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Miscellaneous - 1444 SALEM STREET 4/30/2018
i 4 G North Andover Board of Assessors Public Access Page 1 of 1 noRrti 'rqv ,ofWor,tthl And*,, Board Of'Assessp s 4 Return to the Home page click on loco MATCHING PARCELS Fiscal Parcel ID Address Owner Name Year New Search DAGHLIAN, ARSHAG Sales 2008 210 106.A-0020-0000.0 1440 SALEM LUCY&SONIA STREET. DAGHLIAN 2008 210/106.A-0025-0000.0 1447 SALEM BURNS, MARY B STREET C/O IRENE DEFREITAS 2008 210/106.A-0029-0000.0 1454 SALEM MOLINO,THOMAS J STREET KARIN MOLINO 2008 210/106.A-0024-0000.0 1459 SALEM MCCUE, ARTHUR J. STREET 2008 210/106.A-0019-0000.0 1468 SALEM NAJARIAN, STEVEN STREET NAJARIAN, NAOMI J. 2008 210/106.A-0031-0000.0 1469 SALEM ODAMS, NEIL& STREET LORRIE 2008 210/106.A-0149-0000.0 1472 SALEM LAVISKA, RICHARD A STREET LINDA T LAVISKA 2008 210/106.A-0018-0000.0 1476 SALEM KOENIG, ALBERT F - STREET GENEVIEVE M KOENIG 1483 SALEM SUTTLER, HENRY 2008 210/106.A=0023-0000.0 STREET GOODLOE 1499 SALEM SHAH, ASHISH D 2008 210J106.A-0030_0000.0 STREET POONAM A SHAH I j Page:23 of 29 << < 21 22 23 24 25 26 27 28 29 > http://csc-ma.us/NandoverPubAcc/jsp/Home.jsp?Page=2&RecNo=221 3/10/2008 North Andover Board of Assessors Public Access Page 1 of 1 r nuRry Tpwt3i of'Noxtr Andover, °�',•' •'"� Rom of°Assessors, F -Z > + 1 mak...:.;... y �4�snet+us�' Return to the Home page click on logo MATCHING PARCELS Fiscal parcel ID Address Owner Name Year New Search 1348 SALEM CANNING, PHILIP G Sales 2008 210/106.A-0163-0000.0 STREET KATHRYN E CANNING 2008 210/106.A-0138_0000.0 1353 SALEM GREENE,JEFFREY D - STREET EVELYN V GREENE 2008 210/106.A-0164-0000.0 1360 SALEM GAN, PIN PIN STREET 2008 210J106.A-0139_0000.0 1365 SALEM FIORE, STEVEN STREET FIORE,JOANNE E. 2008 210/106.A-0137-0000.0 1411 SALEM HOLBROOK,JAMES M STREET ANDREA M HOLBROOK 2008 210/106.A-0120-0000.0 1412 SALEM KOMARONI, JANOS G — STREET JUDIT KOMARONI 2008 210/106.A-0026-0000.0 1423 SALEM CHAKRAVARTI, ARNAB& STREET KIMBERLY 2008 210/106.A-0022-0000.0 1424 SALEM HALL, KERRI&JOHN STREET 1432 SALEM LANZAFAME,TOMMASO 2008 210/106.A-0021-0000 0 ANNUNZIATA — STREET LANZAFAME 2008 210/106.A=0032-0000.0 1435 SALEM GAUL, JAMES H STREET EDITH M GAUL Page:22 of 29 << < 21 22 23 24 25 26 27 28 29 > >> http://csc-ma.us/NandoverPubAcc/j sp/Home.j sp?Page=2&RecNo=211 3/10/2008 North Andover Board of Assessors Public Access Page 1 of 1 IOORT#t rth, Andover Board of Assad . 3? e�;,,, ...».. a o� ��SSACNUS TZPropert3 Click Seal To Return Parcel ID :210/106.A-0024-0000.0 FY:2011 Community : SKETCH PHOTO Click on Sketch to Enlarge Click on Photo to Search for Parcels Y, Y «, Search for Sales { I_- Su'mmary K Residence , } _ Detached Structure -- ,rp- Condo 1459 SALEM STREET Commercial Location: 14441444 SALEM STREET Owner Name: HAMMERSMITH,RYAN EDMONDSON,VIRGINIA Owner Address: 1444 SALEM STREET City: NORTH ANDOVER State: MA Zir i Neighborhood: 6 - 6 Land Area: 1. DLES Total Finished Area: 24 LENT YEAR PREVIO 481,000 484 0 268,800 271 212,200 212 r f i 200 l0 TEST SALE Sale Date: 06/05/2008 VALID Grantor: MCC UE,A ---- Book: 11206 P, http://csc-ma.us/PROPAPP/display.do?linkId=1707705&town=NandoverPubAcc 3/18/2011 Commonwealth of Massachusetts RECEIVED City/Town of 2014 System Pumping Record SEP 1 Form 4 TOWN Ul-NURi H ANDOVER. HEALTH DEPARTMENT DEP has provided this form for use-by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility. Information 1. System Location: Let I ht front of hou , Left/Right rear of house, Left/right side of house, Left/ Right side of building, Left/Rig t nt of building, Left/Right rear of building, Under deck Address T444 fav` i City/Town State Trp Code 2. System Owner. Name Address(if different from location) Cityfrown state C Telephone Number B Pum-ping Record 1. Date of Pumping Date2. Quantity Pumped: Gallons 3. Type of system. ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes 0<0 If yes, was it cleaned? ❑ Yes ❑ No: 5. Condition of System: 6. System Pumped By. i Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc- Company j 7. Locatio ere contents were disposed: �I-S. Lowell Waste Water Sig Haul Date t5form4.doc•06/03 System Pumping Recons•Page 1 of 1 6In �. COPYLLE PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division �I��II FIC.ATE OT C0�41t-D.GI.AACE As of: Warch 28 2011 This is to cert that the individuaCsubsurface dzsposaCsystem received a S3VSE.ACT01RT1XYPEC' 10Yof the: - Instaffaction of an 91-20 Oistii6ution Box for an On Site Sewage OlisposalSystem By ®hn DiVince ® At: 1444 Sarem Street Wap-10 6.A-Parcel-0024 Parcel ID :210/106.A-0024-0000.0 WorthAndover, � � A 01 84S The Issuance of t ' certificate shaft not 6e construedas a guarantee that the system wiff function satisfactori y. ,Susan rX.Sawyer, / (&61u:JfeaCth Director 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com MCOPY �l PUBLIC HEALTH DEPARTMENT Town of North Andover (ommunity Development Division CE�2I�'ICA�� OE C014PL r-.,4XCE As of: r Marchi 289 2011 This is to cert that the individual subsurface disposa[system received a j SA`I7SEWTORTINWECTIOYof the: InstaCCation of an M-20 Oistfi6ution Box for an On Site Selvage Dis =(System B john ON.,o wcenzo At: 1444 Safi= Street map-106..,E--%1'arcef-0024 Parcel ID :210/106.A-0024-0000.0 North.Andove�, W.9 01 845 The Issuance of t ' certificate shaft not be construed as a guarantee that the system willfunction satisfactori y. usan .Sawyer, 9�/ fu6CicYfealth Director 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover:com �g fir' -ats nl PUBLIC HEALTH DEPARTMENT Town of North Andover (ommunity Development Division CEI��II FIC,�2E OE C0�44PLI ONCE � \ As of: . 94arch 28, 2011 This is to cert that the individuafsu6surface disposafsystem received a SA7IST,4CrI0RT IJVSPEC 10X of the: Instaffatzon o an 91-20 Oistri6ution Bo .f x , for an On Site Sewage Disposafsystem By: John DiVincerzo � At: _ 1444 Safem Street W ap-106..E~'arcef-0024 Parcel ID :210/106.A-0024-0000.0 Xorth Andover 9W X 0184.E The Issuance of t certificate shaff not be construedas a guarantee that the system wiff/unction satinfactoriy. I i3'usan . Sawyer, RO&A?, (Pu6Cu-leafth Director 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com 1 Zr J PUBLIC HEALTH DEPARTMENT Town of North Andover (ommunity Development Division FIC.A`�E O(' CO�44 P'L T UWE As of: Warchi 28, 2011 1 This is to cert that the individuafsu6surface dlsposaf system received a SA`IISTFACTo<RTIJVSPEMONof the: Instaffation of an Yf-20 Oistfi6ution Box for an On Site Sewage osaCS stern By: John DiVincewofit._ .. 1444 Saler Street Wada-106..,E~Parcel-0024 Parcel ID :210/106.A-0024-0000.0 Xonh.xndover, XX 01 845 The Issuance of t ` certificate shaff not be construedas aguarantee that the system wiCCfunction satisfactorily. xSrusan If tSauyer, _ (Pu6Cu Zeafth Director 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover:com NORTF" 6'9N0 OL O � t � �A COCMIC WKN`y SSACHUS� PUBLIC HEALTH DEPARTMENT (ommunity Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATI IN ADDRESS: (J� ��j/ q�� MAP. T. INSTALLER: DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: -- INSPECTIONS TANK.INSPECTION: 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 ❑ gallon tank has been installed loading ❑ Monolithic tank construction ❑ Watertightness of tank has been achieved by 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Inspection Form June 2008 NORTH OF�t�gp 6 6 0 O � t � °P C0CN1[NIwKM y1' ArED SSACHUS� PUBLIC HEALTH DEPARTMENT fommunity Development Division 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 final 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 ❑ gallon Pump Chamber installed ❑ loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑` Pump(s) installed on stable base F-1Alarmfloat working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Watertightness 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: 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Inspection Form June 2008 NORTH 0�"ILID /6 gtiO OL O n e~ O GOCMIf Mi wKM 1' 4°4AreD SSACHIJs� — PUBLIC HEALTH DEPARTMENT Community Development Division //2DISTRIBUTDION-BOX / Installed on stable stone base ✓ H-20 D-Box -� -�'`�� [❑j Inlet tee (if pumped or >0.08'/foot) 0/- Hydraulic cement around inlet & outlets ©� Observed even distribution ® Speed levelers provided (not required) Comments: SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder/ concrete /timber/ block ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel-less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.com Inspection Form June 2008 NORTH 1 Q`�tti E0 6 q1.0 O d O uM COCKIC CWKK V AOR�TeO SPP` �y �SSAC HU`-'�� PUBLIC HEALTH DEPARTMENT Community Development Division BM = HR = HI = SYSTEM ELEVATIONS ROD ELEVATION AS-BLT INVERT ELEV DESIGN INVERT ELEV Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT :Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 TOP Lateral 1 INVERT Lateral 2 TOP Lateral 2 INVERT . Lateral 3 TOP Lateral 3 INVERT Lateral 4 TOP Lateral 4 INVERT Lateral 5 TOP Lateral 5 INVERT Lateral 6 TOP Lateral INVERT i Top of Chamber Bottom of Bed/Chamber 1600 Osgood Street,North Andover,Massachusetts-01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Inspection Form lune 2008 NORTH a OL y P T O coc"Ic wKK V^ T ��SSACHus���y PUBLIC HEALTH DEPARTMENT (ommunity Development Division SKETCH PLAN 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Inspection Form June 2008 r NORTFr D�,�t LlG 06 If LAKI O CCICNIc"l-K V^ TED SSACHUs���y PUBLIC HEALTH DEPARTMENT (ommunity Development Division CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- Waterline 10 10 101 ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh, Inland/Coastal Banka 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib.to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot.Area ® Reservoirs 400 400 ® Drains(wat. supply/trib.) 50 100 ® Drains(intercept g.w.) 25 50 ® Drains(Other)Foundation 10(5) 20(10) ® Drywells 20 25 1 Suction line 222(2) 2100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54,and 10.30,respectively,pursuant to 15.211(3),also by NA wetland bylaws 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.com Inspection Form June 2008 w �T J and S Development Corp 58 South Kimball St Bradford, Ma 01835 978-372-7471 North Andover Board of Health .C 1600 Osgood St 1,,e11 Building 20 Suite 2-36 `it North Andover ma 01845 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT To whom it may concern, We recently completed a Title V at 1444 Salem St in North Andover. The system was conditionally passed, until the d-box was replaced. Attached you will find page 1-2 which is the new papers showing the system now passes, and the work has been complete and inspected. Also there was an error on page 7 of the Title V; the laundry system is NOT on its own sewage system. The wrong box was checked. Any questions please Ashley @ 978-372-7471 Thanks in advance It 9 John DiVincenzo Andover Septic Service President/TitleV Inspector < Commonwealth of Massachusetts } -i Title 5 Official Inspection For _ - W p �'i , U11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessm nts TOWN OF NORTH ANDOVER 1444 Salem St _ HEALTH DEPARTMENT Property Address — Ryan Hammersmith _ Owner Owner's—Name — information i's required for North Andover Ma q -- 01886 3/1/2011 __ 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 John DiV_incenzo cursor-do not use the return Name of Inspector key. Stewart Septic Service Company Name 58 South Kimball _ Company Address -- Bradford Ma 01830 e"tl" Cit /Town y State Zip Code 978_-372-7471 S113386 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 th . p e inspection. The inspection was performed bas p p ed on m training and experience in the r Y 9 p proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑Needs Further Evaluation by the Local Approving Authority 3/22/2011 Inspector's Signature -- — 9 � Date he 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. ****phis 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. 15ins•11/10 - Title5 Oficial Inspection Form:Subsurfacebsurface Sewage Disposal sal Syslem•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 1444 Salem St Property Address Ryan Hammersmith Owner Owner's Name information is required for North Andover Ma 01886 3/1/2011 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: All repairs have been completed ans inspected by the Health Department of The Town of North Andover. Water test was also good. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1444 Salem St Property Address Ryan Hammersmith Owner Owner's Name information is required for North Andover Ma 01886 3/1/2011 every page. City/Town 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? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage Well 9 ( Y 9 (gPd))� Detail: Well Sump pump? ® Yes ❑ No Last date of occupancy: occupied 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts `rI 4 _ _ r "Title 5 Official Inspection Form �� . _ = Subsurface Sewage Disposal System Form Not for Voluntary Assessmen s �ta-� .1444 Salem St _ f�AR 10 j� Property Address --------------- -------- ---- — �/•s,� Y/Q��ly/ TOWN NORTH ANDOVER Ryan Hammersmith HEALTH DEPARTMENT Owner 'sNme— information —--------__-_ _ -- — ---- -------- ---------- Ownerame ---- information is North Andover required for _�— _-�_—_— Ma - 01886 3/1/2011 _ 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 John DiVincenzo cursor-do not use the return Name of Inspector — — key. Stewart Septic Service _— — Company Name ------ r� 58 South Kimball —_---_- Company Address Bradford __ Ma01830 rerun City/Town State —_ _ Zip Code 978-372-7471 _ �— _ S113386 Telep hone Number License Number — — B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails Needs Further Evaluation by the Local Approving Authority x1 Insp'ector's Signature I I Date Th, 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+11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 IIS y Commonwealth of Massachusetts z - W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1444 Salem St _ Property Address - �— Ryan Hammersmith Owner Owner's Name --information is North Andover _ Ma _ 0188_6 3/1/2011 _ required for r _ _ _ 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: 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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): l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 .z Commonwealth of Massachusetts s Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e, p 1444 Salem St Property Address Ryan Hammersmith Owner Owner's Name _ information is North Andover Ma _01886 3/1/2011 required for _ _ every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below). ® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): D-box is corroded, outlets are leaking ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts - - Title N 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ase'` 1444 Salem St Property Address Ryan Hammersmith Owner Owner's Name — --i information is _North Andover _ Ma01886 3/1/2011 required for every page. CityCrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) Y 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: Records from town hall ** 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) 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 '/2 day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts I Title 5 Official Inspection Form -- = Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . . 1444 Salem St Property Address --- — Ryan H_ammersmith Owner Owner's Name — —�— - — information is _North Andover Ma 01886 3/1/2011 required for __._—.. _— _ 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. ❑ N Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone 11 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14_44 Salem St _ Property Address —— Ryan Hammersmith Owner Owner's Name information is required for __North Andover _ _ Ma_ 01886 3/1/2011 every page. City/Town — VState Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: I ® ❑ 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1444 Salem St Property Address man Hammersmith_ Owner Owner's Name information is North Andover Ma 01886 3/1/2011 required for every page. City/Town 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? [if yes separate inspection required] ® Yes ❑ No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd))� Well _ Detail: Well Sump pump? ® Yes ❑ No Last date of occupancy: occupied 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: - — _ l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 1 Commonwealth of Massachusetts 4 u _ s Title 5 Official Inspection Fora - — a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1444 Salem St Property Address Ryan m Hamersmith Owner Owner's Name -------— ----------- --------- --- - -------- information is required for North Andover _ Ma 01886 3/1/2011 _ _ _ _ _ every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: see attached-Andover Septic _ Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? — Reason for pumping: inspect tank 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): i t5ins•11/10 _ - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 it o Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1444 Salem St Property Address ---- RyanHammersmith Owner Owner's Name -- information is required for North Andover Ma 01886 3/1/2011 _ every page. Cit /Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 9 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet r ,Material of construction: cast iron ❑ 40 PVC ❑ other(explain): — ---f SCD ;-Distance from private water supply well.or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: - - — --- feet Material of construction: 0 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: - ------ Sludge depth: ---- ------------- t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts N _ Title 5 official Inspection Form —_- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1444 Salem St Property Address Ryan Hammersmith Owner Owner's Name information is required for North Andover— Ma_ 01886 3/1/2011 — __—_-- _ every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) 25" Distance from top of sludge to bottom of outlet tee or baffle - , Scum thickness 1 --- Distance from top of scum to top of outlet tee or baffle 7_5 — Distance from bottom of scum to bottom of outlet tee or baffle 14 ---- Tape measure and sludge judge How were dimensions determined? — Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet tee's in placejAuid levels ood 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 u Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments A 1444 Salem St Property Address Ryan Hammersmith Owner Owner's Name information is required for North Andover Ma 01886 3/1/2011 _ every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: ---- -- Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: --- -- Capacity: gallons Design Flow: gallons per day — Alarm present: ❑ Yes ❑ No Alarm level: — --- Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts - - Title 5 official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1444 Salem St Property Address ---'---- —— Ryan Owner's Owner —--- _— -- -- ---.—.------ -- wne�s Name -- -- ---- -- information is North Andover required for –___- ��— Ma 01886 — 3/1/2011 ---- 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.): Dist. box needs to be replaced, leakage around outlet Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: noop nding _,__no hydraulic failure t5ins•11/10 "------------ ----- -- -------- Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i - Commonwealth of Massachusetts 0A Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1444 Salem St Property Address —— "`-- —------ — --- Ryan_Hamm_ersmith Owner Owner's Name --- information is required for -North--Andover_ __- _ Ma 01886 3/1/2011 every page, Cit /TownState Zip Code ,Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ------ — ❑ leaching galleries number: -- ❑ leaching trenches number, length: ---- 20 X 30 ® leaching fields number, dimensions.- overflow imensions: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.): i 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•11110 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 144_4 Salem St Property Address ---- ___ Ryan Hammersmith Owner Owner's Name _ information is --- required for North Andover Ma 01886 _ _ 3/1/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: ---- Dimensions — Depth of solids. — Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/1 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts w --- _ Title 5 Official Inspection Fora — Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1444 Salem St Property Address— ----- ---- ------ -- --- Ryan Hammersmith Owner Owner's Name information is required forNorth Andover Ma 01886 3/1/2011 —..--------�----------..— -- — -- -- every page. ity/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: pP Y 9 ❑ hand-sketch in the area below ® drawing attached separately t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1444 Salem St Property Address Ryan Hammersmith Owner Owner's Name information is required for North Andover Ma 01886 3/1/2011 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 If checked, date of design plan reviewed: 3/7/2008 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: The USGs map database did indicate that the water was >6. feet. You must describe how you established the high ground water elevation: The system is 1.5-2 ft under ground, The yard drops 20' in rear of house with no wetlands at the base of the hill. See attached for water test. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 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 1444 Salem St _-- Property Address ------ ----- -- — Ryan Hammersmith Owner Owner's Name ------- —---- ---------- --- ---- ---- — on requiratifor is NorthAndover Ma _Andov _ -- _ required for _01886 _ 3/1/2011_ every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked Z 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 1444 Salem Street _ Property Address Arthur McCue Owner Owner's Name information is required for No Andover MA_ 01845 3/7!2008 _ _ _ — every page. City/Town State Zip Code 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. �--- w c l l TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 15 1 0. ` Northeast Environmental Laboratory, Inc. 18 Riverside Avenue, Danvers, MA 01923 978-777-4442 DEP#MA123 Stewarts Environmental Services Report Number 33204 20 South Mill Street Report Date 03/11/11 Bradford,MA 01835 83081 1444 Salem St.,North AndoverA � r.� �x Collected 3/8/11 at 08:52 by AM Preservation 4°C,HCI,H2SO4 Received 3/8/11 at 09:50 by PT Parameter Result MDL Units Method Analyzed By Lab Cert.* Ammonia as N <0.02 0.02 mg/L 350.1 03/10/11 DCH CT008 N Coliform Bacteria(MI) 0 0 /100mI 1604 03/08/11 KH CT008 P Nitrate 2.5 0.02 mg/L 300.0 03/08/11 JL . MA123 P,N Volatile Organics 0.0014 0.0005 mg/L 524.2 03/09/11 AMH CT008 P See attached Analytical Data Report for 524.2 parameter-specific data. References Methods for Chemical Analysis of Water and Wastes,EPA-600/4-79-020,1983. Methods for the Determination of Inorganic Substances in Environmental Samples,EPA/600/R-93/100,August, 1993. Methods for the Determination of Organic Compounds in Drinking Water,EPA-600/4-88/039,Revised July 1991. EPA 821-R-02-024 -Total Coliforms and Escherichia coli in Water Using a Simultaneous Detection Technique(MI Medium). * MADEP certified for this parameter potable water (P)-non-potable water (N) Reviewed and Approved by: John L�at�t- Laboratory Director j Premier Laboratory, Inc A Analytical Data Report Report No: E10349.4 Customer: Northeast Environmental Lab Sample No: I Project: Drinking Water Samples Sample Description: 83081 Date Collected: 03/08/201108:52 Matrix: Aqueous Date Received: 03/08/20.11 15:10 Percent Moisture: N/A Date Analyzed: 03/09/2011 13:46 By: AMH Dilution Factor: 1 Analytical Method: 524.2 Lab Data File: M55363.D QC Batch#: 83202 CAS No. Parameter Result DL Units 71-43-2 Benzene ND 0.50 ug/L 108-86-1 Bromobenzene ND 0.50 ug/L 74-97-5 Bromochloromethane ND 0.50 ug/L 75-27-4 Bromodichloromethane ND 0.50 ug/L 75-25-2 Bromoform ND 0.50 ug/L 74-83-9 Bromomethane ND 0.50 ug/L 104-51-8 n-Butylbenzene ND 0.50 ug/L 135-98-8 sec-Butylbenzene ND 0.50 ug/L 98-06-6 tert-Butylbenzene ND 0.50 ug/L 56-23-5 Carbon tetrachloride ND 0.50 ug/L 108-90-7 Chlorobenzene ND 0.50 ug/L 75-00-3 Chloroethane ND 0.5.0 ug/L 67-66-3 Chloroform 1.4 0.50 ug/L 74-87-3 Chloromethane ND ' 0.50 ug/L ' 95-49-8 2-Chloroioluene ND 0.50 ug/L 106-43-4 4-Chlorotoluene ND 0.50 ug/L 96-12-8 1,2-Dibromo-3-chloropropane(DBCP) ND 0.50 ug/L 124-48-1 Dibromochloromethane ND 0.50 ug/L 106-93-4 1,2-Dibromoethane(EDB) ND 0.50 ug/L 74-95-3 Dibromomethane ND 0.50 ug/L 95-504t 1,2-Dichlorobenzene ND 0.50 ug/L 541-73-1 1,3-Dichlorobenzene ND 0.50 ug/L 106-46-7,r 1,4-Dichlorobenzene ND 0.50 ug/L 75-71-8 Dichlorodifluoromethane ND 0.50 ug/L 75-34-3 1,1-Dichloroethane ND 0.50 ug/L 107-06-2 1,2-Dichloroethane ND 0.50 ug/L 75-35-4 1,1-Dichloroethene ND 0.50 ug/L 156-59-2 cis-1,2-Dichloroethene ND 0.50 ug/L 156-60-5 trans-1,2-Dichloroethene ND 0.50 ug/L 78-87-5 1;2-Dichloropropane ND 0.50 ug/L 142-28-9 1,3-Dichloropropane ND 0.50 ug/L 594-20-7 2,2-Di6hloropropane ND 0.50 ug/L 563-58-6 1,1-Dichlor6propene ND 0.50 ug/L 10061-01-5 cis-1,3-Dichloropropepp,; ND 0.50 ug/L 10061-02-6 trans-i;3-Dichioroprop ND 0.50 ug/L 100-41-4 Ethylbenzene ND 0.50 ug/L 87-68-3 Hexachlorobutadiene ND 0.50 ug/L 98-82-8 Isopropylbenzene ND 0.50 ug/L, ' 99-87-6 4-Isopropyltoluene ND 0.50 ug/L 1634-04-4 Methyl tert-butyl ether(MTBE) ND 0.50 ug/L hp 4 ors I I , x e 4' Premier Laboratory, Inc Analytical Data Report Report No: E 103494 Customer: Northeast Environmental Lab Sample No: 1 Project: Drinking Water Samples Sample Description: 83081 Date Collected: 03/08/2011 08:52 Matrix: Aqueous Date Received: 03/08/2011 15:10 Percent Moisture: N/A Date Analyzed; 03/09/2011 13:46 By: AMH Dilution Factor: 1 Analytical Method: 524.2 Lab Data File: M55363.D QC Batch#: 83202 CAS No. Parameter Result DL Units 15-09-2 Methylene chloride ND 0.50 ug/L 31-20-3 Naphthalene ND 0.50 ug/L 103-65-1 n-Propylbenzene . ND 0.50 ug/L 100-42-5 Styrene ND 0.50 ug/L 36-18-4 1,2,3-Trichloropropane ND 0.50 ug/L 526-73-8 1,2,3-Trimethylbenzene ND 0.50 ug/L 330-20-6 1,1,1,2-Tetrachloroethane ND 0.50 ug/L 19-34-5 1,1,2,2-Tetrachloroethane ND 0.50 ug/L 127-18-4 Tetrachloroethene(PCE) ND 0.50 ug/L 108-88-3 Toluene ND 0.50 ug/L 37-61-6 1,2,3-Trichlorobenzene ND 0.50 ug/L 120-82-1 1,2,4-Trichlorobenzene ND 0.50 ug/L 71-55-6 1,1,1-Trichloroethane ND 6.50 ug/L; 79-00-5 1,1,2-Trichloroethane ND X0.50 ug/L 79-01-6 Trichloroethene(TCE) ND 0.50 ug/L 75-69-4 Trichlorofluoromethane ND 0.50 ug/L 35-63-6 1,2,4-Trimeihylbenzene ND 0.50 ug/L 108-67-8 1,3,5-Trimethylbenzen'e ND 0.50 ug/L 75-01-4 Vinyl chloride ND 0.50 ug/L 1330-20-7 Xylenes(total) ND 0.50 ug/L ;ample OC >urroeate Recovery OC Limits .,2-Dichlorobenzene-d4 83% 70%-130% 3romofluorobenzene 93% 70%-130% Page 5 or 5 CHAIN OF CUSTODY RECORD Analyses Required Client 97Ew,4,er S Project T e / Container Preservation 411" T. Time Composite Metas HNO3 pH<2 t F.C.= Flow Composite TPH, 0&G HCl +DH<2 Grab Nitrogen, COD H2SO4 pH<2 Q c P= Plastic Cyanide* NaOH pH>12 ti fl[ i G =Glass BOD, Solids sampler and cooler iced 4°C J4 Q V=VOA vial I*.Neutralize chlorine.with ascorbic acid Sarni .le Description Type/Container/Volume Preservation V NEL ID / o I -r 41-5 l Collected by: Received by: Dae 4 Time Comments: EE Relinquished by: Re d- D e Time Northeast Environmental.Laboratory, Inc. r�� l jS�C�C / 3X/l9 ":, 18 Riverside Avenue Relinquished by: R ceived.by: Date&Time Danvers, MA 01923 Phone:978-777-4442 Fax: 1-866-270-6240 Relinquished by: Received by: Date&Time Email: COntaCt@noftheastlab.COm a . x144 K � tiz,� i tdn�rb psitdj� ,�+ hM ikJt}6 a ;t Ktl K s r ,�`r z k,+>,e �ar {1:n�d ���� �� +i4 u t�!T�.E�Iu tir 4�Y'{ � 1 � i � � •� t i �i r >, a.r r tt ti d a� i i ds�•�J. hf + , r �1,s F fl r + I r f 1•c rJ .1 � ¢'"[ q{ `Vftr..'tAI 9 hf�� fin r. 11 ft 1 iw IY t t ,._ J r'.. i - a •h'ti't,. f{ 1 j P L i (•Yt b t X11{WF t19 Plfif�. 7<� u1 Wf l 't'+.11 � 1"ly r 1.0 ./27U 1 '. 1 of Custody Re ',LS � �+GF,�3 �•�`. I: .,Ku y }K�lfy f�. `P1;"a�A,'x'St ift YdS:. :7+d drJ 1�'•Y' 13 M1J}i'71R d?!�HI k rf A. �4 1 2 ^irl .. ,. -,�•.': _ ortheast'Envtronmentalhboratory, Inc; k` NEL Report33204COC1 8 Riverside-Avenue� 7n' (978)°'777-4442 anvers, MA 01923 contact0northeastlab.com Date Time #,of EL ID Sample Type Collected .'`Collected'' Preservatlon Bottles Analyses Requested 3081 . 3./8/11 08:52 '_ pH<2 H25Q4,4°C 1 Ammonia as N 3081 3/8/11 08:52 4°C 1 Coliform Bacteria(MI) 3081 3/8/11 ' 08:52 pH<2 HCI,4°C 2. Volatile Organics(VOA) t L I 1 , fir , d r s q-. , t � .. q.u�.a r r r. a d —J 1 f 1^f r r 5 rr -r t q J• {.rte i rl 4inquished By' ! Received By; I Date.&Time: r 1inquished'By l5'' l0 Received t y; CIL— Date &Time: _ a "DRT// r� 5268 � cf� ?o i do t o _ L Town of North Andover � o'••,,,.o.. HEALTH DEPARTMENT CHUstt J =CHECK#: �� DA .2: / D� r , LOCATION: - H/O NAME: . CONTRACTOR NAME: Type of Permit or LicensVCheck box) ❑ Animal $ ❑ Body Art Establishment $ r ❑ Body Art Practitioner $ f A ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ' ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ a -F ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems ❑ Septic-Soil Testing $ ❑ Septic-Design Approval: $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title nspector $ itle 5 Report ❑ Other. (Indicate) $ `i Health Agent Initials' White-Applicant. Yellow-Health. Pink-Treasurer:;' n' j. G.F Commonwealth of Massachusetts Map-Block-Lot ----------------------- Q - Board of Health Permit No as North Andover BHP-2011-0548----------------------- 548 P.I. FEE �S��ecu4 F.I. $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted ----------------------------------- ________________________ _-________________-_ to(Repair-REPLACEMENT TO H-20 DISTRIBUTION BOX)an Individual Sewage Disp at No 1444 SALEM STREET -- ------------ ---------------------------------------------------------------------------------------------------------- ------------------- as shown on the application for Disposal Works Construction Permit No. BHP_72011-054 Dated ---------- ----------------------- ---- - ---=.;_------ ------------------------ Issued On:Mar``-07-2011 �" B �jth tr 14*Rrir G Map-Block-Lot Am Commonwealth of Massachusetts p Board of Health ►' North Andover �� �°9•=�� '�� } CERTIFICATE OF COMP -I'ANCE THIS IS TO CERTIFY That the Individual w Se a Disposal System (Repair-REPLACEMENT TO by -------------------------------------------------------- ------------------------- --------------------------------- Installer at No 1444 SALEM STREET ----=------------------------------------------=----=------------------------------------------- has been installed in accordance with the ovisions of TITLE 5 of the State Environmental Code as described in the application for\Disposal Works Cons ction Permit No. BHP-2011-054 Dated - ------------- ------------------------------ Printed On: Mar-21- 1-1Board of Health ,,Commonwealth of Massachusetts Map-Block-Lot Board of Health Permit No + - BHP-2011-0548 North Andover ----------------------- 48 °y ,^ •' s FEE �BAwv $125.00 DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted -------------------------------- to(Repair-REPLACE DISTRIBUTION BOX)an vidual Sewage Disposal System. at No 1444 SALEM STREET as shown on the application for Dis osal Works Construction Permit No. BHP-2011-054 Dated -------------- d - Iss e4W ab On:Mar-07-20 . r t ---------- ------------------ --------------------------------- '�"t!� e _ u 04 Commonwealth of Massachusetts Map-Block-Lot ----------------------- 0 -- --------- -------gBoard of Health Permit No North Andover BHP-2011-0548----------------------- P.I. HP-2011-054$P.I. FEE F.I. $125.00 ----------------------- DISPOSAL WORKS CONISTRUCTIONI PERMIT Permission is hereby granted ___ _ 0_ to(Repair-REPLACE DISTRIBUTION BOX an Individual Sewage Disposal System. ( P ) at No 1444 SALEM STREET U ---------------------------------------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP-201.1-054 ,Dated------------------------------ ------------------------------------------------------------ ----------------------------------------------------------------------------- Issued On:Mar-07-2011 Board of Health f 46.� Commonwealth of Massachusetts Map-Block-Lot Q Opyym°. . -0�d sl! Board of Health i 4#1 p a North Andover s r, • CERTIFICATE OF COMPLIANICE THIS IS TO CERTIFY,That the Individual Sewage Disposal System (Repair-REPLACE DISTRIBU by ------------------------------------------------------------------------------------------------ Installer at No .1444 SALEM STREET ---------------------------------------------------------------------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. BHP-2011-054 Dated --------------------- Printed On:Mar-07-2011 Board of Health 5280 • Town of North Andover ,,.e::t�` HEALTH DEPARTMENT SAC NU+f .! CHECK#: DATE: G�®� LOCATION- H/0 OCATION:H/O NAME: . J CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ;{ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septi Design Approval Septic �4 )c Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink- Treasurer ' °Rxb,tio Application for Septic Disposal System 7 / to Construction Permit - TOWN OF TCDftS DATE ORTH ANDOVER, MA 01845 $250.00—Full Repair $125.00 -Component 4SS4cHu5et 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 key to move your R4epair or replace an existing system component—What? 01-5-r. &)C cursor-do not use the return key. A. Facility Information Address or Lot City/Town 2.-*TYPE OF SEPTIC SYSTEM*: ❑ Pump NGravity (choose one) ***If purrfp system, attach copy of electrical permit to application*** IT Conventional System (pipe and stone system) LLQ: Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D-Box)(Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D-Box Present)S.A.S. 2. Owner Information / 4 Name Address(if different fr m ab�oyy��) City/Town State Zip Code Telephone Number 3. Installer Information ��al 1. /J/Y/ 6 �fC�Ct rf1 S r� /c_ Name Name of Company Address AIM 6City/Town State Zip Code 277-g'®� �5'� :?-1 Telephone Number(Cell Phone#if possible please) 4. Designer Information Name Name of Company Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 Ln °tR?h; Application for Septic Disposal Svstem 6 0 TODAY'S DATE Construction Permit - TOWN OF ORTH ANDOVER, MA 01845 $250.00-Full Repair .pw SUCH�Se<' $125.00-Component PAGE 2 OF 2 A. Facility Information continued.... 5. Type of Building: &sidential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, aswel as the Local Subsurface Disposal Regulations for the Town of No rt A ove , an of to lace the system in operation until a Certificate of Compliance has bee is ed y th Boa of Health. N e Date Application proved By: oard of Health Representative) Name % Date J,. plica/ lica ion Disa proved for a following reasons: I � For Office Use Only: 1. Fee Attached. Yes No 2. Project Manager Obligation Form Attached? Yes No 3. Pump System? Ifso,Attach copy ofElectrical Permit Yes No 4. Foundation As-Built?(new construction ronly): Yes No (Same scale as approved plan) 5. Floor Plans?(new construction only): Yes No I Application for Disposal System Construction Permit•Page 2 of 2 I I Starr, Sandy From: Willett, Tim Sent: Tuesday, April 09, 2002 11:35 AM To: Carney, John Cc: Hmurciak, Bill; Beshara, Robert; Cyr, John; Starr, Sandra; Lagrasse, Brian; Hmurciak, Linda Subject: WATER BAN-`121 4 SALEM ST The home owner's well at 1444 Salem Street has gone dry. He currently has a meter pit on the side of the road for outside watering. I gave him permission to connect a garden hose from the pit to his house so he can use some water inside temporarily. Arco will install permanent copper pipe from the pit to the house later this week. I thought you might need to know about this situation if you get any calls from concerned residents. 1 NEW ENGLAND ENGINEERING SERVICES INC VD June 24, 2005 9 ZQ05 ,�uN ti N OF �N ANDOVER SOW NDE p,RTMENT North Andover Board of Health HEP,�TH 400 Osgood Street - North Andover, MA 01845, RE: TITLE V REPORT: RE: 1444 Salem Street North Andover, MA Dear Sir or Madam: Enclosed is a copy of the Title V report for the above referenced property. The system PASSED our inspection. �r. If there are any questions please call me at my office, 686-1768. 5i i i� re Sincerely, n�amin C. OsVnsp�ector " Certified Title 5 y 60 BEECHWOOD DRIVE-NORTH ANDOVER, MA 01845-(978)686-1768-(888)359-7645-FAX(9 78)685-1099 r 7 •' ....................................... 1 of 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1444 Salem Street North Andover,MA 01845 Owner's Name: Helen Horton Owner's Address: 1444 Salem Street North Andover,MA 01845 l Date of Inspection: June 22,2005 Name of Inspector:(please print) Benjamin C.Osgood,Jr.Certified Title 5 Inspector Company Name! New England Engineering Services Inc. Mailing Address: 60 Beechwood Drive North Andover,MA 01845 Telephone Number: 978-686-1768 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 the on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15340 of Title 5(310 CMR 15.000).The system: V Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: � Date: V O The system inspection shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes anmm d Comments cc UJ Cit Teri rt-( A c q ****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. i 2of11 - OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1444 Salem Street North Andover,MA 01845 Owner's Name:1 Helen Horton Date of Inspection: June 22,2005 fi Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: �—I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N 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 I 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: 3of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1444 Salem Street North Andover,MA 01845 Owner's Name: Helen Horton Date of Inspection: June 22,2005 C. Further Evaluation is Required by the Board of Health: N 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 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 stem has a septic tank and SAS Soil Absorption System and the A system ( e S S and the SAS is within 100 P ) rP y 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 the SAS is within 50 feet of a private water supply well. _The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organize 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 5ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: SCS wr LLL. �.r4'f' � 1LS1 0lrw-fie/ 4of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1444 Salem Street North Andover,MA 01845 Owner's Name: Helen Horton Date of Inspection: June 22,2005 D. System Criteria applicable to all systems: You must indicate"yes or No"to each of the following for all inspections: Yes No V 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 overload or clogged SAS or cesspool. 'Static liquid level in the distribution box above outlet invert due to an overload or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped v 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 G 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. r, Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (this system passes if the well water analysis,performed at a DEP certified laboratory for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrogen is equal to or less than 5ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) A10 ,(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 must 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 sy is within 400 feet of a surface drinking water supply The system is wi 00 feet of a tributary to a surf g water supply The system is located in a ni n i ve area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply we If you answered"yes"to an stion in Section E the system is idered a significant threat,or answered"yes"in Section D above the large system ed The owner or operator of any large syste nsidered a significant threat under Section E or failed under Section D shall pgrade the system in accordance with 310 CMR 15.304. system owner should contact the appropriate regional office of the Department. 5 of 11 - OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1444 Salem Street North Andover,MA 01845 Owner's Name: Helen Horton Date of Inspection: June 22,2005 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_? v 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 an 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 sign of break out? Were all system components, g excludin the SAS,located on site? Po Were all the septic tank manholes uncovered, n opened, the interior of the tank inspected forcondition 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 difference from owner)provided with information on the proper maintenance of the subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No / ✓ /Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] I it i 6of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1444 Salem Street North Andover,MA 01845 Owner's Name: Helen Horton Date of Inspection: June 22 2005 P , FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design) � Number of bedrooms(actual): DESIGN flow based in 310 CMR 15.203r fo example:( e. 110 gpd x #of bedrooms). Number of current residents: Z Does residence have a garbage grinder(yes or no): c� . Is laundry on a separate sewage system(yes or no): A.A 0_[if yes separate inspection required] Laundry system inspected(yes or no):— Seasonal use:(yes or no): ALQ_ Water meter readings,if available(last 2 years usage(gpd):k j.)-c L k--- Sump Pump (yes or no): ,/ . Last date of occupancy ,, r c h;r COMMERCLUANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no) Water meter readings,if available: Last date of occupancy/use: I OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: /1/0 U 2 Ucv y Was system pumped as part of the inspection(yes or no): Al[7 If yes,volume pumped: gallons–How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM 7 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 Attached a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: U' Iq Re.1 �-,�L Were sewage odors detected wen arriving at the site(yes or no): _ 7of11� OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1444 Salem Street North Andover,MA 01845 Owner's Name: Helen Horton Date of Inspection: June 22,2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron 40 PVC_othera lain ( xp ) Distance from private water supply well or suction line: 'to ' Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) Depth below grade:� Material of construction: concrete metal fiberglass polyethylene j 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: CrIq L L,3,.A s Sludge depth: 2°' Distance from top of sludge to bottom of outlet tee or baffle: Z 2- Scum thickness: Z Distance from top,,of scum to top of outlet tee or baffle: `l L Distance from bottom of scum to bottom of outlet tee or baffle as" How were dimensions determined: c-4 ,2c s,A«4, 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: A� 14 (locate on site plan) Depth below grade: Materials of construction: concrete metal fiberglasspolyethylene other (explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from botton of sludge to bottom of outlet tee or baffle:. Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc. i 8of11• OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) j Property Address: 1444 Salem Street North Andover,MA 01845 Owner's Name: Helen Horton j Date of Inspection: June 22,2005 TIGHT OR HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Materials of construction: concrete metal fiberglass polyethylene other (explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidnence of solids carryover,any evidence of leakage into or out of box,etc.): �r, 1 © I.L CO, D „l�/l_ D 'S 12I e,0 - 3 tcz�Jf3l._ NJ .UCL- v C` o(l �GL 1 N ;2 ��✓I PUMP CHAMBER: (locate on sire plan) Pumps in working order(yes or no) Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 9 of 11, OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1444 Salem Street North Andover,MA 01845 Owner's Name: Helen Horton Date of Inspection: June 22,2005 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 in length leaching fields,number,dimensions: / r-/e-L,.D s ,2 J N K N o -.v 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) 2 i— OF' ,j171G- VIZ vN Osi A"L. Q &EPiZO EjING- IA,' /j lni 17 CESSPOOLS (cesspool must be as of inspection) ovate on sire P P� mspech )(1 Plan) Number and configuration: Depth—top of liquid to inlet invert Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of Construction Indication of groundwater inflow(yes or no) Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: X11�}" (locate on site plan) Material of construction: Dimensions: Depth of solids Comments(note condition of soil signs of hydraulic failure,level of ponding,condition of vegetation,etc. 10 of It OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1444 Salem Street North Andover,MA 01845 Owner's Name: Helen Horton Date of Inspection: June 22,2005 SKETCH OF SEWAGE DISPOSAL SYSTEM iProvide 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. g D,-- 6 J 66 LITTLE TON,ROAD,WESTFORD,MA 01886 (978)692-8395 FAX(978)692-0023 1.800-649-TEST Report Numhcr: 92884 Rcport Tate: 6/22/05 Client: Sample Information: New England Engineering Services 1444 Salem St. 60Beechwood Drive N.Andover MA N.Andover MA 01.845 Sampled by: Client Date Received: 6/21/05 Date Sampled: 6/21/05 Certificate of Anal ;fest Parameter EPA Limit Result's Units Total Coliform(P) 0 0 per I00ml Fecal Coli Corm/E.coli(P) 0 0 per100nt1 AmmoWa N Not Spec. -0.03 mg/L Nitrate-N(P) 10 4,8 Nitrite-NI(P) 1 •=0.01 mg/L i I i Legends: (P)=Primary EPA Standard,(S)—Secondary EPA Standard,µ Exceeds EPA Limit, '1'N'1'C=Too Numerous to Count,*=Rackgruund Bacteria Noted. This water sample as submitted,meets EPA requiruments for the parameters listed above. Massachusetts Certilication#MA048 Michael P.Carlson,for Thorstensen Laboratory lnc. ZOO/ ZOO'd L9'£Z# NaSNEISSEOHs £ZOOZ699L6 09:9Z SOOZ'£Z'Nf11' i �J'�i�%�[/F/����/GFXi'�i c 1����.��/�f'(/�/L J �l�ifi• • 66 LITTLETON ROAD,WESTFORD,MA 01886 (978)692.8395 FAX(978)692-0023 1-800-649-TEST Report Number: 92884 Report bate: 6/2.3/05 I New England Engineering Services 1444 Salem St. 60 Beechwcx)d Drive N.Andover MA N.Andover MA 01945 Date Sampled: 6/21/05 Sampled by: Client FPA 524.2 PARAME'rLlt MCL RFSIJL'1' PARAMETLK MCL RESULT Renk,-no 5,0 NTD 1.,1,2,2-Totraehloroethane - ND Carbon Tetrachloride 5-0 ND 1,3-Dichloropropane - ND 13-Dichloroethylene 7.0 ND Chloromethane NT) 1,2-Dichloroethanc 5.0 ND Rromomethane ND p-T3ichluroBenzene 5.0 Nn 1,2,3-Trichloropropane ND Trichloroethylene 5.0 ND 1,1,1,2-Tetrachluructhaae - ND 1,1,1=ftiChlomethane 200. ND Chloroethane ND Vinyl Chloride 2.0 ND 2,2-Dichloropropane ND Monochlurobenzene 100. ND o-Chlorotoluene - ND ortho-Dichlorotiazene 600. ND p-Chlorotoluene ND trans-1,2-Dich1oroethylene 100, ND Rrcmnobenzene - ND cis-1,2-Diehloroetbylene 70.0 ND 1,3-Dichloropropene - ND 1,24)ichloroprupane 5.0 ND 1,2,4-Tr1me1hylbcnzcne - ND Ltliylbenzenc 700. ND 1,2,3-Trichloroben7ene ND Styrene 100. ND n-Prupylbenzene _. N•D Tetrac:hloroethylene 5.0 ND a-Butylbenzene -- ND Toluene 1000. ND Naphthalene NTD Xylcnes(fotal) . 10000. ND 11exachlombutadiene - ND Dichloromethane 5.0 ND 1,3,5-TriniethylhLnzene -- ND 1,2,4-Trichlorobonvcnu 70.0 ND p-l'strpropyltoluene - NI) 1,1,2-Trichloroethane 5.0 ND Isopropylbenzene -- ND Chloroform I t-Rutylbenzene - ND Rromodichloromethane -- ND sec-Butylhenzcme - ND Chlomdibromorn'cthane -- ND FluoroTrichloromethanc ND Brornoform NT) Dichlorodinuoromethane -- ND m-Dichlorobenzene __ ND Bromochlorometbane ND Dibromomethaue, ND *MethyiTediaryButyWther - 1 1,1-T)ichluropropene -- ND 1;1-Dichloroetbanc ND %kecovery of internal Standards: NT)=None Detected 4-13romofluorobenme 87. MCI=Maximum Contamination Level 1,2-Dichlorobenzene-d. 106 Results are in u2/1 Detection Limit;0.5 1ri/t. "`MTBE!Onticmall Subcontracted to.Mass DLP Lab MA,072. � /J ZC41lel P. .arlsnn. lur Thorstemen Laboratory Inc. ZOO/ ZOO'd L9£L# NdSNSLS2i0Hs £ZOOZ698L6 OS:9Z SOOZ-£Z-NIl1' Septic System Information 1444 SALEM STREET Printed On: Wednesday,June 04, 2008 System ID: BHS-2004-0148 General System Information Latest Permit Information Calcaluted Design Flow: Test Pits Septic Tank Disposal Trench Design Flow: One Two Capacity: Number: Design Flow Provided: Minutes per inch: Width: Width: Total Flow: Depth: Length: Length: Seasonal: No No Depth to Water: Diameter: Leaching: Grinder: No No Soil Type: Depth: Laundry: No No Hauling/Pumping Listing Quantity Tvpe System Type Pumped Pumped By Transferred To Disposed At Date Pumped (gallons) Routine Septic Tank STEWARTS SEPTIC 10/27/2004 750-., Routine Septic Tank Rooter Man GLSD 04/01/2006 1000 Routine Septic Tank Soucy's Sewer Service GLSD 08/02/2007 Comments: ok Inspections: Inspected: Expires: Inspector. Status: 03/07/2008 Benjamin C.Osgood,Jr. Passes Comments: Title 5 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Page 1 of 1 3.309 . NOR71r t S .. s o Town of North Andover HEALTH DEPARTMENT ,SS�CMUStt .. :�r it CHECK#: &2Z19 DATE: ;z ,2� LOCATION: 7% H/O NAME: .. CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ . Food Service-Type: $ ❑ Funeral Directors $ j{ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ O TrashlSolid Waste Hauler . $ ❑ Well Construction SEPTIC Systems: ❑ Septic-Soil Testing . ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑` Septic Disposal Works Installers(DWI) $ J ❑ Title,51nspector $ `? & Title 5 Report i $ ❑. Other:(Indicate) $ . A Health Agent Initials; White-Applicant Yellow-Health Pink-Treasurers`; Commonwealth of Massachusetts r; W ' Title 5 Official Inspection f=orm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments L�L/ rs 1444 Salem Street Property Address Arthur McCue Owner Owner's Name information is No Andover MA 01845 3/7/2008 required for 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. Important: When filling out A. General Information forms on the computer,use1. Inspector: only the tab key to move your Benjamin C. Osgood, Jr. cursor-do not Name of Inspector use the return key. New England Engineering Services, Inc. Company Name �e 1600 Osgood Street Suite 2-64 Company Address No. Andover MA 01845 City/Town State Zip Code 978-686-1768 Telephone Number License Number i I 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: EV/Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspecto' 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. TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts,/- Title assachusetts1<Title 5 official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1444 Salem Street Property Address Arthur McCue Owner Owner's Name information is required for No Andover MA 01845 3/7/2008 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 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 TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1444 Salem Street Property Address Arthur McCue Owner Owner's Name information is required for No Andover MA 01845 3/7/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation b the Board of Health in order to determine� � we�� � q Y 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 � 1- 715.303(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 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. TITLE 5 FORM 2007.DOC•08/06 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Mass6chusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments sO 1444 Salem Street M Property Address Arthur McCue Owner Owner's Name information is required for No Andover MA 01845 3/7/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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". lj e e- w f✓i,[_. w IA-'TE 'TE S l fl-t'CSA-cttC� Method used to determine distance: 575-17^A A--j-e **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ❑/ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ R,-- 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 ❑ 2" Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ [?' Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts W Title 5 official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °v 1444 Salem Street Property Address Arthur McCue Owner Owner's Name information is required for No Andover MA 01845 3/7/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ [ - Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ [9'" Any portion of a cesspool or privy its 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. ❑ E;,'_ 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 ❑ [�J— the system is within 400 feet of a surface drinking water supply ❑ ©-- the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area (interim Wellhead Protection Area- IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1444 Salem Street Property Address Arthur McCue Owner Owner's Name information is required for No Andover MA 01845 3/7/2008 every page. City/Town 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 2-- ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Ell 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? ❑ L2,,- 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) ❑ [T' Was the facility or dwelling inspected for signs of sewage back up? 2 ❑ Was the site inspected for signs of break out?. 2 ❑ Were all system components, excluding the SAS, located on site? i 0` ❑ 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? I 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)] TITLE 5 FORM 2007.DOC-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts W Title 5 official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �.w 1444 Salem Street Property Address Arthur McCue Owner Owner's Name information is required for No Andover MA 01845 3/7/2008 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: ter' Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): / Number of current residents: / —-- Does residence have a garbage.grinder? ❑ Yes 2' No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ❑V' No Laundry system inspected? ❑ Yes [Er No i Seasonal use? ❑ Yes 0'No Water meter readings, if available (last 2 years usage(gpd)): F Lt Sump pump? [-Yes ❑ No Last date of occupancy: -t- 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: Last date of occupancy/use: Date Other(describe): TITLE 5 FORM 2007.DOC-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 official Inspection Fora _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 1444 Salem Street Property Address Arthur McCue Owner Owner's Name information is required for No Andover MA 01845 3/7/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont. General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 7 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: v �T -rf 6`( t-—e-t— O L'9 T TC S Were sewage odors detected when arriving at the site? ❑ Yes E' No TITLE 5 FORM 20107.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 I Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1444 Salem Street Property Address Arthur McCue Owner Owner's Name information is No Andover required for MA 01845 3/7/2008 every page. City/Town State Zip Code. Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: feet Material of construction: 21/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.): L.ot>K> [0=0 o CNT Septic Tank (locate on site plan): r� Depth below grade: feet Material of construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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: /D a v &2&4,n,-a,,5 Sludge depth: — 4 ) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness G 1 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle y How were dimensions determined? AA tGsy 44- s77 c 1( TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts w Title 5 official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1444 Salem Street Property Address Arthur McCue Owner Owner's Name informationi'sNo Andover MA 01845 3/7/2008 required for every page. City/Town 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.): s14A.)K. I At l &-coo G r•+ D,T70 iA S c l{ 'c o PJ e- Te o s l [�ac� Gcl..+tD►7Dw NIA 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Al ( Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): TITLE 5 FORM 2007.DOC-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 �M 1444 Salem Street Property Address Arthur McCue Owner Owner's Name information is required for No Andover MA 01845 3/7/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No i Date of last pumping: Date Comments (condition of alarm and float switches etc.): SII *Attach copy 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 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.): fox ikn o tt co tj 1>1-17 0 C C> c..- c 2 roc Kc. c:i� .*`J E621!S>Cne-C caY' L.co. ,tpjs Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts w Title 5 official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 1444 Salem Street Property Address Arthur McCue Owner Owner's Name information is No Andover MA 01845 3/7/2008 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: leaching fields number, dimensions: f�E� ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): >a(Letf c7 f— ri s7 )4-.1 v r= _014r� V e- G TITLE 5 FORM 2007.DOC-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1444 Salem Street Property Address Arthur McCue Owner Owner's Name information is required for No Andover MA 01845 3/7/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Mn-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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N JA Privy(locate on site plan): 1 Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): TITLE 5 FORM 2007.DOC-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1444 Salem Street �M Property Address Arthur McCue Owner Owner's Name information is required for No Andover MA 01845 3/7/2008 every page. City/Town State Zip Code 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. E---� k•c l l W 1541�ti` 3�.z Z�•� TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 Commonwealth of Massachusetts W Title 5 official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1444 Salem Street Property Address Arthur McCue Owner Owner's Name information is required for No Andover MA 01845 3/7/2008 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 ground water: 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: Date Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: j ❑ Checked with local excavators, installers - (attach documentation) Accessed USGS database-explain: I You must describe how you established the high ground water elevation: S—�dbTevsN 1,C:E 70 2- j—"ec7' 13Cc.ow I lZeU2 No we-'[" LANDS AT $fi-.SC— 0"F +-1)L L. TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 FROM �. '� FAX N0. :9786877096 Mar. 86 21708 176:54PM P2 NEW ENGLAND RADON, LTD. 603-893-4260 -- -- - - 11A Industrial Way,Unit 3 Fax:603-893-8163 Salem,New Hampshire 0.3079 E-Mail:nerOchoiceonemail.com Wabs,ite:www.newenglendradon;com WATER ANALYSIS RESULTS DATE: 4 Mar 2008 NAME: R. 7. xN'�J?E,GTZONFi 1 Osgood Stroot. Methuen, MR 01844 Vate & Lime Sampled: 03/02/2006, 3.5:30 Date RRceived: 03/03/2008 � TEST SIT't:: 1444 SALEM ST, NO ANDOVER (536997) LAB.II 59528 PARAMETERS RESULTS REQUIREMENTS ANALYTICAL DATC: ot, TIME Of MCL/SMCL MPT.HOD ANALYSIS ANALYSIS HARDNESS *# 126.0 75 mg/1 SM2340C 03/04/2008 I(ION "# 0.28 0.3 mg/l EPA 200.8 03/04/2nn8 15:23 MANGANESE *# <0.05 0.05 mq/3 .EPA 200.8 03/04/2008 15;23 PH *# 7.1. 6.5 - 8.5 EPA 150.1 03/03/2008 15:21 C:•1LORIDF *# 43.2 250 mg/l k:PA 300.0 03/04/2008 09:03 TURBIDITY "*# <0.5 L NTU•** EPA 180,1 03/03/7.008 i.oPPER **# <O,S 1.3 mg/1 EPA 200.8 03/05/2008 15:23 SODIUM *# <20.0 '�50 mg/l EPA 200.8 03/04/2008 15:23 NITRATE ``# 3.2 10 mq/1 EPA 300.0 03/04/200A 09:03 COLIL"ORM **M A ABSENCE/100 ml P/A COLISURLa' 03/03/2008 15:10 Z.•COZ,I **# A ABSENCE/100 ml. P/A COLISURE 03/03/2008 15:10 CoL,OR 0 :t5 C.U. HACH 4025 03/03/2008 15:18 (00R ND 3 O.U. $M2150S 03/03/2008 ZS:18 LEAD **# <0.005 0-01.5 mg/1 EPA 200.8 03/04/2008 15:23 ARSENIC w•# <0.005 U,010 mg/1 LPA 200.8 03/04/2008 15:2.3 E11110RIDL -A <0.5 4.0 mq/1 1?uA 300.0 03/04/2008 09:03 CALC),I.VM *0 31.5 100.0 mg/l EPA 200.8 03/04/2008 15.23 Na.TLll1'L *"ll <0_y 1.0 mg/1 IPA 300-0 03/04/2008 09:03 � I "** 5 NTU is allowed for wol..l, wager. THT$ ;;SAMPI,F, MEETS EPA PRIMARY STANDARDS FOR THE PARAMETERS TESTED, These �arRmC'Y.eY.9 exceed the MCI,* or are out oP rang®; Hardness. A -- Absent; P = l?r,n•_AFnt FPA Primary standards are ,standards: that are relatod to bea.LL-h issues, (www.rpa.gov/safewater/ retia.htsml#mels) * EPA Secondary standards are ar-cothoth:ic in quality and Should not affect healthy indi.viductl (www.epa.gov/saafewater/mcl.html#mc1s) Al,,chorl4ed by: fanalysia, s Nspinal. .fclr NER, LTD Maximum Contamant Level.. BMCT,e Secondary MaximumContaminant Level- NOTE: These resuiLs -alattaa only t.o t'he sample as submitted to 'Cho lrnb. # NELAC accredito I 't: �' FROM - FAX NO.,, :9786877096 . Mar. 06 2008 06:54PM P3 _ . __ _ _ - NEW ENGLAND RADON, LTD. 603893-4260 11A Industrial Way,Unit 3 Fax: 603-883-8163 MR69 Salem, New Hampshire 03079 E-Mail: nor®choinsonemail.com Website:www.newenglandradon.com RADON WATER ANALYSTS DATE: 03/04/2006 R.J. INSPECTIONS I Osgoad Street Methuen, MA 01844 Vial 30038 --------------------------------------- ---------------------------- TEST SITE: 1441 SALEM ST, NO ANDOVER, MA SAMPLE NO. : 30038 RESULTS: 3494 pCi/L FOR WATERBORNE RADON (T.E,, RADON IN WELL WKXMR) , NO STANDARD HAS RMCEIV'ED A CONCENSUS, PARTLY BECAUSE TRE HEALTH IMPACTS ARE I.,AAGe:LY INDIRECT AND DEPEND UPON VARYING FACTORS (SUCH AS VENTI- LATION AND WATER USE HABITS) . SOME STATE$ ,HAVE SET GUIDELINES FOR FOLLOW-UP ACTION. IN NEW ENGLAND THEY ARE AS FOLLOWS: MASSACHUSETTS (10,000 pCi/L) MAINE. (4, 000. PCx/L) AND VERMONT (5,00() poi/J,) . FOR NEW HAMPSHIRE SEE NE FACTSH;=ET FOR RADON IN AZR. AND WATER AT: www.des.Strate.nh.us/fa,ctsheets/we/ws-3-12.htm FOR ADDITIONAL INFORMATION ON RADON IN WATER, YOU MAY CONTACT 'YOUR :>TATE RADON OFFICE. CT 203-566-3122 MA 413-596-7525 ME 7.07-287-5743 NH 603-271-4610 RI. 401.-277-24.113 VT 802-865-7730. (THIS RMADTNG IS VAZID ONLY TF ShMPL;_* HAS BEF,N TAKEN AS INDICATED IN THE INSTRtICTiONS. NEW ENGLAND RADON, LTD. CANNOT BE HELD LIABLE FOR IaRRONEOUS RESULTS IF THE SAMPLE IS NOT TAKEN ACCORDING TO THE INSTRUCTIONS. ) llr ' �`, IR 8 C p'r d ' H SET�T ,r;, r,Jl,1•1�;�l;.t ,rJr,�i:�J{�i1��1�11�;''', � '' sir ;, ' ' OCTQ 'Dep:hl.,�,,,,i�ri 'I'y;;;,�,;.1,y��,' 6 2009 d I It,, did 111+ lolrn !or � a o o� I,.,vn)Illcd Io �i Iocll 8crr /' 'o;of , T 1 n o c144EALIPtN[��N A' Faclllty inlorm�!lon �,�,�,��I� � .1 ,I 'J•.' lJ r �V3, � ..•r ' , IJ,'�J, 'I Own e r,'•'.r'•�'''� =� ; . . l.9dlµ+ 14 )lIAI r • I',. A�n buVvnl 74 , d u m PIl I.P I , 9� o r 8' ' /,�' !`I:I �'II��I)�:::�.111 MI11J�•�I I(,�' /� , .�J 4A?ID C> Co>>�ool .� ,Q,rOther(deacriDe � s� d-. yen(I' TeiF�Illr( 1oJonr, [' Yoe n'o c:OdnOp? Sp Y •,;,'I;;;�;,: �1,,, ,Ped i ''•t'i..• ' �M 1 • ".I,J,.''',',;:'1;;'i.'1�'''� •II<<Ir�' ili J' '11 ,� i f l: �" r ,'�rV I�r '• ,L" I �.�1' J�' . 11 ''1; ' 1 111'/ ,'HJT Vl�lul Jc•enll h'v'",;Ir . .._ ,I�`•.,. 1JIl��'�'''�oT9 Q�IPII�'''� II't'���i:'I�)'t�lll�.�l11;" 6ic, so 'llt ,, ri'•/', :I i� 11 ��, (�((in�/ . •..�.,I,;1;•,'�r'I S�AIIIY p� f i )1�rrf.){.,.:,: � t "--- :ma�,por/dr yl• oIII o • . . , I � '.,,, " � )FOCI . . , -C\ Commonwealth of Massachusetts City/Town of NORTH ANDOVER MASSACHUSETTS System Pumping Record REC `VE Form 4 DEP has provided this form for use by local Boards of Healtt The 5'ystem�P? ing Record must be submitted to the local Board of Health or other approving utjwwr��NoRTH ANoo r A. Facility Information 1�j Important: When filling out 1. System L cati n: forms on the computer,use M.tlq Scdc ,m only the tab key Ad res to move your cursor-do not use the return Cit /Town State v Yip Code key. 2. System Owner: Na <z Address different from location) City/Town State� . Zip Cod , Telep one ffumber B. Pumping Record 1. Date of Pumping Date—� 2. Quantity Pumped: Gallons I I Type of system: ❑ Cesspool(s) NAeptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of SystIz- 6. System Pumped By:arnj r-7 r / .j� Vehicle License Number JA Company 7. Location where contents were disposed: Si nature of Haul —� � 9 Date— http://www.mass,gov/diep/water/a rova s/t5forms.htm#inspect t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of lV14issachUsetts RCi � City/Town of irU - K System Pumping Record MAY 11 2006 v ® Form 4-, TOWN OF NORTH AN';_;0VFR _DEP has provided this form"for use by local Boards of Health.Other forms may u tbul:'tWAR !'aEN. information.must be substantially the same as that provided here_ Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important•. When filling out 9. System Location: forms on the / / computer,use `7 only the tab key Addressto move your '1 ► /�'//)- - %n ��� cursor-do not use the return C��o— WET— State Zip Code key. 2. Syste er: , I� Name Address(if different from location) City/Town State Z'p Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity w — Da tY Gallo s 3. Type of system-. ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Fitter present? ❑ Yes ❑ No If yes,wat it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: �50 Vehicle Lice n Number o Company 7. Locatio ere contents were disposed: / U Signature of Hauler Date e t5fornA.doa 0603 System Pumping Record•Page 1 of 1 wn `7 5�r.+''•�ti)yu`,}° � i!:•'7;yi.,�}� i••n4Q'`�I'•, � .. ..• . v �lY lr.!'1. y!•�J\`i\!1�"�'f'Jj�L�JyI�Iy ��IW,`�+'�.' •1•�,...• �� .\.. •�•?••�1.Ii� N¢'k�;,y„v�;I�Y4iY��i�'•�I���vfi RRECEIVED fc)Wr� uF NOR.,'H ,�NLh•.�y JAN 0 6 2005 JySrEr I'f PUMPING Rf'C,OFc TOWN OF NORTH J HEALTH DEPARTV��TER Y s reM a OATS OF PVM NA rvKu op J�RYIC�r xUV'rlNc Uby�RY�'riUNJ,_ � . GOOD.COt�01'!'IUN .U. I'V �'i7 v r x RZAYY OUAsBKOM 8�'y1.8�9 IN N�n�.� ..11..1 WOMB SOUP& 10LtDcAKAYgnX, X P L A IN •~ i I y FrIZECEIVED 'FOWN OF,, ORZ'H ANDOVf,f NOV - 3 2004 Z7 SYSTEM PUMPING.} RECOIZ . � U/1 l'k TOWN OF NORTH ANDOVEP i HEALTH DEPARTMENT SYSTEM OWNF,R & ADDRESS SYSTEM LOCATION l DATE OF PUMPING d ._ — .•D_� �_ ^�QI•IANTITY PUMPED: �J CL SPOOL: Np YBS SOPtiTank: NO �__.._. c..... YES... NA PURE OF SERVICE: KUU'fLN!~ !aM!✓RUI~NC'Y OBSERVATIONS: GOOD CONDITION PULL 'I`U COVER � HEAVY ORF-ASEBAFFLES IN PLACE. ROOT'S LEACHFIF.LD RUNBACK BXCF.SSIVE SOLIDS __. FLOODED SOLD CARRYOVER._. .OTHER EXPLAIN system Rwnpad by .. Lso/_C>/cP� �-'UMMhNTS. �'UN I EN I'S I'KANSF'hf(KbDD l 0 ,iil 74 rr 4' . . ........ i 1 . T `OF NORT AIDOV a � SYSTEM PUM•PINO cp� �. JUL 2953 ,i I Ef>1 OWN FR & ADDRESS SYSTEM LOCATIof� ` - Ce QC/ (ez�m�lel lcfl from u('houst)' t� I OF PVMF No QUANTITY f'UMf CD L Lc�.� YES -.SEPTIC TANK; N0 YES VATUKE OF SERVICE, ROUTINE.: EMERGEN-Cy ii>r'RY��T10NS;: F t UUOD'CUN.UlTION FULL70 CUYGIZ• FII'r1;Y.;Y Ctt ;ASC " � 13AFFLLS` IN PLACP R O.O T,S L EAC H Fl ' CLD f ---� S E 1 S S FLOODED'. SOLA), CARRYO.YER tJ HER (k'x('LA.1N) i lllMkPUM PCI�'t3Y .� CU-MM (:NTS ti I s t y f 1 --------------- a 1 H 11R ...NSl'�IZIZE D '>');. /g 111W,1 0 �'• ,�1 }t "�.i�'1� '+�� ' s r ' ,✓+.� } ! 1, "'� _ - 7P. �ryy"` ,rt,}'t!1 Ny,.•��,,��{�lr n Q•'�4{C'31 ,'., if 1�s'r 1 t .. yL �'Oi � rt�+�ri��.�'i{'}'i l sl•( y}{7t7r n t. "� R 7 r� � 7 s - �. x f i•FtKFyrM a 11 1 1�1 ,rly x a�j•1 v , , t ,fir r. .. - ... ! �t.j�,�'��•t�x!l,,! '.i�?;9�'Ift;, �;1lf.1'�.yti�� t.11r-'�rd Y !'• ,c � 11, f '., 1 - •� ,�l.i�".Jr+j.JYrin`y',�c� 1�?''�r p•tt t qtr}s`tJr,1M+: ;• `'y � {' �. _ T e•� 5��"'�4 �'„' i!✓�Y� �Rq A!�+ . ire h, :t jl+ - ,::1-+•�Ir �C1 ^3 Coor � ., r: y} � at''� }�'�'�1'yt 11 W�/�•Ylv 1 Y,�+�W,`r. •.v r , 7•�4��i �t r ' � ..-..,e. .44 Sy P � - AA �� .,, SING RE �• i av�� ±+ yrs !1�'�i'�} s' ! v i, +t +r?,�•�i N y i 413 ' 1 ..,Za'.r�;Y+V'1A•S:,I'd S��.'.L;}1i{r.�t'}'tt :h :iJ�''l!J ,19 ,., .� -. ADDRESS T.- (616YETE M LO CATIONle imut of 1190a) r��Yi�� itP r tor :... . !.• ,, , .Q�I�ppm (1 R.;N. •'1 r 3 t. •r+t,•�Jjl r r1 r•�ka t,('o j,.;+••. i~ rtN�ia;A�tl�' :;4j, }1�r•as1�,�' 1� 77O��°� .•�M-C. 5 " ��•I.r` .. .. ', _ 'r . 1 , •; ,� <;, �. ;•••�,. .' ,SFP1`IC TANK. _ • NO YES • ' ��L1�«Y�y�t•r ri\�a } }+� 1 l *c^I rK ''!•' �� �w. .. '+. _6'..rF:•r•11�i �'.t{r� rr i.S, 11 x .e ::;�„• ,. r -�' >:. �y.�:,;;)'� •l.A}}.+i'�1 4i•,*ilnh i ' ,i* M. .t ,t v .. . ... • EMERGENCY W.e . r.��Mi rf�°9Y�,: �h Y �1 r•'i��'R�j'�^�r 1:t e. s.,• . ... y�+T�ONS•J Ji$',;1 ,.r ��}1,•t! , .} .•'e? •v �•} R'r r{' •' r.... .. . • Yc i ++Sy of ��GOOD•�CO� ON.� +ti •!� .r ri �, i la 1/�,, ♦qd! r�i`-JMV'Y ,�1 v+•ulr TO COVER . r ' tt •F .Fx'yl+ti 111��;.w!w�1." R - ,` ',�' ^' �"�iIOOTS •.� B�A►FFLES IN PLACE }.'ICM+ -. �• �•1 1 m SOLIDS RUMBA , OT+ A� FLOODED )1'' •Sat !' ';;H; m"'""""" �w•. Ta�Yr �► ��r�1�j�r�/r � y. t eli'n.n y'y� 7.. .b• r i r� a°J;, r•�1 omV.,;!; •�.r'+He! � rr rr�! u.w� .r.tr c.,t��r srr t,• , , .r•K`T a:Y'��1-I�th'jf�'YjstX S.'+�nr A#•44 ali"}!'' .j .{; j **" '`• -, Y r• rt+r 1..:9,.fi'r,1 °;�i:� it'''y,tl}• l �,rJ, ci shy ^ • �.{I °vgYll�;•,aglS.At MN.•+•Si-•..' , jd ! .r J �ti_;,"7. si 'ri.,+�irj It�'i1.1 �..{i1.I� } :x;•. .w .; . lT� �Ibii'rrf j000, i ¢ ,}�11 } :, �,,1 rt 1.r�'1!6 i'.•+)i•It}�1}tNl�{y.! r l.".O� cac^ �. J, 7 i. X1'7: '7 •^ -(' '•r 4t / ,. wF' •.,�,. ,';�r.J �',.:.:)s.t.;1, ,,.F 1,:.. '•. d.' . tr�� � � � r�•+'1 } •• LKr��?r►� 1 L.,-},P�r`J\l�.�,`✓. /�/� `.•r;1, • y/.I i, f , _ Commonwealth of Massachusetts 7RECEIVED H v City/Town of North Andover -7 Z011 System Pumping Record Form 4 TOWN OF NORTH ANDOVER ,M HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out 1. System Location: forms on the computer, use 1444 Salem St only the tab key Address to move your N. Anodver Ma 01886 cursor-do not use the return City/Town State Zip Code key. 2. System Owner: r� Hammersmith Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of PumpingDate ' 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) a?!eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: Clad mrd—. 6. Svstem Pumped By Name kj Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record-Page 1 of 1 s Commonwealth of Massachusetts W City/Town of No. Andover x- a System Pumping Record Form 4 M 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 within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, / / /L/y ( — r use only the tab `7 /,C__/ �( � key to move your Address cursor-do not No. Andover Ma use the return _ key. City/Town _ _ _ State Zip Cede._-• _ 2. System Owner: Mode NameAddress(if different from location) TOWCity/Town State Telephone Number B. Pumping Record 1. Date of Pumping " Dat y 2. Quantity Pumped: Gallons�� 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 0000 6. System Pumped By: Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: 1 Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Si re 41au er T1, Y� Date Signature of Receiving Facili Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 No Andover J&S Development dba 1600 Osgood St Stewart's Septic Building 20 Suite 2-36 Andover Septic No.Andover, Ma 01845 58 South Kimball Street Bradford, MA 01835 DECEIVED Date Name & Address Gallons Comments 1-May, Patterreality 81 Sawmill Rd 1600 Good TOWN nr-NNORTH ANDQ\1R 2-MayMuIc350 Sharpners Pond Rd 1500 Good rig=ACTH DEPgRTI`� l�T Geene 62 Willow Ridge Rd 1000 Good 3-May taOrbssd259 Grandville 2500 Good 4-May�Rm�con 115 Sherwood Dr 1500 Xsolids HG 9-Ma 4Callahn40 Fo ster St 1500 Good Y 10-MaUl�elePm 1444 Salem y St 1500 Xsolids 15-MayzOi aff 116 Brenkin ridge Rd 1500 Good Mepan�175 Stone Cleave Rd 1500 Good 16-May Martin 701 Forest St 1500 Good " .M by 16 Carleton Lane 1500 Good 18--May Van ergraaf:267 Old Cart Way 1500 Good 'olanb 21:98 Tnok St 1000 Rh 21-MayTomicho`115 Laconia Cir 1500 Good Reti 42 Cross Bow 1500 Good M* yACarbonell 1560 Salem St 1000 Good 29-May Thurber 210 Farnum St 1500 Good 31MayCleary 05 Wintergreen Dr 1000 Good