HomeMy WebLinkAboutMiscellaneous - 1264 SALEM STREET 4/30/2018 (4) 1264 SALEM STREET
I 210/106.A-0187-0000.0
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Town of North Andover
HEALTH DEPARTMENT
,SSACHUg��
CHECK#: DATE:
LOCATION:
H/O NAME:
CONTRACTOR NAMEdT IL CC) hw)
Type of Permit or License: (Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type: $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
❑ Title 5 Report $
Other.(Indicate $
Health Agent Initials ,
White-Applicant Yellow-Health Pink-Treasurer
ti
TOWN OF NORTH ANDOVER
Permit Number
NORTH ANDOVER,MASSACHUSETTS 01845 ro�
Date Issued i
t
a xplr.aqAL;
ate
etCbeuS
JUL L 3 2014
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Jackie's Law — Permit Application
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Applicant Phone Cell
Street Address
CitylTown MA ZIP
k��6v--Ir INAk 0ki�
Name of Excavator(if different from applicant) Phone Cell
Street Address 5 PAY-"
City/Town 4.. MA ZIP
Name of Owner(s)of Property Phone Cell
cc-,-r t'A
Street Address
City/Town MA ZIP
Other Contact Permit Fee Received No Yes
Description,location and purpose of proposed trench:
Please describe the exact location of the proposed trench and its purpose(include a description of what is(or is intended)to
be laid in proposed trench(eg;pipes/cable lines eta.)Please use reverse side if additional space is needed.
Insurance Certificate
Name and Contact Information of Insurer:
L7 A tosvv-' �3 �' ►^t crr' Y
Polis Es i ation Date:
A d
Dig Safe#:
'xo
Name of Competent Person(as defined by 520 CMR 7.02):
Massachusetts Hoisting License# (5 1_S317
License Grade: Expiration Date:
BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE
AND CERTIFY THAT THEY ARE FAMILIAR WITH, OR, BEFORE COMMENCEMENT OF THE
WORK, WILL BECOME FAMILIAR WITH, ALL LAWS AND REGULATIONS APPLICABLE TO
WORK PROPOSED,INCLUDING OSHA REGULATIONS,G.L. c. 82A,520 CMR 7.00 et seq.,AND ANY
APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND REGULATIONS AND THEY COVENANT
AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR SUCH WORK WILL
COMPLY THEREWITH IN ALL RESPECTS AND WITH THE CONDITIONS SET FORTH BELOW.
THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND
THE EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER, AND
ALSO, FOR THE DURATION OF CONSTRUCTION,AUTHORIZES PERSONS DULY APPOINTED BY
THE MUNICIPALITY TO ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK
FOR CONFORMITY WITH THE CONDITIONS ATTACHED HERETO AND THE LAWS AND
REGULATIONS GOVERING SUCH WORK.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY
TO REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY
THE MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED
THEREUNDER,INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE
LAW AND CONDITIONS OF THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE
THEREWITH,AND MEASURES TAKEN BY THE MUNICIPALITY TO PROTECT THE PUBLIC
WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO COMPLY THEREWITH
INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED NECESSARY BY
THE MUNICIPALITY.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY
TO DEFEND,INDEMNIFY,AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS
AND EMPLOYEES FROM ANY AND ALL LIABILITY,CAUSES OR ACTION,COSTS,AND EXPENSES
RESULTING FROM OR ARISING OUT OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY
PERSON OR PROPERTY DURING THE WORK CONDUCTED UNDER THIS PERMIT.
APPLICANT SIGNATURE,
DATE
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
DATE:
-2
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CONDITIONS AND REQUIREMENTS PURSUANT TO G.L.C.82A AND 520 CMR 7.00 et seq.
(as amended)
By signing the application,the applicant understands and agrees to comply with the following:
i.
No trench may be excavated unless the requirements of sections 40 through 40D of chapter 82,and any
accompanying regulations,have been met and this permit is invalid unless and until said requirements
have been complied with by the excavator applying for the permit including,but not limited to,the
establishment of a valid excavation number with the underground plant damage prevention system as
said system is defined in section 76D of chapter 164(DIG SAFE);
ii.
Trenches may pose a significant health and safety hazard. Pursuant to Section 1 of Chapter 82 of the
General Laws,an excavator shall not leave any open trench unattended without first making every
reasonable effort to eliminate any recognized safety hazard that may exist as a result of leaving said
open trench unattended. Excavators should consult regulations promulgated by the Department of
Public Safety in order to familiarize themselves with the recognized safety hazards associated with
excavations and open trenches and the procedures required or recommended by said department in
order to make every reasonable effort to eliminate said safety hazards which may include covering,
barricading or otherwise protecting open trenches from accidental entry.
Persons engaging in any in any trenching operation shall familiarize themselves with the federal safety
standards promulgated by the Occupational Safety and Health Administration on excavations:29 CFR
1926.650 et.seq.,entitled Subpart P"Excavations".
iv.
Excavators engaging in any trenching operation who utilize hoisting or other mechanical equipment
subject to chapter 146 shall only employ individuals licensed to operate said equipment by the
Department of Public Safety pursuant to said chapter and this permit must be presented to said licensed
operator before any excavation is commenced;
V.
By applying for,accepting and signing this permit,the applicant hereby attests to the following:(1)that
they have read and understands the regulations promulgated by the Department of Public Safety with
regard to construction related excavations and trench safety; (2)that he has read and understands the
federal safety standards promulgated by the Occupational Safety and Health Administration on
excavations:29 CMR 1926.650 et.seq.,entitled Subpart P"Excavations"as well as any other
excavation requirements established by this municipality;and(3)that he is aware of and has,with
regard to the proposed trench excavation on private property or proposed excavation of a city or town
public way that forms the basis of the permit application,complied with the requirements of sections 40-
40D of chapter 82A.
vi.
This permit shall be posted in plain view on the site of the trench.
For additional information please visit the Department of Public Safety's website at www.mass.eov/dps
3 1 P a g e
4
Summary of Excavation and Trench Safety Regulation(520 CMR 14.00 et seq.)
This summary was prepared by the Massachusetts Department of Public Safety pursuant to G.L.c.82A and does not
include all requirements of the 520 CMR 14.00. To view the full regulation and G.L.c.82A,go to www/mass.gov/dps
Pursuant to M.G.L. c. 82, § 1, the Department of Public Safety,jointly with the Division of Occupational Safety,
drafted regulations relative to trench safety. The regulation is codified in section 14.00 of title 520 of the Code of
Massachusetts Regulations. The regulation requires all excavators to obtain a permit prior to the excavation of a
trench made for a construction-related purpose on public or private land or rights-of-way. All municipalities must
establish a local permitting authority for the purpose of issuing permits for trenches within their municipality.
Trenches on land owned or controlled by a public(state)agency requires a permit to be issued by that public agency
unless otherwise designated.
In addition to the permitting requirements mandated by statute, the trench safety regulations require that all
excavators,whether public or private,take specific precautions to protect the general public and prevent unauthorized
access to unattended trenches. Accordingly,unattended trenches must be covered,barricaded or backfilled. Covers
must be road plates at least V thick or equivalent;barricades must be fences at least 6'high with no openings greater
than 4" between vertical supports; backfilling must be sufficient to eliminate the trench. Alternatively, excavators
may choose to attend trenches at all times,for instance by hiring a police detail,security guard or other attendant who
will be present during times when the trench will be unattended by the excavator.
The regulations further provide that local permitting authorities,the Department of Public Safety,or the Division of
Occupational Safety may order an immediate shutdown of a trench in the event of a death or serious injury;the failure
to obtain a permit; or the failure to implement or effectively use adequate protections for the general public. The
trench shall remain shutdown until re-inspected and authorized to re-open provided, however,the excavators shall
have the right to appeal an immediate shutdown. Permitting authorities are further authorized to suspend or revoke a
permit following a hearing. Excavators may also be subject to administrative fines issued by the Department of
Public Safety for identified violations.
Summary of 1926 CFR Subpart P-OSHA Excavation Standard
This is a worker protection standard,and is designed to protect employees who are working inside a trench. This
summary was prepared by the Massachusetts Division of Occupational Safety and not OSHA for informational
purposes only and does not constitute an official interpretation by OSHA of their regulations,and may not include all
aspects of the standard.
For further information or a full copy of the standard go to www.osha.uov.
Trench Definition per the OSHA standard:
c An excavation made below the surface of the ground,narrow in relation to its length.
o In general,the depth is greater than the width,but the width of the trench is not greater than fifteen
feet.
e Protective Systems to prevent soil wall collapse are always required in trenches deeper than 5',and are also
required in trenches less than 5'deep when the competent person determines that a hazard exists. Protection
options include:
o Shoring. Shoring must be used in accordance with the OSHA Excavation standard appendices,the
equipment manufacturer's tabulated data,or designed by a registered professional engineer.
o Shielding(Trench Boxes). Trench boxes must be used in accordance with the equipment
manufacturer's tabulated data,or a registered professional engineer.
o Sloping or Benching. In Type C soils(what is most typically encountered)the excavation must
extend horizontally 1 '/2 feet for every foot of trench depth on both sides, 1 foot for Type B soils,
and 3/4 foot for Type A soils.
o A registered professional engineer must design protective systems for all excavations greater than
20'in depth.
continued
• Ladders must be used in trenches deeper than 4'.
o Ladders must be inside the trench with workers at all times,and located within 25'of unobstructed
lateral travel for every worker in the trench.
o Ladders must extend 3'above the top of the trench so workers can safely get onto and off of the
Iadder.
• inspections of every trench worksite are required:
o Prior to the start of each shift,and again when there is a change in conditions such as a rainstorm.
o Inspections must be conducted by the competent person(see below).
• Competent Person(s)is:
o Capable(i.e.,trained and knowledgeable)in identifying existing and predictable hazards in the
trench,and other working conditions which may pose a hazard to workers,and
o Authorized by management to take necessary corrective action to eliminate the hazards. Employees
must be removed from hazardous areas until the hazard has been corrected.
• Underground Utilities must be:
o Identified prior to opening the excavation(e.g.,contact Dig Safe).
o Located by safe and acceptable means while excavating.
o Protected,supported,or removed once exposed.
• Spoils must be kept back a minimum of 2'from the edge of the trench.
® Surface Encumbrances creating a hazard must be removed or supported to safeguard employees. Keep
heavy equipment and heavy material as far back from the edge of the trench as possible.
• Stability of Adjacent Structures:
o Where the stability of adjacent structures is endangered by creation of the trench,they must be
underpinned,braced,or otherwise supported.
o Sidewalks,pavements,etc.shall not be undermined unless a support system or other method of
protection is provided.
• Protection from water accumulation hazards:
o It is not allowable for employees to work in trenches with accumulated water. If water control such
as pumping is used to prevent water accumulation,this must be monitored by the competent person.
o If the trench interrupts natural drainage of surface water,ditches,dikes or other means must be used
to prevent this water from entering the excavation.
• Additional Requirements:
o For mobile equipment operated near the edge of the trench,a warning system such as barricades or
stop logs must be used.
o Employees are not permitted to work underneath loads. Operators may not remain in vehicles
being loaded unless vehicles are equipped with adequate protection as per 1926.601(b)(6).
o Employees must wear high-visibility clothing in traffic work zones.
o Air monitoring must be conducted in trenches deeper than 4'if the potential for a hazardous
atmosphere exists. If a hazardous atmosphere is found to exist(e.g.,02<19.5%or>23.5%,20%
LEL,specific chemical hazard),adequate protections shall be taken such as ventilation of the space.
o Walkways are required where employees must cross over the trench. Walkways with guardrails
must be provided for crossing over trenches>6'deep.
o Employees must be protected from loose rock or soil through protections such as scaling or
protective barricades.
5 Page
M.J. Colombo Landscaping & Excavating
48 Argilla Road
Andover, MA.01810
Name/Address
Carrie Rainen
1264 Salem St.
North Andover,Ma.01845
Date Estimate No. Project
07/19/14 14
+ Item Description Quantity Cost Total
i Call Dig Safe Call Dig Safe to locate underground utilities 0.00 0.00
Trench Permit Pull Trench Permit 100.00 100.00
1 Repair 1 "Water service
J Back-fill and compact to correct elevation 0.00 0.00
i Labor Excavation 1,800.00 1,800.00
Re-paving materials and installation Cost will be determined at 0.00 0.00
time of Excavation.
i
call Office to schedule work.978-4 70-1694 Total $1,900.00
Client#:8614 MJCOLOMBO
ACORD. CERTIFICATE OF LIABILITY INSURANCE 7DATE
/23/2014ry Y)
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Doherty Insurance Agency,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
P.O. Box 1985 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
21 Elm Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Andover, MA 01810 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: Arbella Protection Ins Company
M.J.Colombo Landscaping,Inc INSURER B: The Hartford
Michael Colombosian
INSURER C:
48 Argilla Rd INSURER D:
Andover, MA 01810 INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR D TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION
LTR NSR DATE MM/DD/Y`/ DATE MM/DD/YY LIMITS
A GENERAL LIABILITY 8500062562 06/28/14 06/28/15 EACH OCCURRENCE $1,000,000
X COMMERCIAL GENERAL LIABILITY DAEMGE TO RENTED occurrence) $300,000
CLAIMS MADE a OCCUR MED EXP(Any one person) s5,000
PERSONAL&ADV INJURY $1,000,000
GENERAL AGGREGATE s2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000,000
X POLICY PRO LOC
JECT
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO (Ea accident) $
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person) $
HIRED AUTOS
BODILY INJURY $
NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO EA ACC $
OTHER THAN
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR F1 CLAIMS MADE AGGREGATE $
DEDUCTIBLE
RETENTION $ $
B WORKERS COMPENSATION AND 08WECIS7301 05/28/14 05/28/15 X WC STM T OTH-
EMPLOYERS'LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500,000
OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $500,000
If yes,describe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $500,000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
Covering operations usual to M.J.Colombo Landscaping,Inc...
CERTIFICATE HOLDER CANCELLATION 10 Days for Non-Payment
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
Town of North Andover DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL If)_ DAYS WRITTEN
Health Dept NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
1600 Osgood St., IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
Bldg 20, Unit 2035 REPRESENTATIVES.
North Andover,MA 01845 AUTHORIZED R SENTATIVE
ACORD 25(2001108)1 Of 2 #S30780/M30755 L O ACORD CORPORATION 1988
s �
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may
require an endorsement. A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer,and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25-S(2001/08) 2 of 2 #S30780/M30755
North Andover Board of Assessors Public Access Page 1 of 1
NOR71� Forth Andover Board of Assessors
Ot tf 1.•D •�.�.0
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,SSACMUst'� roperty Record Card
Click Seal To Return Parcel ID :210/106.A-0187-0000.0 FY:2009 Community :North Andover
SKETCH PHOTO
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Summary Available
Residence
Detached Structure
Condo
Commercial
Location: 1264 SALEM STREET
Owner Name: VESSAL,AHANG
TAHERI,LADAN
Owner Address: 1264 SALEM STREET
City: NORTH ANDOVER State: MA Zip: 01845
Neighborhood: 6-6 Land Area: 1.17 acres
Use Code: 101-SNGL-FAM-RES Total Finished Area: 2587 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 521,500 537,900
Building Value: 311,600 328,000
Land Value: 209,900 209,900
Market Land Value: 209,900
Chapter Land Value:
LATEST SALE
Sale Price: 545,000 Sale Date: 08/28/2003
Arms Length Sale Code: Y-YES-VALID Grantor: CHRISTPHER BROWN
Cert Doc: Book: 08201 Page: 0219
http://csc-ma.us/PROPAPP/display.do?linkld=1465136&town=NandoverPubAcc 5/26/2009
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* Town of North Andover
` '•f. HEALTH DEPARTMENT
'SS,CMUs°�
CHECK#: DATE:
LOCATION: -
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:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
❑ Title 5 Report $
❑ Other. (Indicate) $
Health Agent Initials
'7hite-Applicant Yellow-Health Pink-Treasurer
I
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Commonwealth of Massachusetts
= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
•'r 1264 Salem Street HAR 31 2014
Property Address
Hank Vessal
Owner Owners Name
information is
required for North Andover MA 01845 3/25/2014
every page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A General Information
When filling out
forms on the
computer,use 1. Inspector:
only the tab key
to move your Neil J. Bateson
cursor-do not Name of Inspector
use the return
key. Bateson Enterprises Inc.
Company Name
111 Argilla Road
Company Address
Andover MA 01810
Cityfrown State Zip Code
978-475-4786 S115
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Nee Further Evaluation by the Local Approving Authority
A 1A
3/25/2014
Insi Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1264 Salem Street
Property Address
Hank Vessal
Owner Owner's Name
information is
required for North Andover MA 01845 3/25/2014
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3113 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
• Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1264 Salem Street
Property Address
Hank Vessal
Owner Owner's Name
information is
required for North Andover MA 01845 3/25/2014
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1264 Salem Street
Property Address
Hank Vessal
Owner Owner's Name
information is
required for North Andover MA 01845 3/25/2014
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1264 Salem Street
Property Address
Hank Vessal
Owner Owners Name
information is
required for North Andover MA 01845 3/25/2014
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
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.
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
u 0
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1264 Salem Street
Property Address
Hank Vessal
Owner owners Name
information is
required for North Andover MA 01845 3/25/2014
every page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 600
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1264 Salem Street
Property Address
Hank Vessal
Owner Owner's Name
information is North Andover MA 01845 3/25/2014
required for
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ® Yes ❑ No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d Yes
9 ( Y 9 (gp ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
JD Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1264 Salem Street
Property Address
Hank Vessal
Owner Owner's Name
information is
required for North Andover MA 01845 3/25/2014
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Pumped 2013, owner
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1500
gallons
How was quantity pumped determined? Measured tank.
Reason for pumping: Inspect tank&tees.
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1264 Salem Street
Property Address
Hank Vessal
Owner, Owner's Name
information is
required for North Andover MA 01845 3/25/2014
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Tank&trenches 20 years old, D-box was replaced 2009, info @ B.O.H.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 4.5
feet
Material of construction:
❑ cast iron ❑ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Finished cellar unable to see piping
Septic Tank(locate on site plan):
Depth below grade: 3.5
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
10'x5'x4'
Sludge depth:
2"
t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1264 Salem Street
Property Address
Hank Vessal
Owner Owner's Name
information is
required for North Andover MA 01845 3/25/2014
every page. City1rown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
31"
Scum thickness
2"
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
11"
How were dimensions determined?
Tape Measure
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. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence
of leakage. Center cover has riser to grade.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1264 Salem Street
Property Address
Hank Vessal
Owner Owner's Name
information is
required for North Andover MA 01845 3/25/2014
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1264 Salem Street
Property Address
Hank Vessal
Owner Owner's Name
information is
required for North Andover MA 01845 3/25/2014
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 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, has flow levelers. Evidence of carryover, pumped d-
box to clean. No evidence of leakage.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
UTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1264 Salem Street
Property Address
Hank Vessal
Owner Owner's Name
information is
required for North Andover MA 01845 3/25/2014
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 3 trenches 35'
long
❑ 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.):
Yard covered in snow, no sign of ponding to surface.
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1264 Salem Street
Property Address
Hank Vessal
Owner Owner's Name
information is
required for North Andover MA 01845 3/25/2014
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
ti Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1264 Salem Street
Property Address
Hank Vessal
Owner Owner's Name
information is
required for North Andover MA 01845 3/25/2014
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
IE
D-
F t�w"�2s
/- -Vo- aA Oic � 6 u
ID-i3
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1264 Salem Street
Property Address
Hank Vessal
Owner Owner's Name
information is
required for North Andover MA 01845 3/25/2014
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: >4feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
Essex County Soil Map
You must describe how you established the high ground water elevation:
Essex County Soil Map, Sheet#36, Canton Soil, Water>6' Deep
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1264 Salem Street
Property Address
Hank Vessal
Owner Owner's Name
information is
required for North Andover MA 01845 3/25/2014
every page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
: .\ Uommonwealth of Massachusetts
Qty Town of
System Pumping Record
Form 4
DEP has provided this form for us&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/ ' ht side'of hous Left/
Right side of building, Left/Right front of building, Left/Right rear of building,Unite
ec
Address f e +
Cityfrown State
Trp Code
2. System Owner.
Name'
Address(if different from location)
CitylTown State Zip Code
Telephone Number
i
B. Pumping Record
1. Date of Pumping
Date . Quantity Pumped:
Gallons
3. Type of system. ❑ Cesspool(s) eptic Tank ❑ Tight Tank
9
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o if,yes, was it cleaned? ❑ Yes ❑ Na
' 5. Conditiorafstern:
'
6. System Pumped By:
Nell Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents-were disposed:
S: Lowell Waste Water
Sig Haul
Date
06m4.dor.-06/03 System Pumping Record•Page 1 of 1
Summary Record Card generated on 3/26/2014 1:17:48 PM by Maureen McAuley Page 1
Town of North Andover
Tax Map # 210-106.A-0187-0000.0
Parcel Id 17330
1264 SALEM STREET
TAHERI, LANDAN
1264 SALEM STREET
NORTH ANDOVER, MA
01845
Class 101 Single Family Property Type 1 Residential
Zoning2 1 Residential Zoning3 1 Residential
Size Total 1,17 Acres
FY 2014
UB Mailing Index
Name/Address Type Loan Number Active/Inact. From Until
TAHERI,LANDAN Payor
1264 SALEM STREET
NORTH ANDOVER,MA
01845
UB Account Maint.
Account No Cycle Occupant Name Active/Inactive
Bldg Id. 17401.0-1264 SALEM STREET Last Billing Date 1/7/2014
3170071 03 Cycle 03 Active
UB Services Maint.
Account No.3170071
Service Code Rate Charge Multiplier/Users
MISCFEE ADMIN FEE 0.635/8 7.82 1/
WTR WATER 01 ALL METER SIZE 120.40 /1
UB Meter Maintenance
Account No. 3170071
Serial No Status Location Brand Type Size YTD Cons
33605542 a Active ERT HH F.RT. b Badger w Water 0.63 0.63 555
Date Reading Code Consumption Posted Date Variance
3/10/2014 701 a Actual 12 -60%
12/6/2013 689 a Actual 28 1/17/2014 -7%
9/10/2013 661 a Actual 32 10/15/2013 96%
6/10/2013 629 a Actual 16 7/24/2013 2%
3/12/2013 613 a Actual 16 4/22/2013 3%
12/10/2012 597 a Actual 15 1/9/2013 -62%
9/12/2012 582 a Actual 41 10/15/2012 148%
6/11/2012 541 a Actual 16 7/16/2012 14%
3/13/2012 525 a Actual 14 4/14/2012 -4%
12/14/2011 511 a Actual 15 1/17/2012 -59%
9/12/2011 496 a Actual 39 10/13/2011 121%
6/6/2011 457 a Actual 16 7/20/2011 23%
3/9/2011 441 a Actual 13 4/13/2011 -41%
12/10/2010 428 aActual 23 1/12/2011 -51%
9/8/2010 405 a Actual 48 10/15/2010 159%
6/4/2010 357 a Actual 17 7/15/2010 42%
3/8/2010 340 a Actual 12 4/14/2010 -40%
12/10/2009 328 a Actual 21 1/12/2010 -60%
9/9/2009 307 a Actual 56 10/15/2009 223%
6/4/2009 251 a Actual 15 7/20/2009 33%
3/12/2009 236 a Actual 13 4/29/2009 -46%
12/5/2008 223 a Actual 22 1/20/2009 -54%
9/8/2008 201 a Actual 52 10/10/2008 211%,
6/4/2008 149 a Actual 15 7/16/2008 19%
3/10/2008 134 a Actual 13 4/11/2008 -56%
12/12/2007 121 a Actual 33 1/22/2008 -48%
9/4/2007 88 a Actual 53 10/12/2007 140%
6/14/2007 35 a Actual 25 7/20/2007 85%
3/13/2007 10 a Actual 10 4/16/2007 -100%
NEW ENGLAND ENGINEERING SERVICES
INC
September 14, 2002
North Andover Board of Health
Town Hall Annex
27 Charles Street
North Andover, MA 01845
RE: TITLE V REPORT: 1264 Salem Street,North Andover, MA
Dear Sirs:
Enclosed is a copy of the Title V report for the above referenced property. The system PASSED
our inspection.
If there are any questions please call me at my office, 686-1768.
Sincerely
Benda
C. 0'
r.
60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
5,.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: Icy 6 A t.F M ST2 r e
P—o a-n- AN Dz-)o1;K- MA
Owner's Name: GN(2 l 6-j-b pq r t&
Owner's Address: 1,2&14 S,4ba v► 5Ti2
,ivp&TIZ A&v Po,)ER-
Date of Inspection:
r—
Name of Inspector:(please print)
Company Name: QEw �►� t.�N�� A9G 1N 2[N G—
Mailing Address: &4-> g E cc H W 06-
1
el J J (L-144 Auk)>
Telephone Number: 2,q— C29 _ ��,g
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:
YYasses
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature:P g Date:Ir - < Z
The system inspector shall submit a copy of this insp ion 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.
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:_ 1264 SALEM STREET
NORTH ANDOVER,MA
Owner: CHRISTOPHER BROWN
Date of Inspection:. 9/14/02
Inspection Summary: Check A Bx,li or r.,nij r a 1 o.�...Y.ete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
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:
' Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:_ 1264 SALEM STREET
NORTH ANDOVER,MA
Owner: CHRISTOPHER BROWN
Date of Inspection:. 9/14/02
C. Further Evaluation is nequirea Dy the noara of neaiin:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is fai' g to protect public health,safety or the environment. /
1. S will pass unless Board of Health determines in accordance with 310 CMR 1 03(lxb)that the
system' not functioning in a manner which will protect public health,safety an a environment:
— Cesspoo privy is within 50 feet of a surface water
_ Cesspool or ivy is within 50 feet of a bordering vegetated wetland or salt marsh
2. System will fail unless the Board o ealth(and Pub ' Water Supplier,if any)determines that the
system is functioning in a manner that p tests the pu is health,safety and environment:
_ The system has a septic tank and soil ab tion system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surfa a supply.
— The system has a septic tank and AS and the S is within a Zone 1 of a public water supply.
— The system has a septic and SAS and the SAS is 'thin 50 feet of a private water supply well.
_ The system has a sep 'c tank and SAS and the SAS is less th 100 feet but 50 feet or more from a
private water supply w **.Method used to determine distance
**This system p ses if the well water analysis,performed at a DEP certi laboratory,for coliform
bacteria and atile organic compounds indicates that the well is free from p lution from that facility and.
the pr of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 in,provided that no other
failur iteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1264 SALEM STREET
NORTH ANDOVER,MA
Owner: CHRISTOPHER BROWN
Date of Inspection: 9/14/02
D. System Failure t liven app.......,..,.-
You must indicate"yes"or`9no"to each of the following for all inspections:
Yes No
_✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
1 Liquid depth in cesspool is less than 6"below invert or available volume is less than%i 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.
V 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.]
- 0 (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:
considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gid.
You must in ' to either`yes"or`no"to each of the following:
(The following cri . apply to large systems in addition to the criteria above)
yes no
_ the system is within 400 f surface drinkin er supply
the system is within 200 feet of a tribu surface drinking water supply
— _ the system is located in a i gen sensitive area(Interim ead Protection Area-IWPA)or a mapped
Zone II of a public w supply well
If you have answer yes"to any question in Section E the system is considered a signi t threat,or answered
"yes"in Secti above the large system has failed.The owner or operator of any large system sidered a
signifi eat under Section E or failed under Section D shall upgrade the system in accordance with 3.10 CMR
15.3 .The system owner should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:_
1264 SALEM STREET
Owner: NORTH ANDOVER,MA
Date of Inspection: CHRISTOPHER BROWN
9/14/02
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?
V/ 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?
V/ Was 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
�/ xisting 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)(6)]
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:_ 1264 SALEM STREET
NORTH ANDOVER,MA
Owner: CHRISTOPHER BROWN
Date of Inspection:_ 9/14/02
RESIDENTIAL
Number of bedrooms(design): 4t Number of bedrooms(actual):
DESIGN flow based on 310 CMR 1,5.203(for example: 110 gpd x#of bedrooms): 6o,00 6-P D
Number of current residents:_51*'
Does residence have a garbage grinder(yes or no): B,
Is laundry on a separate sewage system(yes or no)'. [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)):VA,At ,
Sump pump(yes or no): r).D
Last date of occupancy: G_ y T
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd-
Basis
pdBasis of design flow(se ats/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: tt✓e e6 mctV)
Was system pumped as part of the inspection(yes or no):N0
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_L/�eptic 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:
/`!5::: 4t--.25 IfleA_ /4;� " got L-1!n/
Were sewage odors detected when arriving at the site(yes or no): 4�49
a
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_ 1264 SALEM STREET
NORTH ANDOVER,MA
Owner: CHRISTOPHER BROWN
Date of Inspection: 9/14/02
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-)FESt7CH/�i� fIliy�s �� wA�`
SEPTIC TANK:_(locate on site plan)
Depth below grade: 30"
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: /5-00
Sludge depth: 42-
Distance
ZDistance from top of sludge to bottom of outlet tee or baffle: .2&
Scum thickness: L I "
u
Distance from top of scum to top of outlet tee or baffle:_ 7
Distance from bottom of scum to bottom of outlet tee or baffle: Z
How were dimensions determined:_ iyt EI+S<J ILC s77 C 1<
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"40A 1 > e--�,Ne MOO c-perlLC F 7—CE5 tN GOCD;>
R uE/L O•- c E',u_A;_!Z '?G "140 E P' c 0,4-E,y,.N R LS C915 466- 1
&1V !N 1,IF/ /1,v0 Os Lei 60ot 4&
GREASE TRAP:I&(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.):
a
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_ 1264 SALEM STREET
NORTH ANDOVER,MA
Owner: CHRISTOPHER BROWN
Date of Inspection:_ 9/14/02
TIGHT or HOLDING TANK: UP( (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: gallonstday
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: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: b
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.):
_ge�x IN Crfj-oo cJ;l 0 -10n nes;s2IeL)-1 .� tf�?Jr4I, ..o CJ,jD AjCC
_- bf:� i,FMA R(rE 02 y Lii
PUMP CHAMBER;44'Y (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
Page 9 of 11
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_ 1264 SALEM STREET
NORTH ANDOVER,MA
Owner: CHRISTOPHER BROWN
Date of Inspection•_ 9/14/02
SOIL.ABSORPTION SYSTEM(SAS): ttocate on site pian,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
leaching chambers,number:
leaching galleries,number:
✓leaching trenches,number,length: -3 - S'O i 2�,�C K S
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.)MM
d9f 1-016
CESSPOOLS: (cesspool must be pumped as part of inspectionxlocate 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:&4(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.):
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_ 1264 SALEM STREET
NORTH ANDOVER,MA
Owner: CHRISTOPHER BROWN
Date of Inspection:. 9/14/02
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.
1721 vi%
X/
ti �L
1-�J vs C
Ji
r
vb
2�
hi �bv/
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_ 1264 SALEM STREET
NORTH ANDOVER,MA
Owner: CHRISTOPHER BROWN
Date of Inspection:_ 9/14/02
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water Co feet
Please indicate(check)all methods used to determine the high ground water elevation:
�- Obtained 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:
5 , Vii:til 0i� i(sQEL'1` "")Jk ._ +A'(,1-;12 1V-F, Lit
Pr 2 E 19 -7 c-r R D E
i
Of MORT1 ,
c H
I- p
Town of North Andover
SA HEALTH DEPARTMENT
SAC NU
CHECK#: DATE:
LOCATION:
H/O NAME:
CONTRACTOR NAME: ,SOf2
Type of Permit or License: (Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type: $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Ti e5 Inspector $
Title 5 Report $
❑ Other:(Indicate) $
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer
I
I •
Commonwealth of Massachusetts )�v 11z�!I"Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1264 Salem Street
Property Address
Hank Vessal
Owner Owner's Name
information is
required for North Andover MA 01810 5/1/2009
every page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:
When filling out A. General information
forms on the rRECEIVED
computer,use 1. Inspector:
only the tab key
to move your Todd J. Bateson Y 6 2009
cursor-do not Name of Inspector
use the return
key. Bateson Enterprises Inc. TOWN OF NORTH ANDOVER
Company Name HEAL
111 Argilla Road
Company Address
Andover Ma 01810
Cityrrown State Zip Code
978-475-4786
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
❑ Passes ® Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
511/2009
Inszoessignature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•09/08 Title 5 Official Inspection Foran:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 1264 Salem Street
Property Address
Hank Vessal
Owner Owner's Name
information is
required for North Andover MA 01810 5/1/2009
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E J always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
® One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
"A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ® N ❑ ND(Explain below):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
! , I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 1264 Salem Street
Property Address
Hank Vessal
Owner Owner's Name
information is
required for North Andover MA 01810 5/1/2009
every page. CityrFown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ® N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ® N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ® N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1264 Salem Street
Property Address
Hank Vessal
Owner Owner's Name
information is
required for North Andover MA 01810 5/1/2009
every page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D-Box needs to be replaced, badly corroded.
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins•09/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments j
M SV•r`'t 1264 Salem Street
Property Address
Hank Vessal
Owner Owner's Name
information is
required for North Andover MA 01810 5/1/2009
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. (This
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
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.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 1264 Salem Street
Property Address
Hank Vessal
Owner Owner's Name
information is
required for North Andover MA 01810 5/1/2009
every page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 600
t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M ,•� 1264 Salem Street
Property Address
Hank Vessal
Owner Owner's Name
information is
required for North Andover MA 01810 5/1/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
2
Does residence have a garbage grinder? ® Yes ❑ No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage Yes
9 ( Y 9 (gpd))�
Detail:
Sump pump? ® Yes ❑ No
Last date of occupancy: Current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M ,.•�''r 1264 Salem Street
Property Address
Hank Vessal
Owner Owner's Name
information is
required for North Andover MA 01810 5/1/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Pumped last year, owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M ,•�'� 1264 Salem Street
Property Address
Hank Vessal
Owner Owners Name
information is
required for North Andover MA 01810 5/1/2009
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
15 years old, info at B. O. H.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 4.6
feet
Material of construction:
® cast iron ❑40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Finished cellar,unable to see piping
Septic Tank(locate on site plan):
Depth below grade: 3.5
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
10'x 5'x 4'
Dimensions:
Sludge depth: 1
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1264 Salem Street
Property Address
Hank Vessal
Owner Owner's Name
information is
required for North Andover MA 01810 5/1/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
27'•
Scum thickness 2
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
19„
How were dimensions determined? Tape Measure
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet baffle ok. Outlet baffle ok. Depth of liquid at invert. No evidence of leakage
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins.09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 1264 Salem Street
Property Address
Hank Vessal
Owner Owner's Name
information is
required for North Andover MA 01810 5/1/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,•�''t 1264 Salem Street
Property Address
Hank Vessal
Owner Owner's Name
information is
required for North Andover MA 01810 5!112009
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 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. D-box badly corroded
needs to be replaced.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1264 Salem Street
Property Address
Hank Vessal
Owner Owner's Name
information is
required for North Andover MA 01810 5/1/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 3 trenches 35'
long
❑ 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.):
Soil ok.Vegetation ok. No sign of ponding to surface.
i
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
, 1264 Salem Street
Property Address
Hank Vessal
Owner Owner's Name
information is
required for North Andover MA 01810 5/1/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09/08 Title 5 Official Inspection Form:SubsurFace Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1264 Salem Street
Property Address
Hank Vessal
Owner Owner's Name
information is
required#or North Andover MA 01810 5/1/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system,including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below.
® hand-sketch in the area below
❑ drawing attached separately
O Ux. 2 c+T� { •
a 14
//llf
D �O6u
t5ins-09108 Title 5 olfiaal Moped on Fame Subsurface Sewage Doposai SysWm-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M ,•�''� 1264 Salem Street
Property Address
Hank Vessal
Owner Owner's Name
information is
required for North Andover MA 01810 5/1/2009
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: >6'feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
Essex County Soil Map
You must describe how you established the high ground water elevation:
Essex County Soil Map, Sheet#36, Canton Soil Water>6'deep
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1264 Salem Street
Property Address
Hank Vessal
Owner Owner's Name
information is
required for North Andover MA 01810 5/1/2009
every page. Citylrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•09108 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Pape 17 of 17
Summary Record Card benerated oh 5/20/2009 2:32:20 PM by Karen Hanlon Page 1
Town of North Andover
Tax Map # 210-106.A-0187-0000.0
Parcel Id 17330
1264 SALEM STREET
TAHERI, LANDAN
1264 SALEM STREET
NORTH ANDOVER, MA
01845
Class 101 Single Family Property Type 1 Residential
Size Total 1.17 Acres
FY 2009
UB Mailing Index
Name/Address Type Loan Number Active/Inact. From Until
TAHERI,LANDAN Payor
1264 SALEM STREET
NORTH ANDOVER,MA
01845
UB Account Maint.
Account No Cycle Occupant Name Active/Inactive
Bldg Id. 17401.0-1264 SALEM STREET Last Billing Date 4/6/2009
3170071 03 Cycle 03 Active
UB Services Maint.
Account No.3170071
Service Code Rate Charge Multiplier/Users
MISCFEE ADMIN FEE 0.635/8 7.82 1/
WTR WATER 01 ALL METER SIZE 44.07 /1
UB Meter Maintenance
Account No.3170071
Serial No Status Location Brand Type Size YTD Cons
33605542 a Active ERT HH F.RT. b Badger w Water 0.63 0.63 102
Date Reading Code Consumption Posted Date Variance
3/12/2009 236 a Actual 13 4/29/2009 -46%
12/5/2008 223 a Actual 22 1/20/2009 -54%
9/8/2008 201 aActual 52 10/10/2008 211%
6/4/2008 149 a Actual 15 7/16/2008 19%
3/10/2008 134 a Actual 13 4/11/2008 -56%
12/12/2007 121 a Actual 33 1/22/2008 -48%
9/4/2007 88 a Actual 53 10/12/2007 140%
6/14/2007 35 a Actual 25 7/20/2007 85%
3/13/2007 10 a Actual 10 4/16/2007 -100%
1/3/2007 0 n New Meter 0 1/19/2007 -100%
1/3/2007 2438 r Replacement 25 1/19/2007 -63%
9/18/2006 2413 a Actual 57 10/20/2006 90%
MSG ACTUAL SAYS 413
6/19/2006 2356 a Actual 34 7/10/2006 0%
3/8/2006 2322 a Actual 25 4/17/2006 30%
Trouble Code:03
12/22/2005 2297 m Manual estimate 25 1/17/2006 -68%
MSG
9/14/2005 2272 a Actual 71 10/14/2005 148%
Trouble Code:03
6/15/2005 2201 a Actual 28 7/15/2005 49%
3/18/2005 2173 a Actual 20 4/5/2005 -5%
12/13/2004 2153 a Actual 18 1/14/2005 -64%
9/23/2004 2135 a Actual 57 10/8/2004 107%
6/22/2004 2078 a Actual 21 7/30/2004 48%
4/12/2004 2057 a Actual 26 5/17/2004 0%
+ •-Driving Directions from 1600 Osgood St,North Andover, MA to 1264 Salem St,North A... Page 1 of 2
MAPQUE'ST
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Takes Just seconds to install
Total Time: 15 minutes Total Distance: 6.53 miles
A: 1600 Osgood St, North Andover, MA 01845-1048
Start out going SOUTH on OSGOOD ST/MA-125 toward
1' ORCHARD HILL RD. Continue to follow MA-125. 1.8 mi
2: Turn SLIGHT LEFT onto OSGOOD ST. 0.6 mi
3: Turn SLIGHT LEFT onto STEVENS ST. 1.0 mi
4: Turn SLIGHT RIGHT onto GREAT POND RD. 0.0 mi
4� 5: Turn LEFT onto STEVENS ST. 0.2 mi
6: Turn LEFT onto SALEM ST. 2.4 mi
7: Turn RIGHT to stay on SALEM ST. 0.5 mi
Be End at 1264 Salem St North Andover, MA 01845-4910
B: 1264 Salem St, Norter, 10
Total Time: 15 minutes tal Distance: 6.53 miles
_ O
http://www.mapquest.com/maps?1 c=North+Andover&i s=MA&l a=1600+Osgood+Street... 5/26/2009
Driving Directions from 1600 Osgood St,North Andover, MA to 1264 Salem St,North A... Page 2 of 2
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All rights reserved. Use subject to License/Copyright Map Legend
Directions and maps are informational only.We make no warranties on the accuracy of their content,road conditions or
route usability or expeditiousness.You assume all risk of use.MapQuest and its suppliers shall not be liable to you for
any loss or delay resulting from your use of MapQuest.Your use of MapQuest means you agree to our Terms of Use
http://www.mapquest.com/maps?1 c=North+Andover&i s=MA&l a=1600+Osgood+Street... 5/26/2009
+qRrh Commonwealth of Massachusetts Map-Block-Lot
X40 11�t° ,6.4 106.A-0187-
Board of Health
I- Permit No
North Andover BHP-200-9------ --
-------
------------
` °. •` + P.I. FEE
is3ACM u9F.I. $125.00
-----------------------
Disposal Works Construction Permit
Permission is hereby granted Todd-B-ateson
---------------------------------------------------------------------------------------------------
to(Repair-D-BOX ONLY)an Individual Sewage Disposal System.
atNo 1264 SALEM STREET (R -1)- --------------------------------------------------------------------------------------------------------
-------------------------------------T
as shown on the application for Disposal Works Construction Permit No. BHP-2009-053 Dated May 20,2009
---------------------- ------------------------------
-----
Issued On:May-20-2009 LE bI l h
• "°"$" + Commonwealth of Massachusetts Map-Block-Lot
r�•'"s� �'•.*bo 106.A-0187-
Board of Health --------------------
+ North Andover
.�,•r,p_:,.. Certificate of Complia
S ACwustl
THIS IS TO CERTIFY,That the Individual S e Disposal System (Repair-D-BOX ONLY)
by Todd Bateson
----------------------- ---------------------------------------------------------------------------------------
Installer
atNo 1264 SALEM ST (R-1)---------------------------------------------------------------------------------------------------------
----------------------- - ------------ ------
has been install ' accordance with the provisions of TITLE 5 of the State Environmental Code as described in the
application or Disposal Works Construction Permit No. BHP-2009-053 Dated May-20,-2009
-----------------------------------------------------------------
Printed On:May-26-2009 Board of Health
10PTh .
R t:
Cl z
Town of North Andover N
HEALTH DEPARTMENT
,SSACNUst
CHECK#: DATE.• ,. 2_�
/ F
Z
LOCATION:
o
f W
'-X
H/O NAME: Z- -- NF Z t-
a
CONTRACTOR NA O ow l7
Type of Permit or License:(Check box) j�,�,., 1 OXX
F ti
❑ Animal $ z
❑ Body Art Establishment $ o
❑ Body Art Practitioner $ "' rR
ti
❑ Dumpster
rn
❑ Food Service-Type. $
F=+
❑ Funeral Directors $
S
❑ Massage Establishment $ b r i _•
a i rU
❑ Massage Practice $ z W< s
LO 4 5
N r, °
❑ Offal(Septic)Hauler $ o . W � p.;, r' ti
!y � Q
❑ Recreational Camp o arn
-} d w .a
❑ Sun tanning $ w < o 1
❑ Swimming Pool $ zW a _.
W> .
- y
o ,
❑ Tobacco $ z z ,�a
Oa0 Ir
H
❑ TrashlSolid Waste Hauler LO
$ V`
a ~ ui
❑ Well Construction $ m ! 1
SEPTIC S,stems: O
W O
❑ Septic-Soil Testing $ o
❑ Septic-Design Approval $ f Q wo
❑ Septic Disposal Works Construction(DWC) a-[V-3,: 1,
❑ Septic Disposal Works Installers(DWI)
�$
❑ Title 5 Inspector
❑ Title 5 Reports $
❑ Other:(Indicate) $
r �
I
,%I1ealth AgAt Initials
j`
White-Applicant Yellow-Health Pink-Treasurer
---- --- - ---
pM";�T;1ti Application for Septic Disposal System -0 9
r ���� e*rp
op Construction Permit — TOWN OF
ORTH ANDOVER, MA 0184.
S^CHUS
—t f 1 5 r— S
Important: Application is hereby made for a permit to:
When filling out ❑ Construct a new on-site sewage disposal syste t�-� s�� L Lc- �r l�
forms on the
computer,use ❑ Repair or replace an existing on-site sewage di
only the tab key
to move your 91repair or replace an existing system componel
cursor-do not n
use the return A. Facility Information �\
key.
`a,
Address or Lot# 1
City/Town
2.-*TYPE OF SEPTIC SYSTEM*:
❑ Pump ravity(choose one)
***If pump system,attach copy of electrical permit to application***
916"Onventional System(pipe and stone system)
❑ Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system.
❑ Pressure Distribution S.A.S.(No D-Box) (Attach Draft Maintenance Agreement)
❑ Pressure Dosed (D-Box Present) S.A.S.
2. Owner Information
Name ,
Address(if different from above)
City/Town State . Zip Code
t� t�& — A ISS
Telephone Number
3. Installer Information
C's✓
Name Name of 'afi�`:�G�
Arcg:rl_-j RCS d
Address Anclover, MA 01810
City/Town State Zip Code
C7 7 V 5-'1 S—cV7Q>
Telephone Number(Cell Phone#if possible please)
4. Designer Information
Name Name of Company
Address
Cityrrown State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
i
MORTM Applicatibn for Septic Disposal System
TODAY'S DATE
=Construction Permit — TOWN OF
ORTH ANDOVER MA 01845 $250.00-Full Repair
s,�C S $125.00 -Component
PAGE 2OF2
A. Facility Information continued....
5. Type of Building: esidential Dwelling or❑Commercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore-described
on-site sewage disposal system in accordance with the provisions of Title 5 of the
Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of
North Andover, and not to place the system in operation until a Certificate of Compliance has
been issued is Board of Health.
—
Name Date
Application pp ved By: (Board of Health Representative)
Nam Date
plication Diapproved for the following reasons:
For Office Use Only:
I Fee Attached. Yes V No
2. Project Manager Obligation Form Attached. Yes v No
I P stem? If so.Attach copy ofElectrical Permit Yes No
4. Foundation As- (new construction ronly): Yes No
(Same scale a roved plan)
5. Floor Plans?(new construc only): Yes No
Application for Disposal System Construction Permit•Page 2 of 2
00
SEPTIC SYSTtM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
i .�c. y -:5-4(X, 51,
(Address of septic system) For plans by
(Engineer)
Relative to the application of JA At-�-
(Installer's name) And dated
ngm ate
Dated 5-- a_�7With revisions dated
Ioc�y's ate
(Last revised date)
I understand the following obligations for management of this project:
1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to
performing any work on a site. I must have the approved plans and the permit on site when any work is
being done.
2. As the installer, I must call for any and all inspections. If homeowner, contractor,project manager, or any
other person not associated with my company schedules an inspection and the system is not ready, then
:.item three shall be applicable.
3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as
indicated below. I understand that requesting an inspection without completion of the items in accordance
with Title 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or
my company.
a. Bottom of Bed–Generally, this is the first (1 ) inspection unless there is a retaining wall,which
should be done first. The installer must request the inspection but does not have to be present.
b. Final Construction Inspection–Engineer must first do their inspection for elevations, ties, etc.
As-built of verbal OK(or e-mail to: healthdept(2townofnorthandover.com) from the engineer must
be submitted to the Board of Health,after which installer calls for an inspection time. Installer must
be present for this inspection. With a pump system,all electrical work must be ready and able to
cause pump to work and alarm to function.
c. Final Grade–Installer must request inspection when all grading is complete. Installer does not
have to be on-site.
4. As the installer, I understand that only I may perform the work (other than simple excavation)and I am required
to complete the installation of the system identified in the attached application for installation. I further
understand that work done by others unlicensed to install septic systems in North Andover can constitute
reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of
North Andover. significant fines to all persons involved are also possible.
5. As the installer, I understand that I must be on-site during the performance of the following construction
steps:
a. Determination that the proper elevation of the excavation has been reached.
b. Inspection of the sand and stone to be used.
c. Final inspection by Board ofHealth staff or consultant.
d. Installation of tank,D-Box,pipes, stone, ven;pump chamber, retaining wall and other
components.
6. As the installer, I understand that I am solely responsible for the installation of the system as per the
approved plans No instructions by the homeowner,general contractor, or any other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer: 4 (Today's Date) —dna _o
ame–Print) am igne
` TOWN OF NORTH ANDOVER ct N�RTN
' Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
1600 OSGOOD STREET; Building 2-36 ;;.. .r
NORTH ANDOVER,MASSACHUSETTS 01845
Susan Y. Sawyer,REHS/RS 978.688.9540—Phone
Public Health Director 978.688.8476—FAX
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: /a�� S�- MAP: LOT:
INSTALLER; �� p�
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
INSPECTIONS
2) _�ox
TANK INSPECTION:
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
[]Existing septic tank properly abandoned
❑Internal plumbing all to one building sewer
[]Topography not appreciably altered
Comments:
SEPTIC TANK
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ 1500 gallon tank has been installed
H-10 loading Monolithic construction
❑ Watertightness of tank has been achieved
(Visual or Vacuum Test or Water held for 24hrs)
❑ Inlet tee installed, centered under access port
❑ Outlet tee (gas baffle or effluent filter) installed,
centered under access port
❑ 24" inch cover to within 6" of final grade installed over
one access port, must be over outlet of tank if effluent
filter is present
❑ Hydraulic cement around inlet & outlet
Wastewater System Documentation—Feb 2006
Page 1 of 6
u
r TOWN OF NORTH ANDOVER °E pORTH
Office of COMMUNITY DEVELOPMENT AND SERVICES a� •``� � °
HEALTH DEPARTMENT
1600 OSGOOD STREET; Building 2-36
NORTH ANDOVER,MASSACHUSETTS 01845 3'Ss;;C U
Susan Y. Sawyer,REHS/RS 978.688.9540—Phone
Public Health Director 978.688.8476—FAX
Comments:
PUMP CHAMBER
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ Combo Tank installed. Size:
❑ 1000 gallon Pump Chamber installed
H-10 loading
Monolithic construction)
❑ Inlet tee installed, centered under access port
❑ Pump(s) installed on stable base
❑ Alarm float working
❑ Pump On/Off floats working
❑ Separate on/off floats
❑ Drain hole in pressure line
❑ 24" inch cover to within 6" of final grade installed over
pump access port
❑ Water tightness of tank has been achieved
Visual testing
❑ Hydraulic cement around inlet & outlet
Comments:
ADVANCED TREATMENT TECHNOLOGY
❑ Type of treatment device:
❑ Installed per manufacturers requirements
❑ All components working in accordance with
manufacturer's requirements
Comments:
Wastewater System Documentation—Feb 2006
Page 2 of 6
1.
TOWN OF NORTH ANDOVER t NORTH
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
1600 OSGOOD STREET; Building 2-36 `►", . !,�
NORTH ANDOVER, MASSACHUSETTS 01 845
Susan Y. Sawyer,REHS/RS 978.688.9540—Phone
Public Health Director 978.688.8476—FAX
D-BOX
Installed on stable stone base
[]� Inlet tee (if pumped or >0.08'/foot)
[� Hydraulic cement around inlet & outlets
[✓]� Observed even distribution
[►� Speed levelers provided (not required)
Comments:
o
SOIL ABSORPTION SYSTEM
❑ Bottom of SAS excavated down to soil layer, as
provided on plan
❑ Size of SAS excavated as per plan
❑ Title 5 sand installed, if specified on plan
❑ 3/4-1 %" double washed stone installed
❑ 1/8-1/2" (peastone) double washed stone installed
❑ Laterals installed and ends connected to header
❑ Laterals vented if impervious material above
❑ Orifices @ 5 & 7 o'clock positions
❑ Gravel-less disposal systems: type, number and
location as per plan
❑ Elevations of laterals installed as on approved plan
❑ 40 Mil HDPE barrier installed
❑ Retaining wall (boulder/ concrete /timber/ block)
❑ Final cover as per plan
Comments:
Wastewater System Documentation—Feb 2006
Page 3 of 6
• TOWN OF NORTH ANDOVER E NORTit
• Office of COMMUNITY DEVELOPMENT AND SERVICES
F
HEALTH DEPARTMENT
1600 OSGOOD STREET; Building 2-36
NORTH ANDOVER,MASSACHUSETTS 01 845
Susan Y. Sawyer,REHS/RS 978.688.9540—Phone
Public Health Director 978.688.8476—FAX
PRESSURE DISTRIBUTION
❑ -- inch manifold
❑ laterals installed with end sweeps
size:
material:
❑ Squirt test ft in height
❑ Equal distribution to all laterals
❑ orifice size inch as per plan
Comments:
CONTROL PANEL
❑ Alarm & Pump are on separate circuits
❑ Alarm sounds when float is tripped
❑ Location of control panel:
❑ Rated for exterior if placed outside
Comments:
N
Wastewater System Documentation—Feb 2006
Page 4 of 6
' TOWN OF NORTH ANDOVER of NORTH 1
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT p
1600 OSGOOD STREET; Building 2-36 �, .
NORTH ANDOVER MASSACHUSETTS 01845U Flys`""C.H
s�cNs
Susan Y. Sawyer,REHSIRS 978.688.9540—Phone
Public Health Director 978.688.8476—FAX
CRITICAL SETBACK DISTANCES
Mark those distances checked in the field against the design plan and regulatory
setback
Tank SAS Sewer
❑ Property line 10 10 --
❑ Cellar wall 10 20 --
❑ Inground pool 10 20 --
❑ Slab foundation 10 10 --
❑ Deck, on footings, etc 5 10 --
❑ Waterline 10 10 101
❑ Private drinking well 75 1002 50
❑ Irrigation well 75 100
❑ Surface Water 25 50
❑ Bordering Vegetated Wetland ,
Salt Marsh, Inland/Coastal Banka 75 100
❑ Wetlands bordering surface
water supply or trib. (in Watershed) 150 150
❑ Trib. to surface water supply 325 325
❑ Public well 400 400
❑ Interim Wellhead Prot. Area
❑ Reservoirs 400 400
❑ Drains (wat. supply/trib.) 50 100
❑ Drains(intercept g.w.) 25 50
❑ Drains (Other)Foundation 10(5) 20(10)
❑ Drywells 20 25
Suction line 222(2)
2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02).
3 As defined in 310 CMR 10.55, 10.32, 10.54,and 10.30,respectively,pursuant to 15.211(3),also by NA wetland
bylaws
Wastewater System Documentation—Feb 2006
Page 5 of 6
TOWN OF NORTH ANDOVER t NORTN
Office of COMMUNITY DEVELOPMENT AND SERVICES o`'`L• �•'�°p
HEALTH DEPARTMENT
1600 OSGOOD STREET; Building 2-36
NORTH ANDOVER,MASSACHUSETTS 01845 * ,S
S�cHug
Susan Y. Sawyer,REHS/RS 978.688.9540—Phone
Public Health Director 978.688.8476—FAX
SYSTEM ELEVATIONS
INVERT ON DESIGN PLAN FIELD INVERT ELEV.
Building Sewer OUT
Septic Tank IN
Septic Tank OUT
Pump Chamber IN
Pump Chamber OUT
Distribution Box IN
Distribution Box OUT
Lateral 1 HIGH
Lateral 1 LOW
Lateral 2 HIGH
Lateral 2 LOW
Lateral 3 HIGH
Lateral 3 LOW
Lateral 4 HIGH
Lateral 4 LOW
Lateral 5 HIGH
Lateral 5 LOW
Wastewater System Documentation—Feb 2006
Page 6 of 6
Commonwealth of Massachusetts
h Title 5 Official Inspection For RECEIVED
Subsurface Sewage Disposal System Form-Not for Voluntary As essrr01 2 9 2009
1264 Salem Street
Property Address HEALTH DEPARTMENT
Hank Vessal
Owner Owner's Name
information is
required for North Andover MA 01845 5/26/2009
every page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form.Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:
When filling out A. General Information
forms on the
computer,use 1. Inspector:
only the tab key
to move your Todd Bateson
cursor-do not Name of Inspector
use the return
key. Bateson Enterprises Inc.
Company Name
VQ 111 Argilla Road
Company Address
Andover Ma 01810
City/Town State Zip Code
978-475-4786
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
'�a 5/26/2009
In ctoes Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""*"This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•09/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
° Commonwealth of Massachusetts
m Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1264 Salem Street
Property Address
Hank Vessal
Owner Owner's Name
information is
required for North Andover MA 01845 5/26/2009
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
After permit from Health Dept., install new d-box, inspection from Health Dept., septic system now
passes Title 5 Inspection.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
t..ot R I.tro1* 5ALC-V )
LOT 10 — i a(00 S ALE M
Was Town of 120 Main Street
OFFICES OF: o °�, _ - ,
APPEALS NORTH ANDOVER North Andover,
BUILDING ;,'`�i:'=-r'�sMassachusetts OI845
CONSERVATION ee�cNue�� DIVISION OF (61 7)685-4775
�AHEALTH
IILANN Nj�, PLANNING & COMMUNITY DEVELOPMENT f
KAREN H.P. NELSON, DIRECTOR
r
-2 4f-
June 21 1988
Forbes Realty TrustIr'
%Country Hollow Realty Trust
y , �D
11 Country Hill Lane I, 1 S �I,IIz 10 G
Haverhill, Mass . re=Lots 9&10 Salem St
Lot 21 Forest St.
Thank you for your cooperation in straighteningout the
recent problems at Lot 4 Summer Street. There are still 3 lots
left that I am aware of which have problems Lh.at must be corrected. tj L
Lot 9 Salem St. . This site is being used as a dump while
the house is under construction. The garbage that is among the
rubbish there must be disposed properly.
Lot 10 Salem St. The Septic Tank is covered with about six
feet .of fill . It must have access chimnies installed to within
1 Foot of surface grade so it can easily be pumped out, as required {_
by State law 310 CMR 15.06. 'j
Lot 21 Forest St. The pipe from the house into the Septic p�
Tank appears to be level, if it had more pitch obstructions would (1 v
not occur as they do now. I think the pipe just neec-Is to be ralsedc`b '
a few inches where it Comes out of the house.
P
The residents of Lots 10 and 21 will be expecting to hear �
from you. about arranging a time for repairs . Please have your
crew contact me before repairs are started .
3- cS -��j V,s►7�f `a�
rr Sincerly
--------------------------- �' �V��/l� /'/t"�
Sanitarian Board of c-Iealth
cc: O' Brien 1.260 Salem St.
Messier 109 Forest St.
r �
i
y
r
Id 400 scf
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rv6�lw t5 (0-1
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Page 6 P
ORDER OF CONDITIONS HITCHING POST ROAD D.E.Q.E. 4242-429 '
37. In addition to the requirements of Conditions No. 11, the applicant shall
submit a letter to the NACC from a registered professional civil engineer
certifying compliance with this Order of Conditions. Said letter will
certify, but not be limited to the following:
a. "As-Built" elevations of all drainage ways
constructed within 100 feet of any wetland
resource area.
b. "As-Built" elevations and grades of all filled
or altered wetland resource areas.
c. Distances to all structures and alterations within
100 feet of any wetland resource areas.
An "As-Built" topographic plan of all areas within the jurisdiction
of the Wetland Protection Act and Bylaw shall be submitted when a
Certificate of Compliance is requested.
38. The utilities for any of the houses in this subdivision shall not be
constructed as to pass under or through any wetland resource areas on
the site except as shown on the plans referenced in Condition No. 12b.
39. All effluent catch basins shall contain oil/gasoline traps, and it shall
be a continuing Condition of this Order, even after a Certificate of
Compliance is issued, that the oil/gasoline traps in the catch basins
be maintained.
40. No underground storage of fuel oils shall be allowed on any lot within
one-hundred (100) feet of any wetland resource area. This Conditi6n'!
. shall survive this Order of Conditions, and shall run with the title
of the property.
41. Fertilizers utilized for landscaping and lawn care shall be of the low
nitrogen content variety, and shall be used in moderation. Pesticides
and herbicides shall not be used on any lot in the subdivision within
100 feet of a wetland resource area.
w ,
INTER AGENCY REFERRAL
keport from Date:
Community Agency
From: To:
Tel. No. : Tel. No. :
Attention
Patient Age
Address Date of next clinic app't.
Hosp. Db,
Content of Report to Hospital:
YA-qj 0 �e
Division of Tuberculosis, MDPH
PH-TM-211-2/2/62
64
IIORTH
OtStee 6,94o
BOARD OF HEALTH
A
" * 120 MAIN STREET
"HUS�t`y NORTH ANDOVER, MASS. 01845 TEL. 682-6400
COMPLAINT FORM
DATE
MADE BY: 4
ADDRESS: -Z 54CeM TEL.
NATURE OF COMPLAINT74Sf4r -�p��� �Vr5���%��/�
TZ
LOCATION: ZoT l5AL6--1" S T OCCUPANT
IIWNER FOIZs ADDRESS
DO NOT WRITE BELOW THIS LINE
REFERRED TO DATE OF INVESTIGATION
RESULT OF INVESTIGATION j Haj l'-S-A T 1?ASH PI Le H eRG-
ti'ew "3 /43yT5RS
RECOMMENDATIONS:
ACTION TAKEN:
� �
h
t �
�t
„�
F
JUL 8
r
LaMarche Associates
233 West Central Street-- -
P.O. Box 179
Natick,MA 01760
(508) 650-9777
Fax: (508) 650-9870
June 17, 1997
Building Commissioner/Inspector of Buildings
North Andover,MA 01845
Board of Health/Board of Selectmen
North Andover,MA 01845
NOTICE OF CASUALTY LOSS TO BUILDING
UNDER MASSACHUSETTS GENERAL LAWS.CHAPTER 139,SECTION 3B
Claim has been made involving loss, damage or destruction of the property captioned below, which may either
exceed$1,000.00 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,cause of loss and LA
file number.
Insured: BROWN, CHRISTOPHER
Loss Location: 64 Salem Street
or o�IG 01845
Policy Number: 5511489
Date of Loss: 6/13/97
Cause of Loss: Water
LA File Number: MA-2-14305
On this date, I caused copies of this notice to be sent to the persons named above at the addresses
indicated above by first class mail.
Daniel Johnson
Adjuster
: Commonwealth of Massachusetts s
City/Town of
System Pumping-Record '0y N ZI
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
1. System Location: Left/Right front of house, Left/Right rear of house, Left/ side of hou , Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under
9 9 g, ec c
. Address � � �+ , `• ��ti1``Q��.. � ?
City/Town State Zip Code
2. System Owner.
�Cv `-\ V\
Name'
Address(d different from location)
Cityrrown
State dip Code
Telephone Number `
1
.13. 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 algo If yes, was it cleaned? ❑ Yes ❑ No
' 5. Condition of Systerr� A, .
OS 464�,._
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loc ' where contents were disposed:
L S'. Lowell Waste Wafer
r f �� f
Sign a Haul Date
t5formCdoc-06/03 System Pumping Record•Page 1 of 1