TO D-BOX IS ALL o FUTURE 1ST. ADDITION N 4" SDR 35 PVC \ N W/ CRAWLSPACE B A C ' 4" PVC \ � tH 0Mq CLEANOUT TO GRADE BULKHEAD V Cvn f1� H �, EX. 1 STORY EX 2 STORY p V L GARAGE WD. FRAME _ STRUCTURE o v A TOP OF FND=101.17' 124 OS�NALF \ SEP TIC TIES 1 A B C PIPE @ FOUNDATION 12.0' INTO SEPTIC TANK 16.2' 15.3' THE ONLY NEW SEPTIC COMPONENT INSTALLED AS PART OF THIS AS-BUILT PLAN IS THE OUT OF SEPTIC TANK 26.7' 23.8' 1500 GALLON SEPTIC TANK. D-Box 26.8' 53.2' SEPTIC AS-BUIL T ELEVATIONS 124 S TONECL EA VE ROAD SEWER INV. @ FOUNDATION 97.75' NORTH ANDOVER, MASS. SEWER INV. INTO SEPTIC TANK 97.31' PREPARED BY: SEWER INV. OUT OF SEPTIC TANK 97.06' JOHN D. SULLIVAN III, P.E. SEWER INV. INTO D-Box 96.57' 22 MOUNT VERNON ROAD BOXFORD, MA. 01921 ASSESSOR INFORMATION: (978) 352-7871 TAX MAP 1048 LOT 125 SCALE: 1 "=20' DATE: 5/12/08 1� i RECEIVED MAY -14 2008_ TOWN OF NORTH ANDOVER HEALTH DEPARTMENT A •� J l .`r F I I NORTH q � �t�Bo i6* tiO OL O t� p LAK 9 �9SSACHUS PUBLIC HEALTH DEPARTMENT Community Development Division RTITICA�IE O F C09W)CIANCE As of: May 15, 2008 This is to cert that the individuaCsu6surface disposasystem received a SAT1'SFAC'rI"oRT1NSPECg70Yof the: Tank efocation Only By: ToddBateson At: 124 Stonecleave Wpad Map 104. 1B; (Parce[125 Yorth Andover, w q 01845 die Issuance of this certi)7cate shaf not 6e construed as a guarantee that the system wiff function satisfactorzfy. Susan T Sawyer fific Ylealth Director 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com pORfy O6,,to 0 F p RECEIVED . .� MAY DOW 14 2008 PUBLIC HEALTH DEPARTMENT TOWN OF NORTH ANDOVER Community Development Division HEALTH DEPARTMENT TOWN OF NORTH ANDOVER SEPTIC DISPOSAL SYSTEM—INSTALLATION CERTIFICATION The undersigned hereby certify that the swage Disposal System( )constructed; repaired; By: OW&W (Print Name) Located at: 12y i*�Oaw I�� (Installation Address) Was installed in conformance with the North Andover Board of Heakh approved plan,originally dated • Y' yr� and last revised on •� O with a design flow of gallons per day. The materials used were in conformance with those specified on the approved plan;the system was installed in accordance with the provisions of 310.CMR 15.000,Title 5 and local regulations,and the final grading agrees substantially with the approved plan.All work is accurately represented on the As-built which has been submitted to the Board of Health. Bottom of Bed Inspection Date: 4 A Engi4epretative(Signa e) And–Print Name Final Construction Inspection Date: 30* O,apaly** � En a Sig afore) • jW And–Print Na Installer: (Signature) Date: '_� — a 'U And–Print Name Enginer: (Signature) Date: �" • And–Print Name 1600 Osgood Street, North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web http://www.townofnorthandover.com �9► i %ft%A VVA,%W#t S rr , 4 AS-BUILT CHECKLIST r A .1/ LOT NUMBER, STREET NAME l ASSESSORS MAP & PARCEL NUMBER LOT LINES & LOCATION OF DWELLINGS LOCATIONS &DIMENSIONS OF SYSTEM, INCLUDING RESERVE TIES TO LOT LINES DWELLIN , WELLS -z�y- a. FROM SEPTIC T b. FROM LEACH AREA �j \ `LOCATIONS OF DEEP HOLES &PERC 9 r TESTS w ELEVATIONS OF DISPOSAL SYSTEM TOP OF',FDN ELEVATION LOCATIONS OF WELLS, DRAINS, WATERCOURSES WITHIN 150110F SYSTEM LOCATION O %ATER, GAS, ELECTRIC LINES, CABLE DISTANCES FRORNERS OF HOUSE TO CENTER OF TANK& D-BOX ORIGINAL STAMP& SI NATURE IMPERVIOUS AREAS -DRIVEWAYS, ETC. NORTH ARROW LOCATION & ELEVATIONS OF BENCHMARK USED Sullivan Engineering Group, LLC Civil Engineers&Land Development Consultants May 12, 2008 North Andover Health Department—Susan Sawyer 1600 Osgood Street RECEIVED Building 20; Suite 2-36 North Andover, MA 01845 MAY 14 2008 Re: As-Built Plan — 124 Stonecleave Road TOWN NORTH ANDOVER HEALLTT H DEPARTMENT Ms. Sawyer; Enclosed are the following as part of the Septic As-Built submittal package: 1) Two (2) stamped As-Built Plans 2) A completed/signed Installation Certificate If you have any questions please feel free to contact me. Very TrulyY ur Ja k Sullivan,P.E. Cc: Kevin Murphy - Builder 22 Mount Vernon Road — Boxford,Massachusetts 01921 (978)352-7871-Phone 978352-7871 -Fax I OWNER: BENCHMARK: LOT 22A MICHAEL & NATALIE PAPELL NAIL SET IN 10" OAK 44,031 S.F.f 124 STONECLEAVE ROAD ELEVATION = 100.00' NORTH ANDOVER, MA 01845 (ASSUMED DATUM) 1.4't ABOVE GROUND -o 0 W o i� O NEW 1,500� MONOLITHIC SEPTIC TA / CONCRETE W/ � C NK W � • TEES & OUTLET GAS BAFFLE Z COVERS TO FINISHED GRADE EX. 20' X 45' SEPTIC LEACHING BED WITH LOCATION TAKEN FROMI IAS-BUILT PLAN BY JOSEPH BARBAGALLO DA TED 9/24/78 0 3 2' O I O EX. D-BOX O \ 10.3' W/ NEW COVER 1O1' 10' MIN. PIPING FROM HOUSE 42.0' b �6 TO D-BOX IS ALL C) FUTURE 1 ST. ADDITION N 4" SDR 35 PVC k N W/ CRAWLSPACE B A C \ OFf 4" PVC �• CLEANOUT TO GRADE BULKHEAD V Z � P SIT EX. 1 STORY EX. 2 STORY GARAGE AME U' 00 .1 y WD. FR +_ 8 STRUCTURE co v .e TOP OF FND=101.17' 124 Ri f`SStfi�lAlf SEPTIC TIES ' A B C i PIPE @ FOUNDATION 12.0' INTO SEPTIC TANK 16.2' 15.3' THE ONLY NEW SEPTIC COMPONENT INSTALLED AS PART OF THIS AS-BUILT PLAN IS THE OUT OF SEPTIC TANK 26.7' 23.8' 1500 GALLON SEPTIC TANK. D-BOX 26.8' 53.2' SEP 77C AS BUIL T ELEVATIONS 124 STONECLEA VE ROAD SEWER INV. @ FOUNDATION 97.75' NORTH ANDOVER, MASS. SEWER INV. INTO SEPTIC TANK 97.31' PREPARED BY: SEWER INV. OUT OF SEPTIC TANK 97.06' JOHN D. SULLIVAN 111, P.E. SEWER INV. INTO D—BOX 96.57' 22 MOUNT VERNON ROAD BOXFORD, MA 01921 ASSESSOR INFORMATION: (978) 352-7871 TAX MAP 1048 LOT 125 SCALE: 1 "=20, DATE: 5/12/08 Commonwealth of Massachusetts Map-Block-Lot 104.6-0125- ----------------------- 0 Board of Health Permit No North Andover BHP-2008-0077 P.I. FEE �Oa.n Ate, Ac„usti� F.I. $125.00 Disposal Works Construction Permit Permission is hereby granted Todd_B-ateson ------------------------------------------------------------------------------------------'-------- to(Repair-1500 Gallon Tank)an Individual Sewage Disposal System. at No 124 STONECLEAVE ROAD as shown on the application for Disposal Works Construction Permit No. BHP-2008-007 Dated May 06,_2008__ ------------U, f� IL-t�------------------ Issued On:May-06-2008 Board of Health N°RTH OaAppliolati�,n for Septic Disposal System ,,Jac '°A p a` ' TODAY'S DATE " Xonstruction Permit - TOWN OF ORTH ANDOVER MA 01845 $ 250.00—Full Repair a.�°+,..,.•°� � $125.00 -Component CHU 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 on-site sewage disposal system* only the tab key /�'� �kL ,gK k to move your �if or replace an existing system component—What? cursor-do not use the return A. Facility Information key. ILS Address or Lot# �� • w..� �° - `� `� " MAY 0 6 2008 City/Town 2.-*TYPE OF S TIC SYSTEM*: TOWN OF NORTH ANDOVER [IPump E9,1ravity(choose one) HEALTH DEPARTMENT ***If pump system, attach copy of electrical permit to application*** ❑ Conventional 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) (Attach Draft Maintenance Agreement) ❑ Pressure ©cfsed(6-Box Present)S.A.S. 2. Owner Information Ck R9 �- Name Address(if different from above) City/Town State Zip Code Telephone Number 3. Installer Information _ Name - �/ Name of Company Address Cityfrown State Zip Code Telephone Number(Cell Phone#if possible please) 4. Designer Information Name Name of Company Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 a� °0Te�4 Application for Septic Disposal System 3?e:r _ o' Construction Permit - TOWN OF TODAY'S DATE •'` ORTH ANDOVER MA 01845 $250.00-Full Repair , $125.00 -Component SSACMuS� PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: esidential Dwelling 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 Subsurface Disposal Regulations for the Town of North Andover d not to place the system in operation until a Certificate of Compliance has been issue his B of Health. Name Date Application ro tl By: (Board of Health Representative) Na 67 Date Application Disap oved for the following reasons: For Office Use Only: L Fee Attached. Yes No 2. Project Manager Obligation Form Attached. Yes No 3. Pump Svstem? If so,Attach copy ofElectrical Permit Yes No 4. Foundation As-Built. (new construction ronly): Yes No (Same scale as approved plan) 5. Floor Pians?(new construction only): Yes No Application for Disposal System Construction Permit-Page 2 of 2 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at (Address of septic system) For plans by (Engineer) Relative to the application of � '`� L- (Installer's name) And dated � ngin date) Dated S_- ' With revisions dated o ay s ate (Last revised date) understand the folio obligations for management of this project: I un wing 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner,contractor,project manager,or any other person not associated with my company schedules an inspection and the system is not ready,then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection,without completion of the items in accordance with Title 5 and the Board of Health Regulations may_result in a$50.00 fine being levied against me and/or my company, a. Bottom of Bed—Generally,this is the.first (15)inspection unless there is a retaining wall,which should be done.first. The installer must request.the inspection'but does not have to be present b. Final Construction Inspection—Engineer must first do their inspection for elevations, ties,etc. As-built of verbal OK(or e-mail to: healthdept(u townofnorthandover.com) from the engineer must be submitted to the Board of Health,after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system,all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade—Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation)and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5.' As.the_installer;I understand that I must be on-site during the performance of the following construction steps: a. Detemzinadon that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board ofHealth staff or consultant. d. Installation of tank D-Box,pipes, stone, veno pump chamber,retaining wall and other components. 6. As the installer, I understand that I am solely responsible for the installation of the system as per the approved plans No instructions by the homeowner general contractor.or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: (Today's Date) (y—C 0' � p (Name—Print) ame- igne �,• - RECEIVE® Commonwealth of Massachusetts l/ - Title 5 Official Inspection Form MAR 1 2007 QQWN OF NORTH ANDOVER Subsurface Sewage Disposal System Form -Not for Voluntary Assess eTntSEALTH DEPARTMENT 124 Stonecleave Rd. Property Address Natalee Papell 'Owner Owner's Name information is North Andover MA 01845 3/6/07 required for .every 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. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Chad Jablonski cursor-do not use the return Name of Inspector key. Jablonski &Sons Inc. Company Name 206 Kenoza St. Company Address Haverhill MA 01830 �enm City/Town State Zip Code 978-360-9358 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 Ins o' Sign re Date v The syst Spector shall submit a copy of this inspection report to the Approving Authority(Board of Hea 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. t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 . - e ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 124 Stonecleave Rd. Property Address Natalee Papell Owner Owner's Name Information is required for North Andover MA 01845 3/6/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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°Conditi Pass"section need to be replaced or repaired. The system, upon completion of th placement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND) in for the following statements. If"not determined," please explain. tank i metal and over ears old*or the septic tank whether metal or not is ❑ The septic a s y p ( ) structurally unsound, exhibits bstantial infiltration or exfiltration or tank failure is imminent. System will pass inspecti if the existing tank is replaced with a complying septic tank as approve/the f Health. A metaill pass inspection if it is structurally sound, not leaking and if a Certificate of Compg that the tank is less than 20 years old is available. ND Explai ❑ Observation of sewage backup or break or high static water level in the distribution box due to broken or obstructed pipe(s)or d o a broken, settled or uneven distribution box. System will pass inspection if(with approv Board of Health): ❑ broken pipesa replaced ❑ obstruc' n is removed t5insp-08/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System form -Not for Voluntary Assessments 124 Stonecleave Rd. Property Address Natalee Papell Owner Owner's Name information is required for North Andover MA 01845 3/6/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ /n: ed umping more than 4 times a year due to broken or obstructed pipe(s). The pection if(with approval of the Board of Health): e(s)are replaced n is removed ND 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 p/hde , safety or the env' onment. 1. System will pass unless Balth determin in accordance with 310 CMR 15.303(1)(b)that the system isioning in a anner which will protect public health, safety and the environment: ❑ Cesspool or privy is witof surface water ❑ Cesspool or privy is witof a bordering vegetated wetland or a salt marsh 2. System will fail unless theealth (and Public Water Supplier, if any) determines that the system ' functioning in a manner that protects the public health, safety and environment: ❑ The system h a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surfac ater supply or tributary to a surface water supply. ❑ The syst 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. t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 124 Stonecleave Rd. Property Address Natalee Papell Owner Owner's Name information is required for North Andover MA 01845 3/6/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is I s 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 er analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided t no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less q P than Y2 day flow ❑ ® 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. t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonweal#h of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M •''t 124 Stonecleave Rd. Property Address Natalee Papell Owner Owner's Name information is required for North Andover MA 01845 3/6/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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 o ollowing, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 4 feet of a surface drinking water supply ❑ ❑ the system is (thin 200 feet of a tributary to a surface drinking water supply the sys is located in a nitrogen sensitive area (Interim Wellhead Protection ❑ ❑ Are IWPA)or a mapped Zone II of a public water supply well If you have answere yes"to any question in Section E the system is considered a significant threat, or answered "yes— Section D above the large system has failed. The owner or operator of any large system conside answer,/ a significant threat under Section E or failed under Section D shall upgrade the system in ac rdance with 310 CMR 15.304. The system owner should contact the appropriate regional o e of the Department. t5insp•08/06 TiUe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 124 Stonecleave Rd. Property Address Natalee Papell Owner Owner's Name information is required for North Andover MA 01845 3/6/07 every 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)] t5insp•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts u. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 124 Stonecleave Rd. Property Address Natalee Papell Owner Owner's Name information is required for North Andover MA 01845 3/6/07 every page. Cityrrown State Zip Code Date of Inspection 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): Number of current residents: 5 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 ears usage d Private Well 9 ( Y 9 (gP ))� Sump pump? ❑ Yes ® No Last date of occupancy: Occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallo er day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank presen ❑ Yes ❑ No Non-sanitary waste dischar to the Title 5 system? ❑ Yes ❑ No Water meter reading , If available: Last date of o upancy/use: Date Other(describe): t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 124 Stonecleave Rd. Property Address Natalee Papell Owner Owners Name information is required for North Andover MA 01845 3/6/07 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: NA BOH Pumped 1000 gal 8-1-01,4-20-05 by Andover Septic Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: n/a gallons How was quantity pumped determined? n/a Reason for pumping: n/a Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 34 yrs As-built plan dated4 �1�,.,°�,.?7OW' 9/2,Y/78 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection -Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 124 Stonecleave Rd. Property Address Natalee Papell Owner Owner's Name information is required for North Andover MA 01845 3/6/07 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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: 101+feet Comments(on condition of joints, venting, evidence of leakage, etc.): Watertight at foundation no evidence of leaking Septic Tank (locate on site plan): Depth below grade: 18"tee" Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: n/a years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 8' ` 5'8* 5' Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness less than .5" Distance from top of scum to top of outlet tee or baffle greater than 2" Distance from bottom of scum to bottom of outlet tee or baffle greater than 2" How were dimensions determined? Title V calibrated stick t5insp•08/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 124 Stonecleave Rd. Property Address Natalee Papell Owner Owner's Name information is required for North Andover MA 01845 3/6/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Last pumped 4/20/05, pumping recommended annually Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass El polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scutop of outlet tee or baffle Distance from/boftoof scum to bottom of outlet tee or baffle Date of last pu Date 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 pum ed at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete metal ❑fiberglass ❑ polyethylene ❑ other(explain): t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts _ . Title 5 -Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 124 Stonecleave Rd. Property Address Natalee Pape[[ Owner Owner's Name information is required for North Andover MA 01845 3/6/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gall Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping/larm Date Comments (conditionoat switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 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.): box level, distributing evenly, no sign of solid carryover Pump Chamber(locate on site plan): Pumps in working order: EI Yes ❑ No Alarms in working order- ❑ Yes ❑ No t5insp•08t06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 124 Stonecleave Rd. Property Address Natalee Papell Owner Owner's Name information is required for North Andover MA 01845 3/6/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, c n of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: t _..i L{NG5 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.): tv© S t r- P-j 6 G fi o e 0 2 r.%?U H ►-i yD,e A u L r t5insp•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 124 Stonecleave Rd. Property Address Natalee Papell Owner Owner's Name information is required for North Andover MA 01845 3/6/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 groundwat inflow ❑ Yes ❑ No Comments (note c dition 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 condi ' n of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts _ Tit-le 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 124 Stonecleave Rd. Property Address Natalee Papell Owner Owner's Name information is North Andover MA 01845 3/6/07 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. STC)tit E G LE \CP t I ` OQ L G l►`�•S t r3 t5insp•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts - . Tiale 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 124 Stonecleave Rd. Property Address Natalee Papell Owner Owner's Name information is required for North Andover MA 01845 3/6/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: heck Slope L �% [YSurtace water w O [Check cellar I`� y [Shallow wells NO (,3 " Estimated depth to ground water: 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 'yOy 15, /977 ❑ 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: GCL-LaFC— ww5 le 2- C ti e--E. 1-A CELEt-t�v �tqT� 1 � J l�7 t5insp-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15