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Home My WebLink AboutMiscellaneous - 1324 SALEM STREET 4/30/2018 (2) i I i i i �� I '� 1 /J 'Fran P Mq �olq 9 72 aSg ' FORM U - LOT RELEASE FORM INS T tRUCTIONS: .This form is used to verity that all nec-ssary approvals/permits from beards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. FILLS OUT THIS APPL1CT ,, j1CA, �L 23 � )b C, C. PHCNE LOCATION: j\/lap Nurnber r\ SUEDIVISICN LOT (S) STREET �oZ�' S�� ^ �'� ST. NUMEER I RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED CCMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED to ado DATE REJECTED - COMMENTS -Q75U ie�� Cly a r--e<:? �✓" q�Q /ir/b� l �'46�J S� YY'�/� -0 Y) -7 f67,�4 ave J(dr 31-d / PUELIC WORKS -SENERIWA T ER CONNECTIONS CR1VEWAY PERMIT FIRE DEPARTMENT <E�EiVEC EY EUILDiNG iiISPECTCR CA.T= Revised SIs-, in 6e1 I i' I®I ,J I' It ,a• I L •�,/// � I ell) • AREA CODE NUME !; L�Sa �, -,A L-p;-66 �p fC C deed I 7. Approval of March 23, 2000 Minutes 4 Old Business Allocation of Funds—Web Server Facility 19 Second Street—Lead Court Case Discussion Merrimack College Critique Correspondence Tobacco Use Policy Mass Refusetech, Inc. 57 High Street l r RESTRICTION The Restriction herein set forth shall apply and be appurtenant to the following described property located at 1324 Salem Street,North Andover, Essex County, Massachusetts,being more particularly described as follows: A certain parcel of land located in North Andover, Essex County,Massachusetts,being shown as Lot 4A on a plan entitled, "Plan of Land located in North Andover, MA for B. & R. Construction Scale 1"=40'; March 27, 1985, S.L. Giles R.L.S., Lawrence, MA",being Plan No. 9865. Said Lot 4A containing 49,119 square feet, more of less, according to said Plan. Being the same premises described in deed recorded with Essex North District Registry of Deeds in Book 3905, Page 137. 1. Maximum Number of Bedrooms At all times subsequent hereto,unless connected to an approved municipal sewer, the property described hereinabove shall be limited to use as a single family residence containing no more than four(4)bedrooms. This Restriction is being implemented due to the maximum capacity of the current septic system. 2. Prior to Sale The current owners, Frank J. Mottolo and Margaret L. Mottolo, shall upgrade the septic system to a capacity to serve five(5)bedrooms prior to any sale of the premises unless connected to municipal sewerage. 3. Enforceability These Restrictions may be enforced by the Town of North Andover,by action in equity in any Court of competent jurisdiction. Witness our hands and seal the 3"—day 000. Frank J. Mot olo cJ Margar L. Mottolo COMMONWEALTH OF MASSACHUSETTS Essex, ss o4�) 3 12000 Then personally appeared the above named Frank J. Mottolo and Margaret L. Mottolo and acknowledged the foregoing to be their free act and deed,before me. ary Public My Commission Expires: �o HAG768MESTRICTION.doc i FORM - U - LOT RELEASE FORINT INSTRUCTIONS: This form is used to verify that all-necessary approval/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. APPLICANT-�r l C /�,QT[6_1/0 PHONE �S 31 3 3 ASSESSORS MAP NUMBER 0 LOT NUMBER SUBDIVISIOONCN ( LOT NUMBER STREET V a ```'�'"� S STREET NUMBER OFFICIAL USE ONLY RECOMMENDATIONS OF TOWN AGENTS3c�r\ �Q .. DATE APPROVED CONSERVATION ADMINISTRATOR DATE REJECTED CONIlVTENTS DATE APPROVED TOWN PLANNER DATE REJECTED COMMENTS DATE APPROVED FOOD INSPECTOR-HEALT DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED CONflviENTS PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTMENT DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR DATE MAY. 9 i BK3905 I ' 13'7 QUITCLAIM DEED KNOW ALL MEN BY THESE PRESENTS that we, James Smithers and Joyce Smithers, husband and wife, for consideration paid, and in fU11 lconsideration of Two Hundred Seventy-six Thousand and 00/100 $276,000.00) Dollars grant to Frank J. Mottolo and Margaret L. Mottolo of 1324 Salem Street, North Andover, Massachusetts 01845 as I. tenants by the entirety, with QUITCLAIM COVENANTS, the following: The land with the buildings thereon situated in the Town of North Andover, Essex County, Massachusetts, situated on the northerly side of Salem Street, being Lot #4A as shown in a plan of �^ land entitled "PLAN OF LAND LOCATED IN NORTH ANDOVER, MA. FOR v co B. 5 R. CONSTRUCTION SCALE 1"a40' MARCH 27, 1985, S.L. GILES R.L.S. LAWRENCE, MA Plan #986.5. Said lot being more particularly described as follows: Southerly by Salem Street in 2 courses as shown on said plan 150 feet; Westerly by Lot 5 in 2 courses as shown on said plan, 399.71 Qj feet; Northerly by Lot 5 as shown on said plan, 131.98 feet; and Easterly in 2 courses along Lot 3 as shown on said plan, those 2 courses are 413.90 feet. Containing 49,119 square feet, more or less, according to said plan. w I Meaning and intending to convey the same premises conveyed to us by deed of John N. Thurston and Peggy L. Thurston dated April r 23, 1992 and recorded at the Essex North District Registry of Deeds at Book 3459, Page 157. cc N We, James Smithers and Joyce Smithers, husband and wife, release to said Grantees all rights of homestead and other interests therein. Dated this _1,�ti(day of November, .1993. _ X ?, Jame sthers 7. Joyce Smithers `r � I JAMES J.FLEMING,ATTORNEY AT LAW I i a3 BR3905- COMMONWEALTH OF MASSACHUSETTS { COUNTY OF 4e/. November,--A< , 1993 �? Personally appeared James Smithers and Joyce Smithers, known to -. - me, or satisfactorily proven, to be the persons whose names are subscribed to the foregoing instrument and acknowledged that they executed the same for the purposes therein coained. Before me, JastiaL-af._ e.Peace/ Notary Publ c ?+� ,``:veti. -`}'_i3�•��v`t i W: it •:.v�, .-mss.-. �i,'h:t t Barbara Uingvvali Mills NOTARY PUBLIC 1�rcommis.';Cnen.1.1Wjt +1,20^^ J d r ' Y Y I �i JAMES J.FLEMING,ATTOI,M Y AT uw ti- Al G:EX NORTH REGISTRY OF DEEDS LAWRENCE,MASS.. �` � '06), A TRUE COPY:ATTEST: REGISTER OF DEED RESTRICTION . -7 1 The Restriction herein set forth shall apply and be appurtenant to the following described property located at 1324 Salem Street,North Andover, Essex County, Massachusetts,being more particularly described as follows: A certain parcel of land located in North Andover, Essex County, Massachusetts,being shown as Lot 4A on a plan entitled, "Plan of Land located in North Andover, MA for B. & R. Construction Scale 1"=40'; March 27, 1985, S.L. Giles R.L.S., Lawrence, MA", being Plan No. 9865. Said Lot 4A containing 49,119 square feet, more of less, according to said Plan. Being the same premises described in deed recorded with Essex North District Registry of Deeds in Book 3905, Page 137. 1. Maximum Number of Bedrooms At all times subsequent hereto, unless connected to an approved municipal sewer, the property described hereinabove shall be limited to use as a single family residence containing no more than four(4) bedrooms. This Restriction is being C� implemented due to the maximum capacity of the current septic system. 2. Prior to Sale The current owners, Frank J. Mottolo and Margaret L. Mottolo, shall upgrade the septic system to a capacity to serve five (5) bedrooms prior to any sale of the premises unless connected to municipal sewerage. 3. Enforceability p�u ,00 AM9:2 These Restrictions may be enforced by the Town of North Andover,by action in equity in any Court of competent jurisdiction. Witness our hands and seal the �n� day . , 000: Frank J. Mot olo Q O Margare L. Mottolo COMMONWEALTH OF MASSACHUSETTS Essex, ss M. 3 , 2000 CL n Then personally,appeared the above named Frank J. Mottolo and Margaret L. Mottolo and acknowledge&the`foregoing to be their free act and deed,before me. d ary Public Szo� E. N My Commission Expires: HAG7689\RESTRICTION.doc / r ESSEX NORTH.REGISTRY OF DEEDS LAWRENCE, MASS. A TRUE COPY: ATTEST: REGISTER OF DMD MAY-04-2000 14:50 HATEM and MAHONEY 978 682 1712 P.02f02 O RESTRICTION The Restriction herein set forth shall apply and be appurtenant to the following described property located at 1324 Salem Street,North Andover, Essex County,Massachusetts,being more particularly described as follows: A certain parcel of land located in North Andover, Essex County,Massachusetts,being shown as Trot 4A on a plan entitled,"Plan of Land located in North Andover,MA for B. &R. Construction Scale 1"=40'; March 27, 1985, S.L. Giles R.L.S., Lawrence, MA", being Plan No. 9865. Said Lot 4A.containing 49,119 square feet,more of less,according to said Plan. Being the same premises described in deed recorded with Essex North District Registry of Deeds in Book 3905,Page 137. 1. Maximum Number of Bedrooms At all times subsequent hereto,unless connected to an approved municipal sewer, 1 the property described hereinabove shall be limited to use as a single family G: residence containing no more than four(4)bedrooms. This Restriction is being C:� implemented due to the maximum capacity of the current septic system. 2. Prior to Sale The current owners, Frank J. Mottolo and Margaret L_ Mottolo,shall upgrade the septic system to a capacity to serve five(5)bedrooms prior to any sale of the premises unless connected to municipal sewerage. 3. Enforceability MAV 4'0€1 okT23 These Restrictions may be enforced by the Town of North Andover,by action in equity in any Court of competent jurisdiction. Witness our hands and seal the day ofAo, 00�) Frank J. Motfolo Margate L. Mottolo COMMONWEALTH OF MASSACHUSETTS Essex, ss _ >R� Z , 2000 Then personally appeared the above named Frank J. Mottolo and Margaret L. Mottolo and acknowledged the foregoing to be their free act and deed,before me. ary Public fw �tvN :1 My Commission Expires: HAG768 9WRESTRICTION.doc / t TOTAL P.02 Ma�j._02 00 02: 59p p. 1 i C)� P o� e ,Y, -S Ma,�02 00 02: 59p p, 2 i,►' MAY-02-2000 15:24 HATEM and MAHONEY 978 682 1712 P.02/02 RESTRICTION The Restriction herein set forth shall apply and be appurtenant to the following described property located at 1324 Salem Street,North Andover,Essex County,Massachusetts,being more particularly described as follows; A certain parcel of land located in North Andover,Essex County,Massachusetts,being shown as Lot 4A on a plan entitled,"Plan of Land located in North Andover,MA for B. &R. Construction Scale 1"=40'; March 27, 1985, S.L. Giles R.L.S., Lawrence,MA",being Plan No. 9865. Said Lot 4A containing 49,119 square feet,more of less,according to said Plan. Being the same premises described in deed recorded with Essex North District Registry of Deeds in Book 3905,Page 137. I. Maximum Number of Bedrooms At all times subsequent hereto,unless connected to an approved municipal sewer, the property described hereinabove shall be limited to use as a single family residence containing no more than four(4)bedrooms. This Restriction is being implemented due to the maximum capacity of the current septic system. 2. Prior to Sale The current owners,Frank J.Mottolo and Margaret L.Mottolo,shalt upgrade the septic system to a capacity to serve five(5)bedrooms prior to any sale of the premises unless connected to municipal sewerage. 3. Enforceability These Restrictions may be enforced b the Town of Y Y North Andover,by action in equity in any Court of competent jurisdiction. Witness our hands and seal the day of ,2000. Frank J.Mottolo Margaret L. Mottolo COMMONWEALTH OF MASSACHUSETTS Essex, ss .2000 Then personally appeared the above named Frank J.Mottolo and Margaret L. Mottolo and acknowledged the foregoing to be their free act and deed,before me. Notary Public My Commission Expires: ri:iG76B9�RESTR ICrrrON.doc TOTAL P.02 FORM U - LOT RELEASE FORM liySTRUCTIOi`LS: . This form is used to verify that all nec;,ssary approvals/permits from Boards and Departments having jurisdiction have been abtained. This does not relieve the applicant and/er landowner from compliance with any applicable or requirements. FILLS OUT THIS w APFL!C;,NT FHGNE r� LCCATICN: As-,esz&s iMap dumber / 0 6 FARCE_ SUEDIVISICN LOT (S) STREET / 3,�+ S" ST. NUMEE:R ' OFFICIAL U.,F ONLY RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION .ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS _ 4 1 I I TOWN PLANNER DATE AFPRCVED DATE REJECTED I COMMENTS FOOD INSPECTOR-HEALTH ❑ATE APPROVED ' DATE REJECTED J� SEPTIC 1NSPIEICTOR-HEALTH DATE APPROVED ,? / ' DATE REJECTED COMMENTS �1�(J .L�L,r4y� ;' ✓ �. 1 �r ;1 /" "1 '� ;�� / %;�, %�~✓ ' PUELIC WORKS -SE'NE;R/WA T ER CONNECTIONS DRIVE'NAY PERMIT FIFE DEPARTMENT rRECEiVcC EY EUILDING ii ISPEC T CR CAT= d rRevu.e.. _ _7;m SECTION 4-WORKERS COMPENSATION(M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result ` in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......❑ No....... ` :- SECTION 5 Descrip tion of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: \l C c,� T.a' c-� 5 r �r �=1 c G-t! 2. 1,r,�r a t�� N L, (Sks c 113 p r=/c c �_U 2 ,-•, a i j -ror Q-'-t+per,C � �-c � c c�• t—/ �t ct�� h F'c(Ir..c ✓�^ SECTION 6-ESTLNUVrEff CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant I. Building 3 5, mod (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)r (b) 4 Mechanical(HVAC) 5 Fire Protection 6 Total 1+2+3+4+5 Check Ntunber SECTIO OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNEM ArENT OR CONTRACTOR APPLIES FOR BUILDING (L PERMIT as Owner/Authorized Agent of subject property Hereby a rize V1'r'` e— C" to act on M be all ruh4rqajlive to work authorized by this building permit application. bL`Z'L 1,�Aa'C Signature f Owner Date SECTION 7b O WNER/AUT �HORIZED AGENT DECLARATION I, Cay C e. j P- i as Owner/Authorized Agent of subject property. ''"` Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief C� a,1 Print Name _ Gc Signature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINMERS OT 2ND 3Ku SPAN DIMENSIONS OF SILLS DINIENSIONS OF POSTS DINIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE E 0-s ' 1 ( �� r �-c�►I Xvyl BOJ !•l s �1' •/L.i{ //� 1 I L7 A/ I �4 •S N � G /c, Ob t fl hl h 95-1 Gb:h�,� ISOy . ` �t J -ZZ�s�,� ��=��,zr las 11 �'• �/ 1� �� s3x�r1S3! op C4 �a,9, QL_1sc3r5 �O� qty J xCu�T�G Ti�d�h r CERT/F/ED FOUNDATION PLAN LOCATED /N Q-rz--T-H k' L -r- 4- SCALE/"- 40' DATE•' L. a 0 4 q q S.L.G/LES R.L.S. LAWRENCE Q NORTH ANDOVER 1 _p { V 1 of L r 3 1 �Sr.�7► ou-r i ir—aa I 9 � 4X \ r 06 74M l �`M / CER'T!F•Y THAT ME OFFSETS SHOWN ,4RE FOR--THE USE OF oFFsE rs sHowN THE BUIL DING INSPECTOR ONLY, 8 SUCH CONFORM TO THE USE /S FDR DET6*1?M/NATION OFZON/N ZONING B Y L A fN OF CONFORMITY OR NON CONFORM/rY , . O'o - r �►«��i va WHEN TAKEN. 1 a ; Board of Health• .� ' Haas. .. SEPTIC SISTgit� North An¢overi , INSTA.d.ATICK CHMK LIST LOT # ,TSP COVED DATE DISAPPSC1�ID AVATION 0� fl1IL ea�svnst FAZI. OK 1. Distance To't'' q-3945 a. Wetlands b. Drains c.. Well - sf 2. Water Line Location 31, No PPC Pipe 11. Septic Tank a. _gees -_Length & To Clean Oat Cowers. '---'`~ b. lement Pipe to Tank On Both Sides of Tank 5. DiEtribution Box a. Covers & Box - No Cracks b. All Lines Flowing Equal Amounts c. No Back Flow 6. Leach Field or Trench a. Dimensions b. Stone Depth c ' Capped Fads d. Clean Double Washed Stone 7. Leach Pits a. Dimensions -..— ` b. Stone Depth c. Splash Pads ' d.. Tees e." Cement Pipe to Pit - Both Sides 1. Clean Double Washed Stone 8. No Garbage Disposal 9• Yi al Grading Inspection 10. Barricading Covered System ; . 11. As Built Submitted a. Lot Location b. Dimensions of System c. Location with Regard-to Perc Tegt d. Elevations e. Water Table 1 A Board of Health North.'indoverpMass ,. SUBSURFACE DISPOSAL DESIGN CHECK LIST j(o�-V10l�1J .LOT # APPRMED DATE I� DISAPPROVED DATE Provided: Reasons: Title V FAIL OK Reg 2.5 The submitted plan must show as a minimum: a) the lot to be served-area,dimensions lot #,abutters b location and log deep observation hoes-distance to ties c location and results percolation tests-distance to ties d design calculations & calculations showing required leaching area (e) location and dimensions of system-including veserve area f) existing and proposed contours (g) location any wet areas within 100' of sewage disposal system or disclaimer-check wetlands mapping (h) .surface and subsurface .drains within 1001 of sewage disposal system or disclaimer , (i) ,location any dz`ainagV easements within 1001 of sewage disposal system or disclaiper-Planning Board files (j) knoun'sources ot,vater supply within 2001 of sewage disposal e system or disclainer . (k) location of any proposed well to serve lot-1001 Brom leaching facilit; (1) location'.of water lines on property-101 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 basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and Other elevations (r) maximum ground water elevation in area sewage disposal system (s) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Reg 6 Septic Tanks (a) capacities-150% of flow, water table, tees, depth of tees, access, pumping (b) cleanout (c) l01 from cellar wall or inground swimming pool (d) 251 from subsurface drains Reg 10.2 Distribution Boxes (a) slope greater than 0.08 Reg 10.4 b} sum Jr+s W Subsurface Design Check List Pae 2 FAIL OR Leaching Pits Leaching pits are preferred where the installation is possible Reg 11:2 a) calculations of leaching area-minimum 500 sq ft 11.4 b) spacing 11.10 c) surface drainage 2% 11.11 Id) cover material e) VxVAO splash pad f) tee at elbow g) no bends in pipe from d-box to pipe Leaching Fields Reg 15.1 a) no greater tTian 20 minutes/inch b) area-minimum 900 sq ft 15.4 c) construction of field 15.8 d) surface drainage 2 % 3.7 e) 20 from cellar wall or inground swimming pool Leaching Trenches Reg 14.1 a)cam ons o leaching area-min 500 sq ft 14.3 b) spacing-4 ft min 6 ft with reserve between 14.4 c) dimensions 14.6 d) construction . 14.7 e) stone 14.10 f) surface drainage 2% Downhill Slope a) s ope y x = o be shown) b) y/x 'X 150 = (to be shown) EMS Reg 9.1 a) approval 9.6 b) stand-by power r COMMONWEALTH OF MASSACHUSETTS Z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a DEPARTMENT OF ENVIRONMENTAL PROTECTION r i V y TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 131-7 5-af e u, 1 /Qa-d e e -� Owner's Name: 0 t,e.a 4-4ht 0 R E—CE, Owner's Address: S�-ur e Date of Inspectiow q- �2 3 - 0 SEP 2 9 2004 Name of Inspector: (please print) 5 d u f U TOWN OF NORTH ANDOVER Company Name: el N 4 o v P, o HEALTH DEPARTMENT Mailing Address: 4 n S, m,i/ ,— Telephone Number: 7,t= 3 7 7 7 47 1 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: z�" Date: ', c! --- .. . The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 s � Page 2 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: - / ' '„y/�, ;, a r Owner: Date of Inspection: '- -3-a �-1 Inspection Summary: Check A,B,C,D or E!ALWAYS complete all of Section D A.� System Passes: l'`" 1 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).rg Y 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 I 1 }f A OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A r CERTIFICATION(continued) 4 . f 1 Property Address: !- ./��/ a Owner: Date of Inspection: C. lurther 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 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 isnot 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 u 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 l of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of.a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the.well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than.5 ppm;provided that no other failure-criteria are triggered.A copy of the analysis must be attached to this form,. 3. Other: 3 -,.-'—_-.-...•.... Kai.... . Page 4 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) ;3 zp Property Address: L31 s: Owner: Date of Inspection: !g -j D. System Failure Criteria applicable to all systems: You must indicate"Yes"or"no"to each of the following for all inspections: Yes No -7"Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _t.,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 boz above outlet invert due to an overloaded or clogged SAS or cesspool _r/Liquid,depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow --'Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ ,Any portion of a cesspool or privy is within a Zone l 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 compoueds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303.therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems:N�p To be considered a large system the system must serve a facilitywith a design flow of 10,000 gpd to 15,000 G gpd." You must indicate either"yes"or"no"to each of the following: , (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 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. 4 Page 5 of I 1 A OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST t. Property Address: /317 Sr Owner: Date of Inspection: '. Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health �.---Ci-e-any of the system eomponents pumped,out in the previous-two weeks'N � Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently oras 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 onsite? 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: � Yes no M _/ Existing info`rinaton. For example;a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] 5 Page 6 of 11 a, OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: S /Pq, 5)' /4 /2tk_)(s t-,�-1 Owner: Date of Inspection: FLOW CONDITIONS - RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CM4 C 4 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):Z�lo [if yes separate inspection required] Laundry system inspected(yes or no):_ Seasonal use: (yes or no): .a , Water meter readings,if available(last 2 years usage(gpd)): Sump Pump(yes or no): /fG? Last date of occupancy: rr G�j r d COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203):_ gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): ^� Non-sanitary waste discharged to the Title 5 system(yes,or no):_ Water meter readings, if available: Last date of occupancy/use: K, OTHER(describe): GENERAL INFORMATION Pumping Records Source of information `A V Was system pumped as part of the inspection(yes or no): P,� If yes, volume pumped) rtr0 gallons-- How was quantity pumped determined? Iwo c cc. 1LlP f r-k' Reason for pumping: TYP.E'OF SYSTEM . t Septic tank,distriliuti 'i box, soil absorpti®system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):�(J 6 Page 7 of 1 l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C a SYSTEM INFORMATION(continued) Property Address: r ,�^ X1hi�UcY Owner: Date of Inspection: 9- i '-e) d BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: mast iron 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): �ikrToo_n ' j�!r�N LPar1 � SEPTIC TANK: locate on site plan) Depth below grade:- - Material of constructional oncrete_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 A certificate) Dimensions; Sludge depth: ,'` Distance from top of sludge to bottom of outlet tee or baffle: 36 „ Scum thickness: (� Distance from top of scum to top of outlet tee or baffle: N Distance from bottom of scum to bottom of outlet tee or baffle:1v ' How were dimensions.determined: 13 /,/ St 1 G Comments(on pumping recommendations, inlet and outlet tee or baffle condition,.structural integrity, liquid.levels as related to outlet invert,evidence of leakage,etc.): �N tle 91 Ti t"-/ uti)b /J GREASE TRAP: / (oc�ate on site plan) l .. Depth below irade: 0. Material of construction _concrete metal fiss po berglalyethylene_other (explain): — — r 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: . Cominents(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): f 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) - Property Address: Owner: Date of Inspection: —2-3—o�J TIGHT or HOLDING TANK:�,/Ytank must beum ed at time p p of mspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain):. Dimensions: Capacity: _ 4 e gallons �' Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:L?5(if present must be opened)(locate on site plan) a Depth of.liquid level above outlet invert:440 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.): b ) 6000 odf� 0i T-101-1 l Plate PUMP CHAMBER: �P" (ocate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): 1 Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): y t 8 Page,9.of I 1 e 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 13.17 5&lr ly S Owner: i Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,.number:_ leaching chambers,number: leaching galleries,number: ,,-leaching trenches,number,length: - 4/-¢ 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.): 1 N CESSPOOLS: spool must be pumped as part of ins ection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: ) Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: . oc t/o ite plan) ( P ) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 3 1 9 �t PagC,W of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION(continued) 'Property Address: 131 -7 1 -7 5c��i"st► -5 J— Owner: u "-119 Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. of z 0), C� . ti r /1. 1 10 Page 1 I of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C' SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 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: t 76bserved 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: �U fa 1 Qu a1 �' /4�'U ui�9>�y 01j Sri✓dr t l 1