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HomeMy WebLinkAboutMiscellaneous - 14 PURITAN AVENUE 4/30/2018 14 PURITAN AVENUE -- 210/107.6-0133-0000.0 _ \ 1\ M 1A00 Lot & Street C Map/Parcel CONSTRUCTION APPROVAL _ 5' sus G Has plan review fee been paid: YES NO Permit# Plan Approval: Date: Approved by: Designer: Plan Date: 81X9'197 Conditions: Water Supply: Town Well Well Permit: .., Driller: Well Tests: Chemical a roved Bacteria I Date Approve Bacteria II Date Approved Plumbing Sign-Off: Wiring Sign-Off- Comments: Form"U Approval: Approval to Issue: YES NO Date Issued By: Conditions: Final Approval: All Permits Paid? YES NO Well Construction Approval? YES NO Septic System Construction Approval? YES NO Certification? YES NO Other YES NO Any Variance Needed? YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: APPROVED BY: SEPTIC SYSTEM INSTALLATION Is the installer licensed? NO Type of Construction: � REPAIR New Construction: Certified Plot Plan Review NO Floor Plan Review �L –> NO Conditions of Approval from Form U YES NO Issuance of DWC permit: YES NO DWC Permit Paid? NO DWC Permit #_-1 Installer: —a, z .<* Begin Inspection: YES NO Excavation Inspection: Needed: Passed: - jr-, By: Construction Inspection: Needed: As Built Plan Satisfacto YES: Approval of Backfill: Date:f By: Final Grading Approval: Date: By: Final Construction Approval: Date: G By: Certificate of Compliance: Approval: Date: Commonwealth of Massachusetts r Title 5 Official Inspection Form RECEIVED Subsurface Sewage Disposal System Form-Not for Voluntary Assessments APR 2 S 2016 14 Puritan Avenue Property Address OWN Ur N'_)'< ' K)- F Rong Wu HULTi11:_,.: �,IT Owner Owner's Name information is required for North Andover MA 01845 4/15/2016 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` A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Neil J. Bateson cursor-do not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name VQ 111 Argilla Road Company Address Andover MA 01810 Cityrrown state Zip Code 978-475-4786 SI 15 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 ❑ Nees§urther Evaluation by the Local Approving Authority 4/15/2016 Inspect s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Puritan Avenue Property Address Rong Wu Owner Owner's Name information is required for North Andover MA 01845 4/15/2016 every page. Citylrown 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, inspection from B.O.H., septic system now passes Title 5 inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Jai. PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 4/15/16 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Repair of D-Box By: Todd Bateson At: 14 Puritan Ave, Map 107B Lot 0133 North Andover, MA 01845 'Th�Issuance of this �ert ficat��sha11 not be construed as a guarantee that the system will function satisfactorily. f .t Michele Grant Public Health Agent 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com North Andover Health Department (ommunity and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 14 Puritan MAP: 107B LOT: 0133 INSTALLER: Todd Bateson DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: D-box 4/15/16 DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ ,Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank 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 ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX X Installed on stable stone base X H-20 D-Box ❑ Inlet tee (if pumped or >0.08'/foot) X Hydraulic cement around inlet & outlets X Observed even distribution X Speed levelers provided (not required) X Schedule 40 PVC Pipe Comments: • � � � Commonwealth of Massachusetts Map-Block-Lot t. 107.B0133 BOARD OF HEALTH permit No North Andover -BHP-2016-0065---------------- ------ FEE $175.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Neil J.Rateson to(Repair)an Individual Sewage Disposal System. 'b- atNo 14 PURITAN AVENUE as shown on the application for Disposal Works Construction Permit No. BHP-2016-006 D p 1,2016 -- ------------------ --------- ----------------------------------- Issued On:Apr-11-2016 BOARD OF HEALTH *a Application for SemtiC Disposal .System E' t TODAY'S DATE Construction-ft - TOWN OF $2501:00—Full Repair NORTH .ANDOVER, MA 01845 $1125.00'-Component Important Application is hereby made for a permit to: When filling out ❑Construct a new on-site sewage disposal system' forms on the computer,use ❑Repair or replace an existing.on-site sewage disposal'system' only the tab Ivey B16pair or replace an existing system component–what? — ©X to move your cursor-:do not use the return A. Facility Information key. l PQ 17,4*A/ Address or Lot# tr - Aya, Aky0K �Jq �WED Cityrrown 2:*TYPE OF SEPTIC SYSTEM*: APR 17 2016 ➢ ❑Pump [?'C'ravity(choose one) **If pump system,attach copy of electrical permit to application"` TOWN OF NORTH ANDOVER Y [Z Conventional System (pipe and stone system) HEALTH DVAR p�Ft� ) ➢ F1 Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to install this Pe ars Tem. ➢ ❑Pressure Distribution S.A.S.(No D-Box) ➢ ❑Pressure Dosed(D-Box Present)S.A.S. ➢ ❑Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES=(no funkier info.needed) NO=(Installer must specify brand of filter before DWC issuance) What is the Make? What is the Modc t 2. Owner information *lame Address(if different from above) City/Town State Zip Code q'�sr gas= 9�"9e Telephone Number 3. Installer Information Name Name of ComWON ENTERPRISES INM Z/ Ara"/4, M. 111 ARrll y1 RO,m Address z L ANDOVER,MA 01810 Cityrrown State Zip Code q7r -i'/S- Telephone Number(Cell Phone#If possible please) 4. Designer information Name Name of Company Address Cityrrown State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 ,.r t/ i ::T" w Ap-plipati�on..for Septic Disposal System .�. TODAY'S DATE 3 • ' . °t Construction -Permit ' TONT'OF ORTH ANNDOYLR4 MA 01845 $:zso.00-Full Repair �•.,,.•� 1ss�t►NSE` $125.00.-Component PAGE 20F2 A. Faciiity.information continued.,.. S. Type'of Buffding: e-sidentiai Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system In accordance with the.provlslons of Title Sof the Environmental Code, as well as the Local Subsurface DIsposal Regulatlons for the Town of North Andover, and not to place the system 1n operatlon until a Certificate of Compliance has been Issu d by this Board of Heath. Ll -k—�r- • Nam Date plic ionAPo y: and of Health Represe:(atl,e) t Name Da a Application Disapproved.for the following reasons: For Office Use Only: I 'Fee Attached? , Yes No 2r- ProlectMartaget Obligation Fo=Attached? Yes V No ' 3.: PumJL42 P Ifso, h ceNo 4. Fo dation ' B" 4.7 ` ew co >!strucdon-ronl r � � }!). Yes No (Sam scale as apptoVC plan) S. FloorPlans?phew cons rUedo only); Yes_ No Applicitidn.,for.,o patal.0ystdM':0ons"ctlah Perma Rage 2 of 2 a; ,,LIMC '041 ATIM As f$e•Nqtth Aadovarli=edbsdart frst*6W utnttf rft.'t6sepdc ap MjorthepraV,4,st i4 ` n1' {Ad4ou otsq* } -Act picas by Abd dMod LV Dattd rMsed due) I vaderatand the foDowbg obligations flat a agemcat of Jia erect; thelasbRg4I m.ob%ated to abt&x0perq�atraadBba of�ia�h Reprovedphaa,�� pet is any wo*as s eit. �. As ie .I. eaI[ soy aad Wpodbm T£ spay . at�paeaon riot�oc�s#�ed�my compsnpr •aa��du syate�a sa aot>.�dy than ` vo bsveepacyawo�' ' shtyotlaca' f ''= "X . b 'io # pt �i`apxt�osi mea not lasve to b�prasGtxt: . > t t p ,for Wit ,etr ' o ' 3t'L OIK'(os amsil� �the e�icaer • ba ftibasitt;ed•��.Bo�d ofl�ta�,abet: .'d�it[� far•�a�tune.`I�1ier irni3r P s p t a�t'asgr� a�af be m4y Ind abk to . . hava to bete.• . moattr+oque�meg ,, �!$ �-�s cot�ilate: I�smlicr docc�mot 4. ht du iastalie:,'I d flat only l~tt>sl►g c'�ithrrt6 r in�nss as)find I Aui-feq xed m pkta the t of tare spstx i• it##Iits ed l t a: , 4 M ' 5.. . faaellter,•I t dGataa'd I t o f pact of the 8 caag( c n a Det rlurrrtlamt�hat.�te p rets cJ a�a�a c�ftlrr e�ate�rttaa.t •+baw s b. Iaspaeiraa aFtb jwtoai�ead ?'cam�e . - coo 'Ploapeot�*abpBau�fal.�5Ta6sAfffot�.�aaeufmat d ra tfiltYar °fmak,D�- veal,p,�imep bei,&WO&W wgffmd other . b. As thefls� ",wA..t..h.�a.t LSW a •h ! Ids;.,_�_ n.'!#r.,:�s �• ��eM��.•....;.. � .k.J e1�a .. Rte•^-Il��• i "�so�a ' 'ase f�.obli i� r • , j_ Uudm M UtaftaSq"k.Ii CF t te: . � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Puritan Avenue Property Address Rong Wu Owner Owner's Name information is required for North Andover MA 01845 3/28/2016 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: DECEIVE®A. General Information When filling out forms on the APR 1 1 2016 computer,use 1. Inspector: only the tab key 7OWN OF NORTH ANDOVER to move your Neil J. Bateson HEALTH DEPARTMENT cursor-do not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name 111 Argilla Road �-- � Company Address Andover MA 01810 City/town State Zip Code 978-475-4786 S115 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ UsFer Evaluation by the Local Approving Authority . � i 3/28/2016 Inspe o Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Puritan Avenue Property Address Rong Wu Owner Owner's Name information is required for North Andover MA 01845 3/28/2016 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B System Conditional) Passes: Y Y ® 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", "non 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 exMtration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ® N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Ofificial Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Puritan Avenue Property Address Rong Wu Owner Owner's Name information is required for North Andover MA 01845 3/28/2016 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): Observation of sewage backup or break out or high static water level in h distribution❑ the st bution box due 9 P 9 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 9 t5ins•3/13 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 14 Puritan Avenue Property Address Rong Wu Owner Owner's Name information is required for North Andover MA 01845 3/28/2016 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *' This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: -D-box needs to be replaced D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Puritan Avenue Property Address Rong Wu Owner Owner's Name information is required for North Andover MA 01845 3/28/2016 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply 11 EJ Area 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 9 P� Ys g of 17 Commonwealth of Massachusetts lTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Puritan Avenue Property Address Rong Wu Owner Owners Name information is required for North Andover MA 01845 3/28/2016 every page. City/Town State Zip Code Date of Inspection C. Checklist i Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No i ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts lug09 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Puritan Avenue Property Address Rong Wu Owner Owners Name information is required for North Andover MA 01845 3/28/2016 every page. CitylTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 5 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage Yes 9 ( Y 9 (gPd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Puritan Avenue Property Address Rong Wu. Owner Owner's Name information is required for North Andover MA 01845 3/28/2016 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped last year, owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Measured tank. Reason for pumping: Inspect tank&tees Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Puritan Avenue Property Address Rong Wu Owner Owner's Name information is required for North Andover MA 01845 3/28/2016 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 18 years old, 5/21/1998, as built plan. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.2 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): 4" PVC through wall to septic tank, 3" PVC in house, no leaks visible Septic Tank(locate on site plan): Depth below grade: 0.2 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x 5'x 4' Sludge depth: 2" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Puritan Avenue Property Address Rong Wu Owner Owners Name information is required for North Andover MA 01845 3/28/2016 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 31' Scum thickness 4" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? Tape Measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert, no evidence of leakage. Inlet cover under bush, should be removed. Outlet cover under paver walkway. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal g po System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Puritan Avenue Property Address Rong Wu Owner Owner's Name information is required for North Andover MA 01845 3/28/2016 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: concrete metal fiberglasspolyethylene other(explain): ❑ ❑ ❑ 9 ❑ ❑ 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? El Yes ❑ No t5ins•3113 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 s.y 14 Puritan Avenue Property Address Rong Wu Owner Owners Name information is required for North Andover MA 01845 3/28/2016 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal;any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box cover broken, replaced it. D-box badly corroded, needs to be replaced. Evidence of solid carryover, pumped d-box to clean. No evidence of leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): if SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments •�''y 14 Puritan Avenue Property Address Rong Wu Owner Owners Name information is required for North Andover MA 01845 3/28/2016 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 3 trenches 33' 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Puritan Avenue Property Address Rong Wu Owner Owner's Name information is required for North Andover MA 01845 3/28/2016 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.): I, 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 14 Puritan Avenue Property Address Rong Wu Owner Owner's Name information is required for North Andover MA 01845 3/28/2016 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 5. Ulu a' O � G� �Ca1fw 39 X53 `' t5ins•3/13 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 s..� 14 Puritan Avenue Property Address Rong Wu Owner Owner's Name information is required for North Andover MA 01845 3/28/2016 every page. City/Town 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: 4 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record I If checked, date of design plan reviewed: 7/2/1997 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: Design plan ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: As per test pit data on design plan. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Puritan Avenue Property Address Rong Wu Owner Owner's Name information is required for North Andover MA 01845 3/28/2016 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 I t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 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 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 I. System Location!j§C Rig vont o�ouildifig, eft/Right rear of house, Left/right side of house, Left/ Right side of building, Left/Right frLeft/Right rear of building, Under deck Address A L c4frown State Zip Code 2: System Owner. W Name' Address('d different from location) CifyTrown ' StatZip Code ; Telephone Number `41 I B. Pumping Pecord 1. Date of Pumping Date 2 Quantity Pumped: Gallons i 3. Type-of system. ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes❑ No If es was' �cleaned? Y . Y ❑ es ❑ No, 5. Condition of System: 6: System Pumped By: Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents-were disposed: G-L&D Lowell Waste Water Sign a Haul Date ` t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Summary Record Card generated on 4/5/2016 2:47:05 PM by Karen Hanlon Page 1 Town of North Andover Tax Map # 210-1073-0133-0000.0 Parcel Id 18246 14 PURITAN AVENUE SCOTTIE WYATT 14 PURITAN AVENUE NORTH ANDOVER MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 0.59 Acres FY 2016 UB Mailing Index Name/Address Type Loan Number Activellnact. From Until SCOTTIE WYATT Owner 14 PURITAN AVENUE NORTH ANDOVER MA 01845 LUZZO, MICHAEL Previous Customer Inactive 6/12/2007 14 PURITAN AVE NORTH ANDOVER,MA 01845 JASON VINING Previous Customer Inactive 9/28/2012 14 PURITAN AVENUE NORTH ANDOVER, MA 01845 RONG WU Previous Customer Inactive 1/11/2013 ZHIYU RU 14 PURITAN AVENUE NORTH ANDOVER MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 13329.0-14 PURITAN AVENUE Last Billing Date 3/14/2016 2100027 02 Cycle 02 Active UB Services Maint. Account No.2100027 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.2100027 Serial No Status Location Brand Type Size YTD Cons 33605590 a Active ERT HH b Badger w Water 0.63 0.63 1070 Date Reading Code Consumption Posted Date Variance 2/1/2016 1278 aActual 17 3/28/2016 -75% 10/30/2015 1261 a Actual 64 12/30/2015 24% 8/3/2015 1197 a Actual 55 9/14/2015 129% 5/1/2015 1142 aActual 22 6/22/2015 18% 2/4/2015 1120 a Actual 20 3/20/2015 -60% 11/4/2014 1100 aActual 50 12/15/2014 46% 8/5/2014 1050 aActual 32 9/11/2014 27% 5/12/2014 1018 a Actual 29 6/12/2014 32% 2/3/2014 989 a Actual 21 3/17/2014 1% 11/1/2013 968 aActual 19 12/20/2013 13% 8/7/2013 949 a Actual 18 9/18/2013 -14% 5/7/2013 931 a Actual 21 6/18/2013 -29% 2/4/2013 910 a Actual 8 3/13/2013 -100% 1/10/2013 902 f Final Bill 0 1/10/2013 -100% 10/30/2012 902 a Actual 7 12/13/2012 -60% 9/26/2012 895 f Final Bill 29 9/26/2012 32% 8/1/2012 866 aActual 36 9/26/2012 403% � I r • i ./ •53"E 155-68 \\ / N 9.22 \ \ OR4/N EASEA/ENT LOT >3 25, 675 S.F. \�� \G. \N � \ 'N \ \ TION \ FOUNDA \ EXIST�NO 1 .8 \ T.F70 = \ 168.58 \ Q 0ih0 FN I / �'� /��• 1684970P rANK 189.5 x,.`'1`68.25 �' NOTE: �O 167.76,- DENOTES INVERT 11 OF EXIST. PIPE (TYP.) 168.09 4 PVC { 167.54 168.00` L�67.81 167.53 8167 4` PVC 1 . 167.81 167.71 167.72 4" PVC 1j6?O 167.54 N M F7 /18/2012 10:26 FAX 781 937 1702 ANALOG DEVICES Z001/001 MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH SUBMETERING OF WATER AND SEWER CERTIFICATION FORM In accordance with M.G.L.c, 186,§22 and 105 CMR 410.000:Minimum Standards of Fitness for Human Habitation (State Sanitary Code Chapter II),the following dwelling unit is eligible for the imposition on the-tenants of a charge for water and/or sewer service. PROPERTY INFORMATION Address: url' p h Ave Unit It #Of units in bl ci crown: Norik Ah kvtj - MA zi eodc: 010 'EQUIPMENT INSTALLATION INFORMATION 105 CMR 410,000 requires the installation of water conservation devices prior to a dwelling unit becoming eligible for the imposition on tenants of a charge for water and/or sewer.The devices must meet the following specifications: Showerheads with maximum flow rate not to exceed 2 x fallons per minute(2.5 gpm) Faucets with maximum flow rate not to exceed 2 2/1 gallons per minute(2.2 gpm' Ultra low flush water closets(toilets)not to exceed 1 6110 gallons per flush(1.6 gpf) The submetering equipment used to measure the quantity of water used for each dwelling unit and uommoe area must meet the standards of accuracy and testing of the American Water Works Association or similar mmedited,association. A licensed plumber must install the water closets and submetering equipment. Submetering equipment information: _ Manufacturer Model# Licensed Plumber Certification 1- -in � •t Print Name of Plumber license# Date 1 certify that(check all that apply): I have installed the submetering equipment listed above in accordance with accepted plumbing standards. have installed one or more water closets not exceeding 1.6 gallons per flush. Determined that existing water closets do not exceed 1.6 gallons per flush. n The plumbing permit issued by the city/town,if required,is attached. Dwelling unit is connected directly to a meter installed by a water company and,in accordance with M.G.L .c. IM, §22(p),does not require the Installation of a submeter. .y Signed under the pains and penalties of perjury, Si of Licensed Plumber Property Owner Certification I certify that:(1)This dwelling unit is eligible for the imposition on the tenants of a charge for w*r and/or sewer usage in accordance with the water submetering law(MGL e. 186,§22);(2)All showerheads,faucets,and water closets in this dwelling unit are water conservation devices that meet the standards specified above;(3)The water submeter meastiring the use of water in the dwelling unit was installed by a licensed plumber and is in compliance wi�h the standards specified above,or the water meter measuring the use of water in this dwelling unit was installed by a"water company" as defined in M.G.L.c. 1$6, §22; (4)The water meter or submeter measures the water usage ex.lusive to this unit;(41 will provide to the tenants of this dwelling unit,prior to occupancy,a written rental agreement that clearly provides for the separate charging of water and/or sewer service,and a copy of this certification form;(6)That al l i nformation included on this certification is true and accurate to the best of my knowledge. Signed under the pains and penalties of pei ury, OW wA Au Au 17-Pec.W11 Print Name of Owner iatkw of dQher Date nn- A.M�QY- a M "N rJ- P oard of Aea1 a Ith erhnen 71 R cd B MDPH/CSP Submetering Certification Form,Reviscd 10106 .� MARK BURKE i PLUMBING& HEATING 272 Kenom Street HAVERHILL, MA 01830 16650 (978) 372.7272 PRONE DATE OF ORDER O 'G TO 'SORDER TAKEN BY CUSTOMERORDERNUMBER 1� w ❑ DAY WORK ❑ CONTRACT ❑ EXTRA JOB NAMEINUMBER JOBLOCAT(ON JOB PHONE STARTINO DATE TERMS: Q 'Y IVIAT1iR1dL RICO:` Am UNT t SCI PTCON Olri WOLF K Chet '\ a 1•ieniandnrrL f. `Te Atd all uncollected debt are subject Interest collect this debt. TOTAL OTHER /�/ lAl#bR HFfS FIAf� Am;' qD A TOTALLABOR C DATE COMPLETED TOTAL MATERIALS TOTAL MATERIALS TOTAL OTHER Work Ordered by Signature TAX C� 0 I hereby acknowledge the satisfactory completion at the above described work. 7�_ _,�_J TOTAL, .0 i L\, Comm6nwettlth of Mtssachusetts A SEPTUir; & DnA,W 131 Fores+,Street MI DLET, A 01949 TM e 5 OfficW Inspection Form (97 6685 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments A 66 Oi 85�49 j(U9L7 14 PURITAN AVE., NO.ANDOVER,MA 01845 Property Address JASON VINING Owner Owner's Name V information is V,1 required for NO.ANDOVER MA 01845 5/25/11 every page- Cityrrown state Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information RUIUVIVED When filling out forms on the computer,use 1. Inspector JUN -7 2011 only the tab key to move your JAMES H. CURRIER If cursor-do not Name of Inspector ' TUA110PNORT11 ANDOVER use the return key, J's SEPTIC &DRAIN Company Name 131 FOREST ST. Company Address MIDDLETON MA 01949 City/Town State Zip Code 978-774-6685 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 6 (310 CMR 16.000).The system: Passes ❑ Conditionally Passes F1 Fails ❑ Needs Further Evaluation by the Local Approving Authority 5/25111 ,^edor's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. if the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and Copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the systemfuture under the same or different conditions of use. Mn TITLE V 2008-doc•03108 Title 5 Official trispedion Form:Subsurface Sewage Disposal System-Page 1 of 1 ■ ' L 1 r Gornmonwei1th of Massachusefts Ts SEPT&C & BRAIN - Fest Street TSO fficuW O n ctio Form MIDDLETON,MA 01949 . Subsurface Sewage Disposal System Form-Not for Voluntary Assessments (978)77446685 14 PURITAN AVE., NO.ANDOVER, MA 01845 Property Address JASON VINING Owner Owner's Narne — — requir ation is NO ANDOVER MA 01845 5/25/11 required for every page. cityrrown State Zip code 'Date of Inspection Bs Certification (cont.) Inspection Summary: Check A,B,C,D or E/ahvays complete all of Section D A) System Passes: 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM WORKING PROPERLY. B) Syst m Conditionally Passes: ❑ One r more system components as described in the"Conditional Pass"section need to be sepia or repaired.The system, upon completion of the replacement or repai s approved by the Boa of Health,will pass. Answer yes, no not determined (Y, N, ND)in the❑for the following ements. if"not determined," pleas explain. ❑ The septic tank is etal and over 20 years old*or the sept' ank(whether metal or not) is structurally unsound, xhibits substantial infiltration or a tration or tank failure is imminent. System will pass inspe ion if the existing tank is rep ced with a complying septic tank as approved by the Board o ealth. *A metal septic tank will pas inspection if' s structurally sound, not leaking and if a Certificate of Compliance indicating Haat th tank is ss than 20 years old is available. ND Explain: ❑ Observation of se age backup or break out or high sta ' water level in the distribution box due to broken or ob cted pipe(s)or due to a broken, settled uneven distribution box. System will pass inspech if(with approval of Board of Health): ❑ �tx`oken pipe(s) are replaced ❑ obstruction is removed TITLE V 20MAcc-OMS 'rata 5 Official inspection F,m-Subsurfaces sewage I System.Page 2 of 2 X3 SEPTIC & DRAIN Corr monwealth of Massachusetts 131 Eofest street MIDDLETON, [VIA 01949 . � Ties 5 Official option v (978)774=b685 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 PURITAN AVE., NO.ANDOVER, MA 01845 Property Address JASON VINING Owner Owner's Name information is NO.ANDOVER MA 01845 5/25/11 required for _ every page. Cityrrown State Zip Code Date of Inspection Ba Certification (cont.) B) System Conditionally Passes (cont:): ❑ distribution box is leveled or replaced N xpfain: ❑ The syste retluired pumping more than 4 times a year due to brok or obstructed pipe(s). The system will p s inspection if(with approval of the Board of Heal ❑ broken e(s) are replaced ❑ obstruction i removed ND Explain: C) Further Evaluation is Required by a Board of Health: ❑ Conditions exist which require fu er ev uation by the Board of Health in order to determine if the system is failing to protect blit heal safety or the environment. 1. System will pass unl Board of Health eterrnines in accordance with 310 CMR 15.303(4)(b)that the sy em is not functionin 'n a manner which will protect public health, safety and the enviro ent: ❑ Cesspool privy is within 50 feet of a surface w er ❑ Ce ssp I or privy is within 50 feet of a bordering veg ed wetland or a salt marsh 2. Syste will fail unless the Board of Health (and'Public Wate upplier,if any) determ' es that the system is functioning in a manner that protec the public health, safe and environment: ❑ The system has aseptic tank and soil absorption system (SAS)and t 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 ublic water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a priva water supply well_ T{TLc V�flD3.dai t33£�B Title 6 Of dal Inspectan Form:Subsurface Sewage Disposal System•Page 3 of 3 "Js SEPTIC & BRAIN Commonwealth of Massachusetts 131 Forest Street MIDDLUON, MA 01949 Titge 5 Declog Inspection Fogm (978)774-6685 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 14 PURITAN AVE., NO.ANDOVER, MA 01845 _ Property Address JASON VINING Owner Owner's Narne information is required for NO.ANDOVER MA 01 845 5/25!31 _ every page. c4frown state Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health(cont): ❑ The system bas septic tank and SAS and the SAS is less than 100 feet but 50 fleet or more from a privat ater supply well". Method used to determine ' #once: This system passes if the well water nalysis,perform at a DEP certified laboratory,for coliform bacteria indicates absent and the presen of ammo . nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other fail a cri 'a 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 ❑ N Backup of sewage into facility or system component due to overloaded or dogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or dogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool ❑ ❑0 Liquid depth in cesspool is less than+6"below invert or available volume is less than 'l day flow ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 0 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. T17tE V 2003.der•OMB 73tte 5 Official Inspection Farm:Subsurface Sewage I>lspmal System-Page 4 of 4 Commonwea6th of 3assachc�se s Ts SEPT & DRAIN - d® 131 Forest Street - TM ,� Inspection Farm MID LE ')N A01949 -6685 Subsurface Sewage Disposal System Foran-Not for Voluntary Assessments 14 PURITAN AVE., NO.ANDOVER, MA 01845 Property Address JASON VINING Owner Owner's Name information is NO.ANDOVER MA 01845 5125/11 required for _ every page. city/7-0= State Zip code Date of inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont): Yes No ❑ ❑lkk� Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ❑ filo Any portion of a cesspool or privy is within 50 feet of a private water supply i� well. ❑ ❑41� 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 forma ❑ 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 10,090 gp o 15,000 gpd. For large systems, you must in i to either"yes"or"no"to ch of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within t of a surface drinking water supply ❑ ❑ the system is within 00 fe of a tributary to a surface drinking water supply ❑ ❑ the system is to ted in a nitro n sensitive area(Interim Wellhead Protection Area—IWP or a mapped Zone of a public water supply well If you have answered"yes"to y question in Section E the #em is considered a significant threat, or answered"yes"in Sectio above the large system has fai . The owner or operator of any large system considered a sign' cant threat under Section E or failed un r Section D shall upgrade the system in accordance h 310 CMR 15.304.The system owner shou contact the appropriate regional office of the epartment. TrrE v 2008-doC"030B Tette 5 Official Inspection Soma.Subsurface Sewage Disposal System-Page 5 of 5 Commonwealth of Massachusetts j's SEPM & DRAIN 131 Forest Street - FTdN, MA 01949 Title5 Official Inspection Fops M1017(9L78)774-6685 Subsurface Sewage Disposal System Farm-Not for Voluntary Assessments 14 PURITAN AVE., NO. ANDOVER, MA 01845 Prop"Address — JASON VINING Owner owner's Name information is required for NO. ANDOVER MA 01845 5/25111 _. _ every page. Citylrown 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? E ❑ 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)] rrrt£v 200BA=•o Title 5 C3lrrciat Inspection Fotm:subsurface Sewage Disposal System•Page 6 of 6 PTIC Cart monwealth sof Massachusetts �`� SE Forest DRAIN _ 133 Foresf Street - Title ` cW inspection Fo �I0 9780774-6ss594g = 1= Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 PURITAN AVE., NO.ANDOVER, MA 01845 Property Address JASON VINING Owner Owner's Name information is required for NO. ANDOVER MA 01845 5/25/11 _ �. _ every page. Citytrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 GPD Number of current residents: ONE Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ( ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings„.if available(last 2 years usage(gpd)): 155 GPD Sump pump? ❑ Yes ® No Last date of occupancy: CURRENT _ Date Commercial/Industrial Flow Conditions: Type of Est Iishment: — Design flow(bas on 310 CMR 15203): Gallons per day(gpd) Basis of design flow(s is/persons".ft_,etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank presen ❑ Yes ❑ No Non-sanitary waste discharged the Title ystem? ❑ Yes ❑ No Water meter readings, if ailable: - Last date of occupan /use: to Other(describe . TITLE V 2WB.doc-03MS Tim 5 Official tnscecton Farm:Subsurface eve Disposal Svstem-Rape 7 of 7 J"S SEPTIC & ®RAIN Commonwealth of Massachusetts 131 Forest Street --_ MA Title O�� nO inspection Fw A�IiD(978)�77466859 Sewage Subsurface _ S age Drspasal System t=s►rm-Not for Voluntary Assessments 14 PURITAN AVE., NO.._ANDOVER, NIA 01845 Property Address JASON VINING Owner Owner's Name information is NO.ANDOVER required for MA 01845 5/25111 every page. cityfrou►wn state Zip code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: LPD 9128/2010 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons --- — — Now was quantity pumped determined? — Reason for pumping: --- Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool El 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 grader contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components,date installed(if known) and source of information: ASBUILT DATED 5/21/1998 Were sewage odors detected when arriving at the site? ❑ Yes ® No T{TLE V 2008.doc.03M Title 5Official inspection'Fwm:Subsurface Sewage Disposal System•Page 8 of 8 Commonwealth of Massachusetts 19 SEPM, & DRAIN Form 131 Forese Street Title � : �c� � Inspection orm �n1t�DIl roN,MA 01949 Subsurface Sewage Disposal System Form-:Not for Voluntary Assessments (978)774=66135 14 PURITAN AVE., NO.ANDOVER, MA 01845 erty PropAddress - - -----------------------—J�_ -- JASON VINING Owner Owner's Name information is required for NO. ANDOVER MA 01845 5/25/11 _— every page- cityrrown State zip Code Hate of Inspection —�— D. System Information (cant.) Building Sewer(locate on site plan): ONE FOOT Depth below grade: fpPt Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain):. Distance from private water supply well or suction line. NIA - -- -__-- ----.__ _.-- feet Comments(on condition of joints, venting,evidence of leakage,etc.): PLUMBING GOOD_ Septic Tank (locate on site plan): Depth below grade: 9"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) 0 Yes ❑ No ------------------------------------------------------------------------------------------------------------------------------- Dimensions: 10'X 6'- 1500 GAL. Sludge depth: 2"- 3" Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness 0- 1/2" Distance from top of scum to top of outlet tee or baffle 6" - Distance from bottom of scum to bottom of outlet tee or baffle 14 How were dimensions determineO SLUDGE JUDGE, TAPE MEASURE TME V 2008AOC•03108 Tffle:S T+fflctal 4rtsperkon Form:Subsurf2ce 5mage flisposai System•page 9 of 9 Ts SEPVC & DRAIN Commonwealth of Massachusetts 131 Forest Street S 8 MIDDLETON,MA 01949 e ffi d M �n s p e c � F(Dv (978)774-6685 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �.� 14 PURITAN AVE., NO-ANDOVER, MA 01845 Property Address JASON VINING Owner Owner's flame information is NO-ANDOVER MA 01;845 5125111 required for every page. Catyfrown state Zip irate Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet lee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): t.IQUID LEVEL CORRECT,TEES IN GOOD CONDITION, DOES NOT NEED PUMPING AT THIS TIME. Grea Trap (locate on site plan): Depth be w grade: feet Material of co struction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene other(explain): Dimensions: Scum thickness - Distance from top of scum to top of o et tee or ba - Distance from bottom of scum to bottom o et tee or baffle ---- Date of last pumping: Date Comments(on pumping recomme ations, inlet an outlet tee or baffle condition,structural integrity, liquid levels as related to outlet i ert, evidence of lea ge, etc.): Tight or Holding nk(tank must be pumped at time of inspectio (locate on site plan) Depth below g de: Material o onstruction: ❑ co rete ❑ metal ❑ fiberglass ❑ polyethylene other(explain): TfrLE V 2008_doc>QMB Title 5OTrrcial fnspecton f mr:Subsurface Sewage Disposal System•Page 10 of 10 TIC Commonwealth of Massachuse is J's 5 31 Fore & DRAINI31 Forest Street Tele f cW Inspection Forte MlD�s7a ��4M6��F949 Subsurface Sewage disposal System Form-Not for Voluntary Assessments 14 PURITAN AVE., NO.ANDOVER, MA 01845 _ Property Address ,JASON VINING Owner Owners Name information is NO ANDOVER MA 01845 5/25/11 required for �. _ every page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Tight or tding Tante(cont.) Dimensions: Capacity: — galiorts Design Flow: ons per day Alarm present: ❑ Yes ❑ No Alarm level: — — Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of ala and float switches, etc. - *Attach m of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above Outlet invert 0 --- Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any ei7*dei1 of I ani�aya,tnty^vI o'u.t f,.MUX,atm.). BOX IS LEVEL AND WORKING PROPERLY, NO EVIDENCE OF CARRYOVER, NO EVIDENCE OF LEAKAGE. BOX 16" BELOW GRADE. Pump ChambXord . pian): Pumps in work ❑ Yes ❑ No Alarms in work ❑ Yes ❑ No TITLE V 2 &.doe•0=3 Title 5 Offitiaf Inspedian Form.Subsurface Se`+mge Disposal SySt m-Page I i of 11 ©mmonwealth of f ass chusetts Ts SEPTIC & ®RAIN 131 ForeR street B a , MOD -A MA 01949 T `�Q u l Inspection Farm (978)774-6685 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 PURITAN AVE., NO.ANDOVER,MA 01845 Property Address — JASON VINING Owner Owner's Name information is required for NO ANDOVER MA 01845 5/25/11 _ every page. cjtyrrown State Zip Code hate of Inspection D. System Information (cont.) Comments(note condition of pump chamber, nditio f pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: - � leaching trenches number, length.: THREE-20`EA. ❑ leaching fields number, dimensions: - ❑ overflow cesspool number. — — ❑ innovative/aftemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SOILS DRY, NO SIGNS OF HYDRAULIC FAILURE, VEGETATION NORMAL. TITLE V 2W&d=•03M Tide 5 Oftial inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 ' SEPTIC & DRAM Commonwealth of/Massachusetts131 Forest Street IMIDDLETON, MA 01949 M 5 nuc � Inspection F v i� t�7$)��4-66 5 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments p- , 14 PURITAN AVE., NO. ANDOVER, MA 01845 _ Property Address JASON VINING Cvvner Owner's Mame information is required for NO.ANDOVER MA 01845 5/25/11 _ every page. cityrrown state Zip Code Date of Inspection T D. System Information (cont.) Ces ools (cesspool must be pumped as part of inspection) (locate on site plan): Number d configuration Depth—top o liquid to inlet invert — Depth of solids is er --- Depth of scum layer --– — Dimensions of cesspool - -- Materials of construction ---- Indication of groundwater inflow ❑ Yes En Comments (note condition of soil, si sof hydr/failure, el of ponding, condition of vegetation, etc_)_ Privy(locate on site plan): Materials of constructio _ Dimensions Depth of solids Comments ote condition of soil, signs of hydraulic failure,levet of ponds , condition of vegetation, etc.): 4' TITLE V 200B.doc•03M Tale 5 Official Inspection Fom3:Subsulace Sewage Disposal System•Page 13 of 13 Commonwealth of Massachusetts JS SEPTIC & DRAIN 131 Forest Street 10( )7MA 549TM 5 Official fl s estio P 978 74=668 Subsurface Sewage Disposal System Farm-Not for Voluntary Assessments �w 14 PURITAN AVE., NO.ANDOVER, MA 01845 Property Address JASON VINING Owner Owner's Name information is NO ANDOVER MA 01845 5125111 required for _ _ every page. cityfiovm State Zip Gude Date of Inspection D. System information (cont.) 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. MLE V 2ODB-dac•03M T tfle 5 Offidal Inspection Form Subsurface Sewage Disposal System-Page 14 of 14 J's SEPTIC & DRAIN 131 Forest Street MIDDLETON,MA 01949 (978)774-6685 _ J 1 \ 0RAIN EASEMENT \N p \� O L OT 13 \w ♦♦_� vl \y n V\ v \7G, `a \N k \ rn \ N \ FO�NDOON \ D{fS17NG 170-8 \ 166.58 U �.0^�—i 168.49 jzjvmlfi95 a,•`�68.25 .' MOTE: afl 167.76, DEMOTES INVERT Yr ��►� -�'—�•�—��.,� 'cS_ I. OF EAST. PIPE -) 168.49 4' AVC 168.0 167.81 167.54 167.53 4- 167.81 167.61 167.71 167.72 4� 62D 167.54 N M Commonwealth of Massachusetts Js SEF' & DRAIN Forest Street TRO f cv i l O c i o Form MID(97ETON,8)774-6685 9a9 Subsurface Sewage Disposal System Foam-Not for Voluntary Assessments 14 PURITAN AVE., NO. ANDOVER, MA 01845 roperty Address JASON VINING Owner Owner's Name information is NO.ANDOVER required for MA 01845 5/25111 every page- c+tyrrown state Zip code Date of Inspection Do System Information (cont.) :site Exam: ❑ Check Slope (-1 Surface water ® Check cellar (-1 Shallow wells Estimated depth to high ground water: 58" SHVVT feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked,date of design plan reviewed: 91111199? -- -- 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.- You xplain:You must describe how you established the high ground water elevation: TEST PIT DATA ON FILE WITH Boll. TEST PITS PERFORMED 712/1997_ 'MLE V 2M8.dcc•0.1,103 Tale 5 Official Ln-spe-toa Form.:Subsudace Sed-asp Dspm- 1 System.-Page 15 of 15 COMMONWEALTH OF MASSACHUSETTS tc = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a DEPARTMENT OF ENVIRONMENTAL PROTECTION vy 5� TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 14 pliri tan A pnuP Nn_ AndcwPr, MA 01845 Owner's Name: roti chael T u7.7.n y� tin A17Q Owner's Address: 14 Puri - 3�• -' MIA Nn Andamer MA 01845 Date of Inspection: Q,1-/-1 j;a e(7 JAN 2 2 200 Name of Inspector: (please print) j.M s Wright —H ANDOVER Company Name: -R.T Tnc=ar f i nnG , Tne. NT Mailing Address: 270 T,awrPnr e S-t eet MPt-huPn, MA 01844 Telephone Number: ( 9 7 R ) 6 81 -8 7 5 9 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 Sectiow15.340 of Title 5(310 CMR 15.000). The system: P/asses , Conditionally Passes Needs Further Evaluation by the Local Approving Authority j Fails Inspector's Signature: Date: 14zd The system inspector s ' 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 00 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office officce of low of he DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1 4 Puritan Avenue No_ Andover MA 01845 Owner: Mi cha 1 Luzzo Date of Inspection: n1 /1 7 Inspection Summary: Check A,B,C,D or E/ALWAYS complete.all of Section D A. Sy�ste Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. .*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 14 Puritan Avenue NO, Andover, MA 01845 Owner: Michael Luzzo Date of Inspection: n1 11 q/Q 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 I5.303(1)(b)that the system is not functioning in a m�will protect public health,safety and the environment: Cesspool or privy is withi ce water Cesspool or privy is w' to 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 surface water supply or tributary to a surface water supply. The system has a septic tank and SAS �theS-ig within a Zone 1 of a public water supply. — The system has a septic tank and and the SAS is within 50 feet of a private water supply well. _ The system has a sept ank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**.Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form, 3. Other: 3 Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 14 Puritan Avenue H.Q. Andover, MA 01845 Owner: M;ChaP1 Luzz0 Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes Not r _ / cep of sewage into facility or system component due to overloaded or clogged SAS or cesspool rr/ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or dogged SAS or cesspool l/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or esspool squid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow /Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number tunes pumped y portion of the SAS,cesspool or privy is below high ground water elevation. — --7 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface er supply. portion of a cesspool or privy is within a Zone 1 of a public well. e/ y portion of a cesspool or privy is within 50 feet of a private water supply well. ny portion of a cesspool or privy is less than 100 feet but greater than 50 feet from arivate water supply well with no acceptable water quality analysis. [This system passes if the well 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.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system mast serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no — _ the system is within 400 f a surface drinking water supply — _ the system is w' n 200 feet of a tributary to a surface drinking water supply the syste is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or-answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 14 Puritan Avenue . No. Andover, MA 01 845 Owner: Mir ael T,uzzo Date of Inspection: ()11 1 "1 0 7 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes o Pum ing 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 art of this inspection? P P 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? v 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: Yes o 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 is is unacceptable)[3 10 CMR 15.302(3)(b)] sue approxtmatton of distance 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 14 Puritan Avenue Nn- Andover., MA 01845 Owner:Mich a e 1 T,t»z o Date of Inspection:-0 3 11 -4 n 7 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 b�drooms): Number of current residents:-.17q-- Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):_ [if yes separate inspection required] Laundry system inspected(yes or no):_ Seasonal use: (yes or no):_ Water meter readings, if avail le(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy: -- COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15. gpd Basis of design flow(seats/per sgft,etc.): Grease nap present(yes o):— Industrial waste hold' g tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): Pumping Records GENERAL INFORMATION Source of information: Was system pumped as part of the inspection(yes or no):_ If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: T�TPPF 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�(if known)and source of info ation: Were sewage odors detected-when arriving at the site(yes or no): /16-� 6 Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 14 Pu r i i-;;n A wc3nue Nn_ Anc3nvPrf MA 01845 Owner:—Michael T,u7.7n Date of Inspection:01 .11 -1.10 7 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) Depth below grade: Material of construction: 7'--c'Oncrete metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: x /,-;7 Sludge depth: ?4' Distance from top of sludge to bottom of outlet tee or baffler �r Scum thickness: -2 ,' Distance from top of scum to top of outlet tee or baffle:?, Distance from bottom of scum to bottom of outlet tee or baffle:, "2 y`" How were dimensions determined: (IL�f/f Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal fiberglass_polyethylene_other (explain): — Dimensions: Scum thickness: Distance from top of scum t of outlet tee or baffle: Distance from bottom cum to bottom of outlet tee or baffle: Date of last pump' Comments(on ping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 14 P»r i t a n Avenue N.2 An ayc-r�KA 01845 Owner:_M j-iha-o l r t12:r) Date of inspection:.01 11 ,1 f�� TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate onsite plan) Depth below grade: Material of construction: concrete me fiberglass_polyethylene other(explain): Dimensions: Capacity: allons Design Flow: allons/day Alarm present(yes or Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:-67 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage ' o or out of box,etc.): PUMP CHAMBER: (locate on site plan) Pumps in working order(�or .Alarms in working order Comments(note Gond' ' n of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 14 Puritan Avenue _No_ Andover MA 01845 Owner:-- Mi y-hae1 T „7-ZD Date of Inspection: p 3 .11 .1.1()7. . SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: hing galleries,number: r leaching trenches,number, length: j 2 C2 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.): 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 cess Materials of cons ction: 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 construction: Dimensions: Depth of solids: Comments(note c ition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 .4 Puritan Avenue No. Andover, MA 01845 Owner: Michael Luzzo Date of Inspection: a 111 -1 p 7 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. 10 01/.05/2007 08:3.4 9786888476 HEALTH PAGE 02/02 a / y9 Z� N \ \ \� 4 \� Q w L.OT 13 N v 4 25.. 675 S.F ` \7G, \��, 8• UNp.4 774N ` 70.E \ 168.58 � \\ ho i 7LW TAA6RC �" ��• Er�u��s�,s-�'' •' h g�` ORlliEjf'A) `68.25 Nom: E�4SEMOV 168.09_ 167.f6� 4' OF ERT DUST.IMS PE (rYP. ) vc t 67.54 168.00 t 67.81 i 187.81 167.53 4' pvC 167.81 167.71 "Iry 167.72 167.54 iv �I1ri�11{li16YXUdhY!kla:�'.+.. .... Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_1 4 Puritan Avenue _NO. Andover, MA 01845 Owner:- Mi r•hapl T u7.Zn Date of Inspection: Illi SITE EXAM Slope Surf ter check cellar a ow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: a 11 -Jan 16 0,7 1,1 : 526 P. 1 Summary Record Card generated on 111612007 9:37:47 AM by We Warren Page 1 Town of North Andover �- } Tax Map # 210-107.8-0133-0000.0 / 14 PURITAN AVENUE U LUZZO, MICHAEL 14 PURITAN AVE 1 NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 0.59 Acres FY 2007 UB Mailing Index Name/Address Type Loan:Number Activellnact. From Until LUZZO, MICHAEL Payor 14 PURITAN AVE NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 13329.0- 14 PURITAN AVENUE Last Billing Date 12/15/2006 2100027 02 Cycle 02 Active UB Services Maint. Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.63518 7.82 1/ WTR WATER 01 ALL METER SIZE 56.34 /1 UB Meter Maintenance Serial No Status Location Brand Type Size YTD Cons 43993603 a Active E ENC F.RT. ? w Water 0.63 0.63 0 Date Reading Code Consumption Posted Date Variance 1.1/2/2006 1449 a Actual 18 12/22/2006 -75% Trouble Code:03 8/21/2006 1431 a Actual 88 9/13/2006 430% Trouble Code:03 5/25/2006 1343 a Actual 20 6/20/2006 -13% Trouble Code:03 21$/2006 1323 a Actual 20 3/13/2006 -80% 1118/2005 1303 a Actual 98 12/14/2005 85% Trouble Code:03 8/10/2005 1205 a Actual 57 9/12/2005 236% Trouble Code:03 5/5/2005 1148 a Actual 14 6/8/2005 -19% 2/14/2005 1134 •a Actual 19 3/15/2005 20% 11/18/2004 1115 a Actual 18 12/17/2004 -680, 8/10/2004 1097 a Actual 50 9/20/2004 230% Trouble Code:03 5/14/2004 1047 a Actual 15 6/14/2004 -1% • Page 1 of 3 SUMMARY OF GROUND-WATER LEVELS DECEMBER 2006 PROVISIONAL (NOTE: Wells with * also available in real-time at top of Ground-Water Data page; OWc, monthly measured value used in high ground-water level estimation report, USGS Open-File Report 80-1205. ) WELL L START NET CHANGE DEPARTURE WATER LEVEL T I YEAR IN MONTH IN ONE FROM BELOW LAND- 0 T OF YEAR MONTHLY SURFACE P H RECORD MEDIAN DATUM 0 0 (OWc) (FEET) (FEET) (FEET) (FEET) DAY MASSACHUSETTS ACTON 158 * TS 1965 + 0.31 - 0.11 + 2.97 16.57 18 ANDOVER 462 VS 1968 - 0.38 + 0.83 + 0.17 14.55 18 ATTLEBORO 83 VS 1964 - 0.81 - 0.44 - 0.'20 3.77 19 BARNSTABLE 230 FS 1957 + 0.03 - 1.03 + 0.92 23.55 20 BARNSTABLE 247 FS 1962 - 0.08 - 0.59 + 1.59 23.41 20 BECKET 12 TS 1986 + .0.16 + 0.59 + 0.59 2.74 > 27 BLANDFORD 9 VS 1986 - 0.01 + 0.03 + 0.35 1.69 27 BOURNE 198 FS 1962 ----- ---- ----- BREWSTER 21 FS 1962 - 0.22 + 0.01 + 2.02 8.70 21 BREWSTER 22 * FS 1962 - 0.05 - 0.33 + 1.50 30.12 28 CHATHAM 138 FS 1962 - 0.09 - 0.67 + 0.27 24.15 21 CHESHIRE 2 . HT 1951 + 1.47 + 0.47 + 1.45 3.12 26 CHICOPEE 95 TS 1984 + 0.02 - 0.96 + 0.42 21.80 26 COLRAIN 8 VS 1965 + 0.00 - 0.54 + 2.25 17.61 26 CONCORD 165 TS 1965 - 0.21 + 1.08 + 2.57 39.72 18 CONCORD 167 TS 1965 - 0.59 - 0.43 + 0.28 6.84 18 CUMMINGTON 13 VS 1986 - 0.41 - 0.57 + 0.14 4.60 26 DEDHAM 231 ST 1965 - 0.94 - 1.60 - 1.57 7.22 18 DEERFIELD 44 VS 1965 + 0.54 + 0.22 + 0.82 1.74 > 26 DOVER 10 TS 1965 + 0.52 - 1.56 + 0.78 33.41 18 DUXBURY 79 * VS 1965 - 0.83 - 0.41 - 0.06 7.87 19 DUXBURY 80 VR 1965 - 0.81 - 0.40 - 0.10 21.30 19 EAST BRIDGEWATER 30 HT 1958 - 0.61 - 4.22 - 0.31 9.29 19 EDGARTOWN 52 VS 1976 - 0.45 0.26 + 1.60 17.57 26 FOXBOROUGH 3 TS 1965 - 0.62 - 0.18 + 0.47 18.63 18 FREETOWN 23 TS 1964 - 0.15 - 1.54 + 0.47 13.21 19 GEORGETOWN 168 VS 1965 - 1.37 - 1.26 - 1.61 5.89 < 19 GRANBY 68 VS 1954 - 0.09 - 0.82 + 0.52 7.22 26 GRANVILLE 5 TS 1965 + 0.37 - 0.58 + 1.45 32.52 27 GRANVILLE 6 SS 1965 - 0.04 - 1.18 + 0.19 3.98 27 GREAT BARRINGTON 2 VT 1951 - 1.76 - 1.72 + 0.48 9.89 26 HANSON 76 VS 1964 - 0.56 - 0.19 - 0.23 4 .65 19 HARDWICK 1 TS 1965 - 0.63 - 1.08 - 0.54 14.92 18 HAVERHILL 23 TS 1960 - 0.16 - 1.56 + 0.62 11.99 19 HAWLEY 8 ST 1986 - 0.18 - 0.27 + 0.81 2.97. 26 LAKEVILLE 14 * TS 1964 = 0.19 - 2.21 + 3.46 12.91 19 LEXINGTON 104 VS 1965 - 0.78 - 0.88 + 0.05 2.26 18 MASHPEE 29 FS 1976 - 0.23 - 0.78 + 0.28 8.73 28 MIDDLEBOROUGH 82 VT 1965 + 0.18 - 3.48 - 0.78 8.29 19 MONTGOMERY 19 SS 1986 - 0.35 - 0.24 + 0.54 0.97 27 NANTUCKET 228 FS 1976 ----- - 0.30 + 0.45 25.31 28 NEW BEDFORD 116 VS 1964 - 0.53 - 0.31 - 0.35 4.14 19 NEWBURY 27 VT 1965 - 0.92 - 0.80 + 0.48 5.45 19 NORFOLK 27 * VS 1965 - 0.58 - 0.50 - 0.10 5.87 19 NORTHBRIDGE 54 VS 1984 - 0.38 - 0.38 + 0.23 3.92 21 NORTON 37 FS 1964 - 2.11 - 1.18 - 0.02 6.22 18 ORANGE 63 TS 1985 - 0.57 - 1.09 + 0.30 6.84 18 OTIS 7 VS 1965 - 0.44 - 1.15 - 0.18 8.21 27 PELHAM 23 * SR 1981 + 0.40 - 0.08 - 2.50 14.45 18 http://ri.water.usgs.gov/current_cond/data/2006_12.txt 1/15/2007 Page 2 of 3 PELHAM 24 SS 1984 - 0.42 - 0.87 - 0.42 4.23 18 PETERSHAM 16 ST 1984 - 1.81 - 0.42 - 0.23 13.32 18 PITTSFIELD 51 * VS 1963 - 0.09 - 0.77 + 1.18 14.81 27 PLYMOUTH 22 TS 1956 - 0.10 - 2.03 + 2.03 23.40 28 PLYMOUTH 494 SS 1985 - 0.37 - 0.09 + 3.54 27.10 28 SANDWICH 252 FS 1962 - 0.11 - 0.46 + 0.26 47.32 28 SANDWICH 253 FS 1962 - 0.26 + 0.84 + 2.51 48.21 28 SEEKONK 275 VS 1964 - 0.40 ----- + 0.47 5.70 19 SHEFFIELD 58 FS 1987 - 1.43 - 1.46 + 0.85 12.88 26 SOUTHBOROUGH 12 HT 1990 - 1.74 - 1.91 - 1.40 4.33 18 STERLING 1 ST 1947 - 0.45 - 0.33 + 0.27 2 .89 18 STERLING 177 SS 1995 - 0.83 - 0.14 - 0.14 14.10 18 SUNDERLAND 7 SS 1957 - 1.96 - 5.21 + 3.69 13 .30 26 SUNDERLAND 68 VS 1983 - 0.13 - 0.96 + 0.03 2.93 26 TAUNTON 337 TS 1964 - 1.03 - 0.82 + 0.33 8.47 18 TEMPLETON 3 VS 1957 - 0.23 - 0.13 - 0.21 3.66 18 TOPSFIELD 1 HT 1936 - 1.63 - 2.48 + 0.66 10.52 19 TOWNSEND 13 TS 1965 + 0.11 - 0.68 + 1.81 12 .02 18 TRURO 1 TS 1950 - 0.09 - 0.17 + 0.11 10.59 21 TRURO 89 TS 1962 0.19 - 0.41 + 0.00 12.09 21 WAKEFIELD 38 * FS 1965 - 0.78 - 1.27 - 0.07 6.51 19 WARE 43 VS 1965 - 0.15 - 1.90 + 0.17 8.95 18 WAREHAM 51 TS 1959 - 0.05 - 1.91 + 0.10 8.13 28 WAYLAND 2 TS 1965 + 0.07 - 0.84 - 0.13 16.28 18 WEBSTER 1 HS 1958 - 0.79 - 1.90 - . 0.07 14.06 20 WELLFLEET 17 VS 1962 - 0.24 - 0.56 - 0.09 11.11 21 WENHAM 76 VS 1965 - 0.60 - 0.48 + 0.17 2.28 19 WEST BOYLSTON 26 SS 1995 - 1.61 0.81 + 0.28 4.90 18 WEST BROOKFIELD 2 TS 1959 + 0.09 - 0.85 + 1.53 18.04 18 WESTHAMPTON 20 SS 1986 - 0.47 - 1.95 + 1.35 11.07 27 WESTFIELD 62 SS 1957 - 0.52 - 2.14 - 0.27 7.66 27 WESTFIELD 152 TS 1986 + 0.07 - 0.57 + 0.97 2.41 27 WESTFORD 160 VS 2001 - 0.42 - 0.74 ----- 10.94 19 WEYMOUTH 2 FT 1965 - 0.83 - 2.84 + 1.62 9.72 18 WEYMOUTH 3 VS 1965 - 1.01 - 0.73 + 0.00 4.78 18 WEYMOUTH 4 TS 1965 - 1.38 - 0.81 - 0.16 6.69 18 WILBRAHAM 55 TS 1965 + 0.04 ----- + •1.51 41.41 26 WILMINGTON 78 * FS 1951 - 0.53 - 0.86 + 0.07 7.78 19 WINCHENDON 13 ST 1939 - 0.46 - 1.11 + 0.60 5.04 18 WINCHESTER 14 ST 1940 - 3.01 - 2.55 - 1.46 10.67 19 RHODE ISLAND BURRILLVILLE 187 TS 1968 + 0.08 - 0.35 + 0.10 15.00 21 BURRILLVILLE 395 UT 1992 - 0.59 + 3.87 - 1.00 7.15 27 BURRILLVILLE 396 VT 1992 - 1.17 - 0.94 - 1.24 6.02 < 27 BURRILLVILLE 397 HT 1992. - 0.96 4.79 - 6.73 21.20 27 BURRILLVILLE 398 HT 1992 - 0.96 - 0.80 - 1.58 8.01 27 CHARLESTOWN 18 FS 1946 - 0.79 - 2.17 + 1.62 16.80 21 CHARLESTOWN 586 VT 1992 + 1.13 ----- + 1.17 2.42 > 27 CHARLESTOWN 587 ST 1992 - 1.19 ----- + 0.03 6.08 27 COVENTRY 342 VS 1991 - 1.94 - 0.55 - 0.41 8.36 21 COVENTRY 411 SS 1961 - 1.11 - 0.24 + 1.02 20.58 21 COVENTRY 466 VT 1992 ----- ----- ----- ----- CRANSTON CITY 439 ST 1992 ----- ----- _ CUMBERLAND 265 SS 1946 - 2.18 - 2.38 - 0.11 11.69 21 EXETER 6 VS 1948 - 0.89 - 0.50 + 0.54 5.18 21 EXETER 158 ST 1991 - 2.25 - 1.77 - 0.42 6.85 21 EXETER 238 FT 1991 - 0.67 - 0.50 - 0.29 11.90 21 EXETER 278 HT 1991 - 2.93 - 4.15 + 2.30 10.99 21 EXETER 475 VS 1981 + 0.21 - 0.08 + 1.25 13 .59 21 EXETER 554 SS 1988 - 0.74 - 0.87 + 0.19 9.62 21 http://ri.water.usgs.gov/c urrent_cond/data/2006_12.txt 1/15/2007 F i 4 Page 3 of 3 FOSTER 40 HT 1991 - 1.71 - 1.39 - 1.19 4.65 21 FOSTER 290 HT 1992 ----- ----- _ HOPKINTON 67 ST 1991 - 1.62 - 1.39 + 1.53 14.86 21 LINCOLN 84 VS 1946 - 1.68 - 1.01 - 0.04 5.08 21 LITTLE COMPTON 142 ST 1992 - 5.37 - 2.68 - 3.27 13.18 28 NEW SHOREHAM 258 UT 1991 ----- - 1.10 + 0.68 11.38 23 NORTH KINGSTOWN 255 VS 1954 - 1.28 - 1.42 + 0.80 7.53 21 NORTH SMITHFIELD 21 TS 1947 - 2.02 - 0.81 + 0.19 7.36 21 PORTSMOUTH 551 HT 1992 - 2.88 + 1.08 + 1.61 29.54 28 PROVIDENCE 48 TS 1944 - 0.31 - 0.52 + 2.66 3.75 20 RICHMOND 417 VS 1976 - 0.53 - 0.67 + 0.26 6.40 21 RICHMOND 600* TS 1977 - 0.04 - 1.13 + 0.90 33.34 21 RICHMOND 785 FS 1989 + 0.26 - 0.14 + 2.08 22.60 21 SOUTH KINGSTOWN 6 VS 1955 - 0.53 - 1.45 + 1.25 11.25 21 SOUTH KINGSTOWN 1198FS 1988 - 0.79 - 1.06 + 0.78 7.50 21 TIVERTON 274 TT 1990 ----- ----- _ ----- WARWICK 59 ST 1991 - 0.55 - 0.56 - 0.09 4.99 20 WESTERLY 522 FS 1969 - 0.73 - 0.96 - 0.18 12.07 21 WEST GREENWICH 181 US 1969 - 2.05 - 0.59 - 0.19 15.31 21 WEST GREENWICH 206 ST 1991 - 0.32 - 0.33 - 0.14 4.12 21 --------------------- >> SET NEW HIGH OR EQUALED HIGHEST RECORDED WATER LEVEL FOR PERIOD OF RECORD > SET NEW HIGH OR EQUALED HIGHEST RECORDED WATER LEVEL FOR END OF DECEMBER << SET NEW LOW OR EQUALED LOWEST RECORDED WATER LEVEL FOR PERIOD OF RECORD < SET NEW LOW OR EQUALED LOWEST RECORDED WATER LEVEL FOR END OF DECEMBER ------ - DATA NOT AVAILABLE TOPOGRAPHIC (TOPO) SETTING: F=FLAT, G=FLOOD PLAIN, H=HILLTOP, S=HILLSIDE, T=TERRACE, U=UNDULATING, V=VALLEY, W=UPLAND DRAW LITHOLOGY (LITHO) : G=GRAVEL, R=ROCK, S=SAND, T=TILL CONTENTS OF MAJOR RESERVOIRS (ESTIMATED END OF MONTH READINGS) (MILLIONS OF CUBIC FEET) MONTH-END PERCENT OF PERCENT RESERVOIR CONTENTS AVERAGE FULL BORDEN BR + COBBLE MTN RES, MA 3190 125 94 QUABBIN RESERVOIR, MA 52899 --- 96 SCITUATE RESERVOIR, RI 5254 132 107 STREAMFLOW FOR SELECTED INDEX STATIONS (CUBIC FEET PER SECOND) MONTH-END PERCENT MAXIMUM DATE MINIMUM DATE STREAM MEAN MEDIAN FOR MONTH FOR MONTH CHARLES RIVER, MA 377 99 698 01 226 27 E. BR. HOUSATONIC RIVER, MA 75.0 68 135 27 36 22 PAWCATUCK RIVER, RI 272 119 366 01 188 22 WARE RIVER, MA __-- --_ ----------------------------------------- A MONTHLY REPORT PREPARED BY THE U.S. GEOLOGICAL SURVEY MASSACHUSETTS-RHODE ISLAND WATER SCIENCE CENTER 10 BEARFOOT ROAD, NORTHBOROUGH, MA 01532 IN COOPERATION WITH THE MASSACHUSETTS DEPT. OF CONSERVATION AND RECREATION, gASSACHUSETTS DEPT. OF ENVIRONMENTAL PROTECTION, CAPE COD COMMISSION, RHODE ISLAND DEPT. OF ENVIRONMENTAL MANAGEMENT, AND THE PROVIDENCE WATER SUPPLY BOARD ittp://ri.water.usgs.gOv/current cond/data/2006 12.txt - 1/15/2007 t Town of North Ando\er, \1ass,jchusetis ForrN No. 4 BOARD OF HEALTH June 24 19 98 CERTIFICATE OF COMPLI \NCE 1-his is to certify th.,t the Individual Soil Absorption Sewage Disposal System constructed i X I or repaired by Charles Zaher ( ) INSTALLER at Lot 13 Puritan Circle, N. Andover SITE LOCATION ' MA 01845 has been installed in accordance with Board of Health Regulations as described in the Design Approval Site System Permit No. 962 g dated August 28 19 98 The issuance of this certificate shall not be construed as a guarantee that the system function satisfactorily. iE in rINUINEER c r ii Si l- I. r �t l i-'TUAI - JUAN 24 TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM '�— INSTALLATION CERTIFICATION J The undersigned hereby certify that the Sewage Disposal System ) constructed; ( )repaired; by �i '^ I G c located at /3 P, was installed in conformance with the.North Andover Board of Health approved plan, System Design Permit# qL '?dated ol:�1' 2zb7 with an approved design flow of gallons per day. The materials Us were in conformance with those specified on the approved plan;the system was installed in-accordance with the provisions of 310 CMR 15.000, Title 5 and local regulations, and the final grading'agrees substantially with the approved plan. All work is -accurately represented on the As-built which has been submitted to the Board of Health. Installer: Lic. #: Date: _�6 Design Engineer: d ��� - 2"11 5 Date:�� 9 )�y Town of North Andover, Massachusetts Form No.3 t NORTM BOARD OF HEALTH yh • C ,t`•o e 4, �a 19 DISPOSAL WORKS CONSTRUCTION PERMIT "'4 HU Applicant NAME ADDRESS TELEPHONE Site Location_ TL r c Permission is hereby granted to Construct or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No.- CHAIRMAN,BOARD OF HEALTH Fee D.W.C. No. �.S APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: L CURRENT INSTALLER'S LICENSE# LOCATION: (-v LICENSED INSTALLER: SIGNATURE: 4TELEPHONE# CHECK ONE: REPAIR: NEW CONSTRUCTION. IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. Administrative Use Only $75.00 Fee Attached? Yes No Foundation As-Built? Yes '�� No Floor Plans? Yes No Approval Date: ' �S i Town of North Andover, Massachusetts Form No.2 Of 14OR7h BOARD OF HEALTH w A DESIGN APPROVAL FOR ss"`""5`t SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant 80, Test No. Site Location Lnr k&JL/\, Reference Plans and Specs.— ENGINEER DESIGN DATE f Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. �y CHAIRMAN,BOARD OF HEALTH Fee—lenSite System Permit No. 96'-;� SEPTIC PLAN SUBMITTALS LOCATION: NEW PLANS: YES $60.00/Plan REVISED PLANS: YES $25.00/Plan DATE: DESIGN ENGINEER: 3-a n (C'- K o 'Ka W's When the submission is all in place, route to the Health Secretary PLAN REVIEW CHECKLIST PZ ADDRESS /,� U.�fTi�.1/ U� ENGINEER 111'Ii4<--A L-- 0 GENERAL 3 COPIES STAMP 4- - LOCUS NORTH ARROW SCALE CONTOURS L/ PROFILE L----(Sc) SECTION L-' BENCHMARK.Z SOIL & PERCS t,-' ELEVATIONS L--' WETS. DISCLAIMER 4--"" WELLS & WETS WATERSHED? /0� DRIVEWAY tl`� WATER LINE � FDN DRAIN Z-' M&PZ" SCH40 tl"" TESTS CURRENT? SOIL EVAL Wm, DUF��S,v SEPTIC TANK / MIN 150OG it .17 INVERT DROP GARB. GRINDERA6 (2 comps +200) 10 ' TO FDN L,-' MANHOLE L� ELEV GW '�� ## COMPS. GBy' D-BOX SIZE ## LINES FIRST 2 ' LEVEL STATEMENT INLET XG6 3 7 - OUTLET /l FAy = / (2" OR . 17 FT) TEE REQ'D? 1V0 LEACHING // MIN 440 GPD? `� RESERVE AREA�4 ' FROM PRIMARY?-/`/ 20 SLOPE �J 100 ' TO WETLANDS L--' 100 ' TO WELLS/ 4 ' TO S.H.GWy (5 ' >2M/IN) 20 ' TO FND & INTRCPTR DRAINS L-"*'-400 ' TO SURFACE H2O SUPP L---- 4 ' PERM. SOIL BELOW FACILITY MIN 12" COVERy FILL? L-' (15 ' ) BREAKOUT TRENCHES / � MIN 440 gpd ✓ SLOPE (min .005 or 611/1001 ) � SIDEWALL DIST. 3X EFF. W OR D (MIN 61 ),z RESERVE BETWEEN TRENCHES? y IN FILL?4-""� MUST BE 10MIN. 4" PEA STONE? `X VENT? (>3 ' COVER; LINES >501 ) BOT ( + SIDE __ 2 _ X LDNG `�� = TOT 4- 7 46 Town of North Andover of NORT{y , OFFICE OF � y.<<`a° �o COMMUNITY DEVELOPMENT AND SERVICES ~ A 30 School Street North Andover,Massachusetts 01845 �,9 A,.,o WILLIAM J. SCOTT SSAc►+USE Director September 15, 1997 Merrimack Engineering 66 Park Street Andover, MA 01810 Re: Lot#13 Puritan Ave. To Whom it May Concern: This is to inform you that the proposed plans for the site referenced above have been approved. If you have any questions, please do not hesitate to call the Board of Health Office at the number below. Sincerely, Sandra Starr, R.S. Health Administrator SS/cjp cc: A. Cormier CONSERVATION 688-9530 HEALTH 688-9540 PLAN TING 688-9535 FORM 11 - SOIL EVALUATOR FORM Page 1 No. ............................... Date.... —�� 7. Commonwealth of Massachusetts IJoeTK AMWEIZ, Massachusetts Soil Suitability Assessment for On-site Sewage Disposal Performed By: ....kl.tLL.t.A M.......D.U.t S..W.e......................... ... WitnessedBy: .::.: :US :1 .I. PfL ::::::::::.:::: :::::::::::::::::::::. :::::::::::::.::::.:::.::::::.:::.:: ..........................................................................................................................................................................................................n. ` ' Location Address or Owner's Name. A.C. Su itZE2S 11` C. Lor r LOT l3 Pv 2 TAP1YE. Address.and 33 W ALKSCZ. ROAD Telephone Y No IZTH AI.tDovF2: MA, ©ISMS New Construction Repair ❑ Office Review Published Soil Survey Available: No ❑ Yes Lel Year Published . qO...)..- Publication Scale Soil Map Unit ... .Q... G2 �octG vutcR,P i em til Drainage Class ... Soil Limitations ..... EvE . ....................................................................................H.0c s Surficial Geologic Report Available: No ❑ Yes ❑ Year Published ....r...... Publication Scale GeologicMaterial (Map Unit) .............— ..................................................................................................................................... Landform.......................... ..... .......................................................................................................................................................................... Flood Insurance Rate Map: +1 ZSaO'lg o0 t0 6-/5-- �9 Above 500 year flood boundary No ❑ Yes Within 500 year flood boundary No Yes ❑ Within 100 year flood boundary No LVJ Yes ❑ Wetland Area: National Wetland Inventory Map (map unit) ..............O.1t......S.k.T .......P.i~.(.t.�r. T..O... t...... Wetlands Conservancy Program Map (map unit) ........ Current Water Resource Conditions (USGS): Month vL�/ Range : Above Normal ❑ Normal Q Below Normal ❑ ASsL)M15p Other References Reviewed: I/, S U.S . I"tAP<; . ^ FORM I I - SOIL EVALUATOR FORM � Page 2 On-site Review � ` '� �� �� Deep Hole Nunober '�''��— Da1e:.�m�4��� ` ' Tln�e:'^''���, Weather Location (identify onsite plan) NAKD.--------------------------------___________ Land Use �����^ ^ �|opm (Y6) �^�» �urfeoe ��nnmo *"y ' — �~^^^^'^^�^^~~~� -� -~~~-- -^ jp........................................................ Vegetation ............ Landformn --..WJA.................................................................................................................................................................................................................... Position onlandscape (sketch onthe back) -.. u.................................................................................................................. Distances from: Open Water Body -. feet Drainage way Z.�Zt feet Possible Wet Area '(PP.:t. feet Property Line .-l0..17' feet Drinking Water Well feet Other ----....................... DEEP OBSERVATION HOLE LOG Depth from Surface Soil Horizon Soil Texture Soil Color Soil Mottling Other (inches) (USDA) (Munsell) (Structure,Stones,Boulders, Consistency, %Gravel) ' 40" caas � ' ' � � ~ Parent Material (geologic) - ��-'Tx-�-L...................................................... Depth to Bedrock: ___ Depth to Groundwater: ' Standing Water in the Hole: Weeping ' /,--� Estimated Seasonal High Ground Water: ` — FORM 11 - SOIL EVALUATOR FORM ,r Page 3 Determination for Seasonal High- Water Table Method Used: ❑ Depth observed standing in observation hole.......—` inches ❑ Depth weeping from side of observation hole inches ETDepth to soil mottles W/9-0 inches ❑ Ground water adjustment feet Index Well Number ...:'.. Reading Date ................... Index well level ................... Adjustment factor ........�... Adjusted ground water level ..................................................... Death of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? Y � If not, what is the depth of naturally occurring pervious material? Certification I certify that on (date) I have passed the examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature Date �' FORM 12 - PERCOLATION TEST COMMONWEALTH OF MASSACHUSETTS 1WM &kftvf52 , Massachusetts Percolation Test Date: .....77.7.2,71.71 Time: ... ':.�'`1................. Observation Hole # Depth of Perc 5�.,t 20 -7(p`, Start Pre-soak I Z: L( 3 Z , q g End Pre-soak t2; S l ` 0S Time at 12" l Z ; �- l ; p 3 Time at 9" Time at 6" ( � 3 Time (9"-6") Z O i 3 S h�i Rate Min./Inch Site Passed LJ Site Failed ❑ Performed By: ( S CLOD(11 Witnessed By: �o SA Q rd 2-D Comments: .... ................ .. ................................. . ................ Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH `� tsIE° 61 0 d 19 0 APPLICATION FOR SITE TESTING/INSPECTION SSACHus���y Applicant ' ADDRESSTELEPHONE NAME Site Location Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit NO. Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH ,6gti�0 ff �. APPLICATION FOR SITE TESTING/INSPECTION SSACHUS���� Applicant AU NAME ADDRESS TELEPHONE Site Location L---+- 13 �jcme�� tlo-6� � ,v Engineer NAME j ADDRESS TELEPHONE Test/Inspection Date and Time 0 CHAIRMAN,BOARD OF HEALTH Fee / Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. woo G IVAJ - I I .�»77xz. 4W?t Z4 2¢` ` t„r)V izC3+--+mss >�►-•�-q�cjc-1 c� `>t 1.T' (LT , b Ll f�� A ! i v if 41� FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. *****************Applicant fills out this section***************** APPLICANT: ( l/�/� cif �, Phone LOCATION: Assessor' s Map Number Parcel Subdivision �s .v Lot(s) l� Street �&Ir; an Lek- St. Number ***************** ** **Official Use Only************************ RECO OF TOWN AGENTS: Date Approved Conservation dmipistra or Date Rejected Comments WP--rLf-�( Date Approved C ,town Planner Date Rejected Comments Date Approved Food Inspector-Health Date Rejected Date Approved Septic Inspector-Health Date Rejected Comments Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date Town ofAndover No. dover, Mass., 19 0LAKE '9A.CO JC-H K '9S �AA E co) BOARD OF HEALTH Food/Kitchen , Septic System '�14"PERM T T / 0- � B ING INSPECTOR � THIS CERTIFIES THAT................................ . ..... .............em.A.I.D.E.X...S....................................................................... ou Foundation buildin .. u =1'..f... !J....... .. . . GAJ has permission to erect.................I. s on .......... . ...... g to be Occupied as...............................................S..f �.i�11. 1G.............0=*4�. ..� .. Chimney ........................................... .. provided that the person accepting this permit shall in every respect conform to the to sof the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMB /C INSPECTOR / VIOLATION of the Zoning or Building Regulations Voids this Permit. PERMIT EXPIRES IN 6 MONTHS r9y �/ ELECTRIC IN PE UNLESS CONSTRUCTION ST S ......................................... ....... ..... .. .... ............................... . BUIL G INSPECTOR Fi Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal zl� No Lathing or Dry Wall To BeDone FI DEPARTMENT Until Inspected and Approved by the Building Inspector. �.�� Burner /� ,n� Street No. T t "�' ^. r Ilt�/l Smoke Det. f t (�•L`J s �! i ,