HomeMy WebLinkAboutMiscellaneous - 1260 SALEM STREET 4/30/2018 (2) 1260 SALEM STREET t _
j 210/106.A_01g�0000.0
I
I
Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping-`Record JUL 6 2015
r Form 4 TOWN OF NORTH ANDOVER
z�• HEALTH DEPARTMENT
ENT
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
1. System Location: Left/Right front of house, Left/Right rear of house, Left./ ide of hous , Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under ec
Address
city/Town State Zip Code
2. System Owner.
Name
Address(d different from location)
City/Town ' State a i Code ;
.5
f
Telephone Number
J
B. Pumping Record
1. Date of Pumping Date 2• Quantity Pumped: --=�
Gallons
r
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 of System:
6: System Pumped By.-
Nell.
y:Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Loca' contents were disposed:
GL 8.0 Lowell Waste Water
Signitufe cl HaulwU Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record
M
Form 4 "�R 2C 2013
TOWN OF NORTH ANDOVER
DEP has provided this form for use-by local Boards of Health. Ot erHilM*W6%ThW. bi 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, Left/Right rear of house, Left/ ht �ofhousLeftRight side of building, Left/Right front of building, Left/Right rear of building, Und
Address
City/Town state Zip Code
2. System Owner.
Name
Address(if different from location)
Citylrown Stat Zi Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quante Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition 9f stem:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
4te
e contents were disposed:
Lowell Waste Water
6�
-- 1
Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
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NOTE. T111,5 I-4/V /S NOT ,4 w.4 e,C'gNTY //4 XENOZ,4 q 1/E. 11,,4VE�P�L��� INC.
4.
OF T/IE 5Y57-EM BUT 4 l�E�fFIC,4T/ON
OF Tf/E LOC.4TION OF T,4IE EXIST/QVC
ST,eL/CTU2E5.
• ' , Heal°th /�
,...r�udover,Mass
SUBSURFACE DISPOSAL DESIGN CHECK LIb Hyp
.LOT j
APPFW-7. ED DATE 5-2Z-`6_5 DISAPPROVED DATE Q,Q
Provideds C% Reasons:
y
title 9 FAIL OK
leg 2.5 The submitted plan must show as a minimums.
a) the lot to be served-area,dimensions lot #,abutters
b location and log deep observation hoes-distance to ties
c location and results percolation tests-distance to ties
d design calculations do calculations showing required leaching area
(e) location and dimensions of system-in.clue mg veservt area
f) existing and proposed contours
(g) location any wet areas within 1001 of se rage disposal system or
disclaimer-check wetlands mapping
(h) surface and subsurface drains within 100 of sewage disposal
system or disclaimer
(i) location any drainage easements within 1101 of sewage disposal
system or disclaimer-Planning Hoard file. :
(J) known sources of water supply within 00, of sewage disposal o
system or disclaimer
(k) location of azq proposed well to serve lot-1.001 flrom leaching facility
(1) location of water lines on property-10I fom leaching facility
(m) location of benchmark
(n) 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
other elevations
(r) maximum ground water elevation in area sewage disposal system
s) plan mast be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
Reg 6 SepticTankkss
(a) capacities-150% of flow, water table, tela, depth of tees,
access, pumping
(b) cleanout
(c) 101 from cellar wall or inground swimmin, pool
(d) 25+ from subsurface drains
leg 10.2 Distribution Boxes
(a) -slope greater than 0.08
leg 10.4 b) sump
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT � n
27 CHARLES STREET
NORTH ANDOVER,MASSACHUSETTS 01845 "
Sandra Starr,R.S.,C.H.O. (978)688-9540- Telephone
Public Health Director
(978)688-9542-Fax
Ta From:
Fax: q Pages:
\2
Phone: Date: /4557�&
Ltir�
❑Urgent ❑For Review ❑Please Comment ❑Please Reply ❑Please Recycle
Please.call 978-688-9540 for assistance with any questions. Thank you.
xc: Address File
Chrono File
HP Fax K1220xi Log for
NORTH ANDOVER
9786889542
Jul 24 2003 9:18am
Last Transaction
Date Time Twe Identification Duration Pages Result
Jul 24 9:17am Fax Sent 819783867228 1:09 3 OK
i
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
0— k Q r.p (example: left front of house)
ad
DATE OF PUMPING: QUANTITY PUMPED » GALLONS
i
CESSPOOL: NO YES SEPTIC TANK: NO YES
i
NATURE OF SERVICE: ROUTINE V EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY: „�a�
COMMENTS:
CONTENTS TRANSFERRED TO:
0
5 TOWN OF NORTH ANDOVER/
Town of North ?ndover.L MA BOARD OF HEALTH
Watershed Sept is 8 s tc m
servicing report APR 191995
Dater
Homeowner:_ Pumper
Street
_ l��'d . � Andress:—
Phone : 7 / =- - Pl one
Nature of Sarvice: Routine
Emergency
Observation3: Good Condition t/
Full to Cover
Baffles in P1acE c/
Leachf field Runback
Excessive SolidE
Heavy Grease �✓�
Roots
Other (Explain)
Description of Work:
Comments :
NOR74 J q t
Of ,♦1h0 or v V
3A f J ♦ OL
Town of North Andover
"34 HEALTH DEPARTMENT
cNu
CHECK#: �3� DAT �i W6 �S
LOCATION: A4,062
H/O NAME:
CONTRACTOR NAME:
Type of Permit or License:(Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type. $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
S,s�:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Ti�tl. -Inspector $
W Title 5 Report
❑ Other. (Indicate) $
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer
t
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
Zr7 os
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:_1260 Salem Street_
—North Andover_
Owner's Name:_Angie Cheng FRECEIV,r--
DOwner's Address: 1260 Salem Street
_North Andover,MA 01845Date of Inspection: 6/14/2008 UN 2 5 2008
Name of Inspector:_Neil J.Bateson_ EHEAOL
N F NOR A,, !!OVI:R
Company Name:_Bateson Enterprises Inc._ TH DEPkRTMENT
Mailing Address:_111 Argilla Road_
_Andover,MA 01810_
Telephone Number:_(978)475-4786
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
N ds Further Evaluation by the Local Approving Authority
F
Inspector's Signature: Date: _6/14/2008_
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 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 I
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:_1260 Salem Street_
_North Andover—
Owner:_Cheng_
Date of Inspection:_6/14/2008_
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any
information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304
exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system
components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon
completion of the replacement or repair,as approved by the Board of Health,will pass.Answer yes,no or not
determined(Y,N,ND)in the for the following statements.
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:
Title 5 Inspection Form 6/15/2000 2
Page 3 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:_1260 Salem Street_
_ North Andover_
Owner:_Cheng_
Date of Inspection:_6/14/2008_
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
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:
Title 5 Inspection Form 6/15/2000 3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:_1260 Salem Street_
_North Andover_
Owner:—Cheng_
Date of Inspection:_6/14/2008_
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
_No_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
No— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_No_ Liquid depth in cesspool is less than 6"below invert or available volume is'h day flow.
—No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
—No— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
No_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
_No— Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_No— 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.]
No—(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 large system 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"to each 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 1I of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large 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.
Title 5 Inspection Form 6/15/2000 4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:_1260 Salem Street_
_North Andover_
Owner:_Cheng_
Date of Inspection:_6/14/2008_
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
_Yes_ Pumping information was provided by the owner,occupant,or Board of Health
_No_ Were any of the system components pumped out in the previous two weeks?
_Yes_ Has the system received normal flows in the previous two week period?
_ _No_ Have large volumes of water been introduced to the system recently or as part of this inspection?
Yes_ _ Were as built plans of the system obtained and examined?
Yes_ _ Was the facility or dwelling inspected for signs of sewage back up?
_Yes_ — Was the site inspected for signs of break out?
Yes_ _ Were all system components,excluding the SAS,located on site?
_Yes_ 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?
_Yes_ _ 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:
Yes No
_Yes_ _ Existing information.
_Yes_ _ 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)]
Title 5 Inspection Form 6/15/2000 5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:_1260 Salem Street_
_North Andover—
Owner:_Cheng_
Date of Inspection:_6/14/2008_
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):_4_Number of bedrooms(actual):_4_
DESIGN flow based on 310 CMR 15.203_440_
Number of current residents:_1
Does residence have a garbage grinder(yes or no):_Yes_
Is laundry on a separate sewage system(yes or no):_No_
Laundry system inspected(yes or no): _
Seasonal use:(yes or no):_No_
Water meter reading:_Yes_
Sump pump(yes or no):_No_
Last date of occupancy:_Current_
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203):_gpd
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:_Pumped two years ago,owner_
Was system pumped as part of the inspection(yes or no):_Yes_
If yes,volume pumped:_1500_gallons--How was quantity pumped determined?_Measured tank_
Reason for pumping: _Inspect tank&tees_
TYPE OF SYSTEM
X_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 23 years old,11/23/1985,
as per as built plan_
Were sewage odors detected when arriving at the site(yes or no):_No_
Title 5 Inspection Form 6/15/2000 6
Page 7 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_1260 Salem Street
_North Andover_
Owner:_Cheng
Date of Inspection:_6/14/2008_
BUILDING SEWER_X_ (locate on site plan)
Depth below grade:_48_
Materials of construction: __ cast iron _40 PVC_other
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.)
SEPTIC TANK: X
Depth below grade:_36"_
Material of construction:_X 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:_10' x 5'x 4'
Sludge depth:_4_
Distance from top of sludge to bottom of outlet tee or baffle:_21"_
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:-
8"-Distance from bottom of scum to bottom of outlet tee or baffle: 14"_
How were dimensions determined:_
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc._Pumped septic tank.Outlet tee ok. Depth of liquid at outlet
invert.No evidence of leakage._
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.):
Title 5 Inspection Form 6/15/2000 7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_1260 Salem Street
North Andover
Owner:_Cheng_
Date of Inspection:_6/14/2008_
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/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 BOX X_
Depth below grade _18"_
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.) _D-box level&distribution equal.No evidence of leakage.Evidence of
carryover,pumped d-box to clean. D-box cover broken,replaced it._
PUMP CHAMBER:_(locate on site plan)
Pump in working order(yes or no):—
Alarm in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Title 5 Inspection Form 6/15/2000 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:_1260 Salem Street_
_North Andover_
Owner:_Cheng_
Date of Inspection:_6/14/2008_
SOIL ABSORPTION SYSTEM(SAS): X_(locate on site plan,excavation not required)
If SAS not located explain why:
Type
_Leaching pits,number: _
Leaching chambers,number:
Leaching galleries,number:
_X Leaching trench,number,length:_3 trenches 51' long_
Leaching field,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.):_Soil ok.Vegetation ok.No sign of ponding to surface._
CESSPOOLS:
Number and configuration:_
Depth—top of liquid to inlet invert:
Depth of sludge 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.):
Title 5 Inspection Form 6/15/2000 9
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:_1260 Salem Street_
_North Andover_
Owner:_Cheng_
Date of Inspection:_6/14/2008_
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
House
B -/Ieptic Tank
A
Water Meter
Garage
CD D-Box
A to Tank=24' Driveway
A to D-Box=42'5"
B to Tank=24'2"
B to D-Box=55'4"
Title 5 Inspection Form 6/15/2000 10
Y Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_1260 Salem Street_
_North Andover_
Owner:_Cheng_
Date of Inspection:_6/14/2008
SITE EXAM
Slope_Yes_
Surface water_No_
Check cellar _Yes_
Shallow wells No
Estimated depth to ground water _4.5'_
Please indicate(check)all methods used to determine the high ground water elevation:
X Obtained from system design plans on record-If checked,date of design plan reviewed:_4/26/1985_
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:_As per design plan_
Title 5 Inspection Form 6/15/2000 11
ounnnaiy mtrwiu i.aru generaiea on b/6/zuub 3:U2:31 PM by Lisa Evans Page 1
Town of North Andover
Tax Map # 210-106.A-0186-0000.0
Parcel Id 17329
1260 SALEM STREET
HU, KO-YING Since Jan 2003
ANGIE SHAT-PING
1260 SALEM STREET
NORTH ANDOVER, MA
01845
Class 101 Single Family Property Type 1 Residential
Size Total 3 Acres
FY 2008
UB Mailing Index
Name/Address Type Loan Number Active/inact. From Until
HU,KO-YING Payor
1260 SALEM STREET
N.ANDOVER,MA
01845
UB Account Maint.
Account No Cycle Occupant Name Active/Inactive
Bldg Id. 17400.0-1260 SALEM STREET Last Billing Date 3/28/2008
3170070 03 Cycle 03 Active
UB Services Maint.
Service Code Rate Charge Multiplier/Users
MISCFEE ADMIN FEE 0.635/8 7.82 1/
WTR WATER 01 ALL METER SIZE 25.13 /1
UB Meter Maintenance
Serial No Status Location Brand Type Size YTD Cons
13242126 a Active ERT HH METE METE w Water 0.63 0.63 0
Date Reading Code Consumption Posted Date Variance
3/10/2008 213 a Actual 7 4/11/2008 -29%
12/12/2007 206 a Actual 11 1/22/2008 -46%
9/4/2007 195 a Actual 17 10/12/2007 -4%
6/14/2007 178 a Actual 20 7/20/2007 -2%
3/13/2007 158 a Actual 20 4/16/2007 10%
12/12/2006 138 a Actual 17 1/19/2007 52%
9/18/2006 121 a Actual 12 10/20/2006 4%
6/19/2006 109 a Actual 13 7/10/2006 -4%
3/8/2006 96 a Actual 10 4/17/2006 -19%
12/22/2005 86 a Actual 16 1/17/2006 13%
9/14/2005 70 a Actual 13 10/14/2005 59%
6/15/2005 57 a Actual 8 7/15/2005 -5%
3/18/2005 49 a Actual 9 4/5/2005 5%
12/13/2004 40 a Actual 8 1/14/2005 -41%
9/15/2004 32 a Actual 13 10/8/2004 -1%
6/22/2004 19 a Actual 11 7/30/2004 34%
4/12/2004 8 c Correction 15 5/17/2004 0%
C/O 7+ERT 8=15
12/4/2003 1887 n New Meter 0 12/4/2003 0%
Tel: (978)475-4786
Fax: (978)475-5451
BATESON ENTERPRISES, INC.
Excavating-Water& Sewer Lines-Septic Systems & Pumping Service
111 Argilla Road Andover,Mass. 01810
Title 5 Inspection Report
Property Address: 1260 Salem Street, North Andover
Owner: Cheng
Date of Inspection: 6/14/2008
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.
Nei . Ba son
Bateson Enterprises, Inc.
Commonwealth of Massachusetts
Cityffown of
System Pumping Record
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,tick 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 out 1. System Location:
forms on the
computer, use
only the tab key Address
to mare your t
Cursor-do nd Cityrrown State Zip Code
use the return
key. 2. System Owner-
C�eAAq
Name
n� Address(if different from location)
Cityrr wn State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Stic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Fitter present? El Yes
0'1� If yes,was it cleaned? El Yes E] No
5. Condition of System:
V1 CDO� k 4e�k-c-- d i0 -8G�
6. systemNu2- � � 5
Name Vehicle license Number
-� , �✓ - v'
Company
7. Locatio ere contents wire disposed:
Sign aider Date
t5fomAdoc•06/03 System Pumping Record•Page 1 of 1
Residential Property Record Card
PARCEL_ID:210/106.A-0186-0000.0 MAP:106.A BLOCK:0186 LOT:0000.0 PARCEL ADDRESS:1260 SALEM STREET FY:2009
PARCEL INFORMATION Use-Code: 101 Sale Price: 314,000 Book: 02991 Road Type: T Inspect Date: 05/23/2002
Tax Class: T Sale Date: 08/31/89 Page: 0287 Rd Condition: P Meas Date: 05/23/2002
Owner: Tot Fin Area: 2752 Sale Type: P Cert/Doc: Traffic: M Entrance: C
HU,KO-YING Tot Land Area: 3.00 Sale Valid: Y Water: Collect Id: RRC
ANGIE SHAT-PING Grantor: O'BRIEN,JOHN P Sewer: Inspect Reas: C
Address:
1260 SALEM 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 j
Style: CL Tot Rooms: 7 Main Fn Area: 1324 Attic: NBHD CODE: 6 NBHD CLASS: 6 ZONE: R1
Story Height: 2.00 Bedrooms: 4 Up Fn Area: 1428 Bsmt Area: 1324 Seg Type Code Method Sq-Ft Acres Influ-Y/N Value Class
Roof: H Full Baths: 2 Add Fn Area: Fn Bsmt Area: 1 P 101 S 43560 1.000 208,652
Ext Wall: FB Half Baths: 1 Unfin Area: Bsmt Grade: 2 R 101 A 0 2.000 15,200
Masonry Trim: Ext Bath Fix: 0 Tot Fin Area: 2752 DETACHED STRUCTURE INFORMATION
Foundation: CN Bath Qual: T RCNLD: 316382
Kitch Qual: T Eff Yr Built: 1987 Mkt Adj: Str Unit Msr-1 Msr-2 E-YR-Blt Grade Cond%Good P/F/E/R Cost Class
Heat Type: HW Ext Kitch: Year Built: 1985 Sound Value: G1 S 672 0.00 1985 A A 50///50 9,500
Fuel Type: G Grade: G Cost Bldg: 316,400 VALUATION INFORMATION
Fireplace: 2 Bsmt Gar Cap: Condition: A Aft Str Val 1: Current Total: 549,800 Bldg: 325,900 Land: 223,900 MktLnd: 223,900
Central AC: N Bsmt Gar SF: Pct Complete: Att Str Val2: Prior Total: 566,400 Bldg: 342,500 Land: 223,900 MktLnd: 223,900
Aft Gar SF: %Good P/F/E/R: /100/100/90
Porch Type Porch Area Porch Grade Factor
W 168
SKETCH PHOTO
14
W
12 168 sq.R 12 No Plicture
14 14 38
Fe ig Av 'I& &a.
l
2
1 14 38
Parcel ID:210/106.A-0186-0000.0 as of 6/2/09 Page 1 of 1
Board of Health SF>TIC SISTER
North Ano_overiNaaa.
INSTA.T
ZATIGI4 CHECK LIST
AVATI C81 OK F�1I L
,�P OVID DATg DISAPPROVED
ReauPast
1
f Fn O
1
4
1. Distance Tot
�► --g"�5
A. Wetlands ��vc
b, Drains 0�NfM $AGK VF
Co. Well Ni Sv G-�S�IU ,
t /� c. 1)P4 wAG�
2. Wat-r Line Location �•ciQSIGiN
uJ,O TRK
3. No .'VC Pipe ;
r
4. Ser. do Tank
a. .. 'ees -_Length & To Clean out Covers
b. 1ement Pipe to Tank- On Both Sides of Tank
5. Distribution Box 7-0 1!!FA41L G,
a. Covers & Boz - No Cracks
b. All Lines 'F10 wing Equal Amounts �������
c. No Back Flov P N ro T�0/�►r
6. • Leach held or Trench CCGS�'
a. , Dimensions
b. Stone Depth
Co. Capped Ends Ll Tf-iGf
d. Clean Double Washed Stone
7. Le zch Pits .
a. Dimensions
b. Stone Depth
t Co . Sp' .sh Paris
d. Tees
e. Cent Pipe to Pit - Both Sides
f. lean Double Washed Stone
8. No Garbage Disposal
9. Aral Grading Inspection
10. Barricading Covered System
_- 11. As Built Submitted
a. Lot Location
b. Dimensions of System
c. Location with Regard-to Pere Test
d. Elevations
e; Water Table
t
ORDER OF CONDITIONS: LOT 8 SALEM STREET
a. Notice of Intent of Forbes Realty Trust/Prepared by Christiansen
Engineering, Inc./Dated July 1, 1985/Eight (8) pages.
b. Plan titled "Subsurface Disposal System" Lot 8 Salem Street, North
Andover, NNIA/Prepared by Christiansen Engineering, Inc./Dated April
30, 1985, revised June 25, 1985/Two (2) sheets (l -of 3 and 2 of 3) .
13. The NACC has determined that the plans submitted under this filing, and
also under filings for Lots 9, 10, 11, 12, 13 and 14 contained certain
inaccuracies which make it difficult for the NACC to evaluate the pro-
posed work (i.e. , inconsistent delineation of wetlands and buffer zone) .
Therefore, prior to any work being done on this lot, the following shall
be submitted to the NACC for its approval.
a. Revised plans, drawn accurately, and to scale, so that the NACC can
match the plans for all the above mentioned lots in order to determine
the overall wetlands configuration, flow direction, and size.
b. or, one plan, combining all lots, with wetlands and buffer zone delineated,
as well as houses, drives, and-associated appurtenances.
c. and a plan and calculations, showing how the applicant intends to
decrease, or maintain at zero, the rate of runoff, for this individual
lot.
d. or, rather than item 13c, the applicant may provide an overall plan,
and calculations, showing lots 8 - 14 (inclusive) , and those measures
which will be employed to maintain at zero, or decrease, the change in
the rate of runoff for the entire area (lots 8 - 14 inclusive) .
14. Upon receipt of the above required information, the NACC, if necessary shall
issue, within 21 -.days, additional conditions necessary to adequately protect:..-*
adjacent wetland areas.
15. The provisions of this Order shall apply to and be binding upon the applicant,
its employees, and all successors and assigns in interest or control.
16. Prior to the issuance of a Certificate of Compliance, the applicant shall
submit a letter to the Conservation Commission from a registered professional
engineer certifying that the work is in compliance with the plans referenced
above and the conditions stated above.
17. Members of the NACC shall have the right to enter upon and inspect the
premises to evaluate compliance with this Order of Conditions.
tj
18. Accepted engineering and construction standards and procedures shall be
followed in the completion of the project.
Commonwealth of Massachusetts " V E
OW City/Town of
System Pumping Record JUN 17 2009
so..
Form 4 BOARD OF HEALTH
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 out 1. System Location: Left front, left rear, left side of house. Right front, right rea , right side of house
forms on the
computer,use
only the tab key Address V`.JI
to move your.
cursor-do notCity/Town State Zip Code
use the return
key. 2. System Owner:
Name
Address(if different from location)
Cityrrown State -Zin Code
� a"7
Telephone Number
B. Pumping Record (fo
1. Date of Pumping Date Quantity Pumped: Gallons
3. Type of system: 8 Cesspool(s) Septic Tank Tight Tank
Other(describe):
4. Effluent Tee Filter present? Yes If yes,was it cleaned? Yes No
5. Condition of System: 47e%�
v\,0,r t �v,
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
af u
SD Lowell Waste Water r ^�
YT o —
'1 C7
igna ure of H u r Date
rd e1 of1
t5form4.doc•06103 System Pumping Reco g