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HomeMy WebLinkAboutMiscellaneous - 129 CARLTON LANE 4/30/2018 129 GARLTON LANE 210H W-G-0084-0000.0 _J 1 Commonwealth of Massachusetts 7RECEIVED City/Town of System Pumping Record014 Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 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: Righ hou Left/Right rear of house, Left/right side of house, Left! Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address ^ Cityrrown State Zip Code 2. System Owner. �x Q Name Address(f different from location) Cfyfrown Stateip de t C� i � 1 Telephone Number B. Pumping Record ` A 4�c 1. Date of Pumping Date 2. Quantity Pumped: Canons 3. Type of system: ❑ Cesspool(s) aleptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yep No If yes,was it cleaned? ❑ Yes ❑ No Condition of System: 6. System Pumped By. Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: G, S. Lowell Waste Water Sig Haul Date t5 rmCdoc-06!03 System Pumping Record•Page 1 of 1 Commonwealth.of Massachusetts City/Town of I FRECEIVED kviSystem Pumping Record Form 4 2 9 2006 DEP has provided this form for use by local Boards of Health. T etemPi�tYi irie1ro�d must be submitted to the local Board of-Health or other approving aut oritjf`A" `��`,"p I �` i A. Facility Information Important: When filling out 1. System ocation, e forms the (� computer.use only the tab key Address �x to move your _Q cursor-do not use theretum City/Town State Zip Code key. 2. System Owner: A Name Address(d different from location) City/Town State/ Zip �j de Telephone Number B. Pumping Record I. Date of Pumping Date 2. Quantity`Pumped: Gallons 3. Type of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System-(dad: ` 6: System Pu ed BY Name Vehicle License Number Company ..7. Locatio ere contents vwre di ed: Signatu of aul r Date http://www.mass.gov/dep/water/approvals/`t5forms.htm#inspect t5fonn4.doc•06/03 System Pumping Record•Page 1 of 1 Address eZ 4AlTitle of Fide Page of Date File Open: Date file closed: C►oc Document/Action Title Date of action Refer to other Purpose of Documernt/Action and notes Document/ docurnent/ Num. Action Department ------------ Board of Appeals - Board of Health Planning Board-- Conservation Commission - Building Department �--� � d Commonwealth of Massachusetts Massachusetts System Putuping Record System Owner System Location - 4z)y\ L Date of Pumping: �'�� -cam Quantity Pumped: C gallons Cesspool: No Yes Septic Tank: No Yes Edema System Pumped by: t5etema f!i"evlaa License# Contents transferrred to : Greater Lawrence Sanitary District Date: _ Inspector- Ap 1 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: 3 d SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example: left front of house) ccj- I-VL - ),4 -9�46-� DATE OF PUMPING: ( -t QUANTITY PUMPED 1500 GALLONS CESSPOOL: NO J YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE JEMERGENCY i OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: &1(jyL.�j�(� COMMENTS• 01r, ", „��1 ► 5 7bbt i k CONTENTS TRANSFERRED TO: ('gym nu�i� e�ill�t►f Measaciiug�ila Massachuselt� 5ysteirr i'u�ri�p�n�1 lieuurcl -5yslc�ii�t)w�ie� -- ----- Sysleu�Lucaliu�l c,f P�uu B �a��� t�ualilily 1'�tnil+ed: ��� gallons 1 ate Iiu 6 y e�Nd'1'auk; Ncr IJ Yen r�Y (,cnepuuL Nu I�ti'en �.I � 1 Syslent Pumped by: AC¢dort vkt' ddtfd Lleetts�# Canlen(s Uansle�tred (t� ; ��aaiar r,ryyr�fir;g grtrtller� bicl 1 - Date: I ' f 7 SUBSURFACE SEWAGE DISPOSAL .SYSTEM INSPECTI N FORM Address of property 1 1 act Com- Aa�, VIA_ owner's name JO�'lr1Vl�t OYl uCC Date of Inspection , I` tg `T PART A CHECKLIST Check if llowing have been done: Pumping information was requested of theowner, occupant; and:: Board of Hea. - None of the system components have been pumped .for,at least._tw ,.-,weeks and.:�the.'system has been receiving'`normal" flow "rates during that o period. Large volumes of water have not been introduced into the --Sys recently or as. part of this inspection. As' built plans.. have been obtained and examined. Note if they are not ava ` le ''wth N/A. ' The cility or dwelling was inspected ,for signs of sewage back-up. Th a was inspected for signs of breakout. > :Allsystem components,: excluding the SAS, have-been located on the S 1 .. The septic tank manholes were uncovered,, opened, and the interior:.,`df the septic tank was inspected for"'condition of 'baffles. or Mees, material of construction, dimensions, ,depth .of liquid;. depth ,of sl :depth ,of scum. The size and location of the SAS on the site fias been determined based on ex' g information or approximated by non-intrusive methods..:, ' The facility owner (and occupants, if different ,from owner)' were provided with information on the proper maintenance of SSDS. 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION t r. FLOW CONDITIONS ' If residential L4 number of bedrooms _ number of current residents es garbage grinder, yes or no CS laundry connected to system, yes or no i Ny seasonal use, yes or no I "' If, n nresidential calculated flow: _ _ p 3 a" /3657= Water meter readings, if available. �3 90 2nv IW�Y--13,7� s' Last date of occupancy [ 7 GENERAL INFORMATION Pumping records and source of information: . _ {�QUA. '✓�"'�- ... aL �� System pumped as part of inspection, yes or no _ . if'yes, volume pumped <S�� Reason for pumping: oeva"p 'b� v 1 �S 4L1� N A Y� Typepe 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) Other (explain) I Approximate age of all components. Date installed, if known. Source of 1 information: I e My Sewage odors detected when arriving at the site, yes or no I 3 - � ' 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION .continued SEPTIC TANK: (locate on site plan) r� depth below grade: material of construction: concrete metal FRP other(explain) �j dimensions: 619 5 , 's x � � '7 9 sludge depth 1— 3T distance from top of sludge to bottom of outlet tee or baffle scum thickness " distance from top of scum to top of outlet tee or baffle distance from bottom of scum to bottom of outlet tee or baffle Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakag recomme dations fqr repairs, a c. ��2� O l O 2ti o v\. eFc' bu-� v DISTRIBUTION BOX: v (locate on site plan) depth of squid level above outlet invert — Q `� 8vx �C�s Comments: (note if level and distribution is equal, evidence of solids carryover, e 'dgnce of leakagg,e .�nto r out of box, recommendation or ree�ppair$$, etc. ) 't8 �cL)s �. ('fie wig. �'oG .6 ,3� (�e�F- Z 2 07° ' <-b � ..�.,� Sa � Civ'c' c��'• '-�� �-v�c�-.���. A �- 'dc--,>e PUMP CHAMBER:VV (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc. ) 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type Teaching pits and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil, signs of hydraulic failure, level of pond,ing, condition of egetation, recommendations for, main�n`ance or reps s,et ) -t -_ of Qe V� Klvf�Ma.�. (Zc� gl 04n- (�ar�© (� ; ti S e Coves. "� 1 C2 D V CESSPOOLS (locate on site plan) :j)1,,,, number and configuration depth-top of liquid to inlet invert depthof solids layer depth of scum layer dimensions of cesspool materials of construction indication of groundwater inflow (cesspool must be pumped as part' of inspection) Comments: (note. condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) PRIVY: OOv"& (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, recommendations for maintenance or repairs,etc. ) 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' � Sa l� =oho ase. c. y i A7 a S 5 a = ok o rf 3 .� `� ���- � _ �c�rho �` `Cess- �--.-•- hS'a -----� DEPTH TO GROUNDWATER depth to groundwater o method of determination or approximation: i 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indichte yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined", explain why not) N Backup of sewage into facility? NDischarge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the istribution box ab ve ti e , invert. 42t wQ ux GCOS 4,Io SRno c� - Liquid deh in cesspool <6" below nvert or available volume< 1/2 day flow? /Y Required pumping 4 'times or more in the last year7 number of times pumped AlSeptic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? �1 ) Is any portion of the SAS, cesspool or privy: ✓\/ below the high groundwater elevation? within 50 feet of a surface water? within 100 feet of a surface water supply or tributary to a surface ;water supply? within a Zone I of a public well? / y within. 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS)? /V within 50 feet of a private water supply well? N .. less than 100 feet but greater than 50 feet from a private water ..supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analysi , for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. s 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector NCO J �� Company Nameyj �1 � S t �� ti1a- Company Address Tiq O i e(© Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems. Check one: I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15.303. Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15.303. The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector's Signature 1 Date Original to system owner copies to: Buyer (if applicable) Approving authority - _l •. .♦ � c - i �\ .t at ,yti �.rtl 7C�y�iZ_�y a'�, , � �, y �ti `-. , S. t- ♦ .. r i � 1. � c� j� I i Form No.4 Town of North Andover, Massachusetts BOARD OF HEALTH June 22, 19q_ CERTIFICATE OF COMPLIANCE 1 This is to certify that the Individual Soil Absorption Sewage Disposal System constructed ( ) or repaired (X ) by Benjamin Osgood, Jr. INSTALLER at 129 Carlton Lane, North Andover, MA 01845 SITE LOCATION has been installed in accordance with Board of Health Regulations as described in the Design Approval Site System Permit No. dated 19 . The issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. -� BOARD OF HEALTH , .\ +} i't ` ` x •7 liia•�W_ }\ v s'� F ��_�l n�'�s \n�'l `\j t� , S. i. � \�' �F.�L�'. Town of North Andover, Massachusetts Form No.3 f MORTH BOARD OF HEALTH p�x�ao e'�qp i• 0 19 °•,,.o "� DISPOSAL WORKS CONSTRUCTION PERMIT cNU Applicant_ ,,, ��� C. ��°;L,5�,�_ NAME AD RIESS<'_ ' TELEPHONE Site Location Permission is hereby granted to Construct ( ) or Repair (Kan Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN,BOARD OF HEALTH Feefn D.W.C. No. S� �'i��.�.�:..�._..__/_3.9.__x_��.� `� '� ����( • �� �,,,��.,, i�,�,�N Sill I 71_._ Cy t Qfq Tati _ No►�Tf�l /�r�povEl�, MA, �lP��� Citi Wq�'�� Sc�PPL7 ���t,�nl C] WEc..c._ �P�ou�D11JrC DiC�PPrzov5p 1A Te R�SoNS Dw� SCPT'r C SYSTEM I�5iA l..L,QT►o�..l C`Y"v4TO,�J f"SP6--6T(O&j PArC- ALMC,sT FrADY 4p P45S E] F4IL- F=rNAI; I US(�F�rlonJ 4PP OJEP D/3TC Z AP12ROJIliG AUTHORS i aSI�PP�vv�l� DW i C FVV,QL /3PPNQvAL W rd of Health Koe..Y indover,Mass SUBSURFACE DISPOSAL DESIGN CHECK LIST LOT # 3 3 CQ1&jQt) APPROM DATE DISAPPROVED DATE Provided: Reasons: Tdw�Tt A"Jj7 Z, NO T i vVOC Grl t o r F UL 3, T� � wgr�R r���_ �5 312 Tide V FAIL OK Reg 2.5 The submitted plan must show as a minimum: a) the lot to be served-area,dimensions lot #,abnttera b location and log deep observation hoes-distance to ties location and results percolation tests-distance to ties d design calculations &calculations shoving required leaching area (e) location and dimensions of system-including eeserve area f) existing and proposed contours (g) location any Bret areas within 1001 of sewage disposal system or disclaimer-check wetlands mapping (h) surface and subsurface drains within 1001 of sewage disposal system or disclaimer (i) location any drainage easements within 1001 of sewage disposal system or disclaimer-Planning Board f les (J) known sources of water supply within: -:001 of sewage disposal e 1system or disclaimer (k) location of any proposed well to sere lot-1001 from leaching facilit; (1) location of water lines on property-L 1 from leaching facility (m) location of benchmark (n) driveways (o) garbage disposals (p) no PVC to be used in construction (q) profile of system-elevations of basemen- plumb, pipe, septic tank, distribution,box inlets and outlets, d+.stribution field piping and Other elevations (r) maximum ground water elevation in area sewage disposal system (s) plan mast be prepared by a Professional Engineer or other �. professional authorized by law to prepare such plans Reg 6 Septic Tanks (a) capacities-150of flow, water table, tees, depth of tees, access, pumping (b) cleanout_.. (c) 101 from cellar wall or inground swimming pool (a) 250 from subsurface drains Reg 10.2 Distribution Boxes (a) slope greater than 0.08 Reg 10.4 b) sump � IS ��t � ✓ 14 I v" �-Q _ _SL-{ Loi 3y 5-1-ga& to 3E ( Iz � 2:17 16 2:: I . 1 Cor 3 7 4 win�Mqm i i F !� orm of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B TO: BUILDING COMMISSIONER OR INSPECTOR OF BUILDINGS Town HallEftAw o North Andover, Massachusetts 01845 �y TO: /BOARD OF HEALTH OR BOARD OF SELECTMEN Town Hall North Andover, Massachusetts 01845 RE: Insured: John Antonucci&Sandra Censabella Property Address: 129 Carlton Rd. North Andover,MA 01845 Policy Number: HP1339551 i Date/Cause of Loss: Wind/Rain File or Claim No: 91828-B CLAIM HAS BEEN MADE INVOLVING LOSS, DAMAGE OR DESTRUCTION OF THE ABOVE-CAPTIONED PROPERTY, WHICH MAY EITHER EXCEED $1,000.00 OR CAUSE MASS. GEN. LAWS. CHAPTER 143, SECTION 6, TO BE APPLICABLE. IF ANY NOTICE UNDER MASS. GEN. LAWS, CH. 139, SEC. 313 IS APPROPRIATE, PLEASE DIRECT IT TO THE ATTENTION OF THE WRITER AND INCLUDE A REFERENCE TO THE CAPTIONED INSURED, LOCATION, POLICY NUMBER, DATE OF LOSS AND CLAIM OR FILE NUMBER. Herb Berger, General Adjuster 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. Signature and Date C i i - HALLMARK CLAIM SERVICES - Lakeside Office Park, Door 17, Wakefield, MA 01880 i i FOKM 4- SYSTEM PL:11PL\G RECORD Commonwealth of Massachusetts , Massachusetts System Pumping Record -stem Owner Svstem Location FAAkkvel! ccc' c5( Lv , Date of Pumping: Z l '9 Quantity Pumped: 164c- gallons Cesspool: No Yes ❑ Septic Tank: No ❑ Yes System Pumped b%-: _ License #: Contents transferred to: Date Inspector TOWN OF 4fC SYSTEM P PING RECORD DATE: A SYSTEM OWNER&ADDRESS SYSTEM LOCATION (example:left front of house) 6vsc DATE OF PUMPING: ( QUANTITY PUMPED : 0 GALLONS CESSPOOL. NO � YES SEPTIC TANK: NO YES V NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACIFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED To: G.L.S.D Lowell Waste Commonwealth of Massachusetts City/Town of RECEIVED \j System Pumping Record OCT 3 o Zoos µ Form 4 M TOWN uF•NORTH ANDOVER DEP has provided this form for use by local Boards of Health. thet�fb'ri �itiV� ' sd ut the information must be,substantially the same as that provided here.Before using this form,check with your local Board of Health tq determine the form they use.The System Pumping Record must be submitted to the local Board of Health or%_oth, r approving authority. A. Facility Information 1. System Locatign: Left side of house, Right side of hoVgg�. �Fearof ht front of house, Left rear of hou`sk Right rear of house. Left rear of bug. Address V;Nz: � cityrrown State Zip Code 2. System Owner.- Name wner:Name Address(if different from location) Cityrrown State Zip Code Tele-plione Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) ff-Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes R"No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: L. .D Lowell Waste Water Signature of Hauler Date t5form4.doc•06/03 System Pumping Record•Page t of 1 Commonwealth of Massachusetts City/Town of a System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms m y bt�aed't�ut ttie...p� information must be substantially the same as that provided here. Before usi this A;P1 h��k-6ith yot r local Board of Health to determine the form they use. The System Pumping RAcord must be submitted the local Board of Health or other approving authority. s`��i _4 Q j A. Facility InformationTOWN OF NORTH ANDOVER HEALTH DEPARTMENT 1. System Location eft front of house right front of house, left side of house, right side of house, Left rear of house, right rear o house, eft side of building, right rear of building, under deck. City/Town State Zip Code 2. System Owner: rr L Name Address(if different from location) Cityrrown State Zip Code Telephone Number B. Pumping Record 1. Date of PumpingQuantity Pumped: Date Gallons 3. Type of system: ElCesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes L�' No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: , a�w►� fie 6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Location where contents were disposed: G.L.S. Lowell Waste Water `n ' Signature of Hauler/ Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1