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HomeMy WebLinkAboutMiscellaneous - 136 RALEIGH TAVERN LANE 4/30/2018 (2) 136 RALEIGH TAVERN LANE » 210/107.A-001 8-0000.0 o 0 o r r• North Andover Board of Assessors Publir.w .Access Page 1 of 1 gORT" North Andover Board of Assessors, Ot 4t�ao.01N0 ♦� qqee� jzroperty Record Card Click Seal To Return Parcel 1D :210/107.A-0018-0000.0 FY:2009 Community:North Andover SKETCH PHOTO Click on Sketch to Enlarge Click on Photo to Enlarge Search for Parcels Search for Sales lug Summary " ®. Residence Detached Structure i Condo 136 RALEIGH TAVERN LANE Commercial Location: 136 RALEIGH TAVERN LANE Owner Name: GBF/JGF REALTY TRUST J B,JR&J G FERGUSON,TRS Owner Address: 136 RALEIGH TAVERN LANE City: NORTH ANDOVER State: MA Zip: 01845 eighborhood: 7-7 Land Area: 1.08 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 2284 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 494,100 508,100 Building Value: 268,700 282,700 Land Value: 225,400 225,400 Market Land Value: 225,400 Chapter Land Value: LATEST SALE Sale Price: 1 Sale 10/15/1996 Date: Arms Length Sale F-NO-CONVNIENT Grantor: FERGUSON, Code: GEORGE Cert Doc: Book: 04612 Page: 0094 http://csc-ma.us/PROPAPP/display.do?linkld=1465650&town=NandoverPubAcc 11/2/2009 w TOWN OF NORTH ANDOVER Of NORTH N Office of COMMUNITY DEVELOPMENT AND SERVICES 02 HEALTH DEPARTMENT 1600 OSGOOD STREET;Building 2-36 NORTH ANDOVER,MASSACHUSETTS 01845 "`f sac" SE Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: AP (� LOT: INSTALLER'14 DESIGNER: ® � PLAN DATE: BOH APPROVAL DATE PLAN: INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑Existing septic tank properly abandoned ❑Internal plumbing all to one building sewer ❑Topography not appreciably altered Comments: SEPTIC TANK ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading. Monolithic construction ❑ Water tightness of tank has been achieved (Visual or Vacuum Test or Water held for 24hrs) ❑ Inlet tee installed, centered under access port ❑ Outlet tee (gas baffle or effluent filter) installed, centered under access port ❑ 24" inch cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present ❑ Hydraulic cement around inlet &outlet Wastewater System Documentation—Feb 2006 Page 1 of 6 i 7 TOWN OF NORTH ANDOVER NORT#1 Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT p 1600 OSGOOD STREET;Building 2-36 NORTH ANDOVER,MASSACHUSETTS 0184 "Ss CH„5��th Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ Combo Tank installed. Size: ❑ 1000 gallon Pump Chamber installed H-10 loading Monolithic construction) ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in.pressure line ❑ 24" inch cover to within 6" of final grade installed over pump access port ❑ Water tightness of tank has been achieved Visual testing ❑ Hydraulic cement around inlet & outlet Comments: ADVANCED TREATMENT TECHNOLOGY ❑ Type of treatment device: ❑ Installed per manufacturers requirements ❑ All components working in accordance with manufacturer's requirements Comments: Wastewater System Documentation—Feb 2006 Page 2 of 6 TOWN OF NORTH ANDOVER 1oRT11 O 4teo °�ti Office of COMMUNITY DEVELOPMENT AND SERVICES o� _ _'° m HEALTH DEPARTMENT A 1600 OSGOOD STREET;Building 2-36 5 . .a"" NORTH ANDOVER,MASSACHUSETTS 01845 "ssq�H�set�h Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476=FAX D-BOX /installed on stable stone base ❑� Inlet tee (if pumped or >0.08'/foot) [� Hydraulic cement around inlet & outlets Observed even distribution Speed levelers provided (not required) Comments: SOIL ABSORPTION SYSTEM ❑ Bottom of SAS excavated down to soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 3/4-11/2" double washed stone installed ❑ 1/8-1/2" (peastone) double washed stone installed ❑ Laterals installed and ends connected to header ❑ Laterals vented if impervious material above ❑ Orifices @ 5 & 7 o'clock positions ❑ Gravel-less disposal systems: type, number and location as per plan ❑ Elevations of laterals installed as on approved plan ❑ 40 Mil HDPE barrier installed ❑ Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: Wastewater System Documentation—Feb 2006 Page 3 of 6 NRS, Commonwealth of Massachusetts Map-Block-Lot r,o�,,��° �o��oe 107_A001 Board of Health Permit No „ BHP-2009-0693 North Andover _____ _______________ �w°• �y` P.I. FEE �Ss+acNus�° F.I. $125.00 DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd-Bateson to(Repair-D-BOX ONLY)an Individual Sewage Disposal System. at No 136 RALEIGH TAVERN LANE as shown on the application for Disposal Works Construction Permit No. BHP-2009-069 Dated. November-02,_2009 ;__PV -''-P#�--------------- Issued On:Nov-02-2009 �'B_axd of-- f-011 r, NORTti Applicationlor Septic Disposal System >�1O 41, o-Construction Permit —, TOWN OF TODAYS DATE •'' ORTH .ANDOVER MA Q145; $ o.00—Full Repair ' 1 f`, �- ,25.00-Component ss�C RECEIVED Important: Application is hereby made for a permit to: When filling out ❑Construct a new on-site sewage disposa syst�m"T 3 0 2099 fon-ns on the ! computer,use ❑ Repair or replace an existing on-site sew 3geAisposaIZslysteM-*,,/ER only the tab key HEALTH pEPARTMENT to move your Repair or replace an existing system con Wonent=What? cursor-do not use the return key. A. Facility Information �� L N ISI Address or Lot# CityiTown 2.-*TYPE OF SEPTIC SYSTEM*: ❑Pump ravity(choose one) """If pump system,attach copy of electrical permit to application"* onventional System(pipe and stone system) ❑ Infiltrator or Biodiffuser Gravel-Less Attach a co of our certification to install this of system. ( ) (Attach PY Y tYPe Y ❑ Pressure Distribution S.A.S.(No D-Box)(Attach Draft Maintenance Agreement) ❑Pressure Dosed(D-Bax Present)S.A.S. 2. Owner Information Name _ Address(if different from above) `I y r Cityrrown State E Lr Zip Code Telephone umber 3. Installer Information Name Name _ Address 1 v ��Re5-, Citylrown State Zip Code Telephone Number(Cell Phone#if possible please) 4. Designer Information Name Name of Company Address Cityfrown State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page i of 2 r�,RrH Application for Septic Disposal System - u 3r"`-°` '•`' '�°c pConstruction Permit — TOWN OF TODAY'S DATE ORTH ANDOVER, MA 01845 $250.00-Full Repair ,.. . P $125.00 -Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: esidential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation until a Certificate of Compliance has been issu y this Board of Health. Name Date Applicatia Approved By: (Boar of Health Representative) jz i Name Date 'A lication Disapproved for the following reasons: For Office Use Only: L Fee Attached.? Yes No 2. Project Manager Obligation Form Attached. Yes No 3.: Pump Svstem? If so;Attach copv of Elecuical Permit.. Yes No 4. Foundation As-Built. (new construction ronly): Yes No (Same scale as approved plan) .5 Floor Plans?(new construction only): Yes_ No Application for Disposal System Construction Permit•Page 2 of 2 I ' ,e )SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: (Address of septic system) For plans by ,� (j (En ' ee Relative to the application off o` . And dated (Installers name) j ngm ate Dated ocTay's ate With revisions dated (Lastr�vised ate) I understand the following obligations for management of this project: I. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to performing anywork on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer,I must call for any and all inspections. If homeowner,contractor,project manager, or any other person not associated with my company schedules an inspection and the system is not ready,then item three shall be applicable. 3. As the installer,,I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection,without completion of the items in accordance with Tide 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or my co=an a. Bottom of Bed—Generally,this is the.first (P) inspection unless there is a retaining wall,which should be done.first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection—Engineer must first do their inspection for elevations,ties,etc. As-built of verbal OK(or e-mail to: healthde12t@townofnorthandover.com) from the engineer must be submitted to the Board of Health,after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system, all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade—Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer,I understand that only may perform the work other than ji le excavation and I am required Y ached application for installation. I further n f the system identified in the art. complete the installation 0 to y pp p understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board ofHealtb staff or consultant d. Installation of tank,D-Box,pipes, stone, vent,pump chamber, retaining wall and other components. 6. As the installer, I understand that I am solely responsible for the installation of the system as per the approved plans No instructions by the homeowner,general contractor,or any other persons shall absolve me of this obligation. I Undersigned Licensed Septic Installer: (Today's Date) Tame—Print) igne Commonwealth of Massachusetts a Title 5 Official Inspection ection Fo m Subsurface Sewage Disposal System Form-Not for Voluntary A essme. s xQ�Q41 M 136 Raleigh Tavern Lane Property Address TOWN OF NORT K Jolanda Ferguson HEALTH DEPARTMENT Owner Owner's Name information is required for North Andover MA 01845 11/13/2009 every page. Citylrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your Neil J. Bateson cursor-do not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover Ma 01810 tam Citylrown State Zip Code 978-475-4786 SI15 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further ftalu 'on by the Local Approving Authority / �Al 11/13/2009 Inspe4ory S r ture Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form m - i Subsurface Sewage Disposal System Form-Not for Voluntary Assessmen M �< 136 Raleigh Tavern Lane I9010 Property Address ' Jolanda Ferguson TOWN OF:NORTH Owner Owner's Name ALTH DEPARTMENT information is required for North Andover MA 01845 11/13/2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: After permit from B.O.H., install new d-box&5'of inlet pipe, inspection from B.O.H., septic system now passes Title 5 Inspection. i B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicatingthat the tank is less than 20 ears old is available. Y ❑ Y ® N ❑ ND (Explain below): t5ins-09108 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 RECEIVED Commonwealth of Massachusetts Title 5 Official Inspection Form OCT 3 0 2009 Subsurface Sewage Disposal System Form -Not for Voluntary Assessm IntOWN OF NORTH ANDOVER 136 Raleigh Tavern Lane HEALTH DEPARTMENT Property Address Jolanda Ferguson Owner Owner's Name information is required for North Andover MA 01845 10/23/2009 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: When filling out A. General Information forms on the only compthe tab key uter,use 1. Inspector: to move your Neil J. Bateson cursor-do not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name VQ 111 Argilla Road Company Address Andover Ma 01810 �A81 City/Town State Zip Code 978-475-4786 S115 Telephone Number License Number D. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ® Fails ❑ Needs urther E alua 'on by the Local Approving Authority 10/23/2009 Inspect I's Ignature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Raleigh Tavern Lane Property Address Jolanda Ferguson Owner Owner's Name information is required for North Andover MA 01845 10/23/2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ® N ❑ ND (Explain below): D-box needs to be replaced t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts 4 v v Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 136 Raleigh Tavern Lane Property Address Jolanda Ferguson Owner Owner's Name information is required for North Andover MA 01845 10/23/2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed' ❑ Y ® N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Raleigh Tavern Lane Property Address Jolanda Ferguson Owner Owner's Name information is required for North Andover MA 01845 10/23/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow t5ins-09/08 Title 5 official Inspection Form:Subsurface Sewage Disposal system•Page 4 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 136 Raleigh Tavern Lane Property Address Jolanda Ferguson Owner Owner's Name information is required for North Andover MA 01845 10/23/2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 136 Raleigh Tavern Lane Property Address Jolanda Ferguson Owner Owner's Name information is required for North Andover MA 01845 10/23/2009 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): N/A Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): N/A t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments < 136 Raleigh Tavern Lane Property Address Jolanda Ferguson Owner Owners Name information is required for North Andover MA 01845 10/23/2009 every page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Yes Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-ogim Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 7 of 17 Commonwealth of Massachusetts H v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 136 Raleigh Tavern Lane Property Address Jolanda Ferguson Owner Owner's Name information is required for North Andover MA 01845 10/23/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped 2007, owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Measured tank Reason for pumping: Inspect tank&tees Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared .system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4�M , 136 Raleigh Tavern Lane Property Address Jolanda Ferguson Owner Owner's Name information is required for North Andover MA 01845 10/23/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Original to house Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: I ® cast iron ❑ 40 PVC ® other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): 4"Cast iron thru wall to tank, 3"Copper in house, no leaks visible Septic Tank(locate on site plan): Depth below grade: .5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 6'x 4' Sludge depth: 3 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 9 of 17 Commonwealth of Massachusetts w v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Raleigh Tavern Lane Property Address Jolanda Ferguson Owner Owner's Name information is required for North Andover MA 01845 10/23/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumped septic tank. Inlet tee ok. Outlet tee was replaced by others. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts �:--U9. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 136 Raleigh Tavern Lane Property Address Jolanda Ferguson Owner Owner's Name information is required for North Andover MA 01845 10/23/2009 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 136 Raleigh Tavern Lane Property Address Jolanda Ferguson Owner Owner's Name information is required for North Andover MA 01845 10/23/2009 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert -1" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box cover broken. Installed new cover. Liquid level in d-box below inverts, evidence of leakage. Evidence of solid carryover. D-box needs to be replaced. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-09/08 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 136 Raleigh Tavern Lane Property Address Jolanda Ferguson Owner Owner's Name information is required for North Andover MA 01845 10/23/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 4 trenches 35'long ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: — Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth–top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts G Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 136 Raleigh Tavern Lane Property Address Jolanda Ferguson Owner Owner's Name information is required for North Andover MA 01845 10/23/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 14 of 17 • CX, Commonwealth of Massachusetts w v Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 136 Raleigh Tavern Lane Property Address Jolanda Ferguson Owner Owner's Name information is required for North Andover MA 01845 10/23/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately i L4 MA i 3 7 i t r e ear nn �(�iUQil1-r� �C1S l,i J ® a n L4 I I � SeQ -tom. 3 I rr r, t i t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 136 Raleigh Tavern Lane Property Address Jolanda Ferguson Owner Owner's Name information is required for North Andover MA 01845 10/23/2009 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >4feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: Essex County Soil Map You must describe how you established the high ground water elevation: Essex County Soil Map, Sheet#30, Canton Soil , Water>6'deep Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Y Commonwealth of Massachusetts Title 5 Official Inspection Form Y Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 136 Raleigh Tavern Lane Property Address Jolanda Ferguson Owner Owners Name information is required for North Andover MA 01845 10/23/2009 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Summary Record Card generated on 10123/2009 10:56:49 AM by Karen Hanlon Page 1 ' Town of North Andover Tax Map # 210-107.A-0018-0000.0 _4 Parcel Id 17844 136 RALEIGH TAVERN LANE FERGUSON, JR., GEORGE B. 136 RALEIGH TAVERN LANE N. ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 1.08 Acres FY 2010 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until FERGUSON,JR.,GEORGE B. Payor 136 RALEIGH TAVERN LANE N.ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 14205:0-136 RALEIGH TAVERN.LANE: Last Billing Date 9/2/2009 2100199 02 Cycle 02 Active UB Services Maint. Account No.2100199 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 64.60 /1 UB Meter Maintenance Account No.2100199 Serial No Status Location Brand Type Size YTD Cons 16336802 a Active ERT METE METE w Water 0.63 0.63 65 Date Reading Code Consumption Posted Date Variance 8/3/2009 992 a Actual 17 9/11/2009 1576/o 5/7/2009 975 a Actual 7 6/16/2009 73% 2/3/2009 968 a Actual 4 3/16/2009 -77% 11/3/2008 964 a Actual 18 12/10/2008 -7% 8/1/2008 946 a Actual 19 9/12/2008 63% 5/1/2008 927 a Actual 11 6/18/2008 100% 2/4/2008 916 a Actual 6 3/14/2008 -89% 11/1/2007 910 a Actual 52 1/15/2008 14% 8/3/2007 858 a Actual 46 9/14/2007 203% 5/4/2007 812 a Actual 12 6/26/2007 56% 2/21/2007 800 a Actual 12 3/23/2007 -57% 11/1/2006 788 a Actual 23 12/22/2006 -14% 8/1/2006 765 a Actual 26 9/13/2006 68% 5/4/2006 739 a Actual 16 6/20/2006 78% 2/1/2006 723 a Actual 9 3/13/2006 -81% 11/1/2005 714 a Actual 48 12/14/2005 2% 8/2/2005 666 a Actual 47 9/12/2005 132% 5/3/2005 619 a Actual 20 6/8/2005 80% 2/2/2005 599 a Actual 11 3/15/2005 -74% 11/5/2004 588 a Actual 41 12/17/2004 -21% 8/10/2004 547 a Actual 53 9/20/2004 97% 5/13/2004 494 a Actual 26 6/14/2004 20% Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be,substantially the same as that provided here. Before using this form, check with your local Board of Health tQ determine the form they use. The System Pumping Record must be submitted to the local Board of Health otmotlaer approving authority. A. Facility Information 1. System Location: Left side of house, Right side of house., Left front of house, Right front of house, ear of house fight rear of house. Left rear of building. Right rear of building. Address City/Town State Zip Code 2. System Owner: Name Address(if different from location) C' /Town �y State Zip Code Telephone Number B. Pumping Record 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 [l-N-o If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: f^ t VU2 � 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. M where contents were disposed: D Lowell Waste Water Signature of Hauler Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1