HomeMy WebLinkAboutMiscellaneous - 125 JOHNNY CAKE STREET 4/30/2018 125 JOHNNY CAKE STREET treet _
21A/107A-0186-0000.0
North Andover Board of Assessors Public Access Page 1 of 1
NORT1{ rfh Andover Board of Assesso1. rs
Of tt�a°•°�ti0
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'SSACHl15Et roperty Record Card
Parcel ID:210/107.A-0186-0000.0 FY:2012 Community: North Andover
SKETCH
Click on Sketch to Enlarge Click on Photo to Enlar e
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125 JOHNNY CAKE STREET '
. I
Location: 125 JOHNNY CAKE STREET
Owner Name: WEBSTER,MARK
WEBSTER,EMILY
Owner Address: 125 JOHNNY CAKE STREET
City: NORTH ANDOVER State: MA Zip: 01845
Neighborhood: 8-8 Land Area: 1.12 acres
Use Code: 101-SNGL-FAM-RES Total Finished Area: 2802 syft
CURRENT Y17AR PREVIOUS YEA11
Total Value: 571,200 571,200
Building Value: 340,300 340,300
Land Value: 230,900 230,900
Market Land Value: 230,900
Chapter Land Value:
LATESTSALLI
t
Sale Price: 730,000 Sale Date: 07/05/2005
Arms Length Sale Code: Y-YES-VALID Grantor: LUNT,LAWRENCE
Cert Doc: Book: 9619 Page: 103
http://csc-ma.us/PROPAPP/display.do?linkld=1896176&town=NandoverPubAcc 6/26/2012
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Residential Property Record Card
PARCEL ID:210/107.A-0186-0000.0 MAP:107.A BLOCK:0186 LOT:0000.0 PARCEL ADDRESS:125 JOHNNY CAKE STREET FY:2012
PARCEL INFORMATION Use-Code: 101 Sale Price: 730,000 Book: 9619 Road Type: T Inspect Date: 04/08/2008
Tax Class: T Sale Date: 07/05/05 Page: 103 Rd Condition: P Meas Date: 04/08/2008
Owner: Tot Fin Area: 2802 Sale Type: P Cert/Doc: Traffic: M Entrance: X
WEBSTER, MARK Tot Land Area: 1.12 Sale Valid: Y Water: Collect Id: RRC
WEBSTER, EMILY
Address: Grantor: LUNT, LAWRENCE Sewer: Inspect Reas: C
125 JOHNNY CAKE STREET Exempt-B/L% / Resid-B/L% 100/100 Comm-B/LP/o Indust-B/L% / Open Sp-B/L% /
NORTH ANDOVER MA 01845
RESIDENCE INFORMATION LAND INFORMATION
Style: CL Tot Rooms: 7 Main Fn Area: 1458 Attic:
NBHD CODE: 8 NBHD CLASS: 8 ZONE: R2 j
Story Height: 2.00 Bedrooms: 4 Up Fn Area: 1344 Bsmt Area: 1458 Seg Type Code Method Sq-Ft Acres Influ-Y/N Value Class
Roof: H Full Baths: 2 Add Fn Area: Fn Bsmt Area: 400 1 P 101 S 43560 1.000 229,996
Ext Wall: FB Half Baths: 1 Unfin Area: Bsmt Grade: 2 R 101 A 0 0.120 912
Masonry Trim: Ext Bath Fix: 0 Tot Fin Area: 2802 VALUATION INFORMATION
Foundation: CN Bath Qual: T RCNLD: 340315 Current Total: 571,200 Bldg: 340,300 Land: 230,900 MktLnd: 230,900
Kitch Qual: T Eff Yr Built: 1987 Mkt Adj: Prior Total: 571,200 Bldg: 340,300 Land: 230,900 MktLnd: 230,900
Heat Type: HW Ext Kitch: Year Built: 1985 Sound Value:
Fuel Type: G Grade: GV Cost Bldg: 340,300
Fireplace: 1 Bsmt Gar Cap: Condition: G Att Str Val 1:
Central AC: Y Bsmt Gar SF: Pct Complete: Aft Str Va12:
Aft Gar SF: 576%Good P/F/E/R: /100/100/90
Porch Type Porch Area Porch Grade Factor
P 12
W 280
SKETCH PHOTO
W i
14 280 Sq. 14
FM/B 576 Sq.F z4
FUJFMIB 1426lp.Ft A
1332 Sq.Ft
32
18
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lisp
125 JOHNNY CAKE
STREET '•'�:II
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Parcel ID:210/107.A-0186-0000.0 as of 6/26/12 Page 1 of 1
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N Commonwealth of Massachusetts
W City/Town of NORTH ANDOVER
W° System Pumping Record
i M SVS
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351. RECEIVED
A. Facility Information JUL 73 2015
Important:When
filling out forms 1. System Location: TOWN OF NORTH ANDOVER
on the computer, 125 JOHNNY CAKE STREET HEALTH DEPARTMENT
use only the tab
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
use the return City/Town State Zip Code
key.
2. System Owner:
MARK WEBSTER
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 6/17/15 2. Quantity Pumped: 1500
Date Gallons
3. Component: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
GOOD CONDITION
6. System Pumped By:
JAMES H CURRIER II H79 406
Name Vehicle License Number
X SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
6/17/15 _
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pu.nping Reck,rd•Page 1 of 1
Commonwealth of Massachusetts REC D
City/Town of
System Pumping Record tAy Z 2013
: Form 4
DEP has provided this form for use by local Boards of Health. Other forms the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Le Right rear of ho Left/right side of house, Left/
Right side of building, Left/Right front of building, a ig t rear of building, Under deck
Address
City/Town \ \Wj ) `J\ 1 ` �--State Zip Code
2. System Owner.
Uj
Name
Address(if different from location)
CitylTown State3 J L4 � I . de
l Z7
Telephone Number
B. Pumping Record 5-- -3
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes to - If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
\�
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L S. Lowell Waste Water
Signitufe I Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
DelleChiaie, Pamela
From: Jack Sullivan Dacksu1153@comcast.net]
Sent: Tuesday, June 26, 2012 11:43 AM
To: DelleChiaie, Pamela
Subject: Re: 125 Johnnycake
Hi Pam,
Do you have a Septic As-Built or Title 5 report for 125 Johnnycake that you could e-mail me? Did you
buy a new cell phone yet??
Thank you.
Sullivan Engineering Group, LLC
Jack Sullivan
22 Mount Vernon Road
Boxford, MA 01921
978-352-7871 phone + fax
From: "Jack Sullivan" <jacksuI153@comcast.net>
To: "Pamela DelleChiaie" <pdellech@townofnorthandover.com>
Sent: Wednesday, May 23, 2012 6:15:26 PM
Subject: Re: 193 Berry Street, NA
Hi Pam,
Would you happen to have scanned the Septic Design and Septic As-Built plan for the above
property? If so, would you mind e-mailing it to me...thanks so much.
Sullivan Engineering Group, LLC
Jack Sullivan
22 Mount Vernon Road
Boxford, MA 01921
978-352-7871 phone + fax
From: "Pamela DelleChiaie" <pdellech@townofnorthandover.com>
To: "Jack Sullivan" <jacksu1153@comcast.net>
Sent: Wednesday, May 23, 2012 10:12:02 AM
Subject: RE: Droid
Thanks for the feedback! Enjoy your weekend also! O
From: Jack Sullivan [mailto:jacksu1153@comcast.net]
Sent: Wednesday, May 23, 2012 9:50 AM
To: DelleChiaie, Pamela
Subject: Re: Droid
Pam,
1 ',
My girls are doing great...although I am ready for the 2 1/2 year old to turn 3!! My wife and I just
bought the Droid phones and we love them...we went to the Verizon store to get I-phones, but
somehow we came out with the Droids. I like being able to get my e-mails while I am on the road.
Verizon was really pushing the 4G and said the (phone is only 3G...not sure it makes that big of a
difference, but I bought the sales pitch.
Hope you enjoy the upcoming long weekend.
Sullivan Engineering Group, LLC
Jack Sullivan
22 Mount Vernon Road
Boxford, MA 01921
978-352-7871 phone + fax
From: "Pamela DelleChiaie" <pdellech@townofnorthandover.com>
To: "jacks ull53@comcast.net" <jacksu1153@comcast.net>
Sent: Wednesday, May 23, 2012 9:22:10 AM
Subject: RE: 32 Deer Meadow
You are welcome! How are your little girls? They are s0000 cute! I wanted to ask you how you like your 4g lte
droid? I hae a blackberry,but thinking of getting another type. TTYL,
—Pam,)
From: jacksu1153@comcast.net [mailto:jacksu1153@comcast.net] v`
Sent: Tuesday, May 22, 2012 7:37 PM
To: DelleChiaie, Pamela
Subject: RE: 32 Deer Meadow
Thank you so much!!
Sent from my Verizon Wireless 4G LTE DROID
-----Original message-----
From: "DelleChiaie, Pamela" <pdellech@townofnorthandover.com>
To: "'jacksu1153@comcast.net'" <jacksu1153@comcast.net>
Sent: Tue, May 22, 2012 15:52:31 EDT
Subject: RE: 32 Deer Meadow
Okay....I sent it. O
From: jacksu1153@comcast.net [mailto:jacksu1153@comcast.net]
Sent: Monday, May 21, 2012 5:59 PM
To: DelleChiaie, Pamela
Subject: RE: 32 Deer Meadow
Thanks pam....Tuesday is fine.. no rush
Sent from my Verizon Wireless 4G LTE DROID
-----Original message-----
2
From: "DelleChiaie, Pamela" <pdellech@townofnorthandover.com>
To: Jack Sullivan <jacksu 1153@comcast.net>
Sent: Mon, May 21, 2012 15:20:45 EDT
Subject: RE: 32 Deer Meadow
Hi Jack,
I am out today, so you can call the office and ask for Susan. If you can wait, III do it tomorrow. Tell her the file should
be in the sorter in the general file area if you call.
-Pamela
From: Jack Sullivan Backsu1153@comcast.net]
Sent: Monday, May 21, 2012 11:36 AM
To: DelleChiaie, Pamela
Subject: Re: 32 Deer Meadow
Pamela,
Would you happen to have a septic as-built (or worst case septic design plan) for 32 Deer Meadow?
Hope you enjoyed the weekend......thanks.
Sullivan Engineering Group, LLC
Jack Sullivan
22 Mount Vernon Road
Boxford, MA 01921
978-352-7871 phone + fax
From: "Pamela DelleChiaie" <pdellech@townofnorthandover.com>
To: "Bill Dufresne (wrdufresne@comcast.net)" <wrdufresne@comcast.net>, "Benjamin C. Osgood"
<BOsgood@Pennoni.com>, "C&S (pchristiansen@christiansenandsergi.com)"
<pchristiansen@christiansenandsergi.com>, "Sullivan Jack (jacksu I I 53@com cast.net)"
<jacksuI153@comcast.net>, "John Morin" <John@NeveMorin.com>, "Jim Scanlan"
<jim@scanlanengineering.com>, "Greg Saab" <ess-g reg @corn cast.net>
Cc: "Susan Sawyer" <ssawyer@townofnorthand over.com>, "Michele Grant"
<mgrant@townofnorthandover.com>
Sent: Friday, April 29, 2011 1:11:24 PM
Subject: Septic-Town of North Andover- Septic As-Built Plan Checklist
To: Septic Plan-Engineers
FYI-Attached is the most recently updated Septic As-Built Checklist that should be used as a guide prior to
submitting any Septic As-Built plans to the Health Department. Please call the office if you have any
questions. Thank you.
fiat RC944 a,
Pamela DelleChiaie
Departmental Assistant I Community Development I Health Department
Town of North Andover
1600 Osgood Street I Bldg 20 1 Suite 2-36
North Andover,MA o1845
S Office-978-688-9540
2 Fax-978-688-8476
Email-pdellechiaiePtownofnorthandover.com
`1� Website http://www.townofnorthandover.com/Pages/index
"We can never see the path of our life if we are too busy focusing on the pebbles under our feet."--Anonymous
3
Commonwealth of Massachusetts T
City/Town of
System Pumping Record �A .� Q}
F Form 4 TOWN OF NORTH ANDOVER
M HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, bu e
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Left/ 51 —ht—rear--Of hous Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address ^� 5
Cityrrown t v� State Zip Code
2. System Owner:
Name
Address(if different from location)
Cityrrown State � Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) 2-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5: Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
atueHaulev Lowell Waste Water
Date
form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
_ u City/Town of rRECEiD
} System Pumping Record
Form 4 1-AR 3 0 2011
DEP has provided this form for use by local Boards of Health. OtherAnMNAIM.W
information must be substantially the same as that provided here. Be ith your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left front of house, right front of house, left side of house, right side of houseCLeft>
aro ight rear of house, left side of building, right rear of building, under deck.
�a-5 � C"'a-si- oj�A�
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
CitylTown Sta T� _ C 7 ode
Telephone Number ??yyC`''
B. Pumping Record r-?- -(
1. Date of Pumpingl 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑'No If yes, was it cleaned? ❑ Yes ❑ No
5. Conditi n of S�U�� Ca4a�
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Location where contents were disposed:
G.L.S.D. Aovfell Waste Water
Signatur of (U ler Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
�LN Commonwealth of Massachusetts R CEIVED
City/Town of
System Pumping Record OCT 2 0 2009
Form 4
M 3• TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Oth s may be used, but the
information must be,substantially the same as that provided here. Before using this form, check with your
local Board of Health tQ determine the form they use. The System Pumping Record must be submitted to
the local Board of Health orotber approving authority.
A. Facility Information
1. System Location: Left side ht side of house, Left front of house, Right front of house,
Left rear of house, g rear of hou eft rear of building. Right rear of building.
Address
Cityrrown \VUV V\ State Zip Code
2. System Owner:
Name �lJ
Address(if different from location)
City/Town State/17
n �?_ dip Cpole�
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ai o� If yes,was it cleaned? ❑ Yes ❑ No
5. Condition
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location wher contents were disposed:
L.S.D ' Lowell Waste Water
Signature of Hauler Date
t5form4.doc•06/03 System Pumping Record.Page 1 of 1
R%E C -IV Ea
L4 Commonwealth of Massachusetts
City/Town of AUG 1 S 20
System Pumping Record TOH A°LTHDPA�HH AANNryTER
Form 4
DEP has provided this form for use by local Boards of Health.Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form,check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
Important.
When filling Y
llin out 1. System Location:
forms on the
computer, use
only the tab key Address
to move your
cursor-do not Cityfrown State Zip Code
use the return
key. 2 System Owner:
Name
Address(if different from location)
Citylrown State � TJC�/
r �
TelepgoneNumb6r
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes LJ496If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
0� �&� t'e'�J- '� s� 4
6. System P m �Y: i O �\
Name Vehicle License Number
Company
7. Locatio e e corftptsjvdiem� sposed:
^—
Sign a ler Date C�
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
t
< 'a Commonwealth if Massachusetts
City/Town of NORTH AND MASSACHUSETTS
S .stem Pum in Record
ccr 1 zoos
Form 4 p g
;.i•lE
DEP has provided this form for use by local Boards of Health. The System—Pumping Record mu:
be submitted to the local Board of Health or other approving authority,
A. Facility Information -
Important:
When filling out 1. System Location:
forms on the
computer, use
only the tab key Address --------------..._ i _
to move your
cursor•do not Cit /Town
use the return y ., State Zip Code
key.
2. System Owner:
Name
Address(if different from location)
City/Town -- --•__..__._____-- State _ _–_----- – '—
� Z
� ipe
�
Telephone Number
B. Pumping Record
Date of Pumping e5o b
Date 2 Quantityumped'
Gallons
ype of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
17 lother(describe): - —----- - _._____._..____._
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
r
5. Condition of System:
6. Sy em Pumped By:
ame
�. Vehicle License Number
c5 ,
V Q '
Company —
7. Location where contents were disposed:
*H4&of Date -- '- '�— ----hap://www.mas§igov/d.ep/water/oKprovals/t5forms.htm#inspect
t5form4.doc-06/03 System Pumping Record •Paget of
ill' t
1 \
TOWN OFN0$TH ANDOVER
SYSTEM PUMPING RECORD WA
DATE A L,a •
SYSTEM OWNER&ADDRESS SYSTEM LOCATION
fa.5 Tohnny�gKrz S'T
Norte C?Nwoe►; Mel
DATE OF PUMPING QUANTITY PUMPED
CESSPOOL NO YES SEPTIC TANK NO YES--�
NATURE OF SERVICE: ,RQUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION'S FULL TO COVER
4AVY GREASE BAFFLES IN LACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS •FLOODED
SOLID CARRYOVER OTHER EXPLAIN
SYSTEM PUMPED BY D
COMMENTS:
CONTENTS TRANSFERRED TO S
l/
0 Commonwealth of Massachusetts +,? '7
Massachusetts
System Pumping Record
System Owner System Location
V
N.
Date of Pumping: — Quaf City Pumped: j(3nLJgallon9
� Q �— c7
Cesspool: No Yes U Septic `yank: No n Yes/-K;c
System Pumped by: gawelf S#wvi w License#
Contents rrts trarrsferrred to : Greater Lawrence D Sanitaryistrict
Date: Inspector:
4
t
t
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
Y
F RE
f
Yt
Al1':-ii G 2004
TITLE 5 �duRTH ANDOVER
OFFICIAL INSPECTION FORM—NOT FOR VOL Tov�;� TS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: /7�0 .
Owner's Name:
Owner's Address:
Date of Inspection:
Name of Inspector: (please print) %, Qrr, set
Company Name:
Mailing Address: -q7-.
Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title.5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
ails
Inspector's Signature: Date: 1, 3
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 re!nional office of the
P
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time"of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
— CERTIFICATION(continued)
Property Address:/4 C � 4l(1�a&S
, �v r n
Owner: ,L J
Date of Inspection: —
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:
r/ I� One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired:The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the 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.
ND explain:
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
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 obstructed 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:
2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: l 6 2 '
.._. nrn1 vP r�c�
Owner: 1IV
Date of Inspection: —O
C. Further Evaluation is Required by the Board of Health:
1 ►t 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(l)(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
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 coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: Tun. ,, T.
hn , ( �I(e ?
Nn_ CAJI_�CVfw1. ))10
Owner: 1-1,N I � •
Date of Inspection: q — -
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
'r Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z 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.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public well.
.,� Any portion of a cesspool or privy is within 50 feet of a private water supply well.
-,,-Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
(Yes/No)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:4/4stem
To be considered a the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to4ach of the following:
(The following criteria apply to large systems in addition to the criteria above)
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.I1 of a public water supply well .
4.
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: / -Z5L 4n )n� �A ;f
ff , > Cllr
Owner: !
Date of Inspection: 73
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:
Yew no
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)[3 10 CMR 15.302(3)(b)]
5
Page 6 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: igs S-f
)�
Owner: L1 '
Date of Inspection: 9• � -b
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):t� Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): s/
Number of current residents:
Does residence have a garbage grinder(yes or no): /t/u
Is laundry on a separate sewage system(yes or no):Wu [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(yes or no): HO
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gvd
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:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no): Ll
If yes,volume pumped:/ // .` gallons--How was quantity pumped determined?
Reason for pumping: l"
TYPE OF SYSTEM
_IZSeptic tank,distribution box,soil absorptian 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:
Were sewage odors detected when arriving at the site(yes or no):%/ o
6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
-01f)Property Address: . J
Owner:Lj j
Date of Inspection:
BUILDING SEWER(locate on site plan)
Depth below grade: �.
Materials of construction:_cast iron,-' 40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
r
SEPTIC TANK:I t , (locate on site plan)
Depth below grade: 4�
Material of construction: - concrete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: S
Scum thickness: 1 "
Distance from top of scum to top of outlet tee or baffle:? °
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: 4// S/J'l
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
/.e.,J /"/1//"l/%%yl/ 4/d-1'G 1 .r 5;ry-1
J
GREASE TRAP: (locate on site plan)
Depth below grade:_
Material of construction:_concrete - metal fiberglass polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
f
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
—� SYSTEM INFORMATION(continued)
Property Address: !4r � nhnn, I-,yb �f
1 )r rl.l �' .►T
Owner: J
Date of Inspection:
TIGHT or HOLDING TANKM/ tank must be pumped at time of ins ection locate n site 1
( P P P )( o Pan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOXY!'."5 (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 or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
a ,
8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1 q 7-0L,0L,a1( %)If St
Owner: 1
Date of Inspection: - —
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type t o
leaching pits,number: ,
leaching chambers,number:
leaching galleries,number:
--f'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.):
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 or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 11 of 11
r
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
--�
SYSTEM INFORMATION(continued)
.�I
Property Address: , nhnq i LI/// J
4))-() 8 A yad ,11 ISI .
Owner: ,L_ 1 aIUT
Date of Inspection: 18
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet ) ,
f Y
Please indicate(check)all methods used to determine the high ground water elevation:
ined from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked.with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
T/ %r a F Tiz r--dlr ue _2 /7,p w/,t- I
42
r
r a y
1
1
z
� k
DelleChiaie, Pamela
From: DelleChiaie, Pamela
Sent: Tuesday, June 26, 2012 12:22 PM
To: 'Jack Sullivan'
Subject: 1.R. - 125 Johnny Cake Street, North Andover, MA 01845
Attachments: 2O12O6261153O7393.pdf
Hijack,
I noticed that the T-5 report was cut off at page 15,so here is the revised scan................
Hijack,
Here is the information you requested for 125 Johnny Cake-Title 5 AND As Built in the attached scanned
copy.... O
Hope all is well. Enjoy your afternoon!-
Pamela DelleChiaie
Health Department
Town of North Andover
1600 Osgood Street ! Bldg.20 ! Suite 2-36
North Andover,MA 01845
Phone 978.688.9540
Fax 978.688.8476
Email pdellechiaie(@townofnorthandover.com
Web www.TownofNorthAndover.com
1
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.,_,c�s �/+� GR o� p�� /� -•.fin •� ,-- _-�'�._'
x,..�
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�'4itti ."`�`-:"-.r.`tti:`�Y-.lat.Zjl,gr.
Commonwealth of Massachusetts '
City/Town of i
System Pumping Record MAR. 1 U
Form 4 TOWN O INORTIi!`tNDI,3V,R
WEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be—use , bud e
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use,The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Left I i ht rear of hous Left/right side of house, Left/
Right side of building, Left/Right front of building, Left[Right rear of building, Under deck
Address 1
City/Town state Zip Code
2. System Owner:
Name V
Address(If different from location)
Cityfrown State Zip Code
�j�r7- 1�
Telephone Number
B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
[❑ Other(describe):
4, Effluent Tee Filter present? ❑ Yes No if yes,was it cleaned? ❑ Yes ❑ No
5: Condition of System:
00� -61,Au
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
/6-L.S.p Lowell Waste Water
SignAtule Haule Date
Worm4.doc•06/03 System Pumping Record•Page 1 of 1
'l
i
1
Commonwealth of Massachusetts
City/Town of ���
System Pumping Record
Form 4 I'M s 0 2 011
DEP has provided this form for use by local Boards of Health. Other rTnQA I
information must be substantially the same as that provided here. Be M! ith your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left front of house, right front of house, left side of house, right side of houseCLeft>
ea� ?right rear of house, left side of building, right rear of building, under deck.
Clty/rown Stele zip Code
2. System Owner:
Name
Address(if different from location)
City/Town Sta �� � r�7�ode
Telephone number
B. Pumping Record
1. Date of Pumping Date ` 2. Quantity Pumped: G�
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 2-Np If yes,was it cleaned? ❑ Yes ❑ No
5. Condit n of System:
v� [OuA
c.�
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc. _
Company
7ISignatur
where contents were disposed:
o II Wast W
uter Date
t5form4.doc•08103 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
atva City/Town of RfiCEIVED
System Pumping Record F(HE'Al-11H
C T P 0 N0`3
Form 4
), N()ffr1i AND VER
[)FF'fiRU%,l N-rDEP has provided this form for use by local Boards of Health. Oth be used, but the
Information must be.substantially the same as that provided here. Before using this form,check with your
local Board of Health tQ determine the form they use.The System Pumping Record must be submitted to
the local Board of Health avothe'r approving authority.
A. Facility Information
1. System Location: Left sideous t side of house, Left front of House, Right front of house,
Left rear of house, rear of hou eft rear of building. Right rear of building.
Address
Citylrown Slate
Zip Code
2. System Owner:
Name _._.
Address(if different from(ocation)
cdyrrown State 8'7
,( de
Telephone Number Jv'
B. Pumping Record
1. Date of Pumping
ping Data 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes,was it cleaned? ❑ Yes ❑ No
5. Condition System:
6. System Pumped By:
_Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company –
7. Location whe contents were disposed:
.L.S.D Lowell Waste Water
—
Signature of Hauler Date —�- —
t5form4.docc 06103 System Pumping Record•Page f of i
t�
iK6 'tom-k,.> V,
AD-\ Commonwealth of Massachusetts
tc".,iIAUG ct;t;GCit /Town of
System Pumping Record
"IEN
Form 4 e. ..
DEP has provided this form for use by local Boards of Health.Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form,check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
Important: *�
when fining out 1. System Location:
forms on the
computer,use
only the tab key Address
to move yourd/(-/
cursor- not
use the ret
urn �yrr� State . Trp Code
key. 2. System Owner:
Name
Address(if different from location)
City/Town State
TetepYona um
B. Pumping Record
Q=-
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 1Q if yes,was It cleaned? ❑ Yes ❑ No
5. Condit io of System:
6. System P m ed
Name Vehicle License Number
Company
7. Locatio e icor eats disposed:
Signet rer Date
t5form4.doc-06103 System Pumping Record-Page 1 of 1
' ;cwG:.�t,y.�a�`}`���^til:,h°i'�L}ii.��'i'0.;''J•':5: .i„'., �
\ Commonwealth of Massachusetts _
it' Qwn,,of . ORTH ANDOVER MAS MUS T`TS
.System PumP1ng Record O�; roo
�: Form 4
DEP has provided this form for use by local Boards of Healk The System umping Record mus
be submitted to the local Board of Health or other approving authority,
A. Facility information -
Important,
When filling out I. System Location: _
forms the / y
computer,use
only the tab key Addr�'._ ----..” G���L`����_,_,�_ --•-'---.. . .
to move your
cursor•do not .. _
use the return city/fawn slate — ____,-_•__-_-•._
key. Zip Code
y 2, System Owner:
Name
Address(IfdlNerentfromlocatlon) ••'•`- ------•-••••---•----'•••----•--•---.�..__.__...__
Clty/Town
Telephone Number
B. Pumping Record - -
Date of Pumping ' pa �� 2 Quandt Pumped:
Date y p Gallons
ype of system: ❑ Cesspool(s) Septic Tank
❑ Tight Tank
❑ other(describe): `_....._..-..._--
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes [] No
S. Condition of System:
8. Sy em Pumped By:
'C vehicle License Number
Company
7. Location Where contents were disposed:
at a of Hsu
ter/ proyals/t5fohtp:llwww.m / a. depwrms,ht0inspect pet
e -- - -- ---
WormCdoc-06103
System Pumping Record-Page 1 of 1
-77
TOWN OF'NOWrH ANDOVBR
SYSTEM PUMPING RECORDI'E` 4
DATSLIija ' .
SYSMM OWNER&ADDRESS SYSTEM LOCATION
Ltw' T
/as oAnWo-aka sor
NMrM GN cover ml/(. .
DATE OF PUMPING / QUANTITY PUMPE
/ " D f r�
CESSPOOL NO Y'ES,,,�_
s SEPTIC TANK NO YES•—. ---
NATURE OF SERVICE:;,RQV'I'M; EMERGENCY
OBSERVATIONS;
GOOD CONDITION".:.,- '/ FULL TO COVER
HPAVY GREASE BAFFLES IN LACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS •FLOODED
SOLID CARRYOVER, OTHER EXPLAIN
SYSTEM PUMPED BY D
COMMENTS:
CONTENTS TRANSFERRED TO
rr
d
Commonwealth of Massachusetts
Massachusetts
System Pumping Record
System Owner System Location
/j . y
Date of Pumping: �' --� — �`7 Quantity Pumped: [( 'e-igallons
Cesspool: NoU-- Yes Septic Tank.- No LJ Yesxc
System Pumped by: varedea sfi4r tijd License#
Coutents Iransferrred to : Oteater L wrgnce Qpulta ylj$trict
Date:_ _ Inspector:
f
1
• COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
a
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECE F-0
A U 1 10 2004
TITLE 5 Llllwo,yr ia"A=Ts
OFFICIAL INSPECTION FORM--NOT FOR VOL
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: n
Owner's Name:
Owner's Address:
Date of Inspection:
Name of Inspector: (please print) '"t6lf
Company Name:
Mailing Address: ,
Telephone Number:
CERTIFICATION STATEMENT
1 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
Needs Further Evaluation by the Local
Approving Authority
ails
Inspector's Signature: Date: T, 3— a y
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
""This report only describes conditions at the time f 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 some or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
gage 2 of I 1
d
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Pro erty Address: _,S
OV M17-
Owner:
'lI.Owner L )
Date of Inspection:
Inspection Summary: Check A,B,CDorE/ALWAY complete all of Section D
A. 7ystePasses:
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:
LOne 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.
Answer yes,no or not determined(Y,N,ND)in the 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.
ND explain:
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 Hoard of Health):
broken pipe(s)are replaced
obstiudion is removed.
distribution box is leveled or replaced
ND explain:
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
obstruction is removed
ND explain:
2
n Page 3 of 11
0
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
I roperty Address: (
Owner:. IV
Date of Inspection:
C. Further Evaluation is Required by the Board of Health:
N� 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(i)(b)that the
system is not functioning in it 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
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 I 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 coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
i
' E
I
3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Na
owner:t_tf
Date of Inspection:
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 bA above outlet idvert due to an odrerloade&or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than%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.
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 Iess than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis, [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well Is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
(Yes/No)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 la ge system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"br•"no"to-'gach of the following:
(The following criteria apply to large systems in addition to the criteria above)
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 z;
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: )
Owner:
Date of Inspection:
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 ofthe system components pjpmped opt in the previous two weel4s?
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:
Y ,no
Existing information.For example,a plan at the Board of Health.
t
_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)(3 10 CMR 15.302(3)(b)]
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Page 6 of 1 l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: JJ .
Owner:
Date of Inspection: -
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):(L Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): ,/e
Number of current residents: 7
Does residence have a garbage grinder(yes or no): &
Is laundry on a separate sewage system(yes or no):770 [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or n6):_L&
Water meter readings,if avai))able(last 2 years usage(gpd)):
Sump pump(yes or no): Hd
Last date of occupancy:
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,ctc.):
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:
OTHER(describe):
GENERAL INFORMATION
Pumping Records I
Source of information:l/d _
Was system pumped as pail of the inspection(yes or no):
If yes,volume pumped:/11z gallons--How was quantity pumped determined?
Reason for pumping:
TYPE-OF SYSTEM
_Jzl4ptic 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:
Were sewage odors detected when arriving at the site(yes or no): da i
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Page 7 of 11
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OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: J 'Wn ki ra.�
Owner:
Date of Inspection: ~ ��—
BUILDING SEWER(locate on site plan)
Depth below grade: .s
Materials of construction:_cast irony-' 40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on conditiz'Of�joints,venting,evidence of leakage,etc.):
SEPTIC TAN4"'}(locate on site plan)
Depth below grade:
Material of construction: --concrete_metal_fiberglass_polyethylene
—other(explain)
If tank ispetal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificpte)
Dimcfisions: �G_(> ' /_ S'If
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: _
Scum thickness: /
Distance from top of scum to top of outlet tee or baflle:7
Distance from bottom of scum to bottom of outlet tee or baflle:.1_�/
How were dimensions determined: t9/1 I'l71
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
�(locate
GREASE TRAP: on site plan)
Depth below grade:
Material of cortsfiuction; c`operete=metal fiberglasspolyethylene F other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
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Page 8 of-1 i
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:Jar-:1_ � .
Owner:
Date of nspection:
TIGHT or HOLDING TANK! ft {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: n. Gallons
Design Flow: gallonsiday
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Continents(condition of alarm and float switches,etc.):
DISTRIBUTION BOX-YI.5 (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.):
a
PUMP CHAMBER: (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,etc.):
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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: - r 3�
Owner: )
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
pits,number: 4
leaching chambers,number:
leaching galleries,number:
�--77 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.):
Alo
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 or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
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Page 10 of 11
o '
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE flMSPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM'INFORMATION(continued)
Property Address:
Owner: --
Date of Inspection:
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.
jj o
i3- CP
lbw (//q i> "
Li
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Page 11 of 11
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: r )P
f� ) Cl .
Owner;
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water;<<E feet ,
t
Please indicate(check)all methods used to determine the high ground water elevation:
_L Obtained from system design plans on record-If checked,date of design plan reviewed: / 3
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:
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0 VER
a COMA
21 i 4..i.;•+n.,o.w�f�..H,Cu.rr.+a ^'t.. Mo.w
ro '+i r•
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R-yard Of Health
idux'th Andover,2�Srine. SEPTIC SZSTF.H �
INSTAT•LATICK CHECK LIST LOT
�P OVED DATE DISUPROVED X AVATZCSI OK FAIL
— easnnst
A
SIL OK
1. Distance Tot SYS( wA5 �COGoT
a. wetlands
b. Drains
c.. Well
2. Water Line Location
3. No PVC Pipe
4. Septic Tank
a. _Tees -_Length & To Clem Out Covers
b. Cement Pipe .to Tank On Both Sides of Tank
5. Distribution Box
a. Covers & Box - No Cracks
b. All Linea 'Flowing Equal. Amounts
c. No Back Flow
6. Leach Field or Trench
a. Dimensions
b. Stone Depth
c. Capped Ends
d. Clean Double'Washed Stone
7. Leach Pits
a. Dimensions
b. Stone Depth
c. Splash Pads
d. Tees
e. Cemmt Pipe to Pit - Both Sides
f. Clean Double Washed Stone
8. No Garbage Disposal
9. Final Grading Inspection
10. Barricading Covered System
li. As Built Submitted
a. Lot Location
b. Dimensions of System
c. Location with Regard-to Pere Test
d. Elevations
e. Water Table
TOWN OF NORTH ANDOVER, MASSACHUSETTS
OFFICE of
CONSERVATION COMMISSION
AoRTN
�=O•',,,ad ,,.. 0 TELEPHONE 683-7105
�'SSAGNUS�S�
Pursuant to the authority of the C;etlands Protection Act,
Massachusetts General Laws Chapter .131, .,Section 40, as ar'ended,
-"-- - ana r� e Tomv- u imdovet' s''wetla'C, Pro�,s-ction By Law, the
North iuxLover Conservation Coimission Will hold- a Public Iieetind
on October. 24, 1984 at,'•8 :00, P.M.;. at:'.the To�m,Buildinb
etin� oom, n` Stteet, Worth Atiddver, 1, on the ['etland
Determination 4e.Ve.st:,of 114 Associates Realty Trust
land located at .. Lot 1�5 Willows Industrial Park
may: A. Galvagna
Chairman, NACC
run once in the N.A. Citizen on October 18, 1984
Copies sent to:
Plannino, Board
-_-Board .o r Hejl�Eh
Public i.orks
C.
Hi hwQy Dept.
Applicant
Engineer
DEQE