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Parcel ID:210/038.0-0188-0000.0 Community:North Andover
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Sales
Summary
Residence
Detached Structure
Condo
Commercial !
Comparable Sales
75 NORTH CROSS ROAD
Location: 15 NORTH CROSS ROAD
Owner Name: LINDA HALL
Owner Address: 15 NORTH CROSS ROAD
City:NORTH ANDOVER State:MA ZIP:01845
Neighborhood:7-7 Land Area: 1.16 acres
Use Code: 101 -SNGL-FAM-RES Total Finished Area:3398 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 695,200 725,100
Building Value: 469,200 487,300
Land Value: 226,000 237,800
Market Land Value:226,000
Chapter Land Value:
LATESTSALE
Sale Price:689,900 Sale Date:01/07/2004
Arms Length Sale Code:Y-YES-VALID Grantor:PRUDENTIAL RESIDENTI
Cert Doc: Book:8506 Page:0059
http://csc-ma.us/NandoverPubAce/jsp/Home.jsp?Page=3&Linkld=1175786 8/22/2008
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments + v�
15 North Cross Road
Property Address
Donald Dowden V
Owner Owners Name '
information is
required for every North Andover MA 01845 11/26/2013
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.
my Company Name
111 Argilla Road
Company Address
Andover MA 01810
City/Town State Zip Code
9784754786 S115
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ N eds Further Evaluation by the Local Approving Authority
DEC 23 7013
TOWN Or r; yr.jovER f
C � I-IFALTH OEP,.,2T;��14T
11/26/2013
Ins6eckoetSignatury Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
15 North Cross Road
Property Address
Donald Dowden
Owner Owner's Name
information is
required for every North Andover MA 01845 11/26/2013
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 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 North Cross Road
Property Address
Donald Dowden
Owner Owner's Name
information is
required for every North Andover MA 01845 11/26/2013
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in 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-3/13 Title 5 Official Inspection Forth: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
r 15 North Cross Road
Property Address
Donald Dowden
Owner Owner's Name
information is
required for every North Andover MA 01845 11/26/2013
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
= v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
rt 15 North Cross Road
Property Address
Donald Dowden
Owner Owner's Name
information is
required for every North Andover MA 01845 11/26/2013
page. Cityfrown 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•3/13 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 North Cross Road
Property Address
Donald Dowden
Owner Owner's Name
information is
required for North Andover MA 01845 11/26/2013
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ 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): 5 Number of bedrooms(actual): 5
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
' 15 North Cross Road
Property Address
Donald Dowden
Owner Owners Name
information is
required for North Andover MA 01845 11/26/2013
every page. Cityfrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ® Yes ❑ No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)): Yes
Detail:
Sump pump?
❑ Yes ® No
Last date of occupancy: vacant
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present?
❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°< 15 North Cross Road
Property Address
Donald Dowden
Owner Owner's Name
information is North Andover MA 01845 11/26/2013
required for every
page. Cityrrown 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: Pumped7 two years ago, owner
Was system pumped as part of the inspection? ® Yes ❑ No
If'yes, volume pumped: 1500
gallons
How was quantity pumped determined? Measure 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-3113 Title 5 Official Inspection Forth: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 North Cross Road
Property Address
Donald Dowden
Owner Owner's Name
information is
required for North Andover MA 01845 11/26/2013
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
10 Years old, 12/17/2003, as built plan
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
® cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
1
4"cast iron through wall 3" PVC in house no leaks visible
Septic Tank(locate on site plan):
Depth below grade: 1
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:
5"
t5ins•3/13 Title 5 Official Inspection Form:Subsurface sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�r< 15 North Cross Road
Property Address
Donald Dowden
Owner Owner's Name
information is North Andover MA 01845 11/26/2013
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
28
Scum thickness 5
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.):
Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No
evidence of leakage.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r 15 North Cross Road
Property Address
Donald Dowden
Owner Owner's Name
information is North Andover MA 01845 11/26/2013
required for every
page. City[Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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•3/13 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 North Cross Road
Property Address
Donald Dowden
Owner Owners Name
information is
required for every North Andover MA 01845 11/26/2013
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
0.,
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box level &distribution equal. Evidence of carryover.Pumped d-box to clean. No evidence
of leakage
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°r 15 North Cross Road
Property Address
Donald Dowden
Owner Owner's Name
information is. North Andover MA 01845 11/26/2013
required for every
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions: 1 field 20'x 40'
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil ok. Vegetation ok. No sign of ponding to surface.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r 15 North Cross Road
Property Address
Donald Dowden
Owner Owner's Name
information is North Andover MA 01845 11/26/2013
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
15 North Cross Road
Property Address
Donald Dowden
Owner Owners Name
information is North Andover MA 01845 11/26/2013
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal.System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
0
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
15 North Cross Road
Property Address
Donald Dowden
Groner Owner's Name
information is
required for every North Andover MA 01845 11/26/2013
page. Cityrrown 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: 7/29/2003Date
❑ 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:
Test pit data on design plan
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
15 North Cross Road
Property Address
Donald Dowden
Owner Owner's Name
information is North Andover MA 01845 11/26/2013
required for every
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
Lommonwealth of Massachusetts
City/Town of .
System Pumping Record
Form 4
DEP has provided this form for use,by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using.this form, check with your=
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Information
1. System Location: Left/Right front of house, Left/Right rear of housWG'�righ e , Left/
Right side of building, Left/Right front of building, Left/Right rear of Sul ding, Under deck
Address
Cityfrown State Trp Code
2. System Owner.
Name' f
Address(if different from location)
Ckyfrown State
• _ �t� —'���Cooe
Telephone Number
B. Pumping Record
1. Date of Pumping ` ..
Date 2. Quantity Pumped: Gapons
t
3. Type of system'.yP Y. ❑ Cesspool(S) eptic Tank ❑ right Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0'140 If,yes, was it cleaned? ❑ Yes ❑ No
5. Cord'' n 9f System:
1
6: System Pumped By.
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
ncCompany
7. Locatio contents were disposed:
S Lowell Waste Water
Sig Hauls Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Summary Record Card generated on 12/4/2013 2:45:38 PM by Karen Hanlon Page 1
' Town of North Andover Test
Tax Map # 210-038.0-0188-0000.0
Parcel Id 13258
15 NORTH CROSS ROAD
DONALD & TINA DOWDEN
15 NORTH CROSS ROAD
NORTH ANDOVER, MA 01845
Class 101 Single Family Property Type 1 Residential
Zoning2 1 Residential Zoning3 1 Residential
Size Total 1.16 Acres
FY 2014
UB Mailing Index
Name/Address Type Loan Number Active/Inact. From Until
DONALD&TINA DOWDEN Owner
15 NORTH CROSS ROAD
NORTH ANDOVER,MA 01845
HALL,LINDA Previous Customer Inactive 9/25/2008
15 NORTH CROSS ROAD
NORTH ANDOVER,MA
01845
UB Account Maint.
Account No Cycle Occupant Name Active/Inactive
Bldg Id. 14001.0-15 NORTH CROSS ROAD Last Billing Date 9/9/2013
2100535 02 Cycle 02 Active
UB Services Maint.
Account No.2100535
Service Code Rate Charge Multiplier/Users
MISCFEE ADMIN FEE 1 1 9,18 1/
WTR WATER 01 ALL METER SIZE 340.86 /1
UB Meter Maintenance
Account No.2100535
Serial No Status Location Brand Type Size YTD Cons
33244895 a Active ERT HH b Badger w Water 1 1 612
Date Reading Code Consumption Posted Date Variance
8/5/2013 738 a Actual 68 9/18/2013 1421%
5/2/2013 670 a Actual 4 6/18/2013 -73%
2/6/2013 666 a Actual 17 3/13/2013 -62%
10/31/2012 649 aActual 39 12/13/2012 15%
8/6/2012 610 a Actual 37 9/26/2012 389%
5/4/2012 573 a Actual 7 6/20/2012 -2%
2/7/2012 566 a Actual 8 3/14/2012 -69%0
11/2/2011 558 a Actual 24 12/15/2011 17%
8/4/2011 534 a Actual 21 9/14/2011 37%0
5/4/2011 513 a Actual 15 6/13/2011 -40%
2/3/2011 498 a Actual 26 3/15/2011 -55%
11/1/2010 472 a Actual 54 12/13/2010 7%
8/5/2010 418 a Actual 53 9/13/2010 162%
5/5/2010 365 a Actual 20 6/9/2010 -12%
2/3/2010 345 a Actual 23 3/11/2010 -36%
11/3/2009 322 aActual 35 12/11/2009 121%
8/5/2009 287 a Actual 16 9/11/2009 23%
5/6/2009 271 a Actual 13 6/16/2009 -34%
2/4/2009 258 a Actual 20 3/16/2009 -28%a
11/4/2008 238 a Actual 13 12/10/2008 -62%0
9/22/2008 225 f Final Bill 38 9/22/2008 18%
8/5/2008 187 a Actual 61 9/12/2008 47%0
5/6/2008 126 a Actual 42 6/18/2008 246%
2/4/2008 84 a Actual 12 3/14/2008 -25%
11/5/2007 72 a Actual 16 1/15/2008 7%
8/6/2007 56 a Actual 15 9/14/2007 15%
COMMONWEALTH OF MASSACHUSETTS eeJt� . ter
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
SJeJ� RECEIVED
JUL 0 7 2008
TITLE 5 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 15 North Cross Road_
—North Andover_
Owner's Name:_John Little
Owner's Address:_15 North Cross Road
_North Andover,MA 01845_
Date of Inspection:_6/27/2008
Name of Inspector:_Neil J.Bateson_
Company Name:_Bateson Enterprises Inc._
Mailing Address:_111 Argilla Road_
_Andover,MA 01810_
Telephone Number:_(978)475-4786_
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
ils
Inspector's Signature: Date: 6/27/2008_
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments:
""This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
' Page 2 of 11 '
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 15 North Cross Road_
_North Andover_
Owner:_Little_
Date of Inspection:_6/27/2008_
Inspection Summary:Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any
information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304
exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system
components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon
completion of the replacement or repair,as approved by the Board of Health,will pass.Answer yes,no or not
determined(Y,N,ND)in the for the following statements.
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 exfilttation or tank failure is imminent. System will pass inspection if the existing tank is replaced
with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of
sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or
due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of
Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required
pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with
approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Title 5 Inspection Form 6/15/2000 2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:_15 North Cross Road_
_ North Andover_
Owner:_Little_
Date of Inspection:_6/27/2008_
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
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well".Method used to determine distance_
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
Title 5 Inspection Form 6/15/2000 3
' Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 15 North Cross Road-
-North Andover_
Owner:_Little
Date of Inspection:_6/27/2008_
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
_No_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
No_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_No_ Liquid depth in cesspool is less than 6"below invert or available volume is'h day flow.
_No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
— _No_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
_No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
No_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
_No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
_No_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described
in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to
determine what will be necessary to correct the failure
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
Title 5 Inspection Form 6/15/2000 4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 15 North Cross Road_
_North Andover_
Owner:_Little
Date of Inspection:_6/27/2008_
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
Yes_ Pumping information was provided by the owner,occupant,or Board of Health
No Were any of the system components pumped out in the previous two weeks?
Yes_ Has the system received normal flows in the previous two week period?
No_ Have large volumes of water been introduced to the system recently or as part of this inspection?
Yes_ Were as built plans of the system obtained and examined?
Yes_ _ Was the facility or dwelling inspected for signs of sewage back up?
_Yes_ _ Was the site inspected for signs of break out?
_Yes_ _ Were all system components,excluding the SAS,located on site?
_Yes 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?
_Yes_ _ Was the facility owner(and occupants if different from owner)provided with information on the
proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
_Yes_ _ Existing information.
_Yes_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[3 10 CMR 15.302(3)(b)]
Title 5 Inspection Form 6/15/2000 5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 15 North Cross Road-
-North Andover_
Owner:_Little_
Date of Inspection:_6/27/2008_
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):_5_Number of bedrooms(actual):_5_
DESIGN flow based on 310 CMR 15.203_550_
Number of current residents:_2
Does residence have a garbage grinder(yes or no):_Yes_
Is laundry on a separate sewage system(yes or no):_No_
Laundry system inspected(yes or no): _
Seasonal use:(yes or no):_No
Water meter reading:_Yes_
Sump pump(yes or no):_No_
Last date of occupancy:_Current_
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203):____Md
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:_Never pumped since new installation,owner_
Was system pumped as part of the inspection(yes or no):_Yes_
If yes,volume pumped:_1500_gallons--How was quantity pumped determined?_Measured tank_
Reason for pumping: _Inspect tank&tees
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
_Single cesspool_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
Other(describe):_
Approximate age of all components,date installed(if known)and source of information 5 years old,12/17/2003,
as built plan_
Were sewage odors detected when arriving at the site(yes or no):_No
Title 5 Inspection Form 6/15/2000 6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_15 North Cross Road
_North Andover_
Owner:_Little_
Date of Inspection:_6/27/2008
BUILDING SEWER_X_ (locate on site plan)
Depth below grade:_26"_
Materials of construction: _X_ cast iron —X-40 PVC_other
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.) _4"Cast iron thru wall.3"PVC in house,
no leaks visible
SEPTIC TANK: X
Depth below grade:_16"_
Material of construction: X concrete_metal fiberglass polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 10'x 5'x 4'
Sludge depth —8"_
Distance from top of sludge to bottom of outlet tee or baffle:_19"_
Scum thickness:_6"_
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: 15"_
How were dimensions determined:_
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc._Pumped septic tank.Inlet tee ok.Outlet tee ok. Depth of
liquid at outlet invert.No evidence of leakage._
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Title 5 Inspection Form 6/15/2000
Page 8 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 15 North Cross Road
North Andover
Owner:_Little_
Date of Inspection:_6/27/2008_
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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX X_
Depth below grade _26"_
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 level&distribution equal,has flow levelers.No evidence of leakage.
Evidence of carryover,pumped d-box to clean.
PUMP CHAMBER:_(locate on site plan)
Pump in working order(yes or no):—
Alarm in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): _
Title 5 Inspection Form 6/15/2000 8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 15 North Cross Road_
_North Andover—
Owner:_Little
Date of Inspection:_6/27/2008_
SOIL ABSORPTION SYSTEM(SAS):_X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
Leaching pits,number: _
Leaching chambers,number:
Leaching galleries,number:
_Leaching trench,number,length:
X Leaching field,number,dimensions: _1 field 20' x 40'_
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:
Number and configuration:_
Depth—top of liquid to inlet invert:_
Depth of sludge layer:_
Depth of scum layer:_
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):—
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (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.):
Title 5 Inspection Form 6/15/2000 9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 15 North Cross Road_
_North Andover—
Owner:_Little_
Date of Inspection:_6/27/2008_
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building
A to Septic Tank=4212"
B to Septic Tank=14'7"
B to D-Box=4913"
C to D-Box=5515"
D-Box
C
♦_ Septic Tank Porch
B
House Driveway
A
Water Meter
Title 5 Inspection Form 6/15/2000 10
` Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 15 North Cross Road_
_North Andover—
Owner:_Little_
Date of Inspection:_6/27/2008
SITE EXAM
Slope_No_
Surface water_No_
Check cellar _Yes_
Shallow wells No
Estimated depth to ground water _4'_
Please indicate(check)all methods used to determine the high ground water elevation:
_X_ Obtained from system design plans on record-If checked,date of design plan reviewed:_7/29/2003_
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:__
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:_As per design plan test pit data_
Title 5 Inspection Form 6/15/2000 11
c.va rM Uy L138 tvans
Town of North Andover Page,
• Tax Map # 210-038.0-0188-0000.0
Parcel Id 13258
15 NORTH CROSS ROAD
LINDA HALL Since Jan 2005
15 NORTH CROSS ROAD
NORTH ANDOVER, MA
_ 01845
Class 101 Single Family Property T e
Size Total 1.16 Acres p � yp 1 Residential
FY 2008
UB Mailing Index
Name/Address Type Loan Number
Active/Inact. From Until
HALL,LINDA Payor
15 NORTH CROSS ROAD
NORTH ANDOVER, MA
01845
UB Account Maint.
Account No Cycle Occupant Name
Bldg Id. 14001.0-15 NORTH CROSS ROADActive/Inactive
2100535 02 Cycle 02 Last Billing Date 6/11/2008
Active
UB Services Maint.
Service Code Rate Charge
MISCFEE ADMIN FEE 1 1Multiplier/Users
WTR WATER9.18 1/
01 ALL METER SIZE
193.03 /1
UB Meter Maintenance
Serial No Status Location Brand
33244895 a Active ERT HH b Bad w W Size YTD Cons
Badger
Date Reading Code g N/Water 1 1
5/6/2008126 a Actual Consumption Posted Date Variance 2/4/2008 84 a Actual 42. 6/18/200812 3/14/2008 246%
11/5/2007 72 a Actual 16 1/15/2008 -25%
8/6/2007 56 a Actual 15 9/14/2007 7%
5/7/2007 41 a Actual 10 6/22/2007 15%
2/26/2007 31 a Actual 20 3/23/2007 -18%
11/3/2006 11 a Actual 11 12/22/2006 1%
Trouble Code:03 0%
8/31/2006 0 n New Meter 0 9/13/2006
8/31/2006 5010 r Replacement 25 9/13/2006 0%
5/25/2006 4985 m Manual estimate 15 6/20/2006 80%
MSG 30%
2/8/2006 4970 a Actual 10 3/13/2006
Trouble Code:03 -51%
11/8/2005 4960 a Actual 20 12/14/2005
Trouble Code:03 -100%
8/10/2005 4940 c Correction 0 9/12/2005
5/12/2005 4945 m Manual estimate 15 6/8/2005 -100%
2/15/2005 4930 m Manual estimate 20 3/15/2005 -22%
MSG -38%
11/17/2004 4910 m Manual estimate 35 12/17/2004
8/12/2004 4875 a Actual 9/20/2004 -100%
5/19/2004 4875 m Manual estimate 35 6/14/2004 -100%
2/17/2004 4840 a Actual 11 4/16/2004 256%
11/6/2003 4829 n New Meter 0 11/6/2003 0%
0%
• Tel: (978) 475-4786
Fax: (978)475-5451
BATESON ENTERPRISES, INC.
Excavating-Water& Sewer Lines-Septic Systems &Pumping Service
111 Argilla Road Andover,Mass. 01810
Title 5 Inspection Report
Property Address: 15 North Cross Road, North Andover
Owner: Little
Date of Inspection: 6/27/2008
My report contained herein does not constitute a guarantee of future usage and the functionality of the existing
septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further
operation of your current septic system.
Neil J. Bateson
Bateson Enterprises,Inc.
Town of North Andover f %ORYh
Office of the Health Department
s _ A
Community Development and Services Division ° **
27 Charles Street
North Andover,Massachusetts 02845 Rssgc►+us�`t
Heidi Griffin Telephone (978)688-9540
Acting Public Health Director Fax(978)688-9542
TOWN OF NORTH ANDOVER
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
DATE OF COMPLIANCE
December 24, 2003
This is to certify that
the individual subsurface disposal system
constructed ( ) repaired (X)
by
Peter Breen
at
15 North Cross Road
North Andover, MA 01845
as been installed in accordance with the provisions of Title V of the State Sanitary Code and with the
North Andover Board of Health regulations.
The Issuance of this certificate shall not be construed as a guarantee that the system will function
satisfactorily.
Jonathan arkey
ChairmAi,North Andover Board of Health
BOARD OF APPEALS 688-9541 BLTILDING 688-9545 CONSERVATION- 688-9530 HEALTH 688-9540 PLANINING 688-9535
� ' 1
TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM
INSTALLATION CERTIFICATION
The dersigned hereby certify that the Sewage Disposal System ( ) constructed,
( repaired:
by ( GTE a
located at
was installed in conformance with the North Andover Board of Health approved plan,
System Design Permit# , dated with an approved design
flow of 5; 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 CMR 15.000, Title 5 and local regulations, and the final grading agrees
substantially with the approved plan. All work is accurately represented on the As-built
which has been submitted to the Board of Health.
Bed inspection date: tai Lle f?r12f"a;'WM r-AP lun5io
Engineer Representative
Final inspection date: l Z- 6o -0--'j
Engineer Represet tative c
L �
Installer: t��e. t �� � - Lic.#: Date: 12, 1
Design Engineer: w-� Date: . 17--19--o�
r T("a11v OF NORTH ANLA,
BOAR€}OF HEALTH
!' S 2 3 2004
AS-BUILT CHECKLIST _
- TC i,114 OF NORTH ANltt,
BOARD OF HEALTH ^
LOT NUMBER, STREET NAME
✓ 2 3 2004
ASSESSORS MAP& PARCEL NUMBER
LOT LINES & LOCATION OF DWELLINGS
LOCATIONS & DIMENSIONS OF SYSTEM,
TIES j0 LOT LINES &DWELLING, WELLS
a. FROM SEPTIC TANK
/ b. FROM LEACH AREA
V LOCATIONS OF DEEP HOLES& PERC
TESTS
ELEVATIONS OF DISPOSAL SYSTEM
TOP OF FDN ELEVATION
LOCATIONS OF WELLS,DRAINS, WATERCOURSES
WITHIN 150' OF SYSTEM tjA
LOCATION OF WATER,GAS,ELECTRIC LINES, CABLE
`f DISTANCES FROM CORNERS OF HOUSE TO CENTER OF
TANK&D-BOX =
ORIGINAL STAMP& SIGNATURE
IMPERVIOUS AREAS -DRIVEWAYS, ETC.
NORTH ARROW
LOCATION&ELEVATIONS OF BENCHMARK USED
3
i
3
Page 1 of 1
Ilk
DelleChiaie, Pamela
From: Dan Ottenheimer[info@ millriverconsulting.com]
Sent: Monday, December 08,2003 1:15 PM
To: Heidi Griffin; Brian LaGrasse; Pamela Dellechiaie
Subject: 15 North Cross Construction Inspection
Heidi, Brian and Pam,
Attached please find the construction inspection form for the bottom of bed
inspection at 15 North Cross Road. All was fine.
Dan
Daniel Oftenheimer, President
Mill River Consulting
Septic System Management Services
5 Blackburn Center
Gloucester, MA 01.930-2259
978-282-0014 or 1-800-377-3044
fax: 978-282-0012
www.millriverconsulting.com
info@millriverconsulting.com
12/8/2003
i
MILL RIVER CONSULTING
Septic System Management Services
TOWN OF NORTH ANDOVER
SEPTIC SYSTEM CONSTRUCTION NOTES
ADDRESS: 15 North Cross Road MAP: 38 LOT: 188
INSTALLER: Peter Breen
DESIGNER: Merrimack Engineering
PLAN DATE: 11/25/03
BOH APPROVAL DATE ON PLAN:
DATE OF BED BOTTOM INSPECTION: December 4, 2003
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SELECT SYSTEM TYPE
X GRAVITY DISTRIBUTION
PRESSURE DISTRIBUTION
PRESSURE DOSING
HOLDING TANK
ADVANCED TREATMENT
OTHER
COMPONENT SUMMARY FROM PLAN
GALLON TANK = 1,500
LOADING OF SEPTIC TANK = H-10
GALLON PUMP CHAMBER =
LOADING OF PUMP CHAMBER =
TYPE OF SAS = Field
DIMENSIONS AND DETAILS OF SAS: 38' x 20'
SITE CONDITIONS
Inspections
❑ Existing septic tank properly abandoned
❑ Internal plumbing all to one building sewer
❑ Topography not appreciably altered
Comments:
5 Blackburn Center, Gloucester, Massachusetts 01930-2259
toll free 1.800.377.3044 978.282.0014 info@millriverconsulting.com
Page 1 of 3
MILL RIVER CONSULTING
Septic System Management Services
SEPTIC TANK
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ gallon tank has been installed
(H-10 or H-20) (monolithic or 2 piece)
❑ Water tightness of tank has been achieved
(Visual or Vacuum Test or Water held for 24hrs)
❑ Inlet tee installed, over access port
❑ Outlet tee (gas baffle or effluent filter) installed, over
access port
❑ inch cover to within 6" of final grade installed over
one access port, must be over outlet of tank if effluent
filter is present
❑ Hydraulic cement around inlet &outlet
Comments:
D-BOX
❑ Installed on stable stone base
❑ Inlet tee (if pumped or >0.08'/foot)
❑ Hydraulic cement around inlet & outlets
❑ Observed even distribution
❑ Speed levelers provided (not required)
Comments:
SOIL ABSORPTION SYSTEM
0 Bottom of SAS excavated down to C soil layer, as
provided on plan
D Size of SAS excavated as per plan
❑ Title 5 sand installed, if specified on plan
❑ 3/4-11/27 double washed stone installed
❑ 1/8-1/2" (peastone) double washed stone installed
❑ laterals installed and ends connected to header (and
vented if impervious material above)
❑ Orifices @ 5 & 7 o'clock positions
5 Blackburn Center, Gloucester, Massachusetts 01930-2259
toll free 1.800.377.3044 978.282.0014 info@millriverconsulting.com
Page 2 of 3
1
MILL RIVER CONSULTING
Septic System Management Services
❑ Gravelless disposal systems: type, number and
location as per plan
❑ Elevations of laterals installed as on approved plan
❑ 40 Mil HDPE barrier installed
❑ Retaining wall (boulder/ concrete /timber/ block)
❑ Final cover as per plan
Comments:
SYSTEM ELEVATIONS
Benchmark:
Rod at Benchmark:
Height of Instrument:
INVERT ON DESIGN PLAN ELEV 01 TOP OF PIPE INVERT ELEVATION
Building Sewer OUT
Septic Tank IN
Septic Tank OUT
Pump Chamber IN
Pump Chamber OUT
Distribution Box IN
Distribution Box OUT
Manifold
Lateral 1 HIGH
Lateral 1 LOW
Lateral 2 HIGH
Lateral 2 LOW
Lateral 3 HIGH
Lateral 3 LOW
Lateral 4 HIGH
Lateral 4 LOW
Lateral 5 HIGH
Lateral 5 LOW
5 Blackburn Center, Gloucester, Massachusetts 01930-2259
toll free 1.800.377.3044 978.282.0014 info@millriverconsulting.com
Page 3 of 3
M
� 1
MILL RIVER CONSULTING
Septic System Management Services
0 Elevations of laterals installed as on approved plan
❑ Final cover as per plan
Comments: Potable water supply line from street to house was not as shown on design
plan. Pipe was rerouted around soil absorption system with slight modification in
location of soil absorption system. Waterline location to be depicted on as-built plan.
SYSTEM ELEVATIONS
Benchmark: 100.00
Rod at Benchmark: 3.36
Height of Instrument: 103.36
INVERT ON DESIGN PLAN ELEV(cD TOP OF PIPE INVERT ELEVATION
Septic Tank IN 97.39 97.84 97.51
Septic Tank OUT 97.14 97.44 97.11
Distribution Box IN 96.92 97.36 97.03
Distribution Box OUT 96.75 97.16 96.83
Lateral HIGH 96.70 97.08 96.75
Lateral LOW 96.47 96.86 96.53
5 Blackburn -Center, Gloucester, Massachusetts 01930-2259
toll free 1.800.377.3044 978.282. 0014 info@millriverconsulting.com
Page 3 of 3
Clear Day Page 1 of 1
DelleChiaie, Pamela
From: Dan Ottenheimer[info@milldverconsulbng.com]
Sent: Thursday, December 04, 2003 9:30 AM
To: pdellechiaie@townofnorthandover.com
Subject: RE: 15 North Cross Road-Bottom of Bed Inspection
All set for 3:00 today (12/4)
Daniel Ottenheimer,President
Mill River Consulting
Septic System Management Services
5 Blackburn Center
Gloucester, MA 01930-2259
978-282-0014 or 1-800-377-3044
fax: 978-282-0012
www.millriverconsulfing.com
info@milltiverconsulting.com
-----Original Message-----
From: Pamela DelleChiaie [mailto:pdellechiaie@townofnorthandover.com]
Sent: Wednesday, December 03, 2003 1:58 PM
To: Daniel Ottenheimer(E-mail)
Subject: 15 North Cross Road - Bottom of Bed Inspection
Importance: High
Please schedule a Bottom of Bed Inspection for the above with Peter Breen -978.265.7580. He will be
ready tomorrow morning.
Thanks,
Pam
Pamela DelleChiaie, Health Dept. Assistant
Town of North Andover
Community Development& Services
27 Charles Street
North Andover, MA 09845
pdellechiaie@townofnorthandover.com
Tel. 978-688-9540
Fax 978-688-9542
12/4/2003
Page 1 of 2
DelleChiaie, Pamela
From: Dan Ottenheimer[info@milldverconsulting.com]
Sent: Wednesday, November 12, 200310:27 AM
To: pdellechiaie@townofnorthandover.com
Subject: RE: 15 North Cross Road-Urgent Plan Review Request
We will make this a priority. Regarding construction, if the contractors can get clean stone and the frost
is not too thick I do not have a problem with continuing construction beyond December 1.
Dan
Mill River Consulting
Septic System Management Services
5 Blackburn Center
Gloucester,NLA,01930-2259
978-282-0014 or 1-800-377-3044
fax: 978-282-0012
info@millriverconsulting.com
-----Original Message-----
From: Pamela DelleChiaie [mailto:pdellechiaie@townofnorthandover.com]
Sent: Wednesday, November 12, 2003 10:06 AM
To: Daniel Ottenheimer(E-mail)
Cc: Lagrasse, Brian
Subject: 15 North Cross Road - Urgent Plan Review Request
Importance: High
Hi Dan,
The homeowner of 15 North Cross Road, Jan Rooney, came in this morning concerned about her plans
getting reviewed in time for septic construction. These are revised plans submitted by the engineer last
week. Here is her situation:
Mrs. Rooney and her husband are being transferred to St. Louis, and are moving the first week of
December. The closing on the house is Dec. 9th. Her main concern is that they have buyers for
their house, and as this is a revised set of plans, if it does not pass,they will lose the sale, and be
out of state, and can't do anything about it. She states that she knows that Nov. 30th is the cutoff
for construction.
November 30th is the formal cutoff construction date in the regulations, but my understanding is that,
based on the weather conditions, and working within reason, a system could be potentially
be repaired/constructed after that date if there is a hardship, or a situation warrants it being so.
Therefore, can you make this revised plan review a priority due to the above situation? I know that you
have lots of other things going on, but I did tell Ms. Rooney that I would forward her concems to you. If
you want to call her at all, her number is: 978.682.4741.
Thank you.
Pamela DelleChiaie, Health Dept. Assistant
11/12/2003
Commonwealth of Massachusetts Map-Block-Lot
038.0-0188-
Board Of Health -- --
Peermit No ------
North Andover BHP-2003-0381
--- -------------
P.I. PEE
F.I. $250.00
-----------------------
Disposal Works Construction Permit
Permission is hereby granted Peter-Breen
- - - ----------------- --------------------- --------- --- - -- -------------
w-
to(Repair)an Individual Sewage Disposal System. —�
t%
at No 15 NORTH CROSS ROAD
as shown on the application for Disposal Works Construction Permit No. BHP-2003-038 Dated December-0-2,2003
-----------------------------------------------------------------
Issued On:Dec-02-2003 Board Of Health
.............. .................. .....................................................................................................................................
r
i
r
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: 1� i D 3 CURRENT INSTALLER'S LICENSE#
LOCATION: f S^ &j_1 (%
LICENSED INSTALLER:
SIGNATURE: /'�G ` TELEPHONE#
CHECK ONE:
REPAIR: NEW CONSTRUCTION:
IF NEW CONSTRUCTION, PLEASE ATTACH FOUNDATION AS-BUILT.
�`� e)l �' Administrative Use Only
4o-0
Fee Attached? Yes No
Foundation As-built? Yes No
Floor plans on file? Yes No
Approval Date:
r
Y
Ti
15 NORTH CROSS ROAD JS-2004-0060
Proiect Detail Report
Printed On:Thu May 13,2004
Project Name:
GIS#: 2168 Project No: JS-2004-0060 Owner of Record ROONEY FAMILY TRUST&J M
Map: 038.0 Date Submitted: Jun-26-2003 15 NORTH CROSS ROAD
Block: 0188 Status: Open NORTH ANDOVER,MA 01845
Lot: Work Category: Work Location: 15 NORTH CROSS ROAD
Zoning: Proposed Use: District:
land Use: 101 Proposed Use Detail Subdivision
Description Soil Testing Comments:
of Work:
J
Department Status
GeoTMS Module: /TEN
sFile No. Comments: LCDate:
Board of Health FLAG BHJ-2003-0065 5/13/04-Dan called and said that he would go by the property to check it. Would not contact
fr the homeowner at this time. Just wants to see it. Thinks that Peter Breen probably did not
n backfill it correctly,and will let us know.--p.d. '
J5/13/04-H/O going away tomorrow morning to Tuscon Arizona. Please call before then. If
you cannot,his cell is:603.818.9585.
5/12/04-Received a call from the new homeowner,John Little. His girlfriend,Linda Hall is
actually the homeowner. They moved in after New Years. The sellers were actually the
relocation company. Peter Breen installed the system in earl
/ Y Y November when there was still
snow on the ground. The ground is now caving in all around the system,and he can see the
indent all around the perimeter of the leaching field. In addition,Richard Pantadoso,their next
/s door neighbor(as you face the house,he is on the left)property is in jeaprody as the system is
raised up and graded toward Mr.Pantadoso's yard,so if there is ever a failure,it will flow into
the neighbor's yard. Mr.Little has a real problem with the fact that the ground area is caving in
around the system. He is pursuing Mr.Breen with his lawyer to have him fix the system,and f
wanted the BOH to know about it. Please call Mr.Little at 978.687.1915 to follow-up.--p.d. v
12/24/03-COC Issued
12/23/03-Peter Breen stopped by with the As Built and Installation Certification. He is
looking for COC. Left file with Brian for review.
12/8/03-Bottom of Bed Inspection
12/2/03-DWC permit application received.
12/2/03-Received$175 check. Sent back to h/o requesting the$75 fee instead.
11/24/03-Denial Letter-in the meantime,faxes and phone conversations between Bill
Dufresne and Brian LaGrasse and John Markey resulted in a revised plan being dropped off on
11/26/03 by Bill Dufresne. Brian will review this afternoon.
11/05/03-Revised Plan received,forwarded to Consultant.
9/24/03-Plan denied
9/3/03-Plan application received
7/29/03-Soil testing performed.
GeoTMS®2004 Des Lauriers Municipal Solutions,Inc. Page 1 of 2
15 NORTH CROSS ROAD JS-2004-0060
Project Detail Report
Printed On:Thu May 13,2004
7/3/03-Scheduled for July 29,2003 after 990 Johnson.
7/2/03-Received back from NACC
7/1/03-Application for soil tests pending response from Conservation.
Permit History
Type: Permit No: Issue Date Status Work Category Contractor Project No: Description of Work:
DWC-System Repair BHP-2003-0381 Dec-02-2003 SIGNED OFF JS-2004-0060 Repair-Complete
Plan Review BHP-2003-0379 Nov-26-2003 SIGNED OFF JS-2004-0060 Plan Review-
Plan Review BHP-2003-0361 DENIED JS-2004-0060 Plan Review
Plan Review BHP-2003-0298 DENIED JS-2004-0060 Plan Review J
Repair Soil Tests BHP-2003-0150 Jul-01-2003 SIGNED OFF JS-2004-0060 Soil Testing
Inspection History
Inspection Type: Permit Type: Permit No: Insp Date: Status: Inspector: Project No: Comment:
Final Grade DWC-System Repair BHP-2003-0381 Dec-24-2003 FULL COMPLY Brian LaGrasse JS-2004-0060
Bottom of Bed Inspection DWC-System Repair BHP-2003-0381, Dec-08-2003 SIGNED OFF Dan Ottenheimer JS-2004-0060
GeoTMS®2004 Des Lauriers Municipal Solutions,Inc. Page 2 of 2
WRIMACK
"-=ENGINE'ER NG SERVICES INC. C�C�44CG3 O� e CrJ� 1044La�
Engineers • Surveyors • Planners
66 Park Street
ANDOVER, MASSACHUSETTS 01810 DATE JOB NO.
(978) 475-3555 ATTENTION
Fax (978) 475-1448
TO RE:
WE ARE SENDING YOU ❑ Attached ❑ Under separate cover via the following items:
❑ Shop drawings ❑ Prints ❑ Plans ❑ Samples ❑ Specifications
❑ Copy of letter ❑ Change order ❑
COPIES DATE NO. DESCRIPTION
THESE ARE TRANSMITTED as checked below:
For approval ❑ Approved as submitted ❑ Resubmit copies for approval
❑ For your use ❑ Approved as noted ❑ Submit copies for distribution
❑ As requested ❑ Returned for corrections ❑ Return corrected prints
❑ For review and comment ❑
❑ FORBIDS DUE ❑ PRINTS RETURNED AFTER LOAN TO US
REMARKS
T���l z or S TSA 16 N���P_-z
1 rJ -r.4 is 6(C;2fe , 4A-51>, Ap Rcxjel-;' -711 e el,�AIC 4:S
Imo- 'r�'q �N�� �D S �"� js 1f .�/= 1-74,f ESSttlICe To l"'J
COPY TO
SIGNED:-
If
IGNED:-if enclosures are not as noted,kindly notify us at once.
North Andover Health Department
• 27 Charles Street
North Andover,MA 01845
• (978)688-9540
fax(978)688-9542
To: Bill Dufresne,Merrimack Eng. Fax 475-1448
From: Brian J.LaGrasse,Health Inspector Date: 11/25/03
Re. 15 North Cross Road Pages. 1
CC Home owners,File
X Urgent ❑For Review ❑Please Comment ❑ Please Reply ❑ Please Recycle
. . . . . . . . . .
Mr.Dufresne:
I am sending you this correspondence subsequent to our discussion earlier
today per your request The Board will not grant a Local Upgrade Approval for
groundwater separation from 4'to Sand requires maximum feas le compliance
unless extenuating circumstances and site constraints exist A pump chamber
can be used to obtain maximum compliance and sufficient groundwater
separation of 4'.
The potential increase in depth of stone is not pertinent to this particular site
since a pump chamber must be utilized to obtain adequate ground water
separation. If you have any questions,comments or concerns feel free to call me.
Thankyo
r 17
,19
Tian J.LaGrasse
.: . . . . . . . . . . . . . . . . . . . . . .
! TOWN OF NORTH ANDOVER ct�10RTit 1
Office of COMMUNITY DEVELOPMENT AND SERVICES F: •.; =.'` �p
HEALTH DEPARTMENT
27 CHARLES STREET °*
NORTH ANDOVER, MASSACHUSETTS 01845
�,SS^CHU+Et�
Heidi Griffin 978.688.9540—Phone
Acting Health Director 978;688.9542—FAX
November 24, 2003
Daniel Koravos
Merrimack Engineering Services
66 Park Street
Andover, MA 01810
RE: 15 North Cross Road, Map 38, Lot 188
Dear Mr. Koravos,
The proposed septic system design plans for the above site dated November 3, 2003 have been
reviewed. Unfortunately, the plans cannot be approved as submitted. The following items are in
need of attention prior to approval:
1. The system profile indicates 10" of stone depth is to be provided beneath the leach
field when another section indicates 6" of stone depth will be provided. Please clarify
this matter.
2. Please indicate that removal of soil horizons A&B shall extend at least 6" into the
suitable soil of the C horizon or request a variance from this regulation. (NA 9.02)
3. Trenches are to be used as the soil absorption system mechanism whenever possible.
Please use trenches in this instance or explain why they cannot be utilized. (3 10 CMR
15.240)
4. The leach field is proposed to contain 6" of leach stone beneath when it is understood
leach fields in North Andover are required to utilize 12" of leach stone. A note is
provided explaining the reason 6" is provided however it appears quite possible to
relocate the soil absorption system as described below and maintain compliance with
the wishes of the North Andover Board of Health.
5. As indicated in the previous review of the design plan: "The design includes a Local
Upgrade Approval request to reduce the separation from the bottom of the soil
absorption system to the estimated seasonal high ground water from the required 4' to
3'. Several sections of Title 5 do not allow this request to be granted including 310
CMR 15.401 and 404(1)which indicates that whenever feasible a design should
maintain full compliance with the standards in the regulations. While the concern
stated in the Local Upgrade Approval application regarding pumping to the soil
absorption system has legitimacy, it cannot displace the regulatory requirement to
maintain full compliance with the code whenever feasible." Additionally, a Local
i
Upgrade Approval application must accompany such a request should you continue to
seek this reduced design standard.
Additionally, though not a reason for plan disapproval, you may wish to consider the possibility of
relocating the proposed soil absorption system to another portion of the parcel to facilitate use of
a gravity-based soil absorption system in compliance with the state and local regulations. The
location of the test pits excavated on the site allow for the placement of the soil absorption system
further downgradient than currently specified.
Please feel free to contact the office with any questions you may have. We look forward to
working with you to obtain a replacement septic system which will be in compliance with all
regulations and assure protection of public health and the environment of North Andover.
Since ely,
Brian LaGrasse
Health Inspector
cc: Homeowner
CD&S Dir.
File
Page 1 of 2
DelleChiaie, Pamela
From: Dan Ottenheimer[info@milldverconsulbng.com]
Sent: Monday, November 24,2003 8:40 AM
To: Heidi Griffin; Brian LaGrasse; Pamela Dellechiaie
Subject: 15 North Cross Road
Heidi, Brian and Pam,
We have reviewed the septic system design plan and unfortur)ately again do not
believe it appropriate for the Town to approve the septic design as proposed. The
revised plan does correct a number of problems identified in the earlier version but
does not address the critical issues related to the type of soil absorption system
proposed and the separation to ground water not being maintained as required in the
regulations. These are important characteristics to assure proper wastewater
treatment. The design plan also requires'an Application for Local Upgrade Approval
as an accompaniment which does not appear to have been provided.
On a specific note, the design uses a leach field (when trenches could be used) but
also does not provide for the 12" of leach stone which the Board of Health indicated
they wished to see underneath a leach field. We are frankly not sure how it is best for
the Town to handle this situation.
Las�hl e septic design plans in to th a record plan land for the en arcel
has been s d as an attachmen e plan. Could yo eck to make su s
in the file? 0\1\3 T-
I know this is a complex situation which is not made easier by the partial compliance
with the regulations provided by this design plan so feel free to call should you need to
discuss this further.
Warning, the following is an editorial observation: It is clear to us that a complying
system can be designed on this parcel based upon the information provided on the
plans and we do not believe this site warrants any reduced standards from what is
specified in the regulations. Other septic system designers do not seem to have a
problem maintaining compliance with the design standards in Title 5 and those of the
North Andover Board of Health, and we believe it would be unwise of the Town to not
provide a uniform playing field for all.
Dan
Daniel Ottenhelmer, President
Mill River Consulting
Septic System Management Services
5 Blackburn Center
11/24/2003
Page 1 of 1
DelleChiaie, Pamela
From: Johnson,Adele
Sent: Friday, November 21,2003 10:50 AM
To: Santilli, Ray; Lagrasse, Brian
Cc: DelleChiaie, Pamela
Subject: Mr.Jay Rooney re: Septic System Approval
Mr. Rooney called on Wed. Nov. 19, and I received a second call from Mr. Rooney today. He has not heard
anything from the Town on the status of an approval of submitted plans for a new septic system to be installed on
his property. He is relocating to St. Louis in 2 weeks and the sale of his home is pending on the installation of the
new septic system. He asked if this could be a priority because of the time and weather conditions to be able to
install a new septic system.
I told him someone would call him today or Monday with an explanation.
Adele J.Johnson
Administrative Secretary
Town Manager's Office
978-688-9510
tmsecretary -townofnorthandover.com
11/21/2003
MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS
66 PARK STREET•ANDOVER,MASSACHUSETTS 01810•TEL(978)475-3555,373-5721 •FAX(978)475-1448•E-MAIL:merreng@aol.com
November 3, 2003
Mr. Brian LaGrasse
Health Inspector
Town of North Andover TOWNOF N"ORTH ,-NDG-7R/
27 Charles Street P " `,F HE,--:,-FH
North Andover, MA 01845
NOV 5 2003
RE: 15 North Cross Road
Dear Mr. LaGrasse:
We have received your letter dated September 24, 2003 regarding the above referenced
project. Items 1-12, 15 and 16 have been addressed and the plan has been revised
accordingly.
Items 13, 14 and 17 all relate to additional fill and materials resulting in unnecessary cost to
the homeowner especially#17, which if not granted, results in having to pump the system.
Item 18 relates to the percolation test which the Health Inspector on site determined was
consistent with the soils observed and could be utilized for this design, additionally it is our
opinion that 310 CMR 15.100 relates to the soil evaluation process not the percolation test
process which remains unchanged.
On behalf of our client, we feel the issues have been adequately addressed and the design is
consistent with the Boards policies and respectfully request the design be approved as
resubmitted.
Very truly yours,
MERRIMACK ENGINEERING SERVICES
v v
William Dufresne
Project Manager
cd
Page 1 of 1
DelleChiaie, Pamela
From: Lagrasse, Brian
Sent: Friday, September 26,2003 1:08 PM
To: DelleChiaie, Pamela
Subject: FW: 15 North Cross Plan Review
did this letter go out?
-----Original Message-----
From: Dan Ottenheimer[mailto:info@millriverconsulting.com]
Sent: Wednesday, September 24, 2003 2:41 PM
To: Heidi Griffin; blagrasse@townofnorthandover.com; pdellechiaie@townofnorthandover.com
Subject: 15 North Cross Plan Review
Heidi, Brian and Pam,
Attached please find the pian review for #15 North Cross Road. Some of the required
changes have been previously discussed with Merrimack Engineering on the
telephone and are being indicated here because this plan was drafted some time
ago. Future plans of theirs should not have as many concerns as we are seeing now.
Dan
Mill River Consulting
Septic System Management Services
5 Blackburn Center
Gloucester, MA 01930-2259
978-282-0014 or 1-800-377-3044
info@milldverconsulting.com
9/26/2003
TOWN OF NORTH ANDOVER f NURTM 7
Office of COMMUNITY DEVELOPMENT AND SERVICES F p
HEALTH DEPARTMENT
R;4
27 CHARLES STREET * t r
� + r
NORTH ANDOVER,MASSACHUSETTS 01845 � CO
?SSACHUs�t
Heidi Griffin 978.688.9540-Phone
Acting Health Director 978.688.9542-FAX
September 24, 2003
Daniel Koravos, P.E.
Merrimack Engineering Services
66 Park Street
North Andover, MA 01845
Re: 15 North Cross Road, Map 38, Lot 188
Dear Mr. Koravos:
The proposed septic system design plans for the above site dated July 29, 2003 and signed August
28, 2003 have been reviewed. Unfortunately, the plans cannot be approved as submitted.
The following items are in need of attention prior to approval:
1. Please provide all the legal boundaries of the property being served. (3 10 CMR
15.220(4)(a)
2. Please provide the abutter's name for the western boundary. (NA 8.02j)
3. Please provide the distances from the septic tank to the property line and dwelling.
(NA 8.03a-c)
4. Please provide the location and elevation of the foundation drain. If there is no drain,
please make a statement to that effect on the plan. (NA 8.02y)
5. Please specify a compacted firm base for laying the building sewer. (3 10 CMR
15222(5))
6. Tees may not be replaced with"pre-cast concrete tees". (3 10 CMR 15. 227(1))
7. Tees must extend 6" above the flow line. (3 10 CMR 15. 227(1))
8. The inlet and outlet tees must be located directly under the manholes. (3 10 CMR
15.227(1))
9. Three (3) access manhole covers are required. (3 10 CMR 15.228(2))
10. The septic tank loading must be stated on the plan. (3 10 CMR 15.226(3))
11. Please depict existing and proposed grades in the system profile. (3 10 CMR
220(4)(0))
12. It is not clear from the profile whether there is more than 36" of cover material over
the d-box. Please clarify with either the proposed grade over the d-box and/or a note
requiring a maximum of 36" cover material.
13. Trenches are to be used as the soil absorption system mechanism whenever possible.
Please use trenches in this instance or explain why they cannot be utilized. (3 10 CMR
15.240)
14. Please indicate that removal of soil horizons A&B shall extend at least 6" into the
suitable soil of the C horizon. (NA 9.02)
15. Final grade over the leach facility must be indicated to slope 0.02ft/ft. (3 10 CMR
15.240(10))
16. Please specify that the distribution lines in a leach field must be connected with a
solid pipe. (N.A. 15.01)
17. The design includes a Local Upgrade Approval request to reduce the separation from
the bottom of the soil absorption system to the estimated seasonal high ground water
from the required 4' to 3'. Several sections of Title 5 do not allow this request to be
granted including 310 CMR 15.401 and 404(1)which indicates that whenever
feasible a design should maintain full compliance with the standards in the regulations.
While the concern stated in the Local Upgrade Approval application regarding
pumping to the soil absorption system has legitimacy, it cannot displace the
regulatory requirement to maintain full compliance with the code whenever feasible.
18. A percolation test performed in compliance with the 1995 Code must be completed
and utilized as the basis for the septic system design. (3 10 CMR 15.100)
Additionally, while not a reason for disapproval you are encouraged to consider the following:
1. You should depict the trees and other vegetation which are located in or in close
proximity to the proposed soil absorption system. This will allow you to factor tree
removal or damage in the system layout (if necessary), allow the property owner to
better understand the location and potential impact of the design on the landscape, and
allow the licensed installer to better price the construction.
2. The benchmark selected is for the top of foundation but without a location specified.
In this instance the dwelling is faced with both wood and brick and the foundation
might vary or be difficult to access for the licensed installer. You are encouraged to
consider an exterior elevation which is easy to access and locate.
3. You may wish to design a soil absorption system for the required 743 square feet of
leach area rather than the 900 square feet which is included in this design.
Please feel free to contact the office with any questions you may have. We look forward to
working with you to obtain a replacement septic system which will be in compliance with all
regulations and assure protection of public health and the environment of North Andover.
Sincerely,
Brian LaGrasse
Health Inspector
cc: Homeowner
CD&S Dir.
File
a
SEPTIC PLAN SUBMITTAL FORM
LOCATION: 15� u8I'L-nA e�505, rzam2
NEW PLANS:
6ES $225.001P1an'� Check #: t 9
(Includes I"Re-Rev }
REVISED PLANS: YES $60.00/Plan Check#:
SITE EVALUATION FORMS INCLUDED: YES NO
r
LOCAL UPGRADE FORM INCLUDED: YES NO
- 3
DATE: 6"Z7-15731 DATE TO CONSULTANT: ------------
�. DESIGN ENGINEER: HKhAe-iw p)►��ir'elephone#(
OFFICE USE ONLY
When the submission is complete(including check):
i. _^-Date stamp plans
2. Complete the= DESIGN APPROVAL FOR SOIL ABSORPTION
SEWAGE DISPOSAL SYSTEM form
3. Attach file and route to the Health Director for review
�. -0 /
r
" t� owner's Name: .J A tJ . t1,_w f e.(
el: fJ4 30 TL liv Addresr. 15 KV F-TI�Tel#:_ Z-''�'!�Y New(sem) Repair ✓
Date: 7-ZA-a3 Wetlands — Zone)3 --- Soil Symbol C:- SoU]R me fA'p;y SonOu,,__5
Deep Observation Hole Logs
Elevation Depth Soil Horizon Soil Texture Soil Color Soil Mottling % Gravel,Stones,etc:
I '
7� L
IdyM31 I-►�n• - Kit.
yet Cl 6 w•L A,
Intl/�
V, F4 5Y' /`f" r-t•t r Fit�+�
Parent Material - w _Depth to BedrocL•" standin=Nater in the Hol,1 9 w-p{n=from Pit Face 1 tel' M
_.,_F.sHG%Y. (OW
�t � IZ�Li " �, �yL; l�Y�OZ ►..IG.Gvw�,�fsM.l�
• Zt-�t7t� bl ��i.t, . �.SY►st/a -- 1,,�,�t`�,+�t•.�ra�
�t'/•142 G i.t Q l 5, 5y IF/b h,� -d-77 d rte. ''PrM AWL&
Parent Material I l.t. Depth to Bedrock ^ rhodin=iVow ht the Hoh» � Weepin;trots Pit Face—Lo—!LEMGIYt-7 7 a
Date Percolation Tests
Observation Hole#
Depth of Pe
rc -
Start Pre-soak-
Time at 12"
Time at 9"
Time at 6"
Time(9"-611 I
•Rate Min/Inch
Performed Br Witnessed Bv:
FORM 9A - Application for Local Upgrade Approval
Commonwealth of Massachusetts
i oDug-w ,Massachusetts
(Cityfrown)
Application for LOCAL UPGRADE APPROVAL
Title 5,.310 CMR 15.000
DEP Approved Form Required by 310 CMR 15.403(1)
Form 9A is to be submitted.to the Local Board of Health for the upgrade of a failed or
nonconforming septic systeta with a design flow of less than 10,000 gpd,where full compliance,as
defined in 310 CMR 15.40411),is not feasible.
System upgrades that cannot be performed in accordance with 310 CMR 15.404 and 15.405,or in full
..compliance with the requirements of 310 CMR 15.000,require a variance pursuant to 310 CMR
15.410 through 15.417.
NOTE:Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of a
new design flow to a cesspool or-privy,or the addition of a new design flow above the existing approved
capacity of a septic system constructed in accordance with either the 1978 Code or 310 CMR 15.000.
Facility Address:_15; 1D�� C{?oS5 - City/Town: Noi l-1-4 A i. roy'
Facility/System owner: K) lzoe2oe�-Y
Address:
City/Town: T State: 01
Telephone: ( q�D
Type of Facility(check all that apply): esidential ❑Institutional ❑ Commercial ❑School
Describe facility
Type of existing system: ❑Privy ' ❑Cesspool(s) E3Conventional System
❑Other(describe)
Type of soil absorption system(trenches,chambers,leach field,pits,etc)TI?
Design Flow per 310 CMR 15.203:.
Design flow of existing system gpd
Design flow of proposed upgraded system gpd
Design flow of facility — -0 gpd
Proposed upgrade of system is: oluntary ❑Required by order,letter,etc.(attach copy)
❑Required following inspection pursuant to 310 CMR 15.301
Provide date of inspection
FORM 9A - Application for Local Upgrade Approval
Department of Environmental Protection DEP Approved Fom►-3/20/02
Page I of 3
�k
Describe the proposed upgrade to the system
G
Local Upgrade Approval is requested for:
❑ Reduction in setback(s) (Describe reductions)
❑ Percolation rate for 30 to 60 mintinch Percolation rate inch
❑ Reduction in SAS area of up to 25%
(SAS size and%reduction) SAS sq ft Reduction %
Reduction in separation between the SAS and high groundwater
Separation reduction_J____ft Percolation ratee_min/inch
Depth to groundwater__:?,,
❑ Relocation of water supply well(Explain)
❑ Other requirements of 310 CMR 15.000 that cannot be met
Describe and specify sections of the Code
If the proposed upgrade involves a reduction in the required separation between the bottom of the soil
absorption system and the high groundwater elevation,an Approved Soil Evaluator must determine the.
high groundwater elevation pursuant to 310 CMR 15.405(1)(i)(1).The soil evaluator must be a"member
or anent of the local annrovinQ authority.
High groundwater elevationdetermined by: '
(Pant or type evaluator's Name) (Signature of evaluator) (Evaluation Date)
Explain why full compliance,as defined in 310 CMR 15.404(1),is not feasible.
(Each section must be completed)
1. An-upgraded system in full compliance with 310 CMR 15.000 is not feasible:
r
I-ULLt W K
2 An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible:'",
Department of Envirorunental Protection DEP Approved Form-320/02
Page 2 of 3
FORM 9A - Application for Local Upgrade Approval
3. A shared system is not feasible: `JA
4. Connection to a public sewer is not feasible:
The Application for Local Upgrade Approval must be accompanied bi all of the following:
(Check the appropriate boxes)
❑ Application for Disposal System Construction Permit
Lid Complete.plans and specifications
Site evaluation forms
❑ A list of abutters affected by reduced setbacks to private water supply wells or property lines.
Provide proof that affected abutters have been notified pursuant to 310 CMR 15.405(2).
❑ Other(List)
CERTIFICATION: .
"I,the facility owner,certify under penalty of law that this document and all attachments,to the best
of my knowledge and belief,are true,accurate,and complete.I am aware that there may be
significant consequences for submitting false information,including,but not limited to,penalties or
fine and/or imprisonment for deliberate violations.
/Facility owners signature Date /2Z4-0 3�
Print name
Name of preparer �i� - j a�_661ij 6ewo6 Date' / Z41 0-5,Preparer 's Address:
City/Town: State: f-lAps- . Zip:�1
Preparer's telephone:_f 111,h ) �-�5-55
NOTE: 310 CMR 15.403(4)requires the system owner to provide a copy of the local upgrade
approval to the appropriate Regional Office of the Department of Environmental Protection,Bureau
of Resource Protection,Division of Watershed Management,upon issuance by the local approving
authority and before commencement of construction.
Departrne It of Environmental Protection DEP Approved Forth—3/20/02
Page 3 of 3
�= BOARD OF HEALTH
�J NORTH ANDOVER, MA 01845
978-688-9540
APPLICATION FOR SOIL TESTS t 2 6 TI
DATE: MAP &PARCEL: �NI ::!20 Wil-
LOCATION OF SOIL TESTS:' c7 V1
OWNER: - 1 TEL. NO.:
ADDRESS:
ENGINEER:
CERTIFIED SOIL EVALUATOR:
Intended Use of Land: Residential�Subdivision Sin y Ho Commercial
t!!
Is This:
Repair Testing: :Undeveloped lot testing:
g
In the Lake Cochichewick Watershed? Yes No
THE FOLLOWING MUST BE INCLUDED WITH THIS FORM
1. Proof of land ownership (Tax bill, or letter from owner permitting test)
2. Plot plan & Location of Testing
3. Fee of$425.00 per lot for new construction. This covers the minimum two deep holes and
two percolation tests required for each disposal area. Fee of$200.00 per lot for repairs or
rg ades. (If time is not critical,fee for repairs is $75.60)
GENERAL INFORMATION
I. Only Certified Soil Evaluators may perform deep hole inspections.
2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans.
3. At least two deep holes and two percolation tests are required for each septic system disposal area.
4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the
BOH representative.
5. Full payment will be required for all additional tests within two weeks of testing.
6. Within 45 days of testing, a scaled plan(no smaller than 1"A 00') shall be submitted to the Board
of Health showing the location of all tests (including aborted tests).
7. Within 60 days of testing soil evaluation forms shall be submitted.
Please Do Not Write Below This Line
N.A. Conservation Commission Approval: Ale 7A�93_
TOW`. ATH. ER/
Date Received: Check Amount: Ch ck Date: OF HF
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PAULSOtl
No.317�25
NOT`
ATL ANT/C ENG/NEER/NG
L 0 LAND SURVEY CONSULTANTS /NC.
IN
MASS. 33 WEST MAIN STREET
7zcv:9�3o186 GEORGETOWN, MASS,
SCALE: 1°=Lid DATE e/13/86
�zto iofz4186
t10RTy
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
27 CHARLES STREET
NORTH ANDOVER,MASSACHUSETTS 01845 �9s°°••° �t��
$ACHUS
Heidi Griffin Telephone(978) 688-9540
Community Development Director FAX(978)688-9542
Acting Health Director
EkX
Daniel Ottenheimer From: Pamela
To:
Mill River Consulting
978.282.0012 Pages:
Fax:
1.800.377.3044 or Date:
Phone: /
978.282.0014
Request for Soil Testing or CC:
Re:
Septic Plan Review
❑ Urgent x For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle
0 Comments:
Septic Plan Review Soil Test OTHER ✓
Note: For plan reviews, this is notification only. Plans will be mailed or arrangements made to pick
them up as requested.
Address.
Please call 978-688-954 sistance with any questions. Thank you.
Cc: File-Address
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Page 1 of 1
Pamela DelleChiaie
From: "Dan Ottenheimer"<info@miilriverconsul6ng.com>
To: "Heidi Griffin"<hgriffin@townofnorthandover.com>;<blagrasse@townofnorthandover.com>;
<pdellechiaie@townofnorthandover.com>
Sent: Monday, September 22,2003 2:56 PM
Subject: 15 North Cross Road
Heidi, Brian and Pam
We are working on the plan review for 15 North Cross Road. Wondering if you could
send over Sandy's field book notes from that site which were recorded on July 29,
2003? Trying to figure something out which is not evident on the plan and hope it was
noted in the field.
Thanks,
Dan
Mill River Consulting
Septic System Management Services
5 Blackburn Center
Gloucester, MA 01930-2259
978-282-0014 or 1-800-377-3044
info@milldverconsuIting.com
9/23/2003
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Town of North Andover, Massachusetts Form No. 1
NORTH BOARD OF HEALTH
O
APPLICATION FOR SITE TESTING/INSPECTION
7 A�AATED PPP �G)
�SSACHUS��
Applicant
E ADDRESS TELEPHONE
Site Location
Engineer
NAME ADD .ESS TELEPHONE
J7
Test/Inspection Date and Time �� s / X
—__..
CHAIRMAN,BOARD OF HEALTH
Fee t Test,No. la'z
4��14�s-, �a�41
S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No.
i
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION OF --�
Property Address:_15 North Cross Road_ 9
_North Andover_ kB
Owner's Name:James Rooney_
Owner's Address:_15 North Cross Road_
_North Andover, MA 01810_
Date of Inspection:_6/20/2003_
Name of Inspector: Neil J.Bateson
Company Name:_Bateson Enterprises Inc._
Mailing Address:_111 Argilla Road_
_Andover,Ma.01810_
Telephone Number:_(978)475-4786_
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper fimction 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
Needs Ftyffier Evaluation by the Local Approving Authority
X Fa'
a
Inspector's Signature: AA Date: _6/20/2003_
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments:
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 15 North Cross Road_
_North Andover—
Owner: Rooney_
Date of Inspection:_6/27/2003_
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303
or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
'Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 15 North Cross Road_
_North Andover—
Owner: Rooney_
Date of Inspection: 6/20/2003_
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
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well".Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 15 North Cross Road_
_North Andover—
Owner:_Rooney_
Date of Inspection:_6/202003
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or`no"to each of the following for all inspections:
Yes No
_Yes_ _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_Yes_ _ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_ No Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow
_No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_ _No_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
_No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
No Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ _No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ _No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
_Yes_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
_ the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:_15 North Cross Road_
North Andover—
Owner: Rooney_
Date of Inspection:_6/20/2003_
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
Yes_ _ Pumping information was provided by the owner,occupant,or Board of Health
No Were any of the system components pumped out in the previous two weeks?
Yes Has the system received normal flows in the previous two week period?
No Have large volumes of water been introduced to the system recently or as part of this inspection?
Yes Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Yes Was the facility or dwelling inspected for signs of sewage back up?
Yes Was the site inspected for signs of break out?
Yes Were all system components,excluding the SAS,located on site?
_Yes_ _ 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?
_Yes_ _ Was the facility owner(and occupants if different from owner)provided with information on the
proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
_Yes _ Existing information..
_No_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[310 CMR 15.302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 15 North Cross Road-
-North
oad__North Andover—
Owner: Rooney_
Date of Inspection:_6/20/2003_
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3_ Number of bedrooms(actual):_5_
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):_450_
Number of current residents:_4
Does residence have a garbage grinder(yes or no): Yes_
Is laundry on a separate sewage system(yes or no):_No_
Laundry system inspected(yes or no):
Seasonal use:(yes or no):_No_
Water meter readings: Yes_
Sump pump(yes or no): No_
Last date of occupancy:—
Current-COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:_Pumped this year,owner_
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped:__gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
_Single cesspool
Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
_Other(describe):_
Approximate age of all components,date installed(if known)and source of information:_16 years old,7/11/1987,
As built plan_
Were sewage odors detected when arriving at the site(yes or no):_No_
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 15 North Cross Road_
_North Andover—
Owner: Rooney_
Date of Inspection:_6/20/2003
BUILDING SEWER(locate on site plan)X
Depth below grade:_3'_
Materials of construction:—X—cast iron _X_40 PVC__other
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):_4"Cast iron thru wall.3"PVC in house,
no leaks visible
SEPTIC TANK: X locate on site plan)
Depth below grade:_21
_
Material of construction:—X—concrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 10'x 5'x 4'
Sludge depth 1"_
Distance from top of sludge to bottom of outlet tee or baffle: 0"_
Scum thickness:_1"_
Distance from top of scum to top of outlet tee or baffle:_0" Tank flooded,above outlet invert
Distance from bottom of scum to bottom of outlet tee or baffle:_0"_
How were dimensions determined:_Measured scum&sludge depth to tee length_
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):_Septic tank flooded,liquid above outlet invert 12".Outlet
tee ok. No evidence of leakage._
GREASE TRAP: (locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass__polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
'Page 8 of 11
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_15 North Cross Road_
_North Andover—
Owner: Rooney_
Date of Inspection:_6/20/2003_
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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: X (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:_8"_
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 level&distribution equal.No evidence of leakage.Evidence of
carryover.Liquid above all inverts_
PUMP CHAMBER: (locate on site plan)
Pump in working order(yes or no):_
Alarms in working order(yes or no):_
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):_
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 15 North Cross Road_
_North Andover—
Owner: Rooney_
Date of Inspection:_6/20/2003_
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
leaching chambers,number:
leaching galleries,number:
_X_ leaching trenches,number,length:—2 trenches 50'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. Sign of hydraulic failure,water above inverts of
leach pipes._
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 or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 15 North Cross Road_
_North Andover—
Owner: Rooney_
Date of Inspection:_6/20/2003_
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
Driveway
House Water Meter
Septic
Tank
B
Porch Deck
A
D-
Box
A to Tank=56'6"
A to D-Box=38' 50'
B to Tank=14'2"
B to D-Box=37'
r
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 15 North Cross Road_
_North Andover—
Owner: Rooney_
Date of Inspection:_6/20/2003_
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 4 feet
Please indicate(check)all methods used to determine the high ground water elevation:
X Obtained from system design plans on record-If checked,date of design plan reviewed:_4/19/1985_
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:_
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:_
You must describe how you established the high ground water elevation: Design Plan_
Tel: (978) 475-4786
` Fax: (978) 475-5451
f
BATESON ENTERPRISES, INC.
Excavating-Water.& Sewer Lines-Septic Systems&Pumping Service
111 Argilla Road Andover, Mass. 01810
Title 5 Inspection Report
Property Address: 15 North Cross Road, North Andover
Owner: Rooney
Date of Inspection: 6/20/2003
My report contained herein does not constitute a guarantee of future usage and the functionality of the existing
septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further
operation of your current septic system.
#_ �J. Bateson
Bateson Enterprises, Inc.
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MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS
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No.37752
MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS 0 LAND SURVEYORS • PLANNERS
" PARK STREET 0 ANDOVER. MASSACHUSETTS 01910 or TEL (617)473-35S3, 3MS7?1