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Home My WebLink AboutMiscellaneous - 15 COLONIAL AVENUE 4/30/2018 (2) 15 COLONIAL AVENUE ' 210/107.13-0122-0000.0 MAP # LOT #- ,..:2 PARCEL # STREET �_ ...�_ l.4. ._..._...r�..... ' �ONSTRUCTI.ON___A�.E�O�lgL_, HAS PLAN REVIEW FEE SEEN PAID? YES NO PLAN APPROVAL: DATE 7 APP. DESIGNER: �(�/^ Hy�% /C/�� PLAN DA'I-E.___ CONDITIONS WATER SUPPLY! \TOW WELL WELL PERMIT _ DRILLER,_...._._.._._._.__...__.._..._......_.__._... WELL TESTS: MICAL DATE APPROVED BACTE I DATE (IPPRUVED BACTERIA II DATE f�I�PftUVED COMMENTS: FORM U APPROVAL: _ APPROVAL TO ISSUE YES NO DATE ISSUED BY CONDITIONS: FINAL APPROVAL: . ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NO ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: BY: -y&1 ..i 1 �. `f' .ti,t.•xr. .d•. .'.f „. a.:' e �.'i�`t- -r"�. !„� {ri \ "S'` y i�r `J. �'v.r ' '' ' xs,� iS THE INSTALLER LICENSED? r♦ NO ; .TYPE OF CONSTRUCTION: ? :` � NEWS REPAIR " .a' h ' NEW CONSTRUCTION: ,:•. CERTIFIED PLOT PLAN ,REVIEW VE NO CONDITIONS OF..APPROVAL YES NO :4 FROM FORM U!.:-..-N f ..ISSUANCE OF DWC PERMIT 'i YE'S , NO ' DWC PERMIT NO. '4- 1 INSTALLER: zt.P" 'BEG IN INSPECTION �E V0: � ' \ EXCAVATION ,INSPECTION: : NEEDED: ' .;:� is � r:'- 1„' - `.. •f - � - _. -- • ' - PASSED ill �� DYJ ., :-;CONSTRUCTION INSPECTIONS NEEDED: AS BUILT PLAN SATISFACTORY: :- ESs APPROVAL TO BACKFILL. DATE. HY ,FINAL - GRADING APPROVAL: DATE : '.FINAL CONSTRUCTION APPROVAL: DATE: ' O/3/ BY ' Commonwealth of Massachusetts RECEIVED Title 5 Official Inspection Form SEP 12 2017 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments TOWN OF NORTH ANDOVER HEALTH DEPARTMENT M 15 Colonial Avenue Property Address Craig Benger Owner Owner's Name information is North Andover MA 01845 8-18-2017 required for every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be ajterqd in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms D MA on the computer, . 0 use only the tab 1. Inspector: key to move your cursor-do not Neil James Bateson use the return Name of Inspector key. Bateson Enterprises Inc. �y Company Name 111 Argilla Road Company Address Andover MA 01810 Cityrrown State Zip Code 978-475-4786 SI-15 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 8-22-2017 Inspector'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 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 15 Colonial Avenue Property Address Craig Benger Owner Owner's Name information is required for every North Andover MA 01845 8-18-2017 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: After permit from B.O.H., install new outlet cover on septic tank& new d-box, inspection from B.O.H.,septic system now passes Title 5 Inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts City/Town of 2 V y F A. System Pumping.Record �; .�`3 1011 Form 4 �`'o�No� DEP has provided this form for use:by local Boards of Health. Other forms may be SsWt the information,must be substantially the same as that provided here. Before using.this form,check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local.Board of Health or other approving authority. A. Facility. Information I. System Locatio , ee''Rig n of house Left/Right rear of house, Left/right side of house, Left/ P Right side of bur ing, Left/Rig- r uilding, Left/Right rear of building, Under deck Address citylrown State - 2. System Owner. Name' Address(if different from location) Citylrown sta DC7 638 ? - Telephone Number .B. Pumping Record 1. Date of Pumping Date 2 Quantity Pumped: Gallons 3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes uxo If yes,was it cleaned? ❑ Yes ❑ No. ' 5. Condition o. f System: � 6: System Pumped By: Neil.Bateson - F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location-where contents-were disposed: S: Lowell Waste Water F Signittle I Haulmu Date t5formCdoc 06/03 System Pumping Record•Page 1 of 1 �l • 5�" -rte • • A North Andover Health Department (ommunity and Economic Development Division `VJ 08/23/2017 Address: 15 Colonial Avenue All North Andover Residents with Septic Systems and Garbage Disposals Please note that due to a recent review of a Title 5 Report, your property has been identified as maintaining a working garbage disposal that is being used in conjunction with a septic system. The Health Department is concerned for the longevity of your septic system. Garbage disposals are never recommended where septic systems are used, but if they are installed, the system must be specifically designed to handle the waste from them; your system can not handle the waste as designed. Please note that continued use of this disposal could quickly cause a pre-mature failure of your septic system, resulting in a large expenditure to replace it. The North Andover Health Department recommends that you remove it from your home as soon as possible. Some information regarding regular maintenance of your septic system is attached. Please call the Health Department at 978.688.9540 if you have any questions, or e-mail your questions to: healthdept@northandoverma.gov. Thank you for taking the time to consider the impact that your current setup has on your septic system and the environment. Sincerely, rian aG/4sse", E Director of Public Health 120 Main Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web http://www.northandoverma.gov APO" 0711�1 • .00 IS/ PUBLIC HEALTH DEPARTMENT (D Town of North Andover Community and Economic Development Division CERTIFICATE OF COMPLIANCE As of: August 22, 2017 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: D- Box Repair On-Site Sewage Disposal System By: Todd Bateson, Bateson Enterprises, Inc At: 15 Colonial Avenue Map 107.B Lot 122 North Andover, MA 01845 jhewance of this ce ' scat ll no , e construed as a guarantee that the system will function satisfactorily. Grant Public Health Agent 120 Main St.,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web www.northandoverma.gov 4 � • North Andover Health Department (ommunity and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 15 Colonial Avenue MAP: LOT: INSTALLER: Todd Bateson DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: D-BOX August 22, 2017 Michele Grant INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROLPANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX ® Installed on stable stone base ® H-20 D-Box ® Inlet tee (if pumped or >0.08'/foot) ® Hydraulic cement around inlet & outlets ® Observed even distribution ® Speed levelers provided (not required) ® Schedule 40 PVC Pipe Comments: SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel-less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = FINAL GRADE ❑ Loamed ❑ Seeded ❑ Cover per plan Comments: DOCUMENTS NEEDED ❑ Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer ❑ As-Built Plan BM = HR = HI = SYSTEM ELEVATIONS ROD AS-BLT INVERT DESIGN INVERT ELEVATION ELEV ELEV Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 TOP Lateral 1 INVERT Lateral 2 TOP Lateral 2 INVERT Lateral 3 TOP Lateral 3 INVERT Lateral 4 TOP Lateral 4 INVERT Lateral 5 TOP Lateral 5 INVERT Lateral 6 TOP Lateral 6 INVERT Top of Chamber Bottom of Bed/Chamber SKETCH PLAN CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- Waterline 10 10 101 ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh, Inland/Coastal Banka 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib. to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot. Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 ® Drains (Other)Foundation 10(5) 20(10) ® Drywells 20 25 ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54,and 10.30,respectively,pursuant to 15.211(3), also by NA wetland bylaws �XD Commonwealth of Massachusetts Map-Block-Lot 107.B0122 Permit No BOARD OF HEALTH ----- -- ---------- • Pe North Andover BHP-2017-0535 P.I. _ FEE F.I. $175.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd Bateson to(Construct)an Individual Sewage Disposal System. y ��d at No 15 COLONIAL AVENUE ---------------------------------------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP-2017-053 Dated August 21,2017 A - Issued O--Aug-21-2017 HALT Commonwealth ofWassachusetts Map-Block-Lot • b, ` \ 107.B0122 BOARD OF HEALTH North Andover CERTIFICATE OF COMPLIA CE THIS IS TO CERTIFY,That the Individual Sewage Disposal System (Co ct) by Todd Bateson ---- - ---- --------------- ----- --- ----- ------- -- ------------------------- - --- . _,_----lnstaler at No 15 COLONIAL AVENUE has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. 13HP-2017-053 Dated August 21,2017 ------------------------------------------------------- Printed On:Aug-21-2017 BOARD OF HEALTH --------------------------------------------------------------------------------- • �� o, , Commonwealth of Massachusetts Map-Block-Lot • 107.Bo122 BOARD OF HEALTH -- ---PermNo North Andover BHP-2017-0535 - --------- ---- E $175.00 DISPOSAL WORKS NSTRUCTIO ERMIT Permission is hereby granted Todd Rateson_----------------- to(Construct)an Individual Sewage Disposal System. at No 15 COLONIAL AVENUE as shown on the application for Disposal Works Cons ction Permit No. BHP-2017- 3 Dated August 21,2017 -- - - - ------- I ---------------------------- - - --- ---------- - -------------------- Issued On-Aug-21-2017 BOARD OF HEALTH L_ -- -------------------------------------------------------------- • G U-°, Commonwealth of Massachusetts Map-Block-Lot e •• 107.Bo122 BOARD OF HEALTH Permit No North Andover BHP-2017-0------------------- - - ------- P.1. FEE F.1. $175.00 - - - I DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd-Bateson to(Construct)an Individual Sewage Disposal System. at No 15 COLONIAL AVENUE - ----------- ------- ---------------------- ------- --- - - - I I as shown on the application for Disposal Works Construction Permit No. BHP-2017-053 Dated August 21,2017 - - ------ --------- ------------------------------ -------------------------- Issued - ----------------------Issued On:Aug-21-2017 BOARD OF HEALTH - - - - -- -- --- --- -- --- — ------ Commonwealth of Massachusetts Map-Block-Lot BOARD OF HEALTH 107.80122 North Andover CERTIFICATE OF COMPLIANCE THIS IS TO CERTIFY,That the Individual Sewage Disposal System (Construct) by Todd Bateson Installer I I at No 15 COLONIAL AVENUE -- - -- _ ---------------- has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. BHP-2017-053- Dated_ _August 21,2017_,-. ------------ ------------ - ------------ -- - ------- - I Printed On:Aug-21-2017 BOARD OF HEALTH • °� Commonwealth of Massachusetts Map-Block-Lot 107.80122 BOARD OF HEALTH Permit No North Andover BHP-2017-0535 FEE $175.00 I ------------------------ DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd Bateson ------------------------------------------------------------------------------ i I to(Construct)an Individual Sewage Disposal System. I at No 15 COLONIAL AVENUE ------------------------------------------------------ as shown on the application for Disposal Works Construction Permit No. BHP-2017-053 Dated August 21,2017 -------------- Issued On:Aug-21-2017 BOARD OF HEALTH • r u _Application for $eptic Disposal Ssfem, TODAY'S DATE Construction Permit - TOWN OF NORTH ANDOVER, MA 01845 $2sooa-Full Repair $425:W-Component Application is hereby made for a permit to: Q Construct a new on-site sewage disposal system* ❑Repair or replace an existing on-eft sewage disposal'system* [repair or replace an existing system component—What? By X A. Facility Information IS LoIBN f-11 i/,41'_ Address or Lot# /I✓d - A-�v v4r-- City/f own ' 2.-*TYPE OF SEPTYSTEW: ➢ ❑Pump cavity(choose one) * If pump syst ,attach copy of electrical permit to application"** onventional System (pipe and stone system) ➢ Q 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) ➢ ❑Pressure Dosed(D-Box Present)S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES=(no further info. needed) NO=(installer must specify brand of filter before DWC issuance) What is the Make? [khat is the Mode•Et 2. Owner Information Mame AVC Address(if different from above) A)5 AZ vel` 4 ! S'' Cityrrown State Zip Code 6,% 7-- S38''3'x Telephone Number 3. Installer Information 1 Name Name of Company TMON ENTERPRISES INC, Address 44 L ANDOVER,MA 01810 Cityrrown State Zip Code Telephone Number(Cell Phone#if possible please) 4. Desi_gnerInformation Name Name of Company Address State Zip Code Cityrrown Telephone Number(Best#to Reach) Application for Disposal System Construction Permit.Page 1 of 2 Applice gn..for. Bpt!C Disposal SVStern r TODAY'S.DATE F Construction Prrtit "��..;,, •�' ORTTTNDbYL Mtn, 01,845 a:zo 00 Full Repair �ss,��•E``6 — �� -� �'i25.00:-Component ,...PAGE 2 OF 2 A. Facility.lnforma ion :continued 5. Type'of Building: esldentlal,Dwelling or❑Commercial B. Agre,emenf The underslgned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance w/tn he provisions of Title 5 of the Environmental Code,as wag as the Local Subsurface Disposal Regulations for the Town of North Andover,and not to place:the system fn oper~atton until a Certificate of Compllatcs has been Issued this Board of Health. `� Name Date (4ZIlro App - y: dof althRepresentative) Ign e ' Date Application Dlsappr.o for the following reasons: For Office Use only 1. Fee Attached? Yes Na 2,• Projectllsanage.,Obligadon Form Attached? Yes No 3, &in SE=? Ifsoj Attach Celzy of -vies Na 4. Focvldatior,As:Bur'!z?(heweonstruetton•ronly); Yes No (Same scale ss approyedplan) A F1oorP1an5p(hew construction'only). Ycs No_ ,+1ppj�catldn'tor,pisppsal.Systetn:C:dMstMCt1C1h Nrmft Race 2 rit 2 5EP'.r`IC•S +ii "•1'� •PRO, !'MAX& iGA�I4i�fS As fhc.NQrth Andover,l n=et#listAuft for 4tlio tntcttvtt f�'thaeeptia syst�cm fo�t.the �e�ae ( tcm) •P'cmpum by Ro&tW to the.tpp of ale'- �• (ih*li s sum) Abd daftd tea A met vdiwd Omm" tea I ucdeutmd the following Obilgatiow fat mstttagement of•this projects i. ha theiastnller,I a .obligated to abdda.aIIpat�ita and Bbs�r�d ofF Apprw� �petbom�ing stflp.' phnspda W. Ol ts'c oa a lite...I mm haore thff-yt+avgam ss" 3. At$ae 1a�talteT;.I,tab'Et=taII�stray and �£hortaeomtse*,ooat�ctr�ptO�eCtm9l!]A�et.or srQp Q eLa01211 �tod w!th MY Y sr 00"•� &#=stnd m,i�, , item duw& azbt smu—sg- A& ? ;F sm�rtgq d bsv a oe y wo :p y ase appJkA*kOic 00 As , 0. a . ahtra�d b , is .i" p s;tbetc srnctsuing ,yicir Vit:Hw c t 4cictliet hm to bt prttcrit�•. ttilo•ifitap }on{��& •'• c vribid OI�'(or ell ttx frol3t thee, must bo ttibimitied•toticII H , ; rat�><fer trema dtae. I�asmlter itsutt heatetpse gtit p to '.- cftffi t ad able to' t~ — itat;+oc 'iaagioat' ' tll d . h�va#o be ngte.• rainpltte•:Ilei does tot 4. As-6e iasmll=I ucd&i=d that only Ftp gt rht 3 1t'�it6Ert6atr ,(e Via) I i te;goiced to aatgpiete thn Ad t of tlx�e sgatd}s i '� atica: •. ,� &r6 An'Twerm on t2 iuA MIA ft.gafig&Ii, 5.. thefnatlIter;.I t�desatai 7 wale t :�ir3 ith �� tx•�f tF�� • amu: Detemrlara�tant that.d�pr�perekr►nt�a c�ft&eexdetvit� :•'•• :• .: � '� ' - . Impeeam wed arrr + t+esrcl�eal a P�aillpBool. tltltb�At@`'01'�0�8 d oftbalr,I5t-40%PPA Vie,vga;P F fiber, cet1►aatt other Omm ri.*. . . Und d =s9dSq)dc. •• ; Crp I to —��' /'7 r� 91 C L / O = T Town of North Andover HEALTH DEPARTMENT ,s.SACHU`�tt CHECK#: S C' DATE: LOCATION: /s co nrn,a-l H/O NAME: A26ae-1 CONTRACTOR NAME: lJC�. A On Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTICSystems : ❑ Septic-Soil Testing $ ❑ Septic-Design Approval ' $ XSeptic Disposal Works Construction(DWC) s /75— ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other:(Indicate) $ A/�-, He gent Initials White-Applicant Yellow-Health Pink-Treasurer Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments a� M 15 Colonial Avenue / Property Address . Craig Benger LS Owner Owner's Name / information is North Andover MA 01845 8-2-2017 i1AAV required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Neil J. Bateson use the return Name of Inspector key. Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover MA 01810 City/Town State Zip Code 978-475-4786 SI-15 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ N ds urther Evaluation by the Local Approving Authority 1 � 1 f 7-28-2017 Inspector's ignature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 i Commonwealth of Massachusetts ' a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 Colonial Avenue Property Address Craig Benger Owner Owner's Name information is required for every North Andover MA 01845 8-2-2017 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ® N ❑ ND (Explain below): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Colonial Avenue Property Address Craig Benger Owner Owner's Name information is required for every North Andover MA 01845 8-2-2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 • Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Colonial Avenue Property Address Craig Benger Gunner Owner's Name information is require for every North Andover MA 01845 8-2-2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Broken outlet cover on septic tank&d-box needs to be replaced D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 Colonial Avenue Property Address _Craig Benger Owner Owner's Name information is required for every North Andover MA 01845 8-2-2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Colonial Avenue Property Address Craig Benger Owner Owner's Name information is required for every North Andover MA 01845 8-2-2017 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A� ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins.doc•rev.6/16 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 15 Colonial Avenue Property Address Craig Benger Owner Owner's Name information is required for every North Andover MA 01845 8-2-2017 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 O — Does residence have a garbage grinder? C® Yes ❑ No -'I Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Yes 9 ( Y 9 (gP ))� Detail: Sump pump? ® Yes ❑ No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 Colonial Avenue Property Address Craig Benger Owner Owner's Name information is required for every North Andover MA 01845 8-2-2017 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped 2015, owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Measured tank Reason for pumping: Inspect tank&tees Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 Colonial Avenue Property Address Craig Benger Owner Owner's Name information is required for every North Andover MA 01845 8-2-2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Original, owner Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.8 feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" PVC through wall, 3" PVC in house , no leaks visible Septic Tank(locate on site plan): Depth below grade: 0.8 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10' x 5'x 4' Sludge depth: 2" t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Colonial Avenue Property Address Craig Benger Owner Owner's Name information is North Andover MA 01845 8-2-2017 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet tee ok. Outlet tee ok. Outlet cover broken, needs to be replaced. Depth of liquid at outlet invert. No evidence of leakage. Pumped septic tank. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Colonial Avenue Property Address Craig Benger Owner Owner's Name information is required for every North Andover MA 01845 8-2-2017 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 Colonial Avenue Property Address Craig Benger Owner Owner's Name information is North Andover MA 01845 8-2-2017 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box cover broken, replaced same. D-box badly corroded needs to be replaced. D-box level & distribution equal. No evidence of leakage. Evidence of light carryover 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.doc-rev.6116 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 15 Colonial Avenue ,p Property Address Craig Benger Owner Owner's Name information is North Andover MA 01845 8-2-2017 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2 trenches 70' long ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts w v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 Colonial Avenue Property Address Craig Benger Owner Owner's Name information is North Andover MA 01845 8-2-2017 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Colonial Avenue Property Address Craig Benger Owner Owner's Name information is North Andover MA 01845 8-2-2017 required for every page. Citylrown 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 �Y Gam . Se01 e I I a=�a (101i a � ��►t �a� rE3 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of.Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 Colonial Avenue Property Address Craig Benger Owner Owner's Name information is North Andover MA 01845 8-2-2017 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 4 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 11-7-1997 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: Design plan ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: As per test pit data on design plan. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 15 Colonial Avenue Property Address Craig Benger Owner Owner's Name information is North Andover MA 01845 8-2-2017 required for every page. Citylrown 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 : Commonwealth of Massachusetts _ CitY/Town of . System Pumping.Record Form 4 DEP has provided this form for useaby local Boards of Health.Other form's may�be bsed,but the information-must be substantially the same as that provided here. Before using.this form,check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted:to the local.Board of Health or other approving authority. A. Facility. Information 1. System Location, L /Right ont of QhouseLeft/Right rear of house, Left/righf side of house, Left/ Right side of buil Ing, Left/Rig rondirig, Left/Right rear of building, Under deck Address CWrom State - Zip Code 2. System Owner. Name Address.(if different from location) citylram ' State- Zi Code � 3�9- : r Telephone Number .B. Pumping record 1. Date of Pumping gate 2. Quantity Pumped: Gallons 3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes alao If yes,was it cleaned? ❑ Yes ❑ No, '5. Condition of System: 6. System Pumped By: Neil.Bateson - F5821 Name Vehicle License Number Bateson Enterprises Inc' Company 7. Location where content&were disposed: G LS Lowell Waste Water SigniWe HwwU Date 5form4.dov 06/03 System Pumping Record•Page 9 of 1 Summary Record Card generated on 7/24/2017 11:21:48 AM by Karen Hanlon Page 1 Town of North Andover Tax Map # 210-1073-0122-0000.0 Parcel Id 18235 15 COLONIAL AVENUE J.C. &WENDY BENGER 2976 WEST CROWN POINT BLVD. NAPLES FL 34112 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zorl 1 Residential Size Total 0.56 Acres FY 2017 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until J.C. &WENDY BENGER Owner 2976 WEST CROWN POINT BLVD. NAPLES FL 34112 BENGER,J.C.&WENDY Payor Inactive 1/12/2017 15 COLONIALAVE NORTH ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 13231.0-15 COLONIAL AVENUE Last Billing Date 6/19/2017 2100016 02 Cycle 02 Active UB Services Maint. Account No.2100016 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 11.40 /1 UB Meter Maintenance Account No.2100016 Serial No Status Location Brand Type Size YTD Cons 36207107 a Active ERT HH b Badger w Water 0.63 0.63 1044 Date Reading Code Consumption Posted Date Variance 5/1/2017 1044 aActual 3 6/26/2017 -38% 2/1/2017 1041 aActual 5 3/14/2017 -85% 11/1/2016 1036 aActual 33 12/19/2016 -51% 8/1/2016 1003 aActual 66 9/21/2016 -100% 5/2/2016 937 aActual 0 6/21/2016 -100% 2/1/2016 937 aActual -97% 10/30/2015 934 a Actual 1202% 8/3/2015 851 a Actual 40ar„ -87% 5/26/2015 846 m Manual r�;.. •,.'ao i J 1143% 3 • o MSG o 2/4/2015 786 a Actual p -92% 11/4/2014 782 a Actual :: , ;; Town of North Andover -42% 8/5/2014 731 a Actual `y•,,•.•.... 845% 5/12/2014 649 a Actual ,SSACMUSfHEALTH DEPARTMENT -4% 2/3/2014 639 a Actual -90% 11/1/2013 629 aActual CHECK#: /ygS DATE: &-a3�10/`7 101% 8/7/2013 533 a Actual 143% 5/4121%/2013 482 a Actual LOCATION: 5 �� 2/4/2013 461 a Actual -86% 10/30/2012 451 a Actual 28% 8/1/2012 387 aActual H/O NAME:__ e�g2/' 284% 5/1/2012 336 a Actual 21% 2/1/2012 323 a Actual CONTRACTOR NAME: /Jl�,c-`�.SO/� -66% 11/1/2011 312 aActual 8/3/2011 288 a Actual 649% 5/3/2011 215 a Actual 14% Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ I ❑ Body Art Practitioner $ ❑ Dumpster ❑ Food Service-Type. $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $_ ❑ Well Construction $ SEPTIC Sustema: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $_ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector i Title 5 Report ❑ Other. (Indicate) $ He Agent Initials White-Applicant Yellow-Health Pink- Treasurer Summary Record Card generated on 7/24/2017 11:21:48 AM by Karen Hanlon Page 1 Town of North Andover Tax Map # 210-107.6-0122-0000.0 Parcel Id 18235 15 COLONIAL AVENUE J.C. &WENDY BENGER 2976 WEST CROWN POINT BLVD. NAPLES FL 34112 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 0.56 Acres FY 2017 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until J.C. &WENDY BENGER Owner 2976 WEST CROWN POINT BLVD. NAPLES FL 34112 BENGER,J.C.&WENDY Payor Inactive 1/12/2017 15 COLONIAL AVE NORTH ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 13231.0-15 COLONIAL AVENUE Last Billing Date 6/19/2017 2100016 02 Cycle 02 Active UB Services Maint. Account No.2100016 Service Code Rate Charge Multiplier/Users MISCFEEADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 11.40 /1 UB Meter Maintenance Account No.2100016 Serial No Status Location Brand Type Size YTD Cons 36207107 a Active ERT HH b Badger w Water 0.63 0.63 1044 Date Reading Code Consumption Posted Date Variance 5/1/2017 1044 aActual 3 6/26/2017 -38% 2/1/2017 1041 aActual 5 3/14/2017 -85% 11/1/2016 1036 aActual 33 12/19/2016 -51% 8/1/2016 1003 aActual 66 9/21/2016 -100% 5/2/2016 937 aActual 0 6/21/2016 -100% 2/1/2016 937 aActual 3 3/28/2016 -97% 10/30/2015 934 a Actual 83 12/30/2015 1202% 8/3/2015 851 a Actual 5 9/14/2015 -87% 5/26/2015 846 m Manual estimate 60 6/22/2015 1143% MSG 2/4/2015 786 a Actual 4 3/20/2015 -92% 11/4/2014 782 aActual 51 12/15/2014 -42% 8/5/2014 731 aActual 82 9/11/2014 845% 5/12/2014 649 a Actual 10 6/12/2014 -4% 2/3/2014 639 a Actual 10 3/17/2014 -90% 11/1/2013 629 aActual 96 12/20/2013 101% 8/7/2013 533 a Actual 51 9/18/2013 143% 5/7/2013 482 a Actual 21 6/18/2013 121% 2/4/2013 461 a Actual 10 3/13/2013 -86% 10/30/2012 451 a Actual 64 12/13/2012 28% 8/1/2012 387 aActual 51 9/26/2012 284% 5/1/2012 336 a Actual 13 6/20/2012 21% 2/1/2012 323 aActual 11 3/14/2012 -55% 11/1/2011 312 aActual 24 12/15/2011 -66% 8/3/2011 288 a Actual 73 9/14/2011 649% 5/3/2011 215 a Actual 9 6/13/2011 14% Of NORTH 1M J Town of North Andover � '• ° HEALTH DEPARTMENT ,s'SACMUSf1 CHECK#: 14165 D//ATE: S /3�dd� LOCATION: 15 H/0 NAME: Ae/7 Q e( CONTRACTOR NAME: &.�`c ,570/I Type of Permit or License: (Check box) 0 Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWQ $ ❑ Septic Disposal Works Installers(DWI) $— [3 ❑ Title 5 Inspector 1 $ Cof)6, Title 5 Report o $ 50 - 0 S0❑ Other. (Indicate) $ 14�17D He Agent Initials White-Applicant Yellow-Health Pink-Treasurer TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System ) constructed; ( ) repaired; b It located at was installed in conformance with the North Andover Board of Health approved plan, System Design Permit# dated J1-71417 , with an approved design flow of gallons per day. The materials used were in conformance with those specified on the approved plan; the system was installed in accordance with the provisions of 310 CN1R 15.000, Title 5 and local regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on th As-bu* hich has been submitted to the Board of Health. Bed inspection date: /2 F Final inspection date: 12-hoZZ 2 .r G Installer: Lic. #: Date: Design Engineer: iv. Date: 1 NORTH Town of 4Andover No. 36 0 - 'fiP' y .r�r ''�J� 0 Zo AE o dover, Mass., �- 19 �c7g,�7'id vel o�t7`,�s paL o COCHICMEWICK� AERATED S BOARD OF HEALTH PERMIT D Food/Kitchen Septic Systeme CT BUILDING INSPECTOR THIS CERTIFIES THAT......... N., ta./ ....................................... Foundation l has permission Ro IF............ felt. . .................... .................... Chimney provided that the ict conform to the terms 4f the appl to be occupied as 'ca 'on on file i n Final this office, and to ig to the Inspection, Alteration and Construction of 7/-Z l Buildings in the T, d n PLUMBINSPECTOR VIOLATION of the —'h F. ou "b MONTHS Final )N ST TS ELECTRICAL INSPECTO ....... .. ................................ rtn G INSPECTOR Final uccupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected -and Approved by the Building Inspector. Burner Street No. Smoke Det. r COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION METROPOLITAN BOSTON-NORTHEAST REGIONAL OFFICE ARGEO PAUL CELLUCCI TRUDY COXE Governor Secretary DAVID B. STRUHS �7 1 Commissioner URGENT LEGAL MATTER: PROMPT ACTION NECESSARY CERTIFIED MAIL: RETURN RECEIPT REQUESTED APR 2 51998 Ms Donna White `Re : ,North Andover Donald F. Johnston & Co. , Inc . 15 Colonial Drive-- 114 Boston Street RTN #3-16618 No. Andover, MA 01845 NOTICE OF RESPONSIBILITY; M.G.L. c . 21E & 310 CMR 40 . 0000 Dear Ms White : On March 23 , 1998 at 9 : 00 AM, the Department of Environmental Protection (the Department or DEP) received oral notification that there is or has been a release of oil and/or hazardous material at the above-referenced property which requires one or more response actions . Based on this information, the Department has reason to believe that the subject property or portion (s) thereof is a disposal site as defined in the Massachusetts Oil and Hazardous Material Release Prevention and Response Act, M.G.L. c . 21E, and the Massachusetts Contingency Plan, 310 CMR 40 . 0000 (the MCP) . The assessment and cleanup of disposal sites is governed by M.G.L. c . 21E and the MCP. The purpose of this notice is to inform you of your legal responsibilities under state law for assessing and/or remediating the subject release . For purposes of this notice, the terms and phrases used herein shall have the meaning ascribed to them by the MCP unless the text clearly indicates otherwise . STATUTORY LIABILITIES The Department has reason to believe that you (as used in this letter, "you" refers to Donald F. Johnston & Co. , Inc . ) are a Potentially Responsible Party (a PRP) with liability under M.G.L. c . 21E, § 5, for response action costs . Section 5 makes the following parties liable to the Commonwealth of Massachusetts : current owners or operators of a site from or at which there is or has been a release/threat of release of oil or hazardous material; 10 Commerce Way 0 Woburn,Massachusetts 01801 • FAX (781) 932-7615 • Telephone (781) 932-7600 9 TDD k(617)932-7679 Page 2 NOR 3-16618 any person who owned or operated a site at the time hazardous material was stored or disposed of; any person who arranged for the transport, disposal, storage or treatment of hazardous material to or at a site; any person who transported hazardous material to a transport, disposal, storage or treatment site from which there is or has been a release/threat of release of such material; and any person who otherwise caused or is legally responsible for a release/threat of release of oil or hazardous material at a site . This liability is "strict" , meaning it is not based on fault, but solely on your status as an owner, operator, generator, transporter or disposer. It is also joint and several, meaning that you may be liable for all response action costs incurred at the site, regardless of the existence of any other liable parties . The MCP requires responsible parties to =ake necessary response actions at properties where there is or has been a release or threat of release of oil and/or hazardous material . If you do not take the necessary response actions, or fail to perform them in an appropriate and timely manner, the Department is authorized by M.G.L. c . 21E to have the work performed by its ccntractors . By taking such actions, you can avoid liability for response action costs incurred by the Department and its contractors in performing these actions, and any sanctions which- may be imposed for failure to perform response actions under the MCP. - You may be liable for up to three (3) times all response action costs incurred by the Department . Response action costs include, without limitation, the cost of direct ^ours spent by Department employees arranging for response actions or overseeing work performed by persons other than the Depar-ment or their contractors, expenses incurred by the Department in support of those direct hours, and payments to the Department 's contractors . (For more detail on cost liability, see 310 CMR 40 . 1200 . ) The Department may also assess interest on cc=--s incurred at the rate of twelve percent (120-. ) , compounded annua-11y. To secure payment of this debt, the Commonwealth may place liens on all of your property in the Commonwealth. To recover the debt, the Commonwealth may foreclose on these liens or the Attorney General may bring legal action against you. In addition to your liability for up to three (3) times all response action costs incurred by the Department, you may also be liable to the Commonwealth for damages to natural resources caused by the release . Civil and criminal liability may also be imposed under M.G.L. c . 21E, § 11, and civil administrative penalties may be imposed under M.G.L. c . 21A, § 16 for each violation of M.G.L. C . 21E, the MCP, or any order, permit or approval issued thereunder. Page 3 NOR 3-16618 r NECESSARY RESPONSE ACTIONS The subject site shall not be deemed to have had all the necessary and required response actions taken unless and until all substantial hazards presented by the site have been eliminated and a level of No Significant Risk exists or has been achieved in compliance with M.G.L. c . 21E and the MCP. In addition, the MCP requires persons undertaking response actions at disposal sites to perform Immediate Response Actions (IRAs) in response to "sudden releases" , Imminent Hazards and Substantial Release Migration. Such persons must continue to evaluate the need for IRAs and notify the Department immediately if such a need exists . The Department has determined that an IRA is necessary at the subject site to respond to the sudden release of over 10 gallons of #2 fuel oil from a oil supply line . The oil supply line had be previously attached to a hot water heater that was stolen. The Department has approved of the collection of impacted groundwater and free phase oil from the residence ' s sump and the installation of additional groundwater access points in the basement . All of the waste water and oil generated must be disposed of off site at a properly permitted and licensed disposal facility. The excavation, stockpiling and disposal of soil has not been approved by the Department at this time. You are authorized to conduct _only the specific response _ actions for which you received oral approval from the Department at the time you provided oral notification to the DEP of the subject release . All additional Immediate Response Actions require DEP approval in accordance with 310 CMR 40 . 0420 . You must employ or engage a Licensed Site Professional (LSP) to manage, supervise or actually perform the necessary response actions at the subject site . In addition, the MCP requires persons undertaking response actions at a disposal site to submit to the Department a Response Action Outcome Statement (RAO) prepared by an LSP in accordance with 310 CMR 40 . 1000 upon determining that a level of No Significant Risk already exists or has been achieved at a disposal site or portion thereof . You may obtain a list of the names and addresses of these licensed professionals from the Board of Registration of Hazardous Waste Site Cleanup Professionals at (617) 556-1091 . There are several other submittals required by the MCP which are related to release notification and/or response actions that may be conducted at the subject site in addition to an RAO, that, unless otherwise specified by the Department, must be provided to DEP within specific regulatory timeframes . The submittals are as follows : (1) If information is obtained after making a oral or written notification to indicate that the release or threat of release didn' t occur, failed to meet the reporting criteria at 310 CMR 40 . 0311 through 40 . 0315, or is exempt from notification Page 4 NOR 3-16618 f pursuant to 310 CMR 40 . 0317, a Notification Retraction must be submitted within 60 days of initial notification pursuant to 310 CMR 40 . 0335; otherwise, (2) If one has not been submitted, a Release Notification Form (RNF) must be submitted to DEP pursuant to section 310 CMR 40 . 0333 within 60 calendar days of the initial date of oral notification to DEP of a release pursuant to 310 CMR 40 . 0300 or from the date the Department issues a Notice of Responsibility (NOR) , whichever occurs earlier; (3) Unless an RAO is submitted earlier, an Immediate Response Action (IRA) Plan prepared in accordance with 310 CMR 40 . 0420, or an IRA Completion Statement (310 CMR 40 . 0427) must be submitted to DEP within 60 calendar days of the initial date of oral notification to DEP of a release pursuant to 310 CMR 40 . 0300 or from the date the Department issues an NOR, whichever occurs earlier; and (4) Unless an RAO is submitted earlier, a completed Tier Classification Submittal pursuant to 310 CMR 40 . 0510 , and, if appropriate, a completed Tier I Permit Application pursuant to 310 CMR 40 . 0700, must be submitted to DEP within one year of the initial date of oral notification to DEP of a release pursuant to 310 CMR 40 . 0300 or from the date the Department issues an NOR, whichever occurs earlier. (5) Pursuant to the Department ' s "Timely Action Schedule and Fee Provisions" , 310 CMR 4 . 00, a fee of $750 must be included with an RAO statement that is submitted to the Department more than 120 calendar days after the initial date of oral notification to DEP of a release pursuant to 310 CMR 40 . 0300 or after the date the Department issues an NOR, whichever occurs earlier, and before Tier Classification. A fee is not required for an RAO submitted to the Department within 120 days of the date of oral notification to the Department, or the date the Department issues an NOR, whichever date occurs earlier, or after Tier Classification. It is important to note that you must dispose of any Remediation Waste generated at the subject location in accordance with 310 CMR 40 . 0030 including, without limitation, contaminated soil and/or debris . Any Bill of Lading accompanying such waste must bear the seal and signature of an LSP or, if the response action is performed under the direct supervision of the Department, the signature of an authorized representative of the Department . The Department encourages parties with liabilities under M.G.L. c. 21E to take prompt action in response to releases and threats of release of oil and/or hazardous material . By taking prompt action, you may significantly lower your assessment and cleanup costs and avoid the imposition of, or reduce the amount of, certain permit and annual compliance fees for response actions payable under 310 CMR 4 . 00 . Page 5 NOR 3-16618 If you have any questions relative to this notice, you should contact Timothy J. Boyle at the letterhead address or (781) 932- 7600 . All future communications regarding this release must reference the Release Tracking Number (RTN #3-16618) contained in the subject block of this letter. Very truly yours, oy �ngineer alTimo� Environm Ro er Chu Branch Chief Emergency Response Section CC : Board of Health Fire Department, DEP data entry/file Attachment : Release Notification & Release Retraction Form, BWSC-103 T 1 �'i�=g .-�' Consulting 2ANS®M 1 �F�� Engineering Environmental - 6 ,�� Hydrogeology Consultants, Inc. a Applied Sciences August 5, 1998 Project 981032 Ms. Sandra Starr Administrator North Andover Board of Health 30 School Street North Andover, Massachusetts 01845 RE: Immediate Response Action(IRA) Completion Report and Response Action Outcome(RAO) Statement 15 Colonial Avenue North Andover, Massachusetts MA DEP Release Tracking No. 3-16618 Dear Ms. Starr: In accordance with the Massachusetts Contingency Plan(MCP), Ransom Environmental Consultants, Inc. (Ransom),at the request of Donald F. Johnston&Company, Inc. (Johnston&Co.),has completed Immediate Response Action(IRA)activities following a release of approximately 60 gallons of home heating oil from an aboveground storage tank located in the basement of the residential building under construction at 15 Colonial Avenue in North Andover, Massachusetts (the Site). The MCP requires that the board of health and chief municipal officer be notified upon completion of an IRA and Response Action Outcome(RAO). The IRA consisted of a reconnaissance of the release area,the removal of the concrete basement floor, excavation and disposal of approximately 30 cubic yards of impacted crushed stone and soil, a subsurface investigation including soil borings and monitoring well installations, laboratory analysis of soil and ground water samples, and the performance of a risk characterization. All activities were conducted in accordance with the MCP and Massachusetts Department of Environmental Protection(MA DEP)requirements. Based on information obtained during the IRA, it is Ransom's opinion that a condition of"No Significant Risk"as defined by the MCP exists with regard to the impacted area, and the conditions of a Class A-2 RAO have been attained for the Site. A copy of the IRA Completion Report and RAO Statement for the Site is available for public viewing at the MA DEP Northeast Regional Office located at 205A Lowell Street in Wilmington,Massachusetts. MA DEP files are open for public viewing by appointment only, Monday through Friday, 9:00 am to 12:00 pm. You may contact the MA DEP Northeast Regional Office at(978)661-7600 for more information on reviewing MA DEP files. Brown's Wharf 56 Court Street 1273 Bound Brook Road,Suite 13 Newburyport,MA 01950 Bristol,RI 02809 Middlesex,NJ 08846-1490 Tel (978)465-1822 Tel (401)254-5070 Tel (732)356-6655 Fax(978)465-2986 Fax(401)253-9508 Fax(732)356-4898 Ms. Sandra Starr North Andover Board of Health Please contact either of the undersigned at(978)465-1822 if you have any questions regarding the IRA activities. Sincerely, RANSOM ENVIRONMENTAL CONSULTANTS,INC. r S man Project Geologist XVice , LSPent of Environmental Services PEH/TJS/SBR:jar Ransom Project 981032 Page 2 P:\981032\BOH.NOT August 5, 1998 • Massachusetts Department of Environmental Protection BWSC-104 Bureau of Waste Site Cleanup _ RESPONSE ACTION OUTCOME (RAO) STATEMENT & Release Tracking Number DOWNGRADIENT PROPERTY STATUS TRANSMITTAL FORM a _ 16618 Pursuant to 310 CMR 40.0180(Subpart B),40.0580(Subpart E)&40.1056(Subpart J) C. DESCRIPTION OF RESPONSE ACTIONS: (continued) Check here if any Response Action(s)that serve as the basis for this RAO Statement Involve the use of Innovative Technologies. (DEP is interested in using this information to create an Innovative Technologies Clearinghouse.) Describe Technologies: D. TRANSPORT OF REMEDIATION WASTE: (if Remediation Waste was sent to an off-site facility,answer the following questions) NameofFacllity. AD$EG_(soil) , Murphy Wast-p- Oil (water/oil mixture) TownandState: Charlton, Maaaarh uc .t s and Woburn, Massa _hu.attc Quantityof Remediation Waste Transported to Date: 50-59 one coil , 400 gal water/oil mix E. RESPONSE ACTION OUTCOME CLASS: Specify the Class of Response Action Outcome that applies to the Site or Disposal Site. Select ONLY one Class: L� Class A-1 RAO: Specify one of the following: O Contamination has been reduced to background levels. O A Threat of Release has been eliminated. Class A-2 RAO: You MUST provide justification that reducing contamination to background levels is infeasible. n Class A-3 RAO: You MUST provide both an implemented Activity and Use Limitation(AUL)and justification that reducing contamination to background levels is infeasible. If applicable,provide the earlier of the AUL expiration date or date the design life of the remedy will end: u Class B-1 RAO: Specify one of the following: O Contamination is consistent with background levels Q Contamination is NOT consistent with background levels. F] Class B-2 RAO: You MUST provide an implemented AUL. If applicable,provide the AUL expiration date: Class C RAO: ❑ Check here if you will conduct post-RAO Operation,Maintenance and Monitoring at the Site. Specify One: Q Passive Operation and Maintenance O Monitoring Only O Active Operation and Maintenance(defined at 310 CMR 40.0006) F. RESPONSE ACTION OUTCOME INFORMATION: If an RAO Compliance Fee is required,check here to certify that the fee has been submitted. You MUST attach a photocopy of the payment. EJ Check here if submitting one or more AULs. You must attach an AUL Transmittal Form(BWSC-113)and a copy of each implemented AUL related to this RAO Statement. Specify the type of AUL(s)below: (required for all Class A-3 RAOs and Class B-2 RAOs) O Notice of Activity and Use Limitation O Grant of Environmental Restriction Number of AULs attached: Specify the Risk Characterization Method(s)used to achieve the RAO described above and all Soil and Groundwater Categories applicable to the Site. More than one Soil Category and more than one Groundwater Category may apply at a Site. Be sure to check off all APPLICABLE categories,even If more stringent soil and groundwater standards were met. Risk Characterization Method(s)Used: ® Method 1 Method 2 ❑ Method 3 Soil Category(ies)Applicable: ® S-1 S-2 ❑ S-3 Groundwater Category(iss)Applicable: ® GWA ® GW-2 ® GW-3 > When submitting any Class A-1 RAO or a Class B-1 RAO where contamination Is consistent with background levels,do NOT specify a Risk Characterization Method. > When submitting any Class A-2 RAO or a Class B-1 RAO where contamination Is NOT consistent with background levels,you cannot use an AUL to maintain a level of no significant risk. Therefore,you must meet S-1 Soil Standards,if using Risk Characterization Method 1. Revised 4/7/95 Supersedes Forms BWSC-004 and 010(in part) Page 2 of 4 Do Not Ager This Form Massachusetts Department of Environmental Protection BWSC-104 Bureau of Waste Site Cleanup RESPONSE ACTION OUTCOME (RAO) STATEMENT $ Release Tracking Number DOWNGRADIENT PROPERTY STATUS TRANSMITTAL FORM _ 16618 Pursuant to 310 CMR 40.0180(Subpart B),40.0580(Subpart E)8 40.1056(Subpart J) A. SITE OR DOWNGRADIENT PROPERTY LOCATION: Site Name:(optional) Street: 15 Colonial Avenue Location Aid: City/Town: North Andover ZIP Code: 01845-0000 �] Check here if this Site location is Tier Classified. If a Tier I Permit has been issued,state the Permit Number: Related Release Tracking Numbers that this Form Addresses: If submitting an RAO Statement,you must document the location of the Site or the location and boundaries of the Disposal Site subject to this Statement. If submitting an RAO Statement for a PORTION of a Disposal Site,you must document the location and boundaries for both the portion subject to this submittal and,to the extent defined,the entire Disposal Site. If submitting a Downgradient Property Status Submittal, you must provide a site plan of the property subject to the submittal and,to the extent defined,the Disposal Site. B. THIS FORM IS BEING USED TO: (check all that apply) Submit a Response Action Outcome(RAO)Statement(complete Sections A,B,C,D.E,F.H.I,J and L). [� Check here if this is a revised RAO Statement. Date of Prior Submittal: Check here if any Response Actions remain to betaken to address conditions associated with any of the Releases whose Release Tracking Numbers are listed above. This RAO Statement will record only an RAO-Partial Statement for those Release Tracking Numbers. Specify Affected Release Tracking Numbers: [� Submit an optional Phase I Completion Statement supporting an RAO Statement or Downgradlent Property Status Submittal (complete Sections A,B.H,I,J,and Q. Submit a Downgradient Property Status Submittal(complete Sections A,B.G,H,I,J and K). Check here if this is a revised Downgradient Property Status Submittal. Date of Prior Submittal: Submit a Termination of a Downgradient Property Status Submittal(complete Sections A,B.1,J and Q. Submit a Periodic Review Opinion evaluating the status of a Temporary Solution(complete Sections A,B,H,I,J and L). Specify one: F-] For a Class C RAO 0 For a Waiver Completion Statement indicating a Temporary Solution Provide Submittal Date of RAO Statement or Waiver Completion Statement: You must attach all supporting documentation required for each use of form indicated,Including copies of any Legal Notices and Notices to Public Officials required by 310 CMR 40.1400. C. DESCRIPTION OF RESPONSE ACTIONS: (check all that apply) ❑ Assessment and/or Monitoring Only ❑ Deployment of Absorbent or Contaminant Materials ® Removal of Contaminated Soils E] Temporary Covers or Caps ® Re-use,Recycling or Treatment [-] Bioremediation O On Site ® Off Site Est.Vol.: 30 cubic yards ❑ Soil Vapor Extraction Describe: Structure Venting System F] Landfill O Cover O Disposal Est.Vol.: cubic yards ® Product or NAPL Recovery Removal of Drums,Tanks or Containers E] Groundwater Treatment Systems Describe: Air Sparging Removal of Other Contaminated Media Temporary Water Supplies Specify Type and Volume: ❑ Temporary Evacuation or Relocation of Residents Other Response Actions Fencing and Sign Posting Describe: SECTION C IS CONTINUED ON THE NEXT PAGE. Revised 4/7/96 Supersedes Forms BMC-004 and 010(in part) Page 1 of 4 Do Not Alter This Form • Massachusetts Department of Environmental Protection BWSC-104 Bureau of Waste Site Cleanup RESPONSE ACTION OUTCOME (RAO) STATEMENT & Release Tracking Number DOWNGRADIENT PROPERTY STATUS TRANSMITTAL FORM _ 16618 Pursuant to 310 CMR 40.0180(Subpart B),40.0580(Subpart E)&40.1056(Subpart J) G. DOWNGRADIENT PROPERTY STATUS SUBMITTAL: (� If a Downgradient Property Status Submittal Compliance Fee is required,check hereto certify that the fee has been submitted. You MUST -- attach a photocopy of the payment. Check here if a Release(s)of Oil or Hazardous Material(s),other than that which is the subject of this submittal,has occurred at this property. Release Tracking Number(s): 0 Check here if the Releases identified above require further Response Actions pursuant to 310 CMR 40.0000. Required documentation for a Downgradient Property Status Submittal Includes,but is not Ikrtited to,copies of notices provided to owners and operators of both upgradient and dovYngradient abutting properties and of any known or suspected source properties. H. LSP OPINION: I attest under the pains and penalties of perjury that I have personally examined and am familiar with this transmittal form,including any and all documents accompanying this submittal. In my professional opinion and judgment based upon application of(i)the standard of care in 309 CMR 4 02(1),(ii)the applicable provisions of 309 CMR 4.02(2)and(3),and(iii)the provisions of 309 CMR 4.03(5),to the best of my knowledge,information and belief, > if Section 8 indicates that a Downgradlent Property Status Submittal is being provided,the response action(s)that is(are)the subject of this submittal(i)has(have)been developed and implemented in accordance with the applicable provisions of M.G.L.c.21 E and 310 CMR 40.0000,(ii) is(are)appropriate and reasonable to accomplish the purposes of such response action(s)as set forth in 310 CMR 40.0183(2)(b),and(iii)complies(y) with the identified provisions of all orders,permits,and approvals identified in this submittal; > if Section 8 indicates that either an RAO Statement Phase I Completion Statement and/or Periodic Review Opinion is being provided,the response action(s)that is(are)the subject of this submittal(i)has(have)been developed and implemented in accordance with the applicable provisions of M.G.L.c.21 E and 310 CMR 40.0000,(ii)is(are)appropriate and reasonable to accomplish the purposes of such response action(s)as set forth in the applicable provisions of M.G.L.c.21 E and 310 CMR 40.0000,and(iii)complies(y)with the identified provisions of all orders,permits,and approvals identified in this submittal. I am aware that significant penalties may result,including,but not limited to,possible fines and imprisonment,if I submit information which I know to be false,inaccurate or materially incomplete. 0 Check here if the Response Action(s)on which this opinion is based,if any,are(were)subject to any order(s),permit(s)and/or approval(s) issued by DEP or EPA. If the box is checked,you MUST attach a statement identifying the applicable provisions thereof. LSP Name: Timothy J_ Snag/ LSP#: 3373 Stamp: 1A(IF Telephone: 9 7 8—4 6 5—18 2 2 Ext.: 2 2 TIMOTHY FAX(optional) 978-465-2986 J. SNAY °f No. 3373 Signature: r 9F p v Date:0.1 I. PERSON MAKING SUBMITTAL: Name of Organization: Ronald F_ Johnston & ComnanY, Inc_ Name of Contact: Ms:- Donna white Title: Street: 114 Boston Street City/Town: North Andover State: to ZIPCode: 01845-0000 Telephone: 97R-689-1 91 9 Ext.: FAX(optional) J. RELATIONSHIP TO SITE OF PERSON MAKING SUBMITTAL: (check one) RP or PRP Specify: ® Owner 0 Operator 0 Generator 0 Transporter Other RP or PRP: E] Fiduciary,Secured Lender or Municipality with Exempt Status(as defined by M.G.L.c.21E,s.2) n Agency or Public Utility on a Right of Way(as defined by M.G.L.c.21 E,s.5Q)) E] Any Other Person Submitting This Form Specify Relationship: Revised 417195 Supersedes Forms BWSC-004 and 010(in part) Page 3 of 4 Do Not After This Form Massachusetts Department of Environmental Protection BWSC-104 Bureau of Waste Site Cleanup RESPONSE ACTION OUTCOME (RAO) STATEMENT & Release Tracking Number DOWNGRADIENT PROPERTY STATUS TRANSMITTAL FORM ❑ - Pursuant to 310 CMR 40.0180(Subpart B),40.0580(Subpart E)&40.1056(Subpart J) 3 16618 K. CERTIFICATION OF PERSON SUBMITTING DOWNGRADIENT PROPERTY STATUS SUBMITTAL: 1, ,attest under the pains and penalties of perjury(i)that I have personally examined and am familiar with the information contained in this submittal,including any and all documents accompanying this transmittal form;(ii)that,based on my inquiry of the/those individual(s)immediately responsible for obtaining the information,the material information contained herein is,to the best of my knowledge, information and belief,true,accurate and complete;(iii)that,to the best of my knowledge,information and belief,I/the person(s)or entity(ies)on whose behalf this submittal is made satisfy(ies)the criteria in 310 CMR 40.0183(2);(iv)that IRhe person(s)or entity(ies)on whose behalf this submittal is made have provided notice in accordance with 310 CMR 40.0183(5);and(v)that I am fully authorized to make this attestation on behalf of the person(s)or entity(ies)legally responsible for this submittal. IRhe person(s)or entity(ies)on whose behalf this submittal is made is/are aware that there are significant penalties,including,but not limited to,possible fines and imprisonment,for willfully submitting false,inaccurate,or incomplete information. By: Title: (signature) For: Date: (print name of person or entity recorded in Section I) Enter address of the person providing certification,if different from address recorded in Section I: Street: City/Town: State: ZIP Code: Telephone: Ext.: FAX(optional) L. CERTIFICATION OF PERSON MAKING SUBMITTAL: If you are completing only a Downgradient Property Status Submittal,you do not need to complete this section of the form. I, Dnnna White ,attest under the pains and penalties of perjury(1)that I have personally examined and am familiar with the information contained in this submittal,including any and all documents accompanying this transmittal form,(ii)that,based on my inquiry of those individuals immediately responsible for obtaining the information,the material information contained In this submittal is,to the best of my knowledge and belief,true,accurate and complete,and(iii)that I am fully authorized to make this attestation on behalf of the entity legally responsible for this submittal. IRhe person or entity on whose behalf this submittal is made amts aware that there are significant penalties,including,but not limited to, possible fines and imprisonment,for willfully submitting false,inaccurate,or incomplete information. 'By- - -" ILA f 1��/'" Title: .0 •/ i. �j i 4 (signature) For: Donald F Johnston & Co_, Tnc. Date: (print name of person or entity recorded in Section 1) Enter address of the person providing certification,if different from address recorded in Section I: Street: CltyRown; State: ZIP Code: Telephone: Ext.: FAX(optional) YOU MUST COMPLETE ALL RELEVANT SECTIONS OF THIS FORM OR DEP MAY RETURN THE DOCUMENT AS INCOMPLETE. IF YOU SUBMIT AN INCOMPLETE FORM,YOU MAY BE PENALIZED FOR MISSING A REQUIRED DEADLINE,AND YOU MAY INCUR ADDITIONAL COMPLIANCE FEES. Revised 47/95 Supersedes Forms BWSC-004 and 010(in part) Page 4 of 4 Do Nn!4Rer This Fnrm Sunrise Homes, Inc. by Don Johnston Builder and Contractor Tel. (64 Ti 682-1619 f ,40RTN � 04 � BOARD OF HEALTH A s l # 120 MAIN STREET TEL. 'SSA H„SEt`h NORTH ANDOVER, MASS. 01845 July 31, 1995 Hayes Engineering, Inc. 603 Salem Street Wakefield, MA 01880 Re: Lot #3 Colonial Drive To Whom it May Concern: This is to inform you that the proposed plans for site referenced above have been disapproved for the following reasons: 1) No foundation drain 2) Septic tank not 25 feet from foundation 3) Leaching area not 35 feet from foundation 4) No soil tests in system 5) Insufficient leach area 6) No benchmark shown within 50-75 feet of system area 7) No wetlands disclaimer 8) Please show depth of trenches on cross section 9) If any building, etc. in PRD buffer, please show approval by the Planning Board If you have any questions, please do not hesitate to call the Board of Health Office at the number above. Sincerely, Sandra Starr, R.S . Health Administrator SS/cjp PLAN OF LAND IN NO, R MA 550, OCTOBER .31, 1997 10 YEN ENGINEER/NG, INC ► 603 SALEM STREET CML ENGINEERS & WAKEFIELD, AASS. 01880 LAND SURVEYORS TEL. (617) 246-2800 / CERTIFY mAr THIS FDUNQ4now IS LOCATED ON THE GROUND AS SHOWN, AND THAT IT CANFARMS TO THE ZONING BY-LAWS OF THE TOWN OF NORTH AM00WR. / FUR7HER CERAFY rHAT TH/S PROIPERTY bog NOT UE WHIN A IZOOD HAZARD AREA (ZONE A OR V� AS SHOWN ON ROOD INSURANCE RATE U4P COMMUNITY PANEL NUMBER 250098 0010 B. EFFECTTVF LUTE ✓UNE 15, 198.3 LUTE 31 - OF + 19�Z----- --- _ _ �N - - SIDNEYy4 PROFESSION�LAW SURVEYOR C. FIELD, JR. X15320 y N� �5• �6�oy 2 , a ZONE.• P.R.D. (R-2) V.R. tR lcr\ `� �o MIN/MUM SETBACKS. FRONT = 20' aW SIDE = 20' (SEE SEC. 8.5.6.D. 1) REAR = 20' LOT 3 24,512 S.F. 40// s so^ r a--��o� � p � TOP OF �� h FOUNDATION 35 \ �� FOUNDATION ELEY=/49.97 NQY% 9 h I� 1 s C� �-14�• �p V 5 R1 2 E A v COLONIAL Town of North Andover, Massachusetts Form No.2 MORTq BOARD OF HEALT ;? 9 ♦b.��---►►►-rrr+++,. " DESIGN APPROVAL FOR ssACHUSEt SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant R-C A ,,n Test No. Site Location `r Q—O Reference Plans and Specs. 117 ENGINEE DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. CHAIRM N,B ARD OF HEALTH Fee Site System Permit No. Timber (508) 682-1619 "°"tr�► FAX: (508) 682-1083 41K 1r1t0 SiO Donald F Johnston&Co.,Inc. Builder&Contractor 114 Boston Street Don Johnston G.B.I. No.Andover,MA 01845 President PLAN REVIEW CHECKLIST ADDRESS,&T �3 �D�I�iV/ G k'. ENGINEER Z X<��5 GENERAL 3 COPIES STAMP LOCUS NORTH ARROW SCALE CONTOURS_&�' PROFILE �� SECTION L---' BENCHMARK &---' SOIL & PERCS ELEVATIONS WETS. DISCLAIMER WELLS & WETS WATERSHED?,AL DRIVEWAY !/ (Elev) WATER LINEr/ FDN DRAIN SCH40_Z"' TESTS CURRENT? SOIL EVAL SEPTIC TANK MIN 1500G C / . 17 INVERT DROP GARB. GRINDERJ_(2 comps +200) 10 ' TO FDN !/ MANHOLE ELEV `� GW '/ # COMPS. GB D-BOX SIZE # LINES FIRST 2 ' LEVEL STATEMENT INLET OUTLET Alp, _ �� (2" OR . 17 FT) TEE REQ'D? !b LEACHING '/ MIN 440 GPD? " RESERVE AREA 41'� 4 ' FROM PRIMARY? � 20 SLOPE 100 ' TO WETLANDS 100 ' TO WELLS G/_ 4 ' TO S.H.GW I-' (51 >2M/IN) 20 ' TO FND & INTRCPTR DRAINS L' 400 ' TO SURFACE H2O SUPP 4 ' PERM. SOIL BELOW FACILITY MIN 12" COVER Z-- FILL? (151 ) BREAKOUT MET? TRENCHES V/ MIN 440 gpd SLOPE (min .005 or 6"/100 ' ) `' SIDEWALL DIST. 3X EFF. W OR D (MIN 6 ' )ice RESERVEBETWEEN TRENCHES /?(�IN FILL? MUST BE 10 ' MIN. 4" PEA STONE?y VENT? y (>3 ' COVER; LINES >501 ) BOT �� t _ + SIDE L� X LDNG = TOT (L x W x #) (DxLx2x#) (G/ft2) Copyright 0 1996 by S.L. Starr SEPTIC PLAN SUBMITTALS LOCATION: NEW PLANS: YES $60.00/Plan REVISED PLANS- YES $25.00/Plan DATE: DESIGN ENGINEER: zo When the submission is all in place, route to the Health Secretary FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or ,landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant! fills out this section***************** APPLICANT: �o�nA�(� }- . 40�n� Phone o1 ` t t LOCATION: Assessor' s Map Number Parcel Subdivision Lot(s) �- Street St. Number — ************************Official Use Only************************ RECO NDATIO TOWN AGENTS: ;ri?2 77 Date Approved ,7 � C servati Administrator Date Rejected Comments �� i4.' Ii Date Approved Town Planner Date Rejected Comments to ccy\,�Vl CL( J�� Cul)� Date Approved Food Insp or-Health Date Rejected Date Approved rl _,hep c I spect -Health Date Rejected Comments Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date ova TONN5 WN()A HAYES ENGINEERING, INC. RD DF EA�H IJ �Lrl] OO �Lfl7(n1ll�J�l1�/IJ��L�11� 'so 603 SALEM STREET 191-16 WAKEFIELD, MA 01880 D E ll JOB NONO W 4!j_Z TEL.: (617) 246-2800 ATTENTIO S FAX : (617) 246-7596 A t\ aE: TO Q Vm 0 GENTLEMEN: , 2� ' + WE ARE SENDING YOU Ottached ❑ Under separate cover via J the following ite s: ❑ Shop drawings Plorints ❑ Plans ❑ Samples ❑ Specifications ❑ Copy of letter ❑ Change order ❑ COPIES DATE NO. DESCRIPTION vISL p THESE ARE TRANSMITTED as checked below: For approval ❑ Approved as submitted ❑ Resubmitcopies for approval ❑ Foryouruse ❑ Approved as noted ❑ Submit—copies for distribution ❑ As requested ❑ Returned for corrections ❑ Return corrected prints ❑ For review and comment. ❑ ❑ FOR BIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS: COPY TO: SIGNED: It enclosures are not as noted.kindly notify us at once. DATE �3d ��' Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEE 1p d PERMIT # 7-1y DATE RECEIVED�v��/� APPLICANT 1,96 ASSESSOR'S MAP ADDRESS PARCEL # LOT # STREET eo�ati/i9C b,P/U� ENGINEER 111-2 yE.S �N�, _Z-.tJ C ADDRESS w/DL�Eri�G PLAN DATE 1Z 1-7-5-- REVISION DATE CONDITIONS OF APPROVAL: APPROVED \/ DISAPPROVED �C UKJ, A)6 �Ov,UD/�Tia,c� �.E'1 i•U /-)2/-2.e1<5 �p i�c>�TCf tiD� , 9, PLAN REVIEW CHECKLIST ADDRESS L3 CoLON / AL 1) R , ENGINEER �`', Pt Y c-S GENERAL 3 COPIES Y STAMP LOCUS NORTH ARROWy SCALEy CONTOURS,--V PROFILE SECTION j BENCHMARK SOIL & PERCS ELEVATIONS WETS. DISCLAIMER WELLS & WETS WATERSHED? AVO DRIVEWAY (Eley) WATER LINE ;�' FDN DRAIN Xo'� SCH40 V TESTS CURRENT? SOIL EVAL SEPTIC TANK MIN 150OG . 17 INVERT DROP GARB. GRINDER EDF) 25 ' TO CELLAR MANHOLE ELEV GW # COMPS. D-BOX 3 SIZE # LINES IRST 2 ' LEVEL STATEMENT -X— INLET/-4T D O - OUTLET, _ ` , " OR . 17 FT) TEE REQ'D? 147- 16 94 LEACHING MIN 660 GPD? �� RESERVE AREA 4 ' FROM PRIMARY? V 2% SLOPE 100 ' TO WETLANDS t/ 100 ' TO WELLS 4 ' TO S.H.GWy (5 '>2M/IN) 35 ' TO FND & INTRCPTR DRAINS 14 325 ' TO SURFACE H2O SUPP 4 ' PERM. SOIL BELOW FACILITY MIN 12" COVER FILL? 6<25 ' if above natural elev; 101if below) BREAKOUT MET? 7, TRENCHES TRENCHES / MIN 660 gpdX SLOPE (min . 005 or 611/1001 ) SIDEWALL DIST. 3X EFF. W OR D (MIN 61 )-Z� RESERVE BETWEEN TRENCHES? llr4V" IN FILL? MUST BE 10 ' MIN. V- 4" PEA STONE?2 VENT? a K.- 3 ' COVER; LINES >501 ) BOT4ftw- + SIDE O D X LDNG , 3 7 = TOT 333 4 2-e)' �� , &-3 46 7 66 No......................... VEA... .. ... ......_ THE COMMONWEALTH OF MASSACHU ETTA1 BOARD OFeHEALT t .�� -- ... .....OF...{•�..4........ .p® .�... ........ ...................... Appliratinn for Bispusal Works Cann urti Application is hereby made for a Permit to Construct ( � or Repair ( ) an Individual Sewage Disposal System at: ................_........ ..1-::_)NJ.►...L..----...............--------------- ------------------------ ..------.................................................. Loca' n r ss or Lot N C.....31..1.E 1 .----lmC.................... 3 A Q ' .._..'1 �-- 1 a o tt. .....----- .. Owner Address w Installer Address Type of Building Size Lot.z ..5...1.3-:...Sq. feet U Dwelling—No. of Bedrooms.......................................Expansion Attic ( ) Garbage Grinder ($15 'k Other—Type T e of Building No. of persons............................ Showers Pk YP g --------•---••-•-----------• P ( ) — Cafeteria ( ) 04 Other fixtures ................................. W Design Flow..............5.5.........ff.,.......gallons per person per day. Total daily flow......... WSeptic Tank—Liquid capacity-.VS gallons Length................ Width................ Diameter................ D th................ x Disposal Trench—No.-._-�„�............. Width.....a.......... Total Length__..�Q....... Total leaching area..... ©sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosi tank ( ) `'' Percolation Test Results Performed by. ?. ..G S....S.... �... . ._ .C-.............. Date... ........... ,.� Test Pit No. I................mmutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -----.-----•--------.---•------------------------------------------------------------------•- 0 Description of Soil........5667.........•-G . ...v.................. ` •-----------------•--------...---•----------------...--•--------...................-•--•-•--- W U --•-••...................................... -------------- ---------------------- .....--------- •------------------- •------ •-------------------------- ....._.......... W ............................. ----•---••--•-•-•-------•--•-----•-•-•-•-------•--...--•-.....--••--------•--•--•------------•-------•-------•-••------•--•-••-•---------------------......-----.......... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... -•..........................•----•---.........---....------•-------------------•-----•-----.................-•----------------•----------------•----•-----------------------------•-----•-•-•--------... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Di sal System in accordance with the provisions of TITLE 5 of the State Environment e—The nder ' n further agrees not to place the system in operation until a Certificate of Complian s een issue y t b of health., Signed .. ..... ... -- ---- - ...... ................................... ...... . ---- ..... Date ApplicationApproved By ...................... .......................................................................................... ............................. ................................. Date Application Disapproved for the following reasons: ........... .... .. ... .................................................................................................... ............................................................................... .......................... ............................................................................................ .................-----...---......------ Date PermitNo. ................ ............ .................................... Igsued ................................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............................................. OF ..... ........................ ..............---- ....................................... tLErltftrato of Tome lame THIS IS TO CEIJTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by ...................................................................................................................Installer.....................----........................................................................................... at ..................................................................................................................................................................................................................................................... has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ................................................ dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.................................................................................................... Inspector .......... ------....----.....................----------------.............---------------------- ----- ------------------------------------ ---- ----- ---- ---------- ------- -- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... No......................... FEE........................ Disposal Worko Tonstrnrtiun prrmit Permissionis hereby granted.............................................................................................................................................. to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo............................................................................................................................................................................................... Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... .......................................•----------------•----....................-•--•--•-••---•-•....._ Board of Health DATE..................•-•---...-•---.....------.................----•------•--.----- Form 1255 H&WHOBBS&WARREN Publishers No......................... Fins.................. _..... . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... ..........OF.....W O........ qaw.k._1 -............... Appliration for Piopoonl Workii Tono#rn.r#ion rami# Application is hereby made for a Permit to Construct ( 1 or Repair ( ) an Individual Sewage Disposal System at: t� Locat' i t d e s or Lot N ..............1._ _ ._._ �'.l?t .., i .�,. _....� '� -i• f t, _ k-------'- .._ �?lt ......... Owner Address W Installer Address 1 Type of Building Size Lot.........:..:...............Sq. feet aDwelling—No. of Bedrooms......_....._..........................Expansion Attic ( ) Garbage Grinder ( ( p, Other—Type of Building ............................ No. of persons.........._................. Showers ( ) — Cafeteria ( ) Pa Other fixtures -------------------------------- . d •. ----------------••.---.........__.. W Design Flow...............5. ...... per person per day. Total daily flow__._....... ...................gallons. � Septic Tank—Liquid capacity_..��Rvallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No. ..__-3........... Width......Z.......... Total Length......Q-..... Total leaching area.__....:!.fir%-�-�S�q. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Other Distribution box ( ) Dosin ank ) j cc.�., '" Percolation Test Results Performed by... Q�.-r_�....y�_,j............................... Date.... .� .._�_.t.! ..._..... aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �+ ................ .......................... =.-------------•----••-----------•----•-----............................................................. O Description of Soil.........5 ...--- . ........� {`�'. W V .... ........... .---- *..... ..----••....... ........-••-------------------------------•-----•••-----------------------------.._....--------------------- ------------- -•-•••---------- •----------------- W ----•---------------------------------------------------------------------------------------------------------------------------------•---------------------.....-----------------........••••..._••.... UNature of Repairs or Alterations—Answer when applicable................................................................................................ -•--•..............................................•----•--•------------------------•---•--------•----------------------------------•-•---•----•----------------------------------------•••-••-••-...... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed ..................... . .... ... ..... ...................................................... ........................................ Dare ApplicationApproved By ................ ....................................................................................... ....... .... .................... ....................te.................... Da Application Disapproved for the following reasons: ....................................... ................. ..... ...... . .. ................................................ ................................................................................................... .......................... ............... .......................................................... ........................................ Date PermitNo- ------------------------------------------ --- --------------- Issued ..--.....----........----...---.....---............................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................... ........................ OF --....-.-......---.....-..------..--.....-------------.......---------------.--------------------- Ter#tfira e of Cfomplinure THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by-----------------------------------------------------------------------------------------------------.........------------ Installer at ......................................................................................................... .... ............................................................................................................................... has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ................................................ dated ...................... ........ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......................................................... .............. ..................... Inspector ....----.............................---....----------....................---- ------------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... No......................... FEE........................ Disposal Worko Tono#rur#ion f ami# Permissionis hereby granted-----------------------------•------.------.--_-.----------------•-••------..----••------•-----------.--....-...-----•----••----..-----.----- to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo....................••-••••••.....................•••-••----•..............•-••--••••-•..........----------------.....................•---•-•------•..................-----•---•-•-••--•....... Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... ----••---•--••------------------------------------------•-----...-------••---------•--•--•-•---........_ Board of Health DATE................................................................................ Form 1255 H&W HOBBS&WARREN Tm Publishers y � the Fire Department: A. Open burning is allowed by ' permit only after consultation with the Fire Department. B. Underground fuel storage will only be allowed in accordance with Town Bylaws and State Statute and only with the review and approval of the Fire Department and Conservation Commission. C. Lot numbers are to be posted clearly during construction and permanent house numbers marked prior to occupancy. D. All structures shall be required to contain residential fire sprinklers systems the design of which will be approved by the Fire Department. E. The water main should be looped through to Wagon Wheel Estates. F. The Street names must be reviewed and approved by the Dispatch Supervisor in order to facilitate implementation of E-911. 10. The applicant shall adhere to the following requirements of the Police Department: A. Adequate site distance shall be maintained at the exit of the project onto Route 114 . B. Appropriate signs shall be placed on Route 114 informing motorists of the intersection during the period of construction activity. C. A "STOP" sign shall be placed as the proposed roadway exits onto Route 114. 11. The applicant shall adhere to the following conditions: A. There will be a 20 foot no-cut zone imposed along the rear lot lines of lots 3 , 4, 5 and 6 which will run with the land in subsequent deeds. The Planning Board agrees to waive the 50 ' buffer requirement along these lots. B. Not less than a 50 foot wide 'no-cut zone' shall be created as part of the open space along the rear lot lines of the remaining lots and along the remainder of the boundary with Harold Parker State Forest, excluding the area along the Eastern open space which has been designated as an easement for a future roadway. 7 i j i i IF I i t I I r� Ma 6 311 i ji � lliIl i I 4 �j � ° viii il ��"yA � � ' �' ��o4liiw� s it � I ------- CS .Q — ----- - - - ---- � bz- �bG ti -- —- — j � j I I ; � 70 - - I -- e c r i , I 5/6.77Y 519W 11 S - . IT z��- lir (RooT111 l ?8 y w = - L 54,t) Form No.4 Town of North Andover, Massachusetts BOARD OF HEALTH 813,1 -1998 CERTIFICATE OF COMPLIANCE This is to certify that the Individual Soil Absorption Sewage Disposal System constructed (4-�or repaired ( ) INSTALLER at SITE LOCATION has been installed in accordance with Board of Health Regulations as described in the Design Approval Site System Permit No. J77111 dated /7-19 17 . The issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. BOARD OF HEALTH ENGINEER Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH 63 6;- - A 01 APPLICATION FOR SITE TESTING/INSPECTION 7 .o°AA TED �SSACHUS�� Applicant C NAME ADDRESS TELEPHONE Site Location ( r- WDo Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time d 1-� vD CHAIRMAN,BOARD OF HEALTH' lp ,�\ Fee �--' `' L/ Test No. Lk y S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts Form No. 1 pORTH BOARD OF HEALTH 6 0e 19 Jq °�XpW1C•� APPLICATION FOR SITE TESTING/INSPECTION 7 "ORATE°PPP` (y �SSACHUS�� Applicant NAME ADDRESS TELEPHONE Site Location Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN, BOARD OF HEALTH Fee Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: A2 CURRENT INSTALLER'S LICENSE# LOCATION: CO `� �''� We_ LICENSED INSTALLER: SIGNATURE: TELEPHONE# ?9 Vv CHECK ONE: REPAIR: NEW CONSTRUCTION: V IF NEW CONSTRUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. Administrative Use Only $75.00 Fee Attached? Yes v' No Foundation As-built? Yes J No Floor plans on file? Yes �� No Approval Date: L `� Town of North Andover, Massachusetts Form No.3 <NORTH BOARD OF HEALTH 3? a�. •" .e OL �/ • KJ 19 • O � I , H 9 DISPOSAL WORKS CONSTRUCTION PERMIT SSACHUSE Applicant NAME ADDRESS TELEPHONE Site Location t Permission is hereby granted to Construct (�or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. 7 CHAIRMAN,BOA OF HEALTH- Fee EALTHFee 7S D.W.C. No. 9 7 i �3. .T .. M r. 1`