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Home My WebLink AboutMiscellaneous - 1459 TURNPIKE STREET 4/30/2018 (3)North Andover Board of Assessors Public Access xoRTy Return to the Home page click on logo New Search Sales Summary Residence Detached Structure Condo Commercial Comparable Sales 'Fvwn of Wor-th A.adover 12koarxi Of'kssessoru, Parcel ID: 210/107.B-0066-0000.0 SKETCH Click on Sketch to Enlarge Page 1 of 1 Property Record Card Community: North Andover PHOTO No Pic Available ,ocation: 1459 TURNPIKE STREET )wner Name: DUBE, KEVIN M HARTLING, JENNIFER )wner Address: 1459 TURNPIKE STREET City: NORTH ANDOVER State: MA ZIP: 01845 leighborhood: 5 - 5 Land Area: 1.06 acres Jse Code: 101 - SNGL-FAM-RES Total Finished Area: 1198 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Cotal Value: 296,300 282,300 3uilding Value: 150,400 154,600 .and Value: 145,900 127,700 ✓Iarket Land Value: 145,900 :hapter Land Value: LATEST SALE ;ale Price: 1 Sale Date: 02/10/2003 lrms Length Sale Code: A -NO -FAMILY Grantor: KEVIN M DUBE �ert Doc: Book: 06340 Page: 0244 http://csc-ma.us/NandoverPubAcc/j sp/Home.j sp?Page=3&Linkld=991762 6/13/2007 Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. K"&M Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1459 TURNPIKE'ROAD 5T . Property Address KEVIN DUBE Owner's Name NORTH ANDOVER MA 01845 City/Town State Zip Code 6/26/15 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. A. General Information RECEIVED Inspector: JUL 13 2015 JAMES H CURRIER II I F 0TH ANDOVER Name of Inspector HEALTH DEPARTMENT J'S SEPTIC & DRAIN — Company Name 131 FOREST ST Company Address MIDDLETON MA 01949 CitylTown State Zip Code 978-774-6685 S12327 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspectors 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 official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 t5ins • 3/13 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1459 TURNPIKE ROAD Property Address KEVIN DUBE Owner's Name NORTH ANDOVER MA 01845 Cityfrown State Zip Code B. Certification (cont.) 6/26/15 Date of Inspection 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: SYSTEM WORKING PROPERLY. 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): Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 2 of 17 t5ins • 3/13 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ~� 1459 TURNPIKE ROAD _ Property Address KEVIN DUBE Owner Owner's Name information is NORTH ANDOVER MA 01845 6/26/15 required for every - — page. Cityrrown State Zip Code Date of Inspectit i B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Healti approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribu-iun 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 replac ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Requir y the Board of Health: ❑ Conditions exist which require flyfthe't1valuation 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1459 TURNPIKE ROAD Property Address KEVIN DUBE Owner's Name NORTH ANDOVER MA 01845 6/26/15 City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presen a of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no otherfai re 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 Allet Itrvc. ' due to an overloaded or clogged SAS or cesspool 1:1 ❑ Liquid depth in cesspool is less than 6" below inver, 3r availoble volume is less than 1/s day flow _ t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disp..al System • Page 4 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1459 TURNPIKE ROAD Property Address KEVIN DUBE Owner Owners Name information is required for every NORTH ANDOVER MA 01845 6/26/15 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. ❑ ❑�\\k Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ❑ �� Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ❑� Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑�� Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply El 11 the system is wi in 2 feet of a tributary to a surface drinking water supply ❑ El Area system is locate in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a ap d Zone II of a public water supply well If you have answered "yes" to any que tion 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1459 TURNPIKE ROAD Property Address KEVIN DUBE Owner's Name NORTH ANDOVER MA 01845 6/26/1.5. City/Town State Zip Code Date of Ins .ction C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of `ie following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board o' Health ❑ ® Were any of the system components pumped out in the previous two wee':s? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 330 GPD t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1459 TURNPIKE ROAD Property Address KEVIN DUBE Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 page. City/Town State Zip Code D. System Information Description: Number of current residents: 6/26/15 Date of Inspection Does residence have a garbage grinder? Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.204 Basis of design flow (seats/persons/sq.ft., etc. Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: ❑ Yes ® No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ® No 118.54 GPD Gallons per day (gpd) ® Yes ❑ No CURRENT Da, ❑ Yc ❑ No �.1 Yes ❑ No ❑ Yes ❑ No t5ins • 3/13 Title 5 official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 • <LN\ Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1459 TURNPIKE ROAD Property Address KEVIN DUBE Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 6/26/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Date Source of information: LPD - 7/30/13 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: How was quantity pumped determined? Reason for pumping: gallons Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 3113 Title 6 Official Inspection Form Subsurface Sewaz .: Disposal System • Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1459 TURNPIKE ROAD Property Address KEVIN DUBE Owner Owner's Name information is NORTH ANDOVER required for every page. Cityrrown D. System Information (cont.) t5ms - 3/13 MA 01845 6/26/15 State Zip Code Date of Inspection Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): 6" feet 22' PUBLIC H2O Distance from private water supply wen or suction unU• feet Comments (on condition of joints, venting, evidence of leakage, etc.): PLUMBING IN GOOD CONDITION, NO SIGN OF LEAKAGE. Septic Tank (locate on site plan): 6" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1000 GALLON - 6' DIAMETER Dimensions: 911-1011 "-10" Sludge depth: Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form a a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'wM y 1459 TURNPIKE ROAD Property Address KEVIN nUBE Owner Owner's Name information is NORTH ANDOVER required for every page. City/Town D. System Information (cont.) Septic Tank (cont.) MA 01845 State Zip Code 6/26/15 Date of Inspection Distance from top of sludge to bottom of outlet tee or baffle 23" V-211 Scum thickness Distance from top of scum to top of outlet tee or baffle 5" - 6" Distance from bottom of scum to bottom of outlet tee or baffle 13" 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.): LIQUID LEVEL CORRECT, INLET AND OUTLET TEE'S IN PLACE, TANK DOES NOT NEED PUMPING AT THIS TIME. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyeth;riene ❑ 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: l5ins • 3/13 Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 d.. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1459 TURNPIKE ROAD Property Address KEVIN DUBE Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 6/26/15 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 Dimensions: Capacity: Design Flow: Alarm present: Alarm level: X gallons ❑ polyethylene ❑ other (explain): gallons per day ❑ Yes ❑ No 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1459 TURNPIKE ROAD Property Address KEVIN DUBE Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 6/26/15 page. Cityrrown 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 a jidence of zolids carryover, any evidence of leakage into or out of box, etc.): BOX REPLACED IN 6/13/07, LIQUID LEVEL CORRECT, NO EVIDENCE OF SOL !DS CARRYOVER. BOX IS 24" BELOW GRADE. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber/ condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1459 TURNPIKE ROAD Property Address KEVIN DUBE Owner Owner's Name information is NORTH ANDOVER MA required for every page. Cityrrown State D. System Information (cont.) Type: ❑ leaching pits ❑ leaching chambers ❑ leaching galleries ❑ leaching trenches ® leaching fields 01845 6/26/15 Zip Code Date of Inspection number: number: number: number, length: number, dimensions: 1) 15'X 60' ❑ 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.): SOILS DRY. NO SIGN OF HYDRAULIC FAILURE, VEGETATION NORMAL. Cesspools (cesspool must be pumped as part of inspection) (locate on siie 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 15ins • 3/13 ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 1459 TURNPIKE ROAD Property Address KEVIN DUBE Owner Owner's Name information is NORTH ANDOVER required for every page. Cityfrown MA 01845 State Zip Code 6/26/15 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 • 3/13 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1459 TURNPIKE ROAD Property Address KEVIN DUBE Owner Owners Name information is required for every NORTH ANDOVER MA 01845 6/26/15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately tSns • 11He 7fBe BMW Uspeetlen Foam: Subsudm SwAso Dbo" Sniem* Pace 15 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1459 TURNPIKE ROAD Property Address KEVIN DUBE Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 page. City/Town State Zip Code D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 52" feet 6/26/15 Date of Inspection 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: PREVIOUS TITLE - V Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: DATA FROM PREVIOUS TITLE - V IN WHICH JOHN SOUCY ESTABLISHED A GROUND WATER ELEVATION AND SHOWS SEPERATION BETWEEN BOTTON OF SYSTEM AND GROUND WATER.TITLE -V DATED 5/17/01. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 { Commonwealth of Massachusetts w Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form Not for Voluntary Assessments -« 1459 TURNPIKE ROAD Property Address KEVIN DUBE Owner Owner's Name information is NORTH ANDOVER MA 01845 6/26/15 required for every page. CitylTown State Zip Code Date of Inspt ^tion E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completeo ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attacher in : eparate file Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 t5ins - 3/13 • b Summary Record Card generated on 6/2212015 8:43:55 AM by Maureen McAuley Page 1 41 Town of North Andover Tax Map # 210-1073-0066-0000.0 Parcel Id 18179 1459 TURNPIKE STREET DUBE, KEVIN 1459 TURNPIKE STREET N. ANDOVER, MA 01845 :lass 101 Single Family Property Type 1 Residential !oning2 1 Residential Zoning3 1 Residential Size Total 1.06 Acres =Y 2015 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until RUBE, KEVIN Payor 1459 TURNPIKE STREET N, ANDOVER, MA )1845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id, 13219.0 -1459 TURNPIKE STREET Last Billing Date 6/4/2015 2100007 02 Cycle 02 Active UB Services Maint. Account No. 2100007 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 49.40 /1 UB Meter Maintenance Account No. 2100007 Serial No Status Location Brand Type Size YTD Cons 16335732 a Active ERT NEPTUNE NEPTUNE w Water 0.63 0.63 366 Date Reading Code Consumption Posted Date Variance 5/1/2015 704 aActual 13 6/22/2015 -7% 2/4/2015 691 a Actual 15 3/20/2015 13% 11/4/2014 676 aActual 13 12/15/2014 -1% 8/6/2014 663 aActual 13 9/11/2014 7% 5/9/2014 650 a Actual 13 6/12/2014 -14% 2/3/2014 637 a Actual 15 3/17/2014 25% 11/1/2013 622 aActual 11 12/20/2013 4% 8/7/2013 611 aActual 12 9/18/2013 -1% 5/1/2013 599 aActual 11 6/18/2013 21112013 588 a c ua 13 3/13/2013 4% 10/30/2012 575 a Actual 12 12/13/2012 -6% 8/1/2012 563 a Actual 13 9/26/2012 -2% 5/1/2012 550 a Actual 13 6/20/2012 11% 2/1/2012 537 a Actual 12 3/14/2012 17% 11/1/2011 525 aActual 10 12/15/2011 -54% 8/3/2011 515 a Actual 22 9/14/2011 103% 5/3/2011 493 a Actual 10 6/13/2011 -5% 2/7/2011 483 a Actual 12 3/15/2011 3% 11/2/2010 471 aActual 11 12/13/2010 -37% 8/2/2010 460 a Actual 17 9/13/2010 60% 5/5/2010 443 a Actual 11 6/9/2010 9% 2/2/2010 432 aActual 10 3/11/2010 -18% 11/3/2009 422 aActual 12 12/11/2009 16% 11 9/11/2009 -45% 8/5/2009 410 aActual 5/1/2009 399 a Actual a, 19 6/16/2009 20% 1/30/2009 380 aActual /a• 15 3/16/2009 46% 11/5/2008 365 aActual (j f�'3 11 12/10/2008 -28% 8/512008 354 a Actual L�> 16 9/12/2008 -11%16 16 6/18/2008 40% 5/1/2008 338 aActual Iu� Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. tIQ ren Commonwealth of Massachusetts .I's SEPTIC & Ards 131 Forest Street Tale 5 Official Inspection Form MID(978) 7 , MA 0174-6685t 1� (978) 7 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1/2 1459 TURNPIKE ST.. NO. ANDOVER. MA 01845 Property Address KEVIN DUBE Owner's Name NO.ANDOVER City/Town MA 01845 State Zip Code 10/17/12 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. edit=ripe A. General Information 1. Inspector: JAMES H CURRIER Name of Inspector J'S SEPTIC & DRAIN Company Name 131 FOREST ST Company Address MIDDLETON City/Town 978-774-6685 Telephone Number B. Certification LN State S12327 License Number mmv 12 2012 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 01949 Zip Code 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 10/17/12 In ctor's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 2 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: SYSTEM WORKING PROPERLY. B) System Conditionally Passes: ❑ One or mo system components as described in the "Condition ass" section need to be replaced or r aired. The system, upon completio/Nfor cement or repair, as approved by the Board of H%expl ll pass. Check the box for o" or "not determined" (Y, Ne following statements. If "not determined," pleasn. The septic tank is metal and ver 20years old* or a septic tank (whether metal or not) is structurally unsound, exhibits s r tial infi on or exfiftration or tank failure is imminent. System will pass inspection if the existin nk is rep ced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspe o if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the to is le than 20 years old is available. ❑ Y ❑ N 0 ND (Explain t5ins - 1111D 'rile 5 Miicad inspection Foam. Subsuftue Sewage Disposal System • Page 2 of 2 Ts E DRAIN Commonwealth of Massachusetts Fo estStreet o Title a Official Inspection Farm MIDDLEtON, MA 019�b9 (978) 774-6685 o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1459 TURNPIKE ST., NO. ANDOVER, MA 01845 Property Address KEVIN DUBE Owner Owner's Name information is required for NO. ANDOVER MA 01845 10/17/12 every page. cityrrown state Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM WORKING PROPERLY. B) System Conditionally Passes: ❑ One or mo system components as described in the "Condition ass" section need to be replaced or r aired. The system, upon completio/Nfor cement or repair, as approved by the Board of H%expl ll pass. Check the box for o" or "not determined" (Y, Ne following statements. If "not determined," pleasn. The septic tank is metal and ver 20years old* or a septic tank (whether metal or not) is structurally unsound, exhibits s r tial infi on or exfiftration or tank failure is imminent. System will pass inspection if the existin nk is rep ced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspe o if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the to is le than 20 years old is available. ❑ Y ❑ N 0 ND (Explain t5ins - 1111D 'rile 5 Miicad inspection Foam. Subsuftue Sewage Disposal System • Page 2 of 2 Owner information is required for every page. Commonwealth of Massachusetts A SEPT 1C & DRNIN, 131 !sorest Street Title 5 Official Inspection Form �I��a 74-6685�4g Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1459 TURNPIKE ST., NO. ANDOVER, MA 01845 Property Address KEVIN DUBE Owner's Name NO. ANDOVER MA 01845 10177/12 Cityrrown State Zip Code Date of inspection B. Certification (cant.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the disAbution box due \to broken or obstructed pipe(s) or due to a broken, settled or uneven dist rtb on box. System will pass inspection if (with approval of Board of Health): broken pipe(s) are replaced ❑ Y ❑ N ❑ j>!f? (Explain below): ❑ obstructionis removed E]Y ElN ND (Explain below): Elistnbution box is leveled or replaced E] E] E]❑ ND (Explain below): ❑ The system required pum ' imore than 4 mes a year due to broken or obstructed pipe(s). The system will pass inspection t (with appro I of the Board of Health): ❑ broken pipe(s) are rept d ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluatio is Required by the Board of Health: ❑ Conditions exist bleb require further evaluation by the Board o Health in order to determine if the system is f fling to protect public health, safety or the environ ent. 9. System 11 pass unless Board of Health determines in acro ce with 390 CMR 15.303(9)( that the system is not functioning in a manner which wi rotect public health, satiety a 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 t5ins • 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 3 X% SEPTEC & f rau€ 131 Forest Stmt DLET01949 Commonwealth of Massachusetts MIt3(978 77 -6 85 -- - -- Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1459 TURNPIKE ST., NO. ANDOVER, MA 01845 Property Address KEVIN DUBE Owner Owner's Name information is required for NO. ANDOVER MA 01845 10117/12 every page. cityfrown State Zip Code Date of Inspection B. Cel" of ca$ion (cont) 2. System%enn fail unless the Board of Health (and Public Water Supplier, if any) determinest the system is functioning in a manner that protects the public health, safety and ironment: ❑ The syst has a septic tank and soil absorption system AS) and the SAS is within 100 feet o surface water supply or tributary to a surf water supply. ❑ The system s a septic tank and SAS and the SA s within a Zone 1 of a public water supply. ❑ The system has supply well. ❑ The system has a septic to more from a private water Method used to determine septic tank and SAS and and SAS and the toly well. / ** This system passes if the well water coliform bacteria indicates absent an to or less than 5 ppm, provided that o be attached to this form_ 3. Other: SAS is within 50 feet of a private water is less than 100 feet but 50 feet or performed at a DEP certified laboratory, for fecal ice of ammonia nitrogen and nitrate nitrogen is equal Lire criteria are triggered. A copy of the analysis must 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 ❑ 10 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 ❑ ❑ t than Y day flow t5ins • 11110 Title 5 Official fispecficn farm' Subsurface Sewage Disposal System • Page 4 of A Commonwealth of Massachusettsill's SEPTUC UC & DRAON 131 Forest Street Title 5 Official Inspection Form ��°°(9 8)7 �s5�4 Subsurface Sewage Disposal System form - Not for Voluntary Assessments 1459 TURNPIKE ST., NO. ANDOVER, MA 01845 Property Address KEVIN DUBE Owner Owner's Name information is required for NO. ANDOVER MA 01845 10117/12 every page. cityrrown State Zip Code Date of Inspection B. Certification (cc)nt.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipes). Number of times pumped: ❑ 0 Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑� Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ❑ 1 Any portion of a cesspool or privy is within 50 feet of a private water supply i� well. ❑ ❑ A 11 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 egnsidered a large system the systemmus erne a facility with a design flow of 10,000 gp 15,000 gpd. For large systems, you must indi=4of of the following, in addition to the questions in Section D. Yes No ❑ ❑ the systemrinking water supply ❑ ❑ the system is within 0 fee\Zone utary to a surface drinking water supply ❑ ❑ the system is to ed in a ninsitive area (interim Wellhead Protection Area — IWPA r a mapped f a public water supply well If you have answered "yes" #o y question in Section E the em is considered a significant threat, or answered "yes' in Section above the large system has fail The owner or operator of any large system considered a signqi&nt threat under Section E or failed un Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner shout ntact the appropriate regional office of the jApartment. tsins • 11110 Title 5 official inspection Form: Subsurface Sexage Disposal System • Page 5 of 5 Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Commonwealth of Massachusetts ❑ J's SEPTIC & DRAINI� ® ❑ Has the system received normal flows in the previous two week period? ❑ ® 131 Forest Street G Ti5 le Official Inspection Form �IO(978)07MA 4-558594g Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Was the facility or dwelling inspected for signs of sewage back up? 1459 TURNPIKE ST., NO. ANDOVER, MA 01845 Was the site inspected for signs of break out? M ❑ Were all system components, excluding the SAS, located on site? Property Address 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, KEVIN DUBE dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ owner Owner's Name information on the proper maintenance of subsurface sewage disposal systems? information is required for NO. ANDOVER MA 01845 10117/12 every page. c4frown State Zip Cade Date of inspection approximation of distance is unacceptable) [310 CMR 15.302(5)] 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? M ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 330 GPD t5ins • 11110 Me 5 Officiat Inspection Fort: Subsurface Sewage Disposal System - Page 6 of 6 Z"s SEPTOC & DRAM" Commonwealth of Massachusetts MiI�iKETf Morest A 01949 Title 5 Official Inspection Form (978:774-6685 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1459 TURNPIKE ST., NO. ANDOVER, MA 01845 Property Address KEVIN DUBE owner Owners Name information is uired far NO ANDOVER MA 01845 10/17/12 req every page- City/Town 1). System Information Description: 110 GPD X 3 BEDROOMS Slate Zip Code Date of Inspection Sump pump? ® Yes ❑ No Last date of occupancy: CURRENT Date Commercial/Industrial Flo Conditions: Type of Establishment: Design flow (based on 310 CMR .203): Gallons per day (gpd) Basis of design flow (sea#s/personsf e# . Grease trap present? ❑ Yes ❑ No Industrial waste holding tank prese ❑ Yes ❑ No Non -sanitary waste discharged the Title 5 sy ? ❑ Yes ❑ No Water meter readings, if t5ins - 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 7 Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [►f yes separate inspection required] [] Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 105.25 GPD Detail: Sump pump? ® Yes ❑ No Last date of occupancy: CURRENT Date Commercial/Industrial Flo Conditions: Type of Establishment: Design flow (based on 310 CMR .203): Gallons per day (gpd) Basis of design flow (sea#s/personsf e# . Grease trap present? ❑ Yes ❑ No Industrial waste holding tank prese ❑ Yes ❑ No Non -sanitary waste discharged the Title 5 sy ? ❑ Yes ❑ No Water meter readings, if t5ins - 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 7 D. System Information (cont.) Last date of occupancy/use: Date Other (describe below): General information Pumping Records: Source of information: LI=D 619/11 Was system pumped as park of the inspection? [j Yes ® No If yes, volume pumped: gations; How was quantity pumped determined? Reason for pumping: - Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins -111!0 Title 5 Urriciat inspeoHan Form: Subsurface Sswrdge Disposal System • ?ago 6 of 8 J's SEPTIC & DRAM Commonwealth of Massachusetts 131 Forest Street — � Title 5 Official Inspection Form �UiIDDLETON, MA 01349 (978)774-6585 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1459 TURNPIKE ST., NO. ANDOVER, MA 01845 Property Address KEVIN DUBE Owner owner's Name information is required for NO. ANDOVER MA 01845 10/97/12 every page• ciTyfrown state Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other (describe below): General information Pumping Records: Source of information: LI=D 619/11 Was system pumped as park of the inspection? [j Yes ® No If yes, volume pumped: gations; How was quantity pumped determined? Reason for pumping: - Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins -111!0 Title 5 Urriciat inspeoHan Form: Subsurface Sswrdge Disposal System • ?ago 6 of 8 J's SEPTIC & DRAOR Commonwealth of Massachusetts 131 forest str01 Mlr)t2LE70N, MA 01949 --- _ Title 5 Official Inspection Farm tg78)774-M o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1459 TURNPIKE ST., NO. ANDOVER, MA 01845 Property Address KEVIN DUBE Owner information is required for every page. Owner's Name NO. ANDOVER MA 01845 10/17112 Cityrrown State Zip Code Date of tnspection D. System Information (cont.) Septic Tante (cont.) Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 5"-66 Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? SLUDGE JUDGE Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): LIQUID LEVEL CORRECT, INLET AND OUTLET BAFFLES IN PLACE AND IN GOOD CONDITION PVC. TANK DOES NOT NEED PUMPING AT THIS TIME. Grease Trap (locate on site plan): Depth below gra Material of construct n: El concrete [ etas Dimensions: Scum thickness Distance from top of scum to Distance from bottom of r Date of last tDumnin feet El fiberglass ❑ polyethylene ❑ other (explain): outlet tee'ir baffle to bottom of outlet tebsor baffle tsins -11!10 Me 5 0ificial Inspection FDw Subsaffam Sewage Disposal System -Page 10 of 10 D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evil nce of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth be w grade: Material of ❑ concrete \ ❑ metal Dimensions: Capacity: Design Flow: Alarm present: Alarm level: Date of last pumping: Comments (condition of fiberglass ❑ gallons per day ❑ Yes ❑ No El other (explain).- gallons explain): Alarm in working order: ❑ Yes ❑ No and float svv tches, etc.): * Attp6h copy of current pumping contract (required). Is copy attached? ❑ l)s ❑ No tsins - 11110 Titfe 5 Official Inspection Fora: Subsurface Sewage Uisposal System • Page 11 of 73 j1% %E SC & DRAUK \ Commonwealth of Massachusetts 191 forest street `title 5 Official Inspection Form MA ��1 �' 949 Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments 1459 TURNPIKE ST., NO. ANDOVER, MA 01845 Property Address KEVIN DUBE Owner Owners Name information is required for NO. ANDOVER MA 01845 10/17/12 every page. c4frown 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, evil nce of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth be w grade: Material of ❑ concrete \ ❑ metal Dimensions: Capacity: Design Flow: Alarm present: Alarm level: Date of last pumping: Comments (condition of fiberglass ❑ gallons per day ❑ Yes ❑ No El other (explain).- gallons explain): Alarm in working order: ❑ Yes ❑ No and float svv tches, etc.): * Attp6h copy of current pumping contract (required). Is copy attached? ❑ l)s ❑ No tsins - 11110 Titfe 5 Official Inspection Fora: Subsurface Sewage Uisposal System • Page 11 of 73 _A Owner information is required for every page. Commonwealth of Massachusetts J's. SEPTIC & DRARM 131 Forest Street Title 5 Official Inspection Form °D 978) 774 -' 685 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1459 TURNPIKE ST., NO. ANDOVER, MA 01845 Property Address KEVIN DUBE owners Name NO. ANDOVER Cityrrown D. System Information (cont.) MA 01845 State Zip Code Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 10/17/12 Date of Inspection Comments (note if box is levet and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): BOX IS LEVEL AND WORKING PROPERLY, LIQUID LEVEL CORRECT, NO EVIDENCE OF CARRYOVER, BOX 24" BELOW GRADE. Pump Cham"r (locate on site plan): Pumps in working%order El Yes E] No Alarms in working ❑ Yes ❑ No Comments (note conditio €pump amber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: f5ins • 11/10 Trite 5 Official MsPeoffon Form: Subsurface Sewa a Disposal pnsal 6ystem •Page 12 of 12 D. System Information (cont.) Type: J's SEPTIC & DRAW leachinq pits Commonwealth of Massachusetts ❑ 131 Forest Street number. Title 5 Official Inspection Form MIDDLETOM, MA 01949 (978)774-6685 ❑ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ® 1459 TURNPIKE ST., NO. ANDOVER, MA 01845 number, dimensions: ❑ overflow cesspool Property Address ❑ innovative/alternative system KEVIN DUBE Owner Owner's Name information is required for NO. ANDOVER MA 01845 10117/12 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leachinq pits number: ❑ leaching chambers number. ❑ leaching galleries number: ❑ leaching trenches number, length: ® leachinq fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system ONE -15' X 60' Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SOILS DRY, NO SIGNS OF HYDRAULIC FAILURE, VEGETATION NORMAL. Cesspools (cesspool mush Number and configuration Depth — top of liquid to inlet Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction pumped as part of inspection) (locate on site plan): Indication of groundwater inflow f5ins - 11190 ❑ Yes ❑ No Trtfe 5 official tnsoutton Fong: Subwutrace Sewage Disposal System , Page 13 of 13 Owner information is required for every page. Commonwealth of Massachusetts S's SMIC & DOWN 131 Forrest Street Title 5 Official Inspection Fora WHO "LIoT0Id, Mel 01949 Subsurface Sewage Disposal System Fore - Not for Voluntary Assessments (97,S) 7N7. 5 1459 TURNPIKE ST., NO. ANDOVER, MA 01845 Property Address KEVIN DUBE Owner's Name NO. ANDOVER MA 01845 10/17/12 Cityrrown state Zip Code Efate of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 1 j Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note conditio/oSIDII, signs of etc.): failure, level of ponding, condition of vegetation, tSins - 11/10 Title 5 Official Inspection Form Subsurface Sewage Disposal System - Page 14 of 14 J's SEPTIC & DRAIN Commonwealth of MasSichusetts 131 Forest Street Title 5 Official inspection Farm MID 9 9) 7 6685 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1455 TURNPIKE ST-, NO. ANDOVER, NFA 01845 Pmp"A* ess KEVIN DUB€ ` owner owners Name irdbMaris regtdredf 1 NO-ANDOVER MA 01845 10117/12 r�equmed for every page. Citylrown sista Zip Code Date of hwpewan ----------- ---- - --- --- ID. 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. 19 hand -sketch in the area below M drawing attached separately met �� f Q 40r Sins • 1:110 Tina 5 MW Imedan Farm: Sttbsudaoe Sewage Dfspos8l SYMM • Pap 15 of 16 Owner information is required for every page. J's SEPTIC & h,0 Commonwealth of Massachusetts 131 Forint street Title 5 Official Inspection For 1 � 0� �kQA 949 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1459 TURNPIKE ST., NO. ANDOVER, MA 03545 Property Address KEVIN DUBE Owner's flame NO. ANDOVER MA 01845 10/17/12 Cityrrown state Zip Code Date of Inspection D. Systema Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 52" FROM SILL feet Please indicate all methods used to determine the high ground water elevation: /0 Obtained from system design plans on record If checked, date of design plan reviewed: PREVIOUS TITLE V Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: Checked with local excavators, installers - (attach documentation) Accessed USGS database explain: You must describe how you established the high ground water elevation: DATA FROM PREVIOUS TITLE V SHOWS JOHN SOUCY ESTABLISHED GROUND WATER ELEVATION BY AUGERING HOLES_ TITLE V DATED 5/17/2001. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins -11110 Rile 5 Officiat Inspection Forth, Subsurface Sewage Disposal System • Page 16 of 16 ® Inspection Summary_ A. B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 11110 Title 5 Official Inspection Form: Subsurface Sewatte Disposal System • Pape 17 of 17 Commonwealth of Massachusetts J'S SEPTIC & DRAD Y Title 5 Official Inspection Form 131 Forest street MIDDLETON, MA 01949 (978) 77466$5 Subsurface Sewage Disposal System Foran - Not for Voluntary Assessments 1459 TURNPIKE ST., NO. ANDOVER, MA 41845 Property Address KEVIN DUBE Owner Owner's Name information is required for NO ANDOVER MA 01845 10/17/12 every page. Cityrrown state Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary_ A. B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 11110 Title 5 Official Inspection Form: Subsurface Sewatte Disposal System • Pape 17 of 17 Commonwealth of Massachusetts m` � '�� DRAIN Title 5 Official Ing �s� Forest MA I�IDI�I_�I`ol�l, f<�A Qt9d�� (97&} 7'7, t� �� Not for Voluntary Assessments � ov Subsurface Sewage Disposal System Form U Inspection results roust be submitted on this form or on the official Title 5 inspection Form dated 611512000. Inspection forms may not be altered in any wa A. Certification RECEIVELl ImpoWhen filling JUN 2 5 2007 When filling out '€ . Property Information: forms on the computer, use 1459 TURNPIKE ST., NO. ANDOVER, MA 01945 only the tab key Property Address 11 VVNU1-NUK1HAKD0VE-R-- to move your JENNIFER DUSE HEALTH DEPARTMENT cursor - do not Owner's Name use the return key. 1459 TURNPIKE_ ST. w- Owner's Address '01 NO. ANDOVER MA 01845 y �� CityiTown State Zip Code -------- Y 6/14/07 Date of Inspection: Date — -- 2. Inspector: JAMES H. CURRIER 11 — Name of Inspector -'--- - - - J's SEPTIC & DRAIN Company Name - 131 FOREST ST. Company Address -------- -� - - MIDDLETON MA 01949 CFty(t awn state Zits Code 978.774-6685 Telephone Number Certification Statement: I certify that I have personally inspected the ;sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection- The inspection was Performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: 0 Passes ❑ Conditionally Passes ❑ Fails ❑ N s Further Eva cation by the Local Approving Authority _ 6/14/07 Ins or'sSign re Date ----- he system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 flays 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 V.doc • 11!2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System . Page 1 of 16 e Cora monwealth of Massachusetts Title 5 OfficialInspection Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.1, 1459 TURNPIKE ST. Property Address NO.ANDOVER Cityrrown JENNIFER DUBE Owner's Name 131 Forest Street %/IDDLErON, MA 0194' (978) 774-66Sr MA €}'1845 State Zip Code 6/14/07 _ Date at Inspection 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 CRR 15.303 or in 310 UAR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM WORKING PROPERLY B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaceor repaired. The system, upon completion of the replacement or 1r, as approved by the Board Health, will pass. Answer yes, no or\metand (Y, N, ND) in the ❑ for the foil ng statements. if "not determined," pleas ❑ The septic tanover 20 years old* or a septic tank (whether metal or not) is structurally unsubstantial infill norexfiltration or#ank failure is imminent. System will pathe existing # is replaced with a complying septic tank as approved by the Board of Heal k A metal septic tank will pass inV66kn if it is structurally sound, not leaking and if a Certificate of Compliance indicating thatXe tank is ss than 20 years old is available. ND Explain: Title V.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts a Title 5 Official Inspection Form�1D131 orate ecj- . Not for Voluntary Assessmentsfs7,9) 774_t,C%-�� ` Subsurface Sewage Disposal System Form A. Certification (cont.) 1459 TURNPIKE ST. Property Address NO.ANDOVER City/Town JENNIFER DUBE Owner's Name B) System Conditionally Passes (cont.): MA State 5!14/07 Date of inspection 01845 Zip Code ❑ Obse ationof sewage backup or break out or high static water level in the distribution box due to broke or obstructed pipe(s) or due to a broken, settled or uneven distribution box. Systems will pass insp ion if (with approval of board of Health): F-1brokenipe(s) are replaced ❑ obstruction -is removed ❑ distribution box' leveled or replaced ND Explain: ❑ The system required pumping more th 4 times ear due to broken or obstructed pipe(s). The system will pass inspection if (with appr al of I a Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain. C) Further l_valuattii 6 is Required by he Board of Health: ❑ Conditions exi which require further evaluation by the Board\wetfandor der to determine if the systema i failing to protect public' health, safety or the env 1. Syst well pass unless Board'of Health determines iith 310 CMR 15.303 )(b) that the system is notfunctioning in a mannetect public health, safer and the environment: f Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering veger a s marsh Title V.doc - 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 16 Commonwealth of 'Massachusetts. -- Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 1459 TURNPIKE ST. Property Address NO.ANDOVER Citylrown JENNIFER DUBE Owner's Name MA state 6114/07 Date of Inspection 's SEPT[C 6'k DRA 131 Forest Street MIDDLETON, MA 0194 (978) 774. 555 01845 Zip Code C) Further Evaluation is Required by the Board of Health (cont.). 2. Systei will fail unless the Board of Health (ands Public Water Supplier, if any) determines hat the systema is funictioning in a manner that protects the public W safety and a ironment: ❑ The syst has a septic tank and soil absorption system (SAS) and e SAS is within 100 feet of surface water supply or tributary to a surface water pply. ❑ The system has a tic tank. and SAS and the SAS is wit a Zone 1 of a public water supply. ❑ The system has a septic supply well. ❑ The system has a septic tank and more from a private water supply // Method used to determine di'snr SAS and theAS is within 50 feet of a private water and the SAS is fess than 100 feet but 50 feet or * This system passes if the well ater analysis, perfarNcop P certified laboratory, for coliform bacteria and volatile ganic compounds in well is free from pollution from that facility and the presen of ammonia nitrogen andgen is equal to or less than 5 ppm, provided that no oth failure criteria are triggerethe analysis must be attached to this form. 3. Other: Title V.doc • 11 I2004 Title 5 Official inspection Fonn: Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts P SEFT&t Fills Official Inspection Form 1101 DLETf�Nsf Street f, 01949 Not for Voluntary Assessments t9i�> ��-��81-�' Subsurface Sewage Disposal System Form A. Certification (cont.) 1459 TURNPIKE ST Property Address — NO. ANDOVER MA 01845 City/Town State ZipCode ---~ JENNIFER DUBE 6/14/07 Owner's Name Date of Inspection D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No F ® 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 ❑ ❑ Ips N Liquid depth in cesspool is less than 6" below invert or available volume is less than Y 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. ❑ ❑ 9t 6 Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ❑ �,A Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑ l 1 � 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.weli is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must: be attached to this forma Yes No ❑ 0 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. Title V.doc • 11 /2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 16 Commonwealth of Massachusetts Fite ficial Inspection Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 1459 TURNPIKE ST. Property Address _ NO.ANDOVER _ Cityfrown JENNIFER DUSE Owner's Name MA State 6/14/07 " SEPTIC & D At Form 131 Forest Street �H f IDDLETON, MA 01949 (978) 774-6685 Date of Inspection 01845 Zip Code E) Large Systerns: o be considered a large system the system mast sere a facility with a design flow of 10,000 d to 15,000 gpd. For large systems, you mu dicate either "yes" or "no" to each of t owing, in addition to the questions in Section D. YES NO ❑ ❑ the system is within 400 of a surface drinking water supply El 1:3 the system is with" ` 00 feet o tributary to a surface drinking water supply ❑ ❑ the system i ocated in a nitrogen nsitive area (Interim Wellhead Protection Area — WA) or a. mapped Zone II ofvpubliG water supply well If you have answered "y to any question in Section E the syst is considered a significant threat, or answered "yes" in ction D above the large system has failed. T �siorn( r operator of any large system considers significant threat udder Section E or failed undeD shall upgrade the system in acco ance with 310 CMR 15.304. The system owner shout the appropriate regional off06 the Department. T itle !l.doc - 1 112004 Title 5 Official inspection Form: Subsurface Sewage Disposal System Page 6 of 16 0 Commonwealth of. Massachusetts J'.% SEPTIC & D H �— �+ �+ 131 Forest Street Title Official Inspection Form f IDDLEON, WA 01949 _ Not for Voluntary Assessments (978) 774-6685 Subsurface Sewage Disposal System Form B. Checklist 14_59 TURNPIKE ST. Property Address NO. ANDOVER MA 01845 City/Town State Zip Code JENNIFER DUBE 6114107 Owner's Name Date of Inspection _� _ Check if the following have been done. You must indicate "yes" or "no' as to each of the following: YES NO ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® 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 NIA) R ❑ 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 Soii 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(3)(b)] Title V.doc • 1112004 Title 5 Official Inspection form: Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts T' s SEMC & DRAM - Till 5 Oficial Inspection Foy 131 Forest street. DL MID(, ETON AAo1949 - - _ Not for Voluntary Assessments 78) 774-�68'"s Subsurface Sewage Disposal System Form C. System Information 1459 TURNPIKE ST, Property Address NO. ANDOVER MA 01845 _ City/Town State Zip Code JENNIFER DUBE 5/14107 Owner's Name gate of Inspection Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 - DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 330 GPD Number of current residents: 3 - 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? fV/F1 Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 83.85 GPD Sump pump? ® Yes ❑ No Last date of occupancy: CURRENT Date Corm►er ial/Industrial Flow Conditions: Type of Establi ent: - — Design flow (based on 0 CMR 15.203): Gallons per day (gpd) V - Basis of design flow (seats/pe s/sq.ft, etc.): -- -- Grease trap present? ❑ Yes [] No Industrial waste holding tank present? F-1 Yes ❑ No Non-sanitary waste discharged to the Title 5 syst ❑ Yes ❑ No Water meter readings, if available: - Last date of occupancy/use: Date Other (describe): — Title V.doc • 11/2(;04 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts u ----� File 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 1459 TURNPIKE ST. Property Address -- — NO.ANDOVERA Ciiy/Town State JENNIFER DUBE 6/14107 Owner's Name r,�►a „f ,, �. , , Ys SEPM & DRQ 131 Forest Street MIDDt 7(T, lsA 0194 01845 Zip Code General Information Pumping Records: Source of information: OWNER - LAST PUMPED 2003 Was system pumped as part of the inspection? U� Yes ❑ No If yes, volume pumped: 1000 GAL. --- gallons How was quantity pumped determined? L X W X D X7.5 Reason for pumping: REGULAR MAINTENANCE Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Over#iow 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 describe): Approximate age o€ all components, date installed (if known) and source of information: REPAIR DONE 1991 Were sewage odors detected when arriving at the site? ❑ Yes M No Title V.doc 1112004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 9 of 16 Title V.doc • 11/2004 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System information (cont.) 1458 TURNPIKE ST. Property Address NO.ANDOVER City/Town _ JENNIFER DUBE Owner's Name 0 state 6/14/07 nate of Inspection X6 SEPT[C & DRI 131 Forest Street MIDDLETON, MA 019, (978) 774-6685 01845 Zip Code (Building Sewer (locate on site plan): Depth below grade: 6" feet _ -- Material of construction: cast iron 40 PVC [j other (explain): — — Distance from private water supply well or suction line: 22` FROM PUBLIC WATER feet Comments (on condition of joints, venting, evidence of leakage, etc.): JOINTS LOOK GOOD Septic Tank (locate on site plan): Depth below grade: � feet —�—"— Material of construction: ® concrete Q metalF1 fiberglass ❑ polyethylene Q other (explain] If tank is metal, list age: _ _ _-- Is age confirmed by a Certificate of Compliance? (attach a copy years of certificate) Yes Q No Dimensions: G DIAMETER Sludge depth: 8" ------_- Distance from top of sludge to bottom of outlet. tee or baffle 12" Scum thickness 1., _ Distance from top of scum to top of outlet tee or baffle 61' - Distance from bottom of scum to bottorni of outlet tee or baffle 21" How were dimensions determined? SLUDGE JUDGE & TAPE MEASURE Title 5 Official Inspection Form: Subsurface Senvage Disposal System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection For Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 1459 TURNPIKE ST. 's SEPTIC & DRA 131 Forest Street MIDDLE€Qin, IMA 0194 (978) 774-568E, napery Haaress __--.— NO. ANDOVER_ MA D184 S CityiTown State-- Zip Code JENNIFER DUBE 6/14/07 Owner's Mame -- Date of Inspection Comments (ora pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): BOTH BAFFLES PREVIOUSLY REPLACED WITH PVC TEES. OUTLET BAFFLE WAS PLACED 1/2 WAY BETWEEN CENTER COVER AND OUTLET COVER. OUTLET TEE IS A LITTLE LONG. TANK SHOULD BE PUMPED ONCE PER YEAR. Grease Trap (locate on site plan): epth below grade: Mat ial of construction: ❑ conc to ❑ metal ❑ fiberglass ❑ polyethylene er (explain): Dimensions: ' Scum thickness Distance from top of scum tt Distance from bottom of scum Date of last pumping: Comments (on pumping recom liquid levels as related to outlet Tight or Holding Depth Xete Materi ❑ con of outlet tee oZor ottani of out Date 6�e and outlet tee or baffle condition, structural integrity, € leakage, etc.): (tank must be pumped at time of insp tion) (locate on site plan): On: ❑ metal ❑ fiberglass ❑ polyethylene y El other (explain): Title V.do - 1112004 Title 5 Official Inspection Form Subsurface Sewage Disposal System - Page 11 of 16 Commonwealth of Massachusetts h -- -i Tile 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System information (cont.) 1459 TURNPIKE ST. _ Property Address NO. ANDOVER,q Citytrown State JENNIFER DUBE _6/44/07 Owner's Name Date of Inspection Tight or reg Tank (cont.) Dimensions:_ -- Capacity: gallons Design Flow: gallons per day ... Alarm present: ❑ Yes ❑ No Alarm level. - Afar in working order:. Date of last pumping: Date Comments (con " on of alarm and float switches, etc.): J's SEPTIC & DRAIN 131 Forest Street MIDDLETON, 1!!!A 01949 (978) 774-058 01845 Zip Code ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0-- – - ----- -------.— Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): AS PART OF TITLE V INSPECTION, WE REPLACED D -BOX Pump Chamber (locate on sl Ian): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Title V.doc • 1112QU4 Title S Official Inspection Form: Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts, Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form System t;. bystem intormation (cont.) 1459 TURNPIKE ST. -VrOpe�� Address-—'----- NO. ANDOVER 64—rrown JENNIFER DUBE �6-w—ne Cs dame Comments (note condition of pump chaNber MA State 6/14/07 01845 Zip Code Date of Inspection on of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required), If SAS not located, explain why: Type: El leaching pits number- ❑ leaching chambers number: ❑ leaching galleries number., ❑ leaching trenches number, length: leaching fields number, dimensions: El overflow cesspool number: El innovative/aftemative system Type/name of technology; (1) 15- X 60- 900 SO. FT. Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp Soil, condition of vegetation, etc.": ALL VEGETATION LOOKS NORMAL, SYSTEM WORKING PROPERLY, NO SIGNS OF HYDRAULIC FAILURE. Title V.doc - 1112004 Title 5 Official Inspection Form: Subsurface Seviage Disposal System - Page 13 of 16 w Fallsffic'i '�a �� XS SEPTIC �� Frest DOR Not for Voluntary Assessments Street131 MIDDLETON MA 019'49 Subsurface Sewage Disposal System Form `�� ?��-�F C. System Information (cont.) 1459 TURNPIKE ST. Property Address --- NO. ANDOVER NIA Cr�yrtawn � 01 X45 state JENNIFER DUBS 6/14107 Zip code Owner s Name Date of inspection Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells Locate where public water supply enters the building. within 100 feet. Title V.doc - 11/2004 �d. ;i* " bJW s� _ 4P 26 O .I--- - ____ — _ .._. Title 5 Official inspection Form: Subsurface Sewage Disposal System Page 15 of 16 Ville 5 Official Inspection Forms SEPTIC & �� 131 Forest Street NIIDDLETON, (VfA 01949 Not for Voluntary Assessments tsps} 7i4-6685 Subsurface Sewage Disposal System Form C. System Information (cont.) 1459 TURNPIKE ST. Property Address _NO. ANDOVER MA 01545 City(Town State --- Zip Code JENNIFER DUBE 6/14107 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: sl?'/ ;5;eo/rc /a P 0 F S'LL 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: TITLE V 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 USOS database - explain: You must describe how you established the high ground water elevation: DATA FROM EARLIER REPORT DONE BY JOHN SOUCY DATED 5/17/01 _ Title V.doc • 11 MG4 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 16 of 16 „oRTy Commonwealth of Massachusetts Map -Block -Lot hyo 107.B- 0066 - x`g OL ----------------------- Board --------------- Board of Health Permit No ' r BHP-2oo7-o17s North Andover `�,,ti:.. .. •`` P.I. FEE ,SSAcuuSE�� F.I. Disposal Works Construction Permit Permission is hereby granted James H. Currier to (Repair -D -BOX) an Individual Sewage Disposal System. at No 1459 TURNPIKE STREET as shown on the application for Disposal Works Construction Permit No. 13HP-20077017 Dated June 13, 2007 �_ _ _.�-------------------- Issued On: Jun -13-2007 f rd�-L E --- Issued of Health --------------------------------------------------------------------------------- 0 p"ppT" Application for Septic Disposal System pConstruction Permit -TOWN OF ` ORTH ANDOVER, MA 01845 SSACHUSti Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. VQ Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system* -,11"41e TODAY'S DATE �S9 00 —Full Repair $125.00 - Componen ❑ R air or replace an existing on-site sewage disposal system* b/Repair or replace an existing system component — What? D A. Facility Information r". /_ Address or Lot # City/Town 2.- *TYPE OFOPTIC SYSTEM*: ZIf p Gravity (choose one) pump system, attach copy of electrical permit to application***entional System (pipe and stone system) ❑ 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 Z&o /1 i 7.r"— V v Name Address (if different from above) City/Town Installer Information State Telephone Number Zip Code Name Name of Company Address Cityrrown State Zip Coddee�� Telephone umber (Cell Pho�lClible please) 4. Designer Information Name Address City/Town Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit - Page 1 of 2 N°RTN q�0 Application for Septic Disposal System pConstruction Permit - TOWN CSF ..+%NORTH ANDOVER. MA 01845 PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: 221/:,'esidential Dwelling or ❑Commercial B. Agreement TODAY'S DATE_ $ 250.004" Full Repair+ $125.00 - Component The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation until a Certificate of Compliance has been i sued by this B and of Health. 14*"e Date T Application Approved By: (Board of Health Representative) Name Date Application Disapproved for the following reasons: For Office Use Only: 1. Fee AttachedP Yes 2. Project Manager Obligation Form Attached. Yes 3. Pump Ss� tem? If so, Attach copy of Electrical Permit Ycs 4. Foundation As -Built? (new construction ronly): Yes (Same scale as approved plan) 5. Floor Plans? (new construction only): Yes No No No No Application for Disposal System Construction Permit • Page 2 of 2 o- SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS dow As the North Andover licensed installer for the construction for the septic system for the property at: (Address of septic system) Relative to the application of,.n (Installer's name) Dated % o ay s ate For plans by And dated With revisions dated I understand the following obligations for management of this project: (Engineer) ngtna ate (Last revised date) 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans rior to performing any work on a site. I must have the approz ved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and allinspections. If homeowner, contractor, project manager, or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that reauestinLy an inspection, without comnletion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or my company a. Bottom of Bed — Generally, this is the first (1s) inspection unless there is a retaining wall, which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection — Engineer must first do their inspection for elevations, ties, etc. As -built of verbal OK (or e-mail to: healthdept(2townofnorthandover.com) from the engineer must be submitted to the Board of Health, after which.installer calls for an inspection time. Installer must be present for this inspection. With a pump system, all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade — Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation) and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board ofHealth staff of consultant. d. Installation of tank, D -Box, pipes, stone, vent, pump chamber, retaining wall and other 6. components. As the installer, understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: 5 eel 4� (Name — not =r -�3 F ,, p'tt�ec ,es•~�O 0 ' {.•- 1e A �t _ ��p_ cec.�uiww�c■ _ 1• PUBLIC HEALTH DEPARTMENT Community Development Division 1z ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: MAP: LOT: 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 � ❑ Exit g septic tank properly abandoned ❑ Internahplumbing all to one building sewer ❑ Comments: Topograp�& not appreciably altered SEPTIC TANK \ ❑ Bo ti m of tank hole has 6" stone base ❑ Wee ole plugged ❑ 1500 g on tank has been installed ❑ Monolithic construction H-10 loa in\ssof Water tightk has been achieved (Visual or stor Water held for 24hrs) ❑ Inlet tee intered under access port ❑ Outlet tee or effluent filter) installed, centered us port 1600 Osgood Phone 978.688.9540 Street, North Andover, Massachusetts 01845 Fax 978.688.8476 Web www.townofnorthandbver.com u Comments: PUMP CHAMBER Comments: DISTRIBUTION -BOX Comments: PUBLIC HEALTH DEPARTMENT (ommunity Development Division ❑ 24" inch cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present ❑ Hydraulic cement around inlet & outlet ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ Combo Tank installed. Size: ❑ 1000 gallon Pump Chamber installed H-10 loading Monolithic construction) ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ 24" inch cover to within 6" of final grade installed over pump access port ❑ Water tightness of tank has been achieved Visual testing ❑ Hydraulic cement around inlet & outlet Installed on stable stone base Inlet tee (if pumped or >0.08'/foot) El Hydraulic cement around inlet & outl is Observed even distribution ®i Speed levelers provided (not required) 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com pORTH OL O I- 'A � O� cecw[�wnca . 1• PUBLIC HEALTH DEPARTMENT Community Development Division SOIL ABSORPTION SYST (General) ❑ Bottom of SAS excavated down to 6 in into C soil layer, as provided on plan ❑ Size of SAS excavated as per plan E] Title 5 sand installed, if specified on plan ❑ 0 Mil HDPE barrier installed ❑ detaining wall (boulder / concrete / timber/ block) ❑ Final cover as per plan Comments: \ SOIL ABSORPTION SYSTEM (Gravel less Chambers) ❑ Brand nd Model of Chamber Infiltrator Quick 4 ❑ Numbe of chambers per row 9 ❑ Number f rows (trenches) 3 El Laterals i stalled and ends connected to header (and Comments: CONTROL PANEL Comments: vented if i pervious material above) ❑ Elevations f laterals and chambers installed as on approved pl n ❑ Alarm & Pump re on separate circuits ❑ Alarm sounds w en float is tripped ❑ Location of contr I panel: El Rated for exterior 'f placed outside ❑ Alarm signal locat inside 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Niqr PUBLIC HEALTH DEPARTMENT Community Development Division SYSTEM ELEVATIONS INVERT INFIELD PLAN INVERT ELEV. Benchmark Building Sower OUT Septic'ank IN Septic Tan OUT Pump Chamber; IN Pump Chamber OUT Distribution Box I Distribution Box OUT Lateral 1 INV Lateral 1 TOP Lateral 2 INV Lateral 2 TOP Lateral 3 INV Lateral 3 TOP Lateral 4 INV Lateral 4 TOP 4 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com 0 No v tt`eV ,6'aryO\ o r► SAS Sewer ❑ operty line 10 PUBLIC HEALTH DEPARTMENT Community Development Division CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA S.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 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com 5 Tank SAS Sewer ❑ operty line 10 10 -- ❑ Ce r wall 10 20 -- ❑ Ingro d pool 10 20 -- ❑ Slab fou dation 10 10 -- ❑ Deck, on ootings, etc 5 10 -- ❑ Waterline 10 10 101 ❑ Private drinki .g well 75 1002 50 ❑ Irrigation well 75 100 ❑ Surface Water 25 50 ❑ Bordering Vegetate Wetland , Salt Marsh, Inland / oastal Banka 75 100 ❑ Wetlands bordering surf water supply or trib. (in Wa e shed) 150 150 ❑ Trib. to surface water supply 325 325 ❑ Public well 400 400 ❑ Interim Wellhead Prot. Area ❑ Reservoirs X00 400 ❑ Drains (wat. supply/trib.) 5 100 ❑ Drains (intercept g.w.) 25 50 ❑ Drains (Other) Foundation 10(5) 20 (10) ❑ Drywells 20 25 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA S.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 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com 5 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: No. a _ Owner's Name: Owner's Address: f ib • A,,. � na. iul � Date of Inspection: 5 / / / )l Name of Inspector: (please print) -ag ,,, . T. x,41 r Company Name: _QfmtuS QP�laor ger-, r o Mailing Address: g3oVy;noSs%.. S *q Telephone Number: _9W - gsi-gg39 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: Passes Conditionally Passes !!ds Further valuation by the Local Approving Authority Inspector's Signature: Date: —p The system inspector shall subm a copy of this/pectionXrt to the Approving Authority (Board of Health or DEP) within 30 days of comple g 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. TOIWN OF NORTH ANDOVER Notes and Comments i BOARD OF HEALTH JUN {3 ****This report only describes conditions at the time of inspection and under the cbndil tons of use at that time. This inspection does not address how the system will perform in the future under conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: $1 i�, q� . �` Ma Owner: 22i u Date of Inspection: — Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A,stem Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ND explain: broken pipe(s) are replaced obstruction is removed 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: -q5q Owner:��,�� Date of Inspection: 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(lxb) 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 .0 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered: "A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:1y� T(,froia �. Owner: YM Date of Inspection: 5 1 D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes Nf ZV 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''/: day flow _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓\ Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] tDQ-)_ (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 `bo" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no — _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: A6q r Owner•CzEd IL 3 Date of Inspection: 3-) ) -) 01 Check if the following have been done You must indicate "yes" or "no" as to each of the following Ye No _. Pumping information was provided by the owner, occupant, or Board of Health _ Were any of the system components pumped out in the previous two weeks ? _ 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 ? -�Z _ Were all system components, excluding the SAS, located on site ? VWere the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the bathes or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? -Z _ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no/ ✓ Existing information. For example, a plan at the Board of Health. zDetermined 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)j Page 6 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: jq!;7-9 7f - Owner: Owner• Date of Inspection: s/ 13 %Q / RESIDENTIAL FLOW CONDITIONS 2 Number of bedrooms (design):..L Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: [ Q Does residence have a garbage grinder (yes or no): N Is laundry on a separate sewage system s or no):_tTO [if yes separate inspection required] Laundry system inspectedes or no): Seasonal use: (yes or no): 1O Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or no): Last date of occupancy: COMMERCIAL/INDUSTRIAL I Type of establishment: Design flow (based on 310 CMR 15.203): end Basis of design flow (seats/persons/sgtetc.): 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.: OTHER (describe): GENERAL INFORMATION PumpingRecords Source of information: �Mn , ,� ieQ ICA 9j Was system pumped as part of the inspection (yes or no): If yes, volume pumped:gallons — How was quanti pupumped determined? Reason for pumping: ` cn. TY r r SYSTEM eptic tank, distribution _ Single cesspool _ Overflow cesspool Privy box, soil absorption system _ 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): age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site (yes or no): *)0 Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: A1,519 Owner: Date of Inspection: T"— BUILDING SEWER (locate on site plan) Depth below grade: y� Materials of construction: _cast iron 40 PVC _other (explain): _ Distance from private water supply well or suction line: la Comments (on condition of joints, venting, evidence of leaks e, etc.): SEPTIC TANK: Zoocate on site plan) Depth below grade: S' Material of construction: =✓ oncrete metal _fiberglass _polyethylene _other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) I II Dimensions: _ (o cli f,;,M Sludge depth: a'" /I Distance from top of sludge to bottom of outlet tee or baffle: 37 Scum thickness: 1_ Distance from top of scum to top of outlet tee or baffle: $_ Distance from bottom of scum to bolt m of outlet tee or b e• y �� How were dimensions determined: at Comments (on pumping recommendation §, inlet and outlet tee olkaffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): GREASE TRAP:.00cate on site plan) Depth below grade: _ 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: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: - ) Owner: Date of Inspection: -//3 Ia 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: eallons Design Flow: aallons/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: Zifpresent 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 leakagg into or out of box_ etc _)• PUMP CHAMBER: ±50cate on site 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.): Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: IgS'9 T�.f.,A,�a Owner•W. r- k4a Date of Inspection: -K// 3 /) 7 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) 9 ) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: aching trenches, number, length: leaching fields, number, dimensions:- overflow cesspool, number:TT— innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.):, CESSPOOLS: cesspool must be pumped as part of inspection)(locate on site'plan) P ) 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: V111(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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: )qeV -rar-^ . i'o -:a Owner: �(Yi,D-. 'Q�� - -_ g, a Date of Inspection:�/? /D 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. Ho 10 3G, ao. Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Y4TO MIQO.r M4 Owner S Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells ' Estimated depth to ground water a oP .bw (;vrft 46p $00) Please indicate (check) all methods used to determine the hitgh ground water elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: ^Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked with local excavators, installers- (attach documentation) Accessed USGS database -explain: ou must describe how you established the high, ground water 11 -MAKE PAYMENTS TO TOWN OF NORTH ANDOVER 18586 TOWN.OF NORTH ANDOVER 1 2001 WATER/SEWER BILL CYCLE #32 ULL BMWE83/27/2001 r x x< P.O. Account: 2100007 x CHARLE/�S��EN� Ar Meter: 2100007 ;.. CpLIELIIIIC Service: 1459 TURNPIKE ST RICHARDS, WILEY 1459 TURNPIKE STREET N. ANDOVER MA`°01845 Retain this v ouch er f or records ecor ds VIIII VIII IIIiI IIS II I� III ql� I IIS qlp q�l nlll SII III IIII qlp Ilq Ilgl � VIII � q� DETACH —la anu return tine Dottom voucher with your payment DETACH %F' TA1AER �P/0� BOX '324' v >n,?216 Orli, RICHARDS, WILEY 1459 TURNPIKE STREET N. ANDOVER MA 01845 TOWN OF NORTH ANDOVER 2001 WATER/SEWER BILL CYCLE #22 Retain this voucher for your records I IIIIIIII III ILII Hill 1111111111 111 111111111111111 In 10469 FALL 9MVSEA2/15/2000 Account: 2100007 Meter: 2100007 Service: 1459 TURNPIKE ST DETACH -- ,mew anti vaLurn tine oozLOm voucher with your payment DETACH MAKE PAYMENTS TO TOWN OF NORTH ANDOVER 3386 TOWN OF NORTH ANDOVCR 2001 WATER/SEWER BILL CYCLE #12 WL WMBE89/15/2000 P.O.; 80X1` v NO �'�ANDO • V�4`� Account: 2100007 ;,t y ROBERTAMeter: 2100007 N�fiiC Service: 1459 TURNPIKE ST N. ACTING ��{� 1Na RICHARDS, WILEY 1459 TURNPIKE STREET N. ANDOVER MA 01845 Retain this voucher for your records 1111111111111 IN11111III11111111111111111111IN11111111111111111111 I -01W YCbONl FWVV anu return the Dottom voucher with your payment DETACH MAKE PAYMENTS TO RICHARDS, WILEY 1459 TURNPIKE STREET N. ANDOVER MA 01845 TOWN OF NORTH VE 2000 WATER/SEWER BILLDCYCLE #42 9fi± '5T-96/15/20005 Account: 2100007 Meter: 2100007 Service: 1459 TURNPIKE ST Retain this voucher for your records IIIIIIII�IIIIIIIIII�IIIIIIIIIIIIIIIIIIIIII��II�IIIIIIIIIII�III�IIIIUlllllll�a ncraru DlaAea tiatArh hara AM ratiirn the hnttnm vrnirhPr with mir nAvm?nt DETACH MAKE PAYMENTS TO TOWN F NORTH OVE 2000 WATERC/SEWER BILLDCYCLE #32 �iE� �E�4/041661 /20000 j � e RICIIARDS, WILEY ,!ti �1,4 1459 TURNPIKE STREET ^_ N. ANDOVER MA 01845 Account: 2100007 Meter: 2100007 Service: 1459 TURNPIKE ST mclouill toM4 vuucner Tor your records %; IIIIIUIl11111111111111111111IN11111111111111111111111111111011 o,a Pa -1-11 wle voTTom voucner with your payment DETACH 570 1 `' i m TOWN OF NORTH ANDOVER Account # 0 od DIVISION OF PUBLIC WORKS -WATER & SEWER DEPARTMENT 6 Application for Abatement of Waatt%er/ wer Charges Dates. Water Current 3c 9 G A Q I Net Due , O Water Arrears Abate Net Due Sewer Current Abate Net Due Sewer No. Andover, MA 01845 MAKE PAYMENTS TO RICHARDS, WILEY 1459 TURNPIKE STREET N. ANDOVER MA 01845 10 �Re(, 3 (p Payable to the Town of North Andover, 120 Main St. TOWN NORTH VE 2000 WATERO/SEWER BILLL�CYCLE #22 MEL WjtjgE�1/18/20023 0 Account: 2100007 Meter: 2100007 Service: 1459 TURNPIKE ST Retain this voucher for your records BillDate: 04/14/99 Account #: 01-2281000-0 TOWN OF NORTH ANDOVER Bill #: 0009031 - Due Date: 05/14/99 Water and Sewer Bill ;:.. :.. :..:.:.: "•`{'C:�:i�ti:•}:/.^•.`v`{2:•ti.+;iri {iC•,:y? f.�.,4 \.• `Lr}:}Y�:i�.: ••i'3::^}., •:::'v>:.:.:: n:?:.;i.: �'•%�\ },tii+.t'�•., ., }},}i`inti/,.;:?}::•,::i:;}'r,:y;::5;:;{:`i,:;�i:}{:. Mtr Previous pmt Bill ... ID Date --ReadingDate ReadingCode Usage - Svc A . 143`J 1 UKN Water Sewer 001 11/30/98 236..2/05/99 255 EST. 19 $51.87 $0.00 $51.87 NEW WATER RATE IS $2.73 PER 100 CF. SEWER RATE REMAINS $2.75 PER 100 CF. UNPAID BALANCES WILL BE SUBJECT TO 14% INTEREST Previous Balance Penalty Charge Interest $0.00 $0.00 $0.00 Water and Sewer Bill Bill Date: 06/15/99 Bill #: 0009031 Account #: 01-2281000-0 Service Address: 1459 TURNPIKE ST Due Date: 07/15/99 Total Due: $51.87 Water Rate is $2.73 and $ewer Rate is $2.75 Per 100 CF. Unpaid balances will be subject to 14 % interest. A TOWN OF NORTH ANDOVER TREASURER -COLLECTOR'S OFFICE 120 MAIN STREET NORTH ANDOVER, MA 01845 Plesse include this portion with your payment Billing and Service Information: DEPARTMENT OF PUBLIC WORKS 384 OSGOOD STREET, NO. ANDOVER TEL: 978-688-9570 HOURS: MON-FRI 8:30 A.M.-4:30 P.M. Remit to: TOWN OF NORTH ANDOVER TREASURER -COLLECTOR'S OFFICE P.O. BOX 124, NO ANDOVER, MA 01845 HOURS MON-FRI 8:30 A.M. - 4:30 P.M. RICHARDS, WILEY 1459 TURNPIKE STREET N. ANDOVER MA 01845 MAKE, RAYMENTt! TO TOWN -OF N6RT�:"AND( P.O. RICHARDS, WILEY 1459 TURNPIKE STREET N. ANDOVER MA 01845 TOWN OF NORTH ANDOVER BILL NUMBER 2680 2000 WATER/SEWER BILL CYCLE #12 BILL DATE: 09/27/1999 Account: 2100007 Meter: 2100007 Service: 1459 TURNPIKE ST Retain this voucher for your records 11111111 IN 1111111111111111111111 11111111111 11111111111 Icuaw Uut-QUI F1CF'V anu return the Dottom voucher with your payment DETACH Bill Date: ol/0 6)99 Bill #: 0009031 TOWN OF NORTH ANDOVERAcmunt #: 01-2281000-0 Water and Sewer Bill Due Date: 02/05/99 Svc Addr: 1459 TURNPIKE ST Mtr Previous mm��m� 11D Date Readin — Date Present Bill Usage Water —01 216_11L20L98 —K%dinge_ Code Sewer �236 EST. �20 $54.60 $0.00 $54.60 NEW WATER RATE IS $2.73 PER 100 CF. SEWER RATE REMAINS $2.75 PER 100 CF. Previous Balance $0.00 UNPAID BALANCES WILL BE SUBJECT To 14% INTEREST Penalty Charge $0.00 Interest S0.00 k: M"d:Mf,''rt•. "'x��"-, '�•..3r,.'Y'r¢"%1"""AW °e fP.k3�-.i l,'+,�,j"e"�"F . . ..1: ...•S,,.L.: � .Sn:?•.' ...- -�� f S'�. r.� r ..:,F .., .s�x'7' i- ., .i..-, J... ,.. 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