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HomeMy WebLinkAboutMiscellaneous - 126 VEST WAY 4/30/2018N O N b m o cn � � D O O MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza Boston, Massachusetts 02108-1904 (617) 723.3800 Ma Only (800) 392.6108, FAX (800) 851-8424 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec.36 NORTH ANDOVER BUILDING COMMOSSIONER NORTH ANDOVER TOWN HALL NORTH ANDOVER MA 01845 Re: Insured: Property Address Policy Number: Type Loss: Date of Loss: Claim Number: CM 6021 DARLENE MARCKINI 126 VEST WAY, NORTH ANDOVER, MA 01845 1277847 Ice Dams 02/18/2015 332478 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1000.00 or cause Massachusetts General Laws, Chapter 143 section 6 to be applicable. If any notice under Massachusetts General Laws Chapter 139 Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. MPIUA Claims Division 2/27/2015 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address- 10 4i, UeS-� C4 Owner: Date of Inspection: jc-) r a 5-9'1-7 B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static'water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s) are replaoed obstruction is removed distribution box is levelled or replaced . The system required pumping more than four 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 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH. AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption "system (W) and the SAS. is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone i of a public water supply well. The system has a septic 'tank and soil absorption system and the SAS is within 50 feet of a private water Supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet of More from a private water supply well, unless a Well water analysis for tolifotm bacteria and volatile organic cohipounds IndiiAes 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. Method used to determine distance ,_, ,..tappiOxWation •trot valid). 3) OTHER (revised 04/25/97) IPA" 2 Ot 10 , v. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: , co vgW Owner: f,:5 ,J C Yl S Date of Inspection: D) SYSTEM FAILS: ' You must indicate either "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to comect the failure. Yes No Backup of sewage into facility or system component due to an 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 Vzclay 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 Soil Absorption System, cesspool or privy Is below the. high groundwater elevation. Any portion of a 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 I of a public well. Any portion of a cesspool or privy is within 50 feet of a private Water supply well. Any porion 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment_.because bne.or snore of the following conditions exist: 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 li of a public water supply well) The owner or operator of any such system shall bring the system and facility into full bompliarice with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. . r� (revised 04/25/97) Pay 2 of 16 . t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .'PART B CMECKLIST Property Address: i,-� w Vk,4 ; Owner: Date of Inspection:to 3,5--q Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes o Pumping information was provided by the owner, occupant, or Boatd of Health. Y None of the system components have been pumped for at least two weeks and 'the system has been feceiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non -sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components;, excluding the Soil Absorption System, have been located ort the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dirrtensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub -Surface Disposal System. Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(30}] e (revised 04/2%/97) iao,4 61 10 r �, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM s PART C SYSTEM INFORMATION Property Address: Owner: Date of Inspection: lo FLOW CONDITIONS RESIDENTIAL: Design flow: !-Ara g!p. /bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: Garbage gander lyes or no): 2-s Laundry connected to systQm, or no):-Y� Seasonal use (yes or no) _r" k /?�- 't l Water meter readings, if available (last two (2) year usage (gpd):`'1 1 x Sump Pump lyes or no): UICU c'3 S Qt3 Last date of occupancy: COMMERCIAUINDUSTRIAL: �g+ Ll Type of establishment: Design flow: gallons/day / D Grease trap�' `� present: lyes or no)_ /,4 Industrial Waste Holding Tank present: lyes or no)_ Non -sanitary waste discharged to the Title S system: (yes or no),_,; 4V ex Water meter readings, if available: last date of occupancy OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or ho)—L/(? If yes, volume pumped: gallons r Reason for pumping: TYPE O�EM 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) VA Technology etc. Copy of up to date contract Llflli APPROXIMATE AGE of all Fomponents, date installed (if known) and source of information:._ ( �'— �' C?3 . OL Aj Sewage odors detected when arriving at the site: (yes or no)d (revised 04/25/97) fags 6 a lb - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: (a vQz,;A- W IUOc` � Owner: Rux'fl S Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construdiom. cast iron _ 40 PVC other (explain) Distance from private water supply well or suction line; Diameter Comments- ( o dltion off joints, venting, evidence of leakage, etc.) NO SEPTIC TANK:. F/ t U (locate on site plan) t tf ( 1 r Depth below grade:[ Material of construction: _Leb"�ncrete metal _Fiberglass ,_,,,Polyethylene _othtr(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance(Yes/No) Dimensions. ori (� 't YiC%• `j S�AD"""� + Sludge depth: ' Disiance from top of sludge to bottom of outlet tee or baffle: Scum thickness: n t� 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 dimensions were determined: Comments: (recommendation for pumping, conditio of inle and outlet tees or baffles,depth of liqu' level i lotion to utlet©vP stryt) integrity evid rice of leakage etc.) �k- 1 t� p� TWO ( — 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 of baffle: Distance from bottom of scum to bottom of outlet tee or baffle:. Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees of. bafflesr'depth of liquid level in telation to outlet invert, structural . integrity, evidence of leakage, etc.) All (revised 00/25/97) jag* i bi 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION. FORM PART C SYSTEM INFORMATION (continued) Property Address: UQs-4- �dr VQ� Owner: V r j Date of. Inspection: to_a g7 , TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level:_ Alarm in working order _ Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: v (locate on site plan) Depth of liquid level above outlet invert: d Comments: ��, l�•c�� (note if lexel and,distribution t equal, evidence of solids carryover, evoe" of leakage into or out of bob:, etc.��„_�r,..,�t,,, PUMP CHAMBER:Wlne-�(k(-C i,!); (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.) (revised 04/25/97) Page 1 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFOFMATION (continued) Property Address: L is v e-�� W Owner:Yl `3 Date of Inspection: f0 a S Q SOIL ABSORPTION SYSTEM (SAS): t� (locate on site plan, if possible; excavation -bot required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: t 1 leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note corjditiorl of soil, signs of hydraulic failure, level of ponding, condition of vegetation,. etc.) A OJ\ \KC' -t , CESSPOOLS: Y\OAP,— (locate on site plan) Number and configuration: Depth4op of liquid to inlet invert: , Depth of solids layer: — Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: ! inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc:) PRIVY: f �t�, (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.) (revised 04/2S/97) lhgi I.dt �0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: DLG \j Qa;k W a, Owner. ��hS Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) ,5 f. k41 _ 34 Yl dal Sri a-�,(✓ � � ty 1, b Pe 44`Q V 5 611 Ljr716 If = & C)16 It o ° o a w 12> I& ♦ n. I nom^ (revised 04/2S/97) y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: V v Owner. Date of Inspection: (c) Depth to Groundwater \ Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtain from Design Plans on record . L-- /Orvation of Site(Abutting property, observation hole, basement sump etc.) t/ Determine it from local conditions T --Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Mu!d be completed) (zaviaue 04/25/47) pagi 10 of 20 I f TEL: (508) 475-1474 FAX: (508) 475-5451 1 -� BATESON ENTERPRISES, INC. Excavating - Water & Sewer lines - Septic Systems & Pumping Service 1 11 Argilla Road & Andover, Mass. 01810 Title 5 Inspection Report I a 6 V e.:�_Wc("A Property Address:----- - owner: ---------__--------------- 1 a—a5"-4ti Date Of Inspection: ---------------- My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. s Neil J& Bateson Bateson Enterprises Inc, M WILLIANI F. WELD Governor ARGEO PAUL CELLUCCI Lt. Governor COMMONVX'EALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTME'XT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON. NIA 032108 617-202-5$00 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTI��TION ' Property Address: �`� VR- -� �..;� .'v ` 0kwos of Owner: Date of Inspection: 1ja— o� �% Of different) . Name of Inspector ��- I am a I)EP Prov system inspector pu" uant to Section 15.340 of Title S (310 CMR, 15.000) 3 Company Name: Mailing Address: Telephone Number: TRUDY CORE . Secm kry DAVID B. STRM Commissioner 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 inspection. The inspection was performed based on my training and experience In the proper function and maintenance of on-site sewage disposal systems. The system: Pas onditionally Passes N s Furt r Eval ion By the local Approving Authority i�497Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Appioving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 16,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional offite of the Department of Environmental Protection, the original should be sent to the'system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, 4, C, or b*, A] SYSTEM PASSES: I have not found any information which indicates that the system Violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.-,.- COMMENTS: elow.-, COMMENTS: B] SYSTE NDITIONALLY PASSES: One or more system components as described in the 'Conditional Pass" section need to be replaced or repai the system, upon comp 'on of the rep) meat or ir, as roved by the card a Hea wi s. Cr.���9 Indicate yes, no, ermined (Y, N, or Nb . Describe :s of deteiiniriatio6 ih all lkanees. it not determined"i explain why not. _ The septic tank is metal,, unless the owner or operator has provided the system inspector with a t oopy of a Certificate of Compliance (attached) indicating that the tank was installed withih twenty (20) years prior to the date of the inspection; or the septic tank, whether or trot metal, is cracked, structurally unsound, shows substaniniiltratlon or exflltratiori, or tank failure is imminent. the system will pass inspection 0 the existing septic a FC is—rept with a conforming`` septsept:c tank as approved by the Board of Health. W (revised 04/25/97) *age i t)f 10 DEF' on Me Worid Wide Web: MtPINW -1109 et state.nal.Meo PmN w on heeled Paper �d5 � 2 3S ..�-r � � � �_� Board o IICal-ua North Ando_Y Maaa. SEPTIC SISTEK -- — INSTALLATICK CHECK LIST LOT Sy rJT EXCAVATION 01 FAIL OK 1. Distance Tos - a. Wetlands b. gains - c. Well 2. Water Line Location -3. -,110 PM Pipe - Septic Tank ' - �._ _ �.. _. ,_ . -a. -_Teas -_Length k To Clean Oat Corers . _ .. b.. Cement Pipe to Tank -- Cn Both Sides of Tank 5. Distribution Box - a. Covers & Box - No Cracks b. All Lines Flooring Equal. Amounts c. No Back Flov 6. ' Leach Field or Trench a. Dimensions b. Stone. Depthi� c: Capped Ends 3 d. .Clean Double Washed Stone 7. Lead is a. cions - b. Stone Depth Splash Pads . Teas e. Cmaent Pipe to Pit -Both Sides f. Clean Double Washed Stone 8. No Garbage Disposal 9. -Final Grading Inspection 10. Barricading Covered System 11. As Built Submitted _ a. Lot Location - - - b. Dimensions of System c. Location with Regard -to, Perc Test d. Elevations e: Water Table Board of Health smdover,Mass SUBSURFACE DISPOSAL DMON CHECK LIST LOT 5� ✓ESTu/A� APPROVED DATE DISAPPROVED DA'I'gl,,_ Provided: Reasons: Title V FAIL, OK . Reg 2.5 The submitted plan must show as a minimum: be dimensions lot #,abutters a) the lot to served -area, holes -distance to ties location and log deep observation location and results percolation tests -distance to ties c design calculations & calculations showing required leaching area (e) location and dimensions of system -including reserve area ) existing and proposed contours g) location any wet areas within 100' of sewage disposal system or disclaimer -check wetlands mapping (h) surface and subsurface drains within 1001 of sewage disposal (i) system or disclaimer location any drainage easements within 100' of sewage disposal system or disclaimer -Planning Board files (j) knov= sources of cater supply within 2001 of sewage disposal a k system or disclaimer location of any proposed well to serve lot -1001 from leaching facility location of water lines on property -10' from leaching facility location of benchmark driveways o garbage disposals p) no PVC to be used in construction (q) profile of system -elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets: distribution field piping and } ®tter elevations maximam ground water elevation in area sewage disposal system S plan must be prepared by a Professional Engineer or other professional authorized by lair to prepare such_ plans Reg 6 (a) Septic Tanks —a—acities_of flog:, meter table, teas, depth of tees, cp pumping kaccess, b cleanout 101 from cellar mil or inground suLmning pool d) 251 from subsurface drains Reg 10.2 Distribution Boxes Rope greater gran 0.08 L-1 Reg 10.4 b} sump e Design Check `�, I FAIL I OK 2 Leaching Fits Leaching pits are preferred where the installation is possible a) calculations of hing area -minimum 500 sq ft b) spacing c) surface a 2% d) cover erial e) k'x2t 0 splash pad f to at elbow g) bends in pipe from d -box to pipe Leaching Fields a no greater t an 20 minutes/inch b area -minimum 900 sq ft c construction of field d) surface drainage 2 % e) 201 from cellar wall or inground swimming pool a) /Ffac s�oleaching area -min 500 eq ft b) t min 6 ft with reserve between c) d) n e) f)inage 2% Downhill Slope a) slope y x = Tto be shown) b) y/x X 150 = (to be shorn) a) royal b stand-by power r1W SOIL PROFILE & PERCOLATION TEST DATA North Andover, Mass. Street No '114:-::�'V w A"-( Lot No !90 Start Saturation Loc/Subd.iv. V-kpra'e S Pland Owner 3P -y C o Soak -Minutes Investigator `��� Observer Imola �- 2 2 SOIL PROFILE DATES Ltlev 2.Elev 3.Elev 4.Elev 3 In 3 Dro of 6" -Time 3 Benchmark Elevation 0 1 0 3 0 Start Saturation Soak -Minutes 2 2 2 0 Ties Test Pi s Drop of 3" -Time 3 3 Dro of 6" -Time 3 -SoNf'( M ms-lst 3" drop 4 4 4 sA-Nt�"( Vi N e- � Percolation 5 6 7 8 9 10 DATES 5 6 7 8 9 10 Location Datum PERCO;,ATION TESTS 5� 6 7 8 9 10 Pit Number 1 2 3 4 Start Saturation Soak -Minutes Start e , Drop of 3" -Time Dro of 6" -Time M ms-lst 3" drop Mins.2nd " Drop Percolation SOIL PROFILE & PERCOLATION TEST DATA �O a .. �•_... Un. RSf rAA�- �� UJLy T.nt No. North An _ -i Loc./Subdiv._ Plan Owner Invest i_gator, _ _ _ Observers kql L SOIL PROFILES -DATE 1' Elev. .- ?' Elev.- Elev. 3' 4.Elev. — 0 0 0 0 Ties to Test Pits Benchmark Elevation 2 2 2 3 3 3 4 4 _ 4 5 6 7 8- 9 10 2 5 6 7 8 9 10 4 5 6 7 8 9 10 Start Saturation NZn Soak -Mins. - Start Test -Time Location Datum Percolation Tests -Date w�.�c-+Z paces ``A) Pit Number 1 2 3 4 S Start Saturation Soak -Mins. - Start Test -Time Drop of 311 -Time - Drop of 6" -Time Nins.lst.3"Dro Z� Mins . 2nd 3"Dro Percolation Rate I