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Miscellaneous - 135 LACONIA CIRCLE 4/30/2018
135 LACONIA CIRCLE - - - -- -- 21.0/1-05_D-0136-0000.0 I{ � t I ���✓lam sly. Commonwealth of Massachusetts City/Town of . RE1VE® h System Pumping.Record I b 2015 Form 4 OF NORTH ANDOVER TQWN LTH DEPARTMENT DEP has provided this form for use. local Boards of Health. Other forms rn; %%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 Righ ear_f hou , Left/right side of house, Left/ Right side of building, Left/Right front of bul'tdin , Left/Right rear of building, Under deck 9 9 g� Address City/Town State o� Zip Code 2. System Owner. • �G-GU�CJ Name' Address(if different from location) CitylTown S � A2) ` ( — ©-- Telephone Number 3 B. Pumping jKecord 1 1. Date of Pumping Date 2. Quantity Pumped: Gallons }. 3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes 3-- o If yes,was it cleaned? ❑ Yes ❑ No • 5. Condition of Syste 6: System Pumped By.- Nell. y:Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatio w re contents were disposed: IneS: Lowell Waste Water Haul Date t5form4.doc-06/03 System Pumping Record•Page 1 of 1 'DelleChiaie, Pamela From: DelleChiaie, Pamela Sent: Friday, October 07, 2011 11:39 AM To: 'mariapapasouliotis@yahoo.com' Subject: I.R. - 135 Laconia Circle- Health Dept. Scanned File Attachments: I.R. - 135 Laconia Circle- 1st half of Health Dept. File; I.R. - 135 Laconia Circle-2nd Half of Health Dept. File To: Maria Papasouliotis 135 Laconia Circle,North Andover 978-208-1860 Dear Maria, I am sorry for the delay. I found that our scanner could not take over 40 pages,so the first time I scanned it did not go through. Attached are your files. Please call with any questions. Have a great weekend! O aw Rgaa a, Pamela DelleChiaie Departmental Assistant I Community Development I Health Department Town of North Andover 1600 Osgood Street I Bldg 20 1 Suite 2-36 North Andover,MA 01845 9 Office-978-688-9540 Fax-978-688-8476 Email-pdellechiaieatownofnorthandover.com '2] Website http://www.townofnorthandover.com/Pages/index "We can never see the path of our life if we are too busy focusing on the pebbles under our feet."-Anonymous If you are happy with the customer service you have received from town departments,please let us know...feel free to complete the general Comment Form (link below): http://www.townofnorthandover.com/Pages/NAndoverMA WebDocs/contact i DelleChiaie, Pamela From: noreply@townofnorthandover.com Sent: Friday, October 07, 2011 10:16 AM To: DelleChiaie, Pamela Subject: I.R. - 135 Laconia Circle- 1st half of Health Dept. File Attachments: 20111007101617114.pdf This E-mail was sent from"RNPOA428C" (Aficio MP C5000). Scan Date:10.07.201110:16:16(0400) Queries to:noreply@townofnorthandover.com Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more information please refer to:http://www.sec.state.ma.us/pre/preidx.htm. Please consider the environment before printing this email. i I i OelleChiaie, Pamela From: noreply@townofnorthandover.com Sent: Friday, October 07, 2011 10:17 AM To: DelleChiaie, Pamela Subject: I.R. - 135 Laconia Circle-2nd Half of Health Dept. File Attachments: 20111007101642716.pdf j This E-mail was sent from"RNPOA428C" (Aficio MP C5000). Scan Date:10.07.201110:16:42 (-0400) Queries to:noreply@townofnorthandover.com Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more information please refer to:http://www.sec.state.ma.us/pre/preidx.htm. Please consider the environment before printing this email. 08111/2011 09:17 19786889573 PAGE 02(02 Summary Record Cwrd generaled an 81111',011 t0:1B:56 AM Cy Karan Hanlon Pape 1 Town of North Andover 711 Tax Map # 2'10-105.D-0136-0000.0 VIMParcel Id 17073135 LACONIA CIRCLE �1 GEORGE PAPASOULIOTIS 135 LACONIA CIRCLE TOWN OF NORTH ANDOVER NORTH ANDOVER, MA 01845 L HEALTH DEPARTMENT Class 101 Single Family Property Type 1 Residential Size Total 1.09 Acres FY 2011 UB Mailing Index NamelAddress Type Loan Number Activelinact, From Until GEORGE PAPASOULIOTIS Owner 135 LACONIA CIRCLE NORTH ANDOVER,MA 01845 KING,THOMAS Previous Customer Inactive 6/25/2004 135 LACONIA CIRCLE N.ANDOVER,MA 01845 CURTIS STAFFORD Previous Customer Inactive 5/12/2006 BRIOGETTE STAFFORD 135 LACONIA CIRCLE NORTH ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name ACtivannactive Bldg Id,17539.0-135 LACONIA CIRCLE Last Billing Date 7/13/2011 3170209 03 Cycle 03 Active UB Services Maint. Account No.3110209 Service Code Bate Charge MultipllerlUsers MISCFEE ADMIN FEE 0,63518 7.82 V WTR WATER 01 ALL METER SIZE $1.17 11 UB Meter Maintenance Account No.3170209 Serlal No Status Location Brand Type Size YTD Cons 32772873 a Active ERT HH b Badger w Water 0.63 0.63 336 Date Reading Code Consumption Posted Date Variance 6!612011 521 a Actual 21 7120/2011 13% 318!2011 500 a Actual 18 4/13/2011 -2% 12/912010 482 a Actual 18 1/12/2011 13% 9/13/2010 464 a Actual 18 10/1512010 -18% 617/2010 446 a Actual 20 7/15/2010 _8% 3/10/2010 426 a Actual 22 4/14/2010 -3% 12/1012009 404 a Actual 23 111212010 -18% 9110/2009 381 a Actual 29 10/15/2009 -10`yo 618/2009 352 a Actual 30 7/20/2009 7% 3/1212009 322 a Actual 30 4129/2009 -13°7 12/9/2008 292 a Actual 33 1/20/2009 -20% 9/912008 259 a Actual 44 10/1012008 31% 6/5/2008 215 a Actual 30 7/16/2008 -3% 3/11/2008 185 a Actual 33 4/11/2008 15% 12110/2007 152 a Actual 30 1/22/2008 11% 91512007 122 a Actual 23 1011212007 5% 6/15/2007 99 a Actual 25 7/20/2007 10% 3/1312007 74 a Actual 22 4/16/2007 10% I I 08/11/2011 09:17 19786889573 PAGE 01/02 TOWN OF NORTH ANDCC 7E DIVISION OF PUBLIC WORKS 384 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845 Bmicr.,D. ThihcucAw7f "0"'",� Tolep w c (978) 08j•09Sp l_)i Nr�rr� FAY (978) 688-9,573 o - � m •*l^CNu0 r4a, x To�� - From: Fax; Pages: Phone: Date: >:te: CC Fax page Page 2 of 2 n ,�:4:-? `�'�;�!�r�3�-�r�,a,� t'�• ten;i.. � - :i rE A?T/FIEV Fa FLAN r� AATFQ IN- A•u s� 1; .l:!.G1LE.S RL., LAWRENCE a NORTH AAIDOVER r ts w So,l i so s r' IL H �3 -y \ lIVy t I I CE;S'i-I Y PYA r rHE OFFSETS SHOWN ARE fOR rNE :,. liei THEB OFNS/NSPECTOH r�NL y , h`5 Fax page Page 2 of 2 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION nTLE S OFFICIAL INSPEC'I`XON FORM—NOT FOR VOLUNTARV ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION - REC-- E' ED Prop"Addrm .. C2 o, �e Owner'afttne: t��Lx 9b930A. MAR 3 0 2005 Otveera Addre�• ��.�....� • TOWN OF NORTH ANDOVER Date of Inspection: mMjj.4a A3 AooG HEALTH DEPARTMENT Name of Vector:(prem print) osaA.• 6aw" CompanyNam: Qa 51.11N. &it-nak-L Mailing Address: xuf M, Telephone Nam Oer:. Lot C99 -iaoz CERTIFICATION STATEMENT I cez*that I have personally inspected the sewage disposal system at this address and stat the infonnabon reported below is true.swam and complete as of the time of the inspection.The iron was performed based on my training and experience in the proper function and maimenartce of on site sewage disposal systems.I am a DEP appmed system inspector pursuant to Section 15.340 of Title S(310 CMR 13.000'). The system: ,Z Passes Conditionelly Passcs Noeds FWther Evaluation by the local Approsing Authority 71 ' F IttspEctotr's Sigurttare: Date: rr\ 3Q, aoo6 The system in orrttr t a copy of this inspection report to the Approving Authority(Board of Health or DBP)within 30 days n.If the system is a shared system or bas a desit flow of 10,000 gpd or greater,the uffeeror and the system owner shall submit the report to the approprintc regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer.if applicable,mid the appreving sutbority. Notes and Comments �***Tbis report only describes conditions at the time of b8pectift and ander the conditions of use at that time.'Ibis kapection does not address hoer the s)*=will perform in the future under the acme or different conditions of We. EQ 397d AdS Xld3S A1NrW3a 50£9-568-'69 96:8T 90®Z/0£/£0 hos://www2.chi.accessline.com/exec/teleweb?ui = fwa convertJpeg&-- --rxpAlmhrnxnirax&... 3/30/2006 Fax page Page 2 of 2 Fags 2 of 1 l OFFICIAL INSPECTION FORINT—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(coatintued) Propetrty Address iaK l.r♦cw%lr+ L**fr t Owner. Date of Inspecdovi; 'I AA-OL Inspection Swmary: Check AAC,D or 9/ALWAYS complete all of Section D A. System IES; I have am bbd any information which indicates that any of the failure criteria described in 310 CMP, 13.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Gbh; 15. SyOa Conditionally Pam: One or more system components as described In the"Conditional Prix'"section need to be replaced or mpalrrd.The system,Wou completion of the int or tom,as approved by the Board of Hicalth,will pass. Answer yes,no or not determined(Y,N,ND)in the_for the Moving statements.if"rat determined'please Ovain. TU septic tonic is mcW wW over 20 yaw old'or tit€septic tank(whether metal or not)is stlucONall}' un$Qund,exbrNu sistatttial infiltration or ex ilaatiion or tank failure is imminent.System will pass inspection if the existing tank is rgiwcd with a complying septic task as appaovod by the Board of Health *A metal septic tank will pass inspection if it is str+rcavally sound,not Waidug and if a Certificate of Cousiiliance indicating that the tarns is less than 20 years old is anti lable. ND vMlain: Obeenatlon of sewage bacimp or break out or high otic%inter level in the distriNxtion box due to broken or obsvocted piWs)or due to a broken,settled or tat w diwft tiou box System gill pass inspection if(with approval of Board of Health): .�,. broken pipe(s)are NOMDed obsrnrctioa is rettovod distribution box is leveled or rtplaed ND eacpiain: Ten systems r*quuvd ping more than 4 times a year due to broken or obstructed pipe(s).The system will pass Wqwm if(with approval of the Board of Health): _broken pipe(s)tlr+e replaced obstruction tion is removed ND explain: Z® 39yd AdS 0I1d3S A1Nf1 V13a S0E9-968-E09 �90:01 900E/0E/E0 https://www2.chi.accessline.com/exec/teleweb?WfWa=convertjpeg&-=rxpAlmlimxnirax 3/30/2006 Fax page Page 2 of 2 Page 3 of 1 l OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Addle ;, ®11C Lacmn`&C; A- ft,5Aadr owner: l}.,I•&ia Hate of tntpectioa: 3-19.06 C. Ft+rdw Eva otku la dui red by the Bosw of Ram; wast wi►ich require fi aW evaluation by the Hoard of Health in order to determine if the system is failing t protect public health,safety or the enviroumem. 1. $ wild pane unless Hoard of®palth deft mim in acaordan a with 310 CMR iS.303(1)(b)that the gym' ftmedooing in a manner wbkb will pr atect public be alae,safety and the enAr+oviacnt: privy is within 50 feet of a s water _ Cesspool o , is within 50 fact of a bordering vegaated%%vAand or a salt marsh Z. Systm will fall ardeaa the of Hem(and PuhiSe Water Supplier,it auy)determines that the .1)VM Is becdowall iia a mann that pro to the pahlie items,as ety and env t an t: Tie syMm has a septic tank soil absorption system(SAS)and the SAS is within 100 feet of a stufacc water supply or tributary to a water supply. S the SAS is within a Zone l of a &k water _ The system has a septic tank and AS p supply. _ The system has a septic tank and SAS and SAS is within 50 fest of a private water supply well. Tie system has a septic tank and SAS and the S is cess than 100 feet but 50 fan cr more from a private water qtly well**.Mid used to detennim ' e•7lus system passes if the well water analysis,performed DEP certified laboratory,for coliform bacteria and,,K►lvile organic compounds indicates that thew e . fret from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrof en is equal to less than 5 ppm,pmwdod that no cher failure criteria are triggered.A copy of the araly=must be o this form. 3. Ott: E® 39Vd A8S 0I1cl3S h1NrHtll3Q S0E9-968-E09 9f3 08 9066/0E/E0 https://www2.chi.accessline.com/exec/teleweb?t ifWa=convertJpeg&-=rxpAlmlimxnirax 3/30/2006 Fax page Page 2 of 2 Page 4of11 OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSIMIIEENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORINT PART A CERTIFICATION(continued) Property Addassc 13 ' Lnta..:n C:rt1t Date of 2-w-ors_ D. System FARM Criteria applicable to all systems. You Ma Wawa des"or"v6'to each of the following for&in�qw. yes _ 70 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool DischW or ponding of effucrit to the stufam of the ground or surface"Wen dui to an overloaded or clogged SAS or oesspool Stabs liquid level in the dismbotion box above outlet invert due to an overloaded or clogged SAS or fel Liquid depth in cesspool is lis Om 6"below invert or available volume is Icss than'h day flow ✓ Itaquired pu nping more than 4 times in the last year NOT duc to clogged or obstructed pipe(s).Number oft mes pumped_ Any portion of the SAS,oesspool or privy is below high grouad water elevation. 7 Any portion of cesspool or privy is within 100 few of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is withina Zone 1 of a public well. Any portion of a cesspool or privy a within 50 feet of a priers water supply well. j Any portion of a oesspool or privy is less than 100 feet but greater than 30 feet t5om a private water supply well with no acceptable water quality analysis.['Ibis system passes if the well water analysla, performed at a DIP certified laboratory,for colifanm bacteria and volatile orpole a mpoun& Bates that the well is face from pollratian from that facility and the prime of ammonia aitroW and[titrate aitroW is equal to or leas fto S ppm,provided that no other falltm criteria an uiWmd.A copy of the analysis atust be attached to this form.[ n0 (Ycsft The system fii�.l have determined toot ore at more of the above failure criteria exist as deTcn1W in 310 CNM 15.303,therefore the system fasts.7Le system owner should contact the Board of Health to determine what will be necessary to cornea the failum L Large System To be musidtred a large symm the system owner servos a facility with a design flow of 10,000 gpd to 15,000 91141. Youmust' e either`des''ar`ho"to each of the following i followiag wia apply to la,ge systems m addition to the criteria above) yes no — the system is\Pjbblic feet of a swfaoe drinking water supply �system isfeet of a trbuMy to a surbm drinl�g water amply thesystmtmis nitrogen sensitive area(lmpim Wellhead Protection Area-IWPA)or a mapped zone It�'a supply well If you hays answerod"yes"to any question in Section E the system is considered a significant threat,or answered "yes"m Section D above the large system has failed.The owner or operator of any large system considered a significm Ong under Section E or failed under Section D shall upgrade the system in accordance with 310 CUR 15.304.Mw system owner should contact the appropriate regional office of the Department. V8 MVd AdS 011d3S A1NrW30 S0E9-568-E09 90:0t 900Z/OE/EO hos://www2.chi.accessline.com/exec/t"eleweb?uifwa=convertJpeg&-=rxpAlmlimxnirax 3/30/2006 Fax page Page 2 of 2 Pap so'11 OMCIAL WSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART E CHECKLIST ProperlyAddrt= %Ig 1.ft&b0axC;Ott Owner. M Date of : 3-29.06 Check if the fold have been done.You wig irate"Y�or"W as to eac b of the followi3: Yep Pio Pmpiag fuferma6on vms provided by tore owner,aecvpam+ftm of Heat\ Were any of the system components pumped out m the previous two works J Has the system received normal flows to the previous two week period _ ✓ Have large volumes of water been imrod000d to the system recerttly or as pan of this inspection ' Were ars bruit plans of the system obWoW and examined?(If they were not available note as N/A) JWas the 6cility or dwelling inVocted for sib of sewage back up _ Was the Mite inspected for sigos of break out Were all system components,excluding the SAS*Wow on site Wena the scp*tai mai*oles urwavcmd,opened,and ft u tedor of the tads mspatad for the condition of tine baffles or tees,material of conon,dimensions,depth of liquid,depth of sludge ad depth of sawn' I � Ways the facility owner(and occupants if different from o%mr)provided with infbtmadon on the proper zitte of suWarfooe sewage disposal"Cuts'. The sbe crud location of the Sal Absorption Syme(SAS)on the sire has been Mermitred bated on: y no F)dsting information.For example,g n at the Board of Health. _ J Ra fined in the held(lf any of the failure criteria m1a"d to Pat C is at issue approximation of dunce is rte) [3 10 CNM 15.302(3)(b)) 99 39Vd At G MUM AAHrHV13a S0£9-S68-£09 90:0T 90®Z/0£/£0 https://www2.chi.accessline.com/exec/teleweb?uifwa=convertJpeg&-=rXpAlmIinixnirax 3/30/2006 Fax page Page 2 of 2 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Pnoperty Addrc= 1'sv i C� Otxr�r: - late of hapecti". FLOWCONDMONS RESMErr7lW Number of bedrooms(design):j Number of bedrooms(astral): 3 DESIGN flow based on 310 CMA 15.203(for example: 110 gpd x 0 ofbodrooms):Gay FK ter•allv^ lamer of current residents: 4 Does ttpd=e have a~gnnda Cm or no): Is latttxby on a srpate%wage system(yes or no).M- [if yes separate inspection required) LuIxty system (yes or no):�h use:(yes or no):04- Water mm rtedings,if available(last 2 y m usage(gpd)): 4%L' 1 Sump Pump(les at no):n. Last date of o6v aney. c0 RCIAL414DUSTRML Typeo lisbu as Desiga 9 (based on 310 CMR 15.203): cud Basisof flow(se&ts*rsonsisgftett.): Grp trA t(yes or no):_ Industrial ltling tank present(}es or no): Nonzsanit uy discharged to the Tide 5 system(yes or no): Watts me if Available: Inst dame of lase: 0778(dcscnbc): GENERAL INF'ORMATION Fnmptng Records Souse of inforoaation: Qa 1� , Qw- r Was Sys"p=PW as part of the kq)cc ion(yes or no): If}vs,volume pumped: gallons—How was quantity pumped determined? Remon for pumping: n TYPE OF SYSTEM Sgmc teak,distribution box,soil absorption system Single cesspool _overflow omool _Shared system(yrs or no)(if M attach previous inspection MW ds,if airy) _Iunavative/Altenaa tiv+e todurology.Aft &a dopy of the arrrent operation and maintenance coat&(to be obteured f m system owner) _Tigbt tank _At"a copy of tlx:DEP approval Other(scribe): Apprommift age of all components,date installed(if known)and source of information: Were sewage odors dewed when arriving at the site(yes or tm): 98 39yd ANG XidM All`PfEV133 GOE9-968-E09 SWOT 9601;/©E/E0 hos://www2.chi.accessline.com/exec/teleweb?uifwa=convertJpeg&-=rxpAlmlimxnirax 3/30/2006 Fax page Page 2 Df 2 Pap 7of11 OFFICIAL INSPECTION FORM—NOT ICOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM FART C SYSTEM FORMATION(continued) Pruperty Addrem, 13C Lbj" A C:n,1e. Owner. Da*of Ikon: 1 t3: BURMING SEWER(locate on site plan) Depth below grade: 1 Materials of constsuctiom_cyst iron _L40 PVC other(explain): Distance from prwate water supply well or bion lic: Comte(ort condi tion of joints,venting,evidence of le aloe,etc.): nw�t. SSMC TANK:—(lite on site pian) Depth Wow Wade:— _ Mataialofoonstruction:�'concrctc_metal fiberglass—yelyet6ytene _otbwe:cplain) 0- r--ow 1 If tank is meal list age:,_ is age confirmed by a Certificate of mplili'm(yes or no):_(attach a copy of cerfificatc) Dimensions: too, til,R&, ShWp depth: x-- Distance from top of sludge to bottom of outlet tee or balite: V C�" Scum this: t' Dism0eftomtopofmi to top of outla tee or bafl3e: LA Distance from bottom of scum to bottom of outlet tee or baffle:jjj�' Flow nve dimensions determined: MA-g- IaAo Comm U(on pumplag reoom mcndauem infet and ou et we or bile condition,smtctu al integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): .► w a GREASE TRAP:_(locate on site plan) Depth below grade: MaterW ofoomstrucoon: concrete metal_fiberglass_potyahyleae other (explain): boas: Swum addamm Distance from top of Senna top of outlet we or baffle: Distance fmm bottom of to bottom of outlet tee or baffle: Date of lust per: Comments(cut pumping regio ons,inlet and outlet we or baffle condition,smugural integrity,liquid lasts as related to outlet invert,evideaec f kEakam etc.): Ltl 39Vd MS 0I1d3S AiNrHV13Q 90£9-968-609 SOOT 9002/06/£0 hos://www2.chi.accessline.com/exec/teleweb?Uifwa=convertJpeg&-=rxpAlmjinlxnirax 3/30/2006 Fax page Page 2 of 2 Page R of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORME PART C SYSTEM INFORMATION(coati-now) Prwrty Adder t,a n c' — Date of 1Gosp don: *1 �-o=ob TIGHT or HOLDING TAMC:_(tank must be pumped at time of inspa tmXiocate on site plan) Material of 'on concme mctal Mxrgtass ,polyeftlene—other(explain): Dimensions: Capacity+: oacs Design Flow: ons/day Alarm p mscat(yes or no): Alarm level: wo"order(yes or no). Date of I"pumping: Comments(condition of alarm oat switches,etc.): DIeSTRMUTIONBOX„—(if presmnt must be opmed)(tom on site plan) Depth of liquid level above outlet it%vt: Comm(nate if boor is level and distntwon to outlets ebb any evidence of solids carryover,any evidence of linkage into or out of box,etc_): c..�c•. P1;1lVip'CRAM SE (locate on site plan) Pumps in woddag ofda or nn):_ Alarms m order(y or no): _ Comments(note ooadition p dmwftr,condition of pumps and appw*zwwes,etc.): 80 39yd A,-,S alMM A1NfIi;13Cj C-0£9-968-E09 90:01 900Z/0E/£0 hos://www2.chi.accessline.com/exec/teleweb?uifwa=convertJpeg&-=rxpAlmlinlxnirax 3/30/2006 Fax page Page 2 of 2 PW 9 of 11 OFFICIAL INSPECTION DORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Addrew MT- 1,acs , C.&IL Owner: Daft of In oo. 3=t9 A SOII.AMRP710N SYSTEM(SAS):_(locate on*e phw,mmdon out required) If SAS not located explain why: TM leeclming pits,mouber:, leacldag chambers,number_ leachivg galkries,number:_ lettctnitag tr+ertdtes,nutrtber,lengtb: 4.,� Gz^ �cti..n�la�_ ti "+ leaching fields,numberdimensions: muflow Wil,munbcs:T imnovanWaltesnative Siston Typetname of techwIM: Comments(note condition of soil,signs of hydraulic bilure,level of ponding,damp sail,condition of vegetation, CESSPOOLS.s(cool must be pumped as part of insPoaion)(tocate on site plan) Number and gurAtion• Depth—topoNiquid to inlet imett: Depth of solids err Bemb of scum, : iDineons of l: Materialsof a Indication of groundwater inflow(yes or no):_ cods(note eaodit on of soil,signs of hydraulic failure,level of portdin&condition ofvegetation,etc.): i PRIVY:_(locate on site plan) Nfaterials of coomued : Dimensions. Depth of sohft Comments(note condition of soil,signs of hydraulic bilum level of ponding,condition of vection,etc.): 60 39Vd AAS OIld3S AJNrHV 13(F S0E9-968-E®9 90:6€ 900Z/0E/E0 https://www2.chi.accessline.com/exec/teleweb?uifwa=convertJpeg&-=rxpAlmlimxnirax 3/30/2006 Fax page Page 2 of 2 Pap 100f 11 OFFICIAI.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(comtiaucd) Owner: Hate of InVeMm, �R _ SKETCH OF SEWAGE DISPOSAL.SYSTEM Pmvide a sketch of ft sewage dispose!*-acro i%iuding ties to at km t%*penummt refcm=lander or bmhmuks.Loan all welts within 100 feet.Locate whm public water supply enws the building, �ae,� tis L�►��. ����, 0T 39yd ANS 3I183S A1Nf-iV 13a S6£9-568-£o9 99:0% gam/o£/£o h4S://www2.chi.accessline.com/exec/teleweb?Wfwa=convertJpeg&-=rxpAlmlimxnirax 3/30/2006 Fax page Page 2 of 2 PW 11of11 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM FART C SYSTEM INFORMATION(cotrtinued) Property Addreew %IV k_kw.:A 0. 1kAAlr Ower. Drat of hmpectian: Ti--aL SFM EXAM Slope 9p cf iv Cl.R+.� Surbm Vara' t1**.. Check otter :V%j Shallow wells nwC Eticnated depth to ground water Lk feet Pts 1>km indsc ote(cdeck)all andoods used to detemuoe the high gmund Vim elevation: _Obtained from systpn design plans on rocord-if chi date of design plan revictcmd: 104S7- Observed 04S- Observed site(abutting property/observation hole witbin 150 feet of SAS) Checkod with local Board of Health-explain: 1 ,t Chucked with local accavarors,insffislas-(�docvmemation) _Acoessed USGS databax-ems: N N,\, \-%, -% You mat dt'be how you established the high ground water devption: 11 33yd 0I1d3S Amrwiw 90£9-968-E09 90:0Z 9002/0£/£0 haps://www2.chi.accessline.com/exec/teleweb?Uifwa=convertJpeg&-=rxpAlmlimxnirax 3/30/2006 Fax page Page 2 of 2 Summery P-awd CW 90AM OA M 31nr=G 10:61,60 AM trr M WVt*% Pipe 1 Town of North Andover Tax Map # 210.1058./-013640000.0 135 LACONIA CIRCLE CURTIS STAFFORD SRIDGETTE STAFFORD 135 LACONIA CIRCLE NORTH ANDOVER, MA 01$45 C1sss /011 Single Fomily Property Type 1 Resklentlsl eke Tommi 1.09 Acres FY 2006 US McHing Index NometAddreae Type Loan Numgar Activeflnegt, from Until CUR718 STAFFORD Owner 8RID0EiTE STAFFORD 136 LACONIA CIRCLE NORTH ANDOVER,MA 01845 KING,THOMAS Provieve Cvotomor lawive 6/25/2004 136 LACONIA CIRCLE N.ANDOVER,MA 01845 US Account Malnt. Account Na Lyda Occupant Nanne Activellnective "Id. 17539.0.135 LACONIA CIRCLE Last 8ilft Date 1110/2006 3170209 03 Cycle 03 Active US Senrifts Maint. $&vim COd! Rete Chat" MdalpserNaere MISCFEE ADMIN FEE 0.63516 7.82 1/ WfR WATER 01 ALL METER SIZE 88.58 /1 US Meter Maintenance Sarin!No $tatur Location 8aand Type 3136 YTD Cam 00306883894 a Active R ENC L METE METE W Water 0.63 0.63 0 Data Rattditly Cede Catsumption Posted Date V 31812008 1821 a Actual 15 -23% 12/21/2005 1606 a Actyul 24 1/1712006 ..816 9/20/2005 1782 a Actual 28 10/14/2005 17% 6/13/2005 1764 m Manual estimate 20 7/1512005 _196 3122/2005 1734 a Actual 24 416/2005 796 12113)2004 1710 a Actual 20 1/1412006 49% 9/11613004. 1690 a Actual 13 10/8/20041296 6/23/2004 1877 f Final Bill 12 6123!2004 4% 411512004 1686 a Actual 20 5117/2004 096 12/17/2003 1648 n New Mater 0 12/17/2003 0% ZT 39Vd AEG OIld3S AiNrW3Q 60£9-966-E09 9e:GT 9002/0£/£0 https://www2.chi.accessline.com/exec/teleweb?wfwa=convertJpeg&-=rxpAlmlimxnirax 3/30/2006 RECEIVED Commonwealth of Massachusetts City/Town of APR 2 3 2009 System Pumping Record TOWN�, D40 RPTA� NUOVER Form 4 MENT DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: Left fron left reer left si hous Right front, right rear, right side of house. forms on the computer,use only the y b key Address to move our. cursor-do not use the return Citylrown State Zip Code key. — 2. System Owner: Name Address(if different from location) Ci (Town tY Stat Zi P Code Telephone Number B. Pumping Record �s Gv 1. Date of Pumping Date 2. Quantity Pumped: Canons 3. Type of system: Q Cesspool(s) eptic Tank Tight Tank Other(describe): 4. Effluent Tee Filter present? E] Yes 0.1 o If yes,was it cleaned? Yes No 5. Condit* n of S stem: W- tQ�ak I 6. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location here contents were disposed: L.S.D Lowell Waste Water igna ure of H u r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 I -C-\ Commonwealth of Massachusetts m City/Town of a w� System Pumping Record APR 27 2010 Form 4 TOWN 07 NORTH AN750VER H[A TH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other 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. S sy to Left side of house, Right side of house, Left front of house, Right front of house, ar of house ight rear of house. Left rea of building. Right rear of building. VSs Address ova City/Town State Zip Code 2. System Owner: Name Address(if different from location) City/Town State Zip Code 20 Telephone Number B. Pumping Record 1. Date of Pumping Lj^ 2 Quantity Pumped: Sob Date Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank r-1Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes © No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: l 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location wcontents were disposed: gtu 4Haulr, Lowell Waste Water Date t5form4.doc•06103 System Pumping Record•Page 1 of 1 i NEW ENGLAND CLAIMS SERVICE, INC. Incorporated 1985 ❑ Reply To Reply To ❑ P.O.BOX 345 %" 100 CONIFER HILL DRIVE,SUITE 308 MANSFIELD MA 02048 ANSSocIA104 MANSFIELD, MPDVDSNf DANVERS,MA 01923 TEL.(508)337-8058 INWm"DNSiPA TEL.(978)777.9900 FAX(508)339-5835 FAX(978)774-9296 wrandall@newenglandclaims.com Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec 3B To: Building Commissioner or Inspector of Buildings City Hall RhCI VE-0 North Andover, MA 01845 TOWN OF NORTH ANDOVER RE: Insured: George Papasouliotis HEALTH DEPARTMENT Property Address: 135 Laconia Circle, North Andover, MA 01845 Cause of Loss/Date: Property Damage Loss of 12/18/2009 File or Claim No: BOSO47457 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Mark Randall Adjuster On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. Signature Da NEW ENGLAND CLAIMS SERVICE, INC. Incorporated 1985 ❑ Reply To Reply To ❑ P.O.BOX 345 100 CONIFER HILL DRIVE,SUITE 308 MANSFIELD,MA 02048 ^:«PMN DANVERS,MA 01923 TEL.(508)337-8058 04MAN TEL.(978)777-9900 FAX(508)339-5835 FAX(978)774-9296 wrandall@newenglandclaims.com Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec 3B To: Building Commissioner or Inspector of Buildings City Hall „4 North Andover, MA 01845 M11 «, ANDOVER 'Pf? c+t$tOPARTMENT RE: Insured: George Papasouliotis Property Address: 135 Laconia Circle, North Andover, MA 01845 Cause of Loss/Date: Property Damage Loss of 12/18/2009 File or Claim No: BOSO47457 Claim has been made involving loss, damage or destruction of the above captioned property, 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 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. Mark Randall 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 Da TOWN OF SYSTEM PUMPING RECORD DATE:__��t— .j SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example:left front of house) 04, QC � InduS-f k �- 1'�5 Laco vv(, 0. DATE OF PUMPING: 0 S QUANTITY PUMPED : GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: i CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste TOWN OF ANDOVER SEPTIC SYSTEM SERVICING REPORT Date:.-/-/- Homeowner: Pumper Street Z 3 '5- Address: Phone C;)-,S S/ Phone Nature of Service: Routine Emergency Observations: Good Condition Full to Cover �d Baffles in Place Leachfield Runback Excessive Solids �� Heavy Grease &d Roots 1-110 Other (Explain) Description of. Work Comments; / ZLI CERT/F/ED FOUNDATION PLAN LOCATED IN SCALE.7"= A- DATE: t 6 B S.L.GILES R.L.S. L AWRENCE a NORTH ANDOVER L A I i i s o,00 Tom-------- I � L�-r �( 1 ler ISA / SO yi �7 lG I I C k'ST N G4cs�sro \ I ' � 3 / 1 + -tA �O /ir SE"F�TtG �ST>F?'1 M O GEn.rt���t>4(16/6', / CEPT/FY THAT THE:OFFSETS SHOWN ARE FOR THE USE OF ' OFFSE TS SHOWN THE BUILDING INSPECTOR ONL Y, B SUCH p CONFO:,7N1 TO THE USE IS FOR DETERMINATION OFZON/NG {' ZONING B Y L A W OF CONFORMITY OR NON CONFORMITY f WHEN TAKEN. j 4- I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL P -,O -CTION ' 11VVi l OFy0TT BOARD OF HEAl.T41 MAY ( 3 9- TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Owner's Name: Owner's Address- Date of Inspection: y-16-ct�T Name of Inspector: (please riot) lose��t�t�..v Company Name: \ �1 Se :L Mailing Address: ` 41 ^V-: \L j Telephone Number: 60-A SSS- �3ar 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: Date: to-Vii-0�1 The system inspector shall 4Z 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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 135- Cl. �,.nd,,ov cr•' M Ar Owner• Date of Inspection: y-t6-c,-1 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: V/ 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: p� I B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repair . The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. . I Answer yes,no r not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits subs i'al infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced wi a complying septic tank as approved by the Board of Health *A metal septic tank will pass i spection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less 20 years old is available. ND explain: Observation of sewage backup or br out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled o even distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s) replaced obstruction is remo d distribution box is leve d or replaced ND explain: The system required pumping more than 4 times a year due to b en 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: IX Lptco,n;a. n. A1\0koutr MA Owner: 1<.`11 Date of Inspection: 1-1-%6-c'%A C. Further Evaluation is Required by the Board of Health: ditions exist which require fiuther evaluation by the Board of Health in order to determine if the system is failing to otect public health,safety or the environment. 1. System wi ass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not ctioning in a manner which will protect public health,safety and the environment: Cesspool or pri i within 50 feet of a surface water _ Cesspool or privy is thin 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health;safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surfac ater supply or tributary to a surface water supply. The syste has a septic tank and SAS and the SAS is within a Zone.1 of a public water supply. _ The system has eptic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**.M od used to determine distance **This system passes if the well water ysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds ' nates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate i ogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analys nust 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: k%T Lpcu r R Cr-,AL r), A o'c 0't'r Owner: Date of Inspection: -16-U-A D. System Failure Criteria applicable to all systems: You must indicate`yes' or"no"to each of the following for all inspections: Yes Nq _ J 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 _ ol is less than 6"below invert or available volume is less than''/z day flow y Liquid depth in cesspo 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 mell 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.] C�n (Ye4go 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 b considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must dicate either`lyes"or"no"to each of the following: (The followi criteria apply to large systems in addition to the criteria above) yes no the system i within 400 feet of a surface drinking water supply the system is wi " 200 feet of a tributary to a surface drinking water supply the system is located in nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water s ly well If you have answered"yes"to any question i Section E the system is considered a significant threat,or answered .Ives" in Section D above the large system has • 'led.The owner or operator of any large system considered a significant threat under Section E or failed under tion D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. J Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: %3S l.RCQV%%n C'J-,,�C n. fAA AQJ Ur Owner: Date of Inspection'' Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Ye$ 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 J _ 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 t/he baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum J _ 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: Ye no _ 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) [3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: X35' LRc.,,�:& Q'AAL (1, A te.,« M(h Owner: 1;;.,� Date of Inspection: -1-1t,-oH FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): G6y e+s `er 0"b" Number of current residents: \ Does residence have a garbage grinder(yes or no):nz Is laundry on a separate sewage system(yes or no):0,a [if yes separate inspection required] j Laundry system inspected(yes or no): Seasonal use: (yes or no): raj Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no):10 Last date of occupancy: c,%,m CQMMERCIAIA NDUSTRIAL Type f establishment: Design w(based on 310 CMR 15.203): gpd Basis of des' flow(seats/persons/sgft,etc.): Grease trap pre t(yes or no):_ Industrial waste bol tank present(yes or no):_ Non-sanitary waste disch to the Title 5 system(yes or no): Water meter readings,if availa Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: ., Was system pumped as part of the in ion(yes or no): (No If yes,volume pumped: gallons--How was quantity pumped determined? .)vw.n Reason for pumping: rN Tr 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 Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(known)and source of information: Were sewage odors detected when arriving at the site(yes or no):no Page 7 of 11 F OFFICIAL INSPECTION FORM—NOT OR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: \Ii (\, Ps,r\wj c.(' M f Owner: -A, Date of Inspection-:7' kA-\h-O" BUILDING SEWER(locate on site plan) Depth below grade.- Materials rade:Materials of construction: _cast iron _�./40 PVC_other(explain). Distance from private water supply well or suction line: n Ire Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:—(locate on site plan) Depth below grade: Material of construction: oncrete_metal fiberglass . _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: Iv�r d- S�t��x`-� a o2e� .� ���� r Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: `a, a.' 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: 1 How were dimensions determined: -'t j e, „a i, �9 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��nvC. (`oV7� -L MPS v.S'2.v./}�GQ•, 7v� C,vI,J'-., a �•I C,r.�c S, GREASE TRAP:—(locate on site plan) Depth belo grade:_ Material of co truction: concrete metal fiberglass—polyethylene—other (explain): — — — Dimensions: Scum thickness: Distance from top of scum t op of outlet tee or baffle: Distance from bottom of scum t ttom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendati inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leaka etc.): i i Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: \3s' 1.a,c��•� C:rY.�e (l. C4^Avg c(' Owner: W-^'- Date of Inspection: TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Dep low grade: Material o onstruction: concrete metal fiberglass_��olyethylene other(explain): Dimensions: Capacity: lions Design Flow: ---gallons/day Alarm present(yes or no): Alarm level: Alarm in g 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: cAV &4 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into orout of box,etc.): ( LA 0 PUMP ER: (locate on site plan) Pumps in workin rder(yes or no): Alarms in working o r(yes or no): Comments(note conditio f pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: (l_ P�wAcsy fir' Owner: W, 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: — \A \A�' leaching trenches,number,length: a >L GS fif'e..iw �' ` 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.):. A CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number d configuration: Depth—top liquid to it invert: Depth of solids er: Depth of scum laye : Dimensions of cesspoo . Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of constructio Dimensions: Depth of solids: Comments(note condition of soil, s 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: Owner: \ �, Date of Inspecti : -�b-u`� 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. S �. Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: C:r,. Owner: Date of Inspection: -\6-by SITE EXAM Slope J�1SGlu o r. Surface water n��t Check cellar Shallow wells ✓�un� Estimated depth to ground water L\ fcet AS 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: AA,/\s u,% �;\e Checked with local excavators,installers-(attach ocumentation) Accessed USGS database-explain: \ You must describe how you established the high ground w ter elevation: IMMMI rill La t.. CL 41 t AA 777- .� ni� A � �`��;fi t , >*r�co,]m�rY�w Nµm,e m-.7 rn�.rY�A u�ea Y•� .•xt 1 .r 9 r Std�. tzlQ(MmdA(w CD DO ,ctm y r .Q CQ am(D C3 p CD(m cm 1w0. 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(' r ' - 47�H.f-+.hM t+r-a I•iµEs'H.'�µ}..Y.i'.W'Yr.H.}+>�'; .�C,I"!�: c*t:A w cn A.,A a A a c;�c?w w: "n ' !`� ',� (' J q.'w al�o^J.(rY•�1.1-��3+a-.7 cn w l-•Cagy o�cr,.P t9` �>v"�; `� r`• F SyF+-0?•@,09�`.A:GQ t1'1"^]+:C)CO 07+O h7-�f(*,9 C^�1+G' �+3�i �.f 7 td::; 9 to �' � t�Y-x Y-+ra� Y.+: ,•+N.N Y-�i•+N(v N c.V a1. � ,� wosr3® C,r7wcoCDH©.�D�;(vS1�?!•+P > C� N.A N I•W t`,p:U^I to Ln to m'rn w N m 69µc�:10 Jar s i f41 y:. �00 Ln Ch.j H F.-''^3-wh T OD.A J(9 CJ,CFr Oi til: WSJ i W,ba ,( H r p(9Q.mCmC.J".C".1:C.•a`C9C`'1.CDoQaQCy70 V !' ". 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''�,;,'t ,�F•: ''�'t>a^� 'g"r �.✓. r s r: .Gtrr L_, 1, ';11:ti''?n • .,._ � :<r�, >d" :7,: �.. �,f�i.,�. ...` '.�= .,r.s� ' mry 7'::� "f Y t ._:t'! ;� ��¢ _ Kt"'�T t.,.". !1 � $ -. , �d�xA3r�W m+� '�1wa ',"l2Gi+FC'Huv,a +7,'M5E W �j• ,� ^ .. ri`��, '�...m ; � ��+..` .. ;�...:,"'�`. •:kE3efad � ..0 .R'. _� .:;�.r.,. wk' � .•�*,4t s . . +'' ..G:,r�. '.S t , +ti?k� t :l$ .'`1.'w'�'r, ". 'M' !r' ua':i�L .z' +i!?•a�.p.,- n ri'%ilr7q. , N' k - ti� �� ,� I �+ +f.S...y'�`"-:,�o �" '� �+�'� k�; -.5 1+'itr-'' A .%,,; .we ttMy��+`'`.,. xai•; 4�f f 4• yi' '••e 1 f+, ...,R w-µf� ds� ft 4ti.i:.,..... ,: •`;te'itt+s r' '•h 'af9�` :��' .iN , � ;,��* Si .�+:.,' ry i 1'o 'ir _ �"'rit HA rY w J. tltyF, a, t e ., { M wk� !k �� , .�' - r�i , .�.6 , rt# yy„ i- ��:ae F r n+4t r +t, �z�-� .,E� � �4-..rNORw '� t!t d Y.7. tq!'�. 't.R' ,�.''�<�.w.. �',, iNMr `�'�: Y Y' .J+p�M''f•3' ;� "�+�" ^' ♦ -`" �"�,. J »R... ' � ,rr �,'� -•'°r '' � `:S "' ,�, i� ':�' _t � r. y � ^t'4F..{:. f e, •r.� �4r • lull bT�+" ' P-04RD of NF A-( Lor 14 w Ndl�TN AtiI��EI�, NIA, ��P�� Cgly I ' WAT6R sS PL( -Jj-jZ)(AJ,-J D wEU— A�+ ouCD TC b �vt"D DArt' ApRwlN6 /orhoi�)ry ('OAJ ITiows D156PPpnvEp 1ATE R QSoNS CX4v4T(o/",J )AJSPt�-.6T(oti 94rC tj- a 1;/'1ss F41L- ��NAL I,VSPF�rIo� 4PP OOEP ( l �� U/JTC AWTIOMAL. IAjsFbc i jo^'5 �J-A►jy) DIS�i PF'1ZdV�D DA r FV AL APM)VAL pot �l l- ,. Commonwealth of Massachusetts RECEI City/Town of System Pumping Record APR 2 2008 Form 4 TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. P T the information must be substantially the same as that provided here. Before using this form,check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System LO io : © �\00%r,2� c-�� O�forms on the i �� Jcomputer,use only the tab key Address to move your cursor-do not Cityfrown State Zip Code use the return key. 2 System Owner: Name Address(if different from location) City/Town StateZip Code _- Telephone Number B. Pumping Record 1. Date of Pumping Date2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes Ej-'No If yes,was it cleaned? ❑ Yes ❑ No 5. Condi 'on of System: S,:-,) 6. Sy Pumped By: ^� Name Vehicle License Number Company Wal 7. Locatioer conte' weroisposed: -P/� C�yb �� e Hauler Date t5form4.doc•06/03 System Pumping Record.Page 1 of 1 Commonwealth of Massachusetts City/Town of FPEICEIVED System Pumping Record Form 4 1'AY � � 401 �M TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. Other fhe 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 front of house, right front of house, left side of house, right side of house, Left rear of house, right rear of house, left side of building, right rear of building, under deck. City/Town State Zip Code 2. System Owner: C�- L) CA� Name Address(if different from location) CitylTown Stat \ Zi Code o <K—M Telephone Number B. 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 �1�To—� If yes, was it cleaned? ❑ Yes ❑ No 5. Conditio of ystem: 6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company i 7. Locati ere contents were disposed: L.S.D. ell Was ter Signat re f H uler Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 i . h Commonwealth of Massachusetts rRECEIVEDCity/Town of UN 2 4 2013 System Pumping Record TOWN OF NORTH ANDOVER lug Form 4 HEALTH DEPARTMENT I 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 y g , Rightf ho , Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address City/Town State Zip Code 2. System Owner. Name Address(if different from location) CitylTown St d Zsp e i rc�-- 'jC R Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: Data Gallons 3. Type of system- ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? []- Yes [] No 5. Condition of System: q ��J l � 6. System Pumped By: Neil Bateson - F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. tSignAtufe e contents were disposed: Lowell Waste Water e Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Town of North Agdo.vet Health Department Date: 4�tv Location: (Indicate Address,if Res4ential,or Name of Business) Check#• Type of Permit or License:(Circle) ➢ Animal $ ➢ Dumpster $ ➢ Food Service-Type. $ ➢ Funeral Directors $ s ➢ Massage Establishment $ ➢ Massage Practice $ ➢ Offal(Septic)Hauler $ ➢ Recreational Camp $ ➢ SEPTIC PERMITS: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC)$ r ❑ Septic Disposal Works Installers(DWI) $ ➢ Sun tanning $ ➢ Swimming Pool $ ➢ Tobacco $ F If ➢ Tras4lSolid Waste Hauler $ ➢ Well Construction $ :. ➢ OTHER:(Indicate) 0 Health Agent Initials b 1 477 White-Applicant Yellow-Health Pink-Treasurer