Loading...
HomeMy WebLinkAboutMiscellaneous - 15 WINTERGREEN DRIVE 4/30/201804/l C�s�wr,G r' North Andover Board of Assessors Public Access Page 1 of 1 o� http://csc-ma.us/PROPAPP/display.do?linkld=1894460&town=NandoverPubAcc 4/12/2012 -C\- Commonwealth of Massachusetts City/T6wn of 1ECEIVED System Pumping Record SEP 2 8 2009 Form 4 N TOWN sir NORTH ANDOVER DEP has provided this form for use by local Boards of Heath. Wif�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 of -other approving authority. A. Facility Information 1. System Location: Left side of house, Right side of house, Left front of house, Right front of house, Left rear of house, rear of ho se. eft rear of building. Right rear of building. ------------- Address C S W\ 1\ Cityrrown 2. System Owner: Name Address (if different from location) Cityrrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): State Zip Code Stat Zi Code r7 s= tG( Telephone Number Date 2. duantity Pumped Cesspools)eptic Tank c� Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: n 0�- 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: G.L.S.D Lowell Waste Water Signature of Hauler F5821 Vehicle License Number Date t5form4.docr 06103 System Pumping Record . Page 1 of 1 n i 5L.0 OS ft1 C', u < P p' 7ETr CAA�_ • � E . ...E - F.S 7"V a, o f 7,q Li1 os os k ti 7e40 ---� `- CAA�_ /sa 0 G q 1• SEP -AI'e I&Ik 3♦ a %fA 16/ IN G R E EIV �,S�%',661- j SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Tii e 5 Inspector $ 1� Title 5 Report $ .50.E C ❑ Other. (Indicate) $ , �,411zl ealth Agent Initials White - Applicant Yellow - Health Pink - Treasurer 6051 ` NORTM 7 ►0' • 9 Town of North Andover �M�'•+. HEALTH DEPARTMENT ,sSACM�st� CHECK #: __./�� DATE: LOCATION: H/O NAME:i.4�1-�� CONTRACTOR NAME Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Tii e 5 Inspector $ 1� Title 5 Report $ .50.E C ❑ Other. (Indicate) $ , �,411zl ealth Agent Initials White - Applicant Yellow - Health Pink - Treasurer ,AORTN F 9 r * Town of North And6ver • i r UV A i Til nUD A DT1%4V XT9r ,SSACMRstt CHECK #: LOCATION: H/O NAME: CONTRACT( 6051 Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑,/Title 5 Inspector $ t'7 Title 5 Report $ ❑ Other: (Indicate) $ Aealth Agent Initials White - Applicant Yellow - Health Pink - Treasurer Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Commonwealth of Massachusetts Title.S Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Wintergreen Street Property Address Krenic Anderbi Owner's Name North Andover Cityrrown MA 01845 State Zip Code 3/31/2012 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see -completeness checklist at the end of the form. A. General Information RECRIV 1. Inspector: APR I 12012 Neil James Bateson TOWN OF NORTH AN Name of Inspector I HEALTH DEPARTMENT I Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover City/Town 978-475-4786 Telephone Number B. Certification MA State SI -15 License Number 01810 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Nee Furth r Evaluation by the Local Approving Authority 3/31/2012 In&p&o(s'SignaturY 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 • 11/10 We 5 official Inspection Forth: 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 Wintergreen Street Property Address Krenic Anderberg Owner Owner's Name information is required for every North Andover MA 01845 3/31/2012 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® 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 E] N ❑ ND (Explain below): t5ins -11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 15 Wintergreen Street Property Address ...... .,... __.. .. Krenic Anderberg Owner Owner's Name information is North Andover MA 01845 3/31/2012 required for every page. Cityrrown state Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Wintergreen Street Property Address Krenic Anderberg Owner's Name North Andover Cityrrown MA 01845 State Zip Code 3/31/2012 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 El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow t5ins • 11/10 Title 5 Official Inspection form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts a Title 5 Official Insp a Subsurface Sewage Disposal System Form M 15 Wintergreen Street Property Address Krenic Anderberg Owner Owner's Name nformation is required for every North Andover page. City/Town B. Certification (cont.) Yes No ❑ ® ection Form - Not for Voluntary Assessments ❑ ® Any portion of the SAS, cesspool or privy is below high groundwater 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. MA 01845 3/31/2012 State Zip Code Date of Inspection f ❑ ® 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 groundwater 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 P Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Wintergreen Street Property Address Krenic Anderberg Owner Owner's Name information is required for every North Andover MA 01845 3/31/2012 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? Z ❑ Were as built plans of the system obtained and examined? (If they were not ,Were note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 600 t5ins • 11/10 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 6 of 17 I Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Wintergreen Street Property Address Krenic Anderberg Owner Owner's Name information is required for every North Andover MA 01845 3/31/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information t5ins - 11110 Description: Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? .Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: A ❑ Yes ® No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ® No Yes No ❑ Yes ❑ ❑ Yes ® No Current Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No 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 M 15 Wintergreen Street Property Address Krenic Anderberg Owner Owner's Name information is required for every North Andover MA 01845 3/31/2012 page. City/Town State Zip Code Date of Inspection E D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Date Pumping Records: Source of information: Pumped two years ago, owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: 1500 gallons Measured tank Inspect tank. ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy _ s❑ 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Wintergreen Street Property Address Krenic Anderberg Owner Owners Name information is required for every North Andover MA 01845 3/31/2012 page. City/Town State Zip Code Date of Inspection t5ins • 11/10 D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 25 years old, 6/9/1987, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: feet Material of construction: ® cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4 " Cast iron thru wall, 3" PVC in house, no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 6 feet ❑ 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 10'x 5'x 4' Dimensions: Sludge depth: 2" 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 15 Wintergreen Street l5ins • 11/10 MA 01845 State Zip Code 3/31/2012 Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 25" 4„ Scum thickness 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 17" How were dimensions determined? Tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, I' quid levels as related to'outlet invert, evidence of leakage, etc.): Pumped septic tank. Tank structural ok. Depth of liquid at outlet invert. No evidence of leakage. Center cover has riser 1' deep. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness ❑ fiberglass 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 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 feet ❑ polyethylene ❑ other (explain): Property Address Krenic Anderberg Owner Owner's Name information is required for every North Andover page. City/Town l5ins • 11/10 MA 01845 State Zip Code 3/31/2012 Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 25" 4„ Scum thickness 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 17" How were dimensions determined? Tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, I' quid levels as related to'outlet invert, evidence of leakage, etc.): Pumped septic tank. Tank structural ok. Depth of liquid at outlet invert. No evidence of leakage. Center cover has riser 1' deep. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness ❑ fiberglass 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 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 feet ❑ polyethylene ❑ other (explain): 0 Commonwealth of Massachusetts u Title 5'Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 15 Wintergreen Street Property Address Krenic Anderberg Owner Owner's Name information is required for every North Andover MA 01845 3/31/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): IIR 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: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ No Alarm in working order: Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ❑ Yes ❑ No * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Owner information is . required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Wintergreen Street Property Address - Krenic Anderberg Owner's Name North Andover MA 01845 3/31/2012 Cityrrown D. System Information (cont.) State Zip Code Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D -box level & distribution equal . No evidence of leakage. No evidence of carryover. Pump Chamber (locate on site plan): Pumps in working order: ® Yes ❑ No Alarms in working order: ® Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump tank ok. Pump ok. Alarm has both audible & visual. Center cover has access to grade. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 11/10 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts . Title' 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Wintergreen Street Property Address Krenic Anderberg Owner Owner's Name information is required for every North Andover MA 01845 3/31/2012 page. City/Town State Zip Code Date of Inspection IE t5ins • 11/10 D. System Information (cont:) Type: 3 trenches 76' long ❑ 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 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: 3 trenches 76' long ❑ 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 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 M 15 Wintergreen Street Property Address _:,.._ ... . Krenic Anderberg Owner Owner's Name information is required for every North Andover MA 01845 3/31/2012 page. City/Town State Zip Code Date of Inspection F 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:): ._ ... is -a •,, ap v:a a'. ... .. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 A Commonwealth of Massachusetts- - Title 5 Official Inspection Form Subsurface Sewage .Disposal System Form - Not for Voluntary Assessments 15 Wintergreen Street Property Address Krenic Anderberg: Owner Owner's Name information is required for every North Andover MA 01845 3/31/2012 page. Cityrrown State Zip Code Date of Inspection IH t5ins • 11/10 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 Title 5 Official Inspection Form; Subsurface Sewage Disposal System • Page 15 of 17 A Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 15 Wintergreen Street Property Address Krenic Anderberg Owner Owner's Name information is required for every North Andover MA 01845 3/31/2012 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells E timated de th to hi h round water >4 s p g g feet ...Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 3/27/1986 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Design plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: As per design plan test pit data Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 15 Wintergreen Street Property Address Krenic Anderberg Owner Owner's Name information is required for every North Andover MA 01845 3/31/2012 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 -11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 Commonwealth of Massachusetts lugCity/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, Le Rig h 67egr of Raii Left / right side of house, Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address Cityrrown State Zip Code 2. System Owner. Name Address (if different from location) Cityrrown State pp Zip Code L3 Telephone Number B. Pumping Record '�3 1. Date of PumpingDate 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes E31T If yes, was it cleaned? ❑ Yes ❑ No 5. Condition ofSystem: Ko Coc1^ 14XIA k o'- 6. System Pumped By. Neil Bateson Name Bateson Enterprises Inc Company ' 7. Location contents were disposed: L.S. Lowell Waste Water N, e t5form4.doc• 06103 F5821 Vehicle License Number "3 —'B f ---t 6 - Date C� -6 System Pumping Record • Page 1 of 1 J Summary Record Card generated on 413/2012 2:52:49 PM by Karen Hanlon Page 1 ' Town of North Andover Serial No Status Tax .Map,,# 210-104.B-0010-0000.0 Location Brand Parcel Id 16339 13242272 a Active 15 WINTERGREEN DRIVE METE METE w Water ANDERBERG, KANRIC Reading Code 15 WINTERGREEN DRIVE Posted Date 3/20/2012 NORTH ANDOVER, MA a Actual 23 01845 12/19/2011 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1 Acres 37 10/13/2011 FY 2012 732 a Actual UB Mailing Index 7/20/2011 3/15/2011 Name/Address Type Loan Number Active/lnact. From Until ANDERBERG, KANRIC Payor 683 15 WINTERGREEN DRIVE 22 1/12/2011 NORTH ANDOVER, MA 661 a Actual 01845 10/15/2010 6/14/2010 UB Account Maint. Account No: Cycle Occupant Name Active/Inactive Bldg Id. 18039.0 -15 WINTERGREEN DRIVE Last Billing Date 1/7/2012 3180068 03 Cycle 03 Active UB Services Maint. Account No. 3180068 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 91.50 /1 UB Meter Maintenance Account No. 3180068 ' Serial No Status Location Brand Type 13242272 a Active 00 METE METE w Water Date Reading Code Consumption Posted Date 3/20/2012 815 a Actual 23 12/19/2011 792 a Actual 23 1/17/2012 9/16/2011 769 a Actual 37 10/13/2011 6/13/2011 732 a Actual 23 7/20/2011 3/15/2011 709 a Actual 26 4/13/2011 12/15/2010 683 a Actual 22 1/12/2011 9/16/2010 661 a Actual 32 10/15/2010 6/14/2010 629 a Actual 22 7/15/2010 3/18/2010 607 a Actual 21 4/14/2010 12/14/2009 586 a Actual 25 1/12/2010 9/16/2009 561 a Actual 27 10/15/2009 6/10/2009 534 a Actual 25 7/20/2009 3/17/2009 509 a Actual 26 4/29/2009 12/15/2008 483 a Actual 21 1/20/2009 9/16/2008 462 a Actual 23 10/10/2008 6/10/2008 439 a Actual 28 7/16/2008 3/14/2008 411 a Actual 26 4/11/2008 12/17/2007 385 a Actual 28 1/22/2008 9/14/2007 357 a Actual 33 10/12/2007 6/20/2007 324 a Actual 25 7/20/2007 3/16/2007 299 a Actual 14 4/16/2007 12/13/2006 285 a Actual : ........_.. _ 24 1/19/2007 9/19/2006 261 a Actual 32 10/20/2006 6/20/2006 229 ' a Actual 26 7/10/2006 3/20/2006 203 a Actual 12 4/17/2006 1/3/2006 191 a Actual 28 1/17/2006 9/15/2005 163 a Actual 38 10/14/2005 6/14/2005 125 a Actual 24 7/15/2005 3/23/2005 101 a Actual 16 4/5/2005 12/15/2004 85 a Actual 23 1/14/2005 Size 0.63 0.63 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION UVAKU OF HEALTH TITLE 5_ OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 15 Wintergreen Drive N. Andover ' n over, Owner's Name: Macu s i —Ma Mllx Owner's Address: same Date of Inspection: ,UJB f n Name of Inspector: (please print John J. Soucy CompanyName:;Soucy, s Sewer Mailing Address;830 Livings on Tewksburv. 6 Telephone Number: ( 9 7 8 5 — 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: —XX Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Sipature: �L".Date: 7.-0 101 The system inspector shall submi a copy of this i pectin roport 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 hpw 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 Winter reen Drive N. Andover, MA U I 64n—' Owner: M-Culski Date of Inspection: 01 Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: xx 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: IL 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, willP ass, Answer yes, no or not determined (Y,N,ND) in the for the following statements. If ,not determined" lease ��' P 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 existing tank is replaced with a complying sexfiltration or tank failure is imminent. System will pass inspection if the eptic 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. approval of Board of Health): System will pass inspection if (with broken pipes) are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will Pass inspection if (with approval of the Board of Health): ND explain: broken pipe(s) are replaced obstruction is removed 2 r Page 3 of I l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 15 Wintergreen Drive Owner: Macuis i Date of Inspection: 0 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 6 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 Wintergreen . Drive N. AndoVer, MA Ot845 Owner: Maculs i Date of Inspection. 0 227 D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes No _ x _ X X X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool . Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than �/, day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply: Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] 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. Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:1 5 Wintergreen Drive N. An over MA 01845 Owner: Maculski Date of Inspection: 0 9/—V7701 Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No xx _ Pumping information was provided by the owner, occupant, or Board of Health XX — _ Were any of the system components pumped out in the previous two weeks ? XX _ _ Has the system received normal flows in the previous two week period ? XX — _ Have large volumes of water been introduced to the system recently or as part of this inspection ? XX _ Were as built plans of the system obtained and examined? (If they were not available note as N/A) XX — _ Was the facility or dwelling inspected for signs of sewage back up ? XX Was the site inspected for signs of break out ? XX _ _Were all system components, excluding the SAS, located on site ? --xx _ 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 ? 3x _ 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 xx _ Existing information. For example, a plan at the Board of Health. XX _ 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)] ;j Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: .15 Wintergreen. Drive • , MA 01845 Owner: Mac Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): A Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):4 4 0 Number of current residents:.3.—_ Does residence have a garbage grinder (yes or no): NL Is laundry on a separate sewage system (yes or no).N.0— [if yes separate inspection required] Laundry system inspected (yes or no): Seasonal use: (yes or no): N Water meter readings, if available (last 2 years usage (gpd)): See attached Sump pump (yes or no): RQ_ Last date of occupancy: r�„_ r- rpt COMMERCIAUINDUSTRIAL Type of establishment: N /A Design flow (based on 310 CMR 15.203): znd Basis of design flow (seats/persons/sgtetc.): Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): _ Non -sanitary waste discharged to the Title 5 system (yes or no): _ Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping'Records also Source of information: pum ped5-01 pumped 90/01 Was system pumped as part of the inspection (yes or no): Te s If yes, volume pumped: 1 500 gallons —How was quantity pumped determined? Gage .on truck Reason for pumping: maintenance and inspect interior 0-f--taffic— TYPE OF SYSTEM xx Septic tank, distribution box, soil absorption system _ Single cesspool Overflow cesspool _ ivy _ 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: 1 �FtF Were sewage odors detected when arriving at the site (yes or no): NO 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 Wintergreen Drive N. Anduvt::rl 1845 Owner: Maculski Date of Inspection: 0 9 2 =0 BUILDING SEWER (locate on site plan) Depth below grade: 4' f eet Materials of construction:. XXcast iron 40 PVC _other/explain): Distance from private water supply well or suction line: AA Comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: :K& (locate on site plan) Depth below grade: 5 , fPet Material of construction: Xconcrete 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: 6 Y 1 1' .£gip t Sludge depth: 1 Distance from top of sludge to bottom of outlet tee or battle: 39_ Scum thickness: , it Distance from top of� scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee orbb-a le: ! i nc . How were dimensions determined: Tape and slucre. tool. Comments (on pumping recommendations, inlet and outlet tee or battle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No garbage disposals allowed, and GREASE TRAP:i /.P(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 battle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or battle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 L 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 Wintergreen Drive 1V. An over, 01845 Owner: Ma t-,11 Gk i Date of Inspection: ag / 9 7 / 01 TIGHT or HOLDING TANK: N/ A (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: aallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: xx (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Float checked O.K. PUMP CHAMBER: ,xx (location site plan) Pumps in working order (yes or no): yes Alarms in working order (yes or no): yes Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): B�esnt ne�� n17mn and hardware 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 Wintergreen Drive N. Andover, MA'7T)1845 Owner: Marail Gk� Date of Inspection: 0 9 / 2 7 / 01 SOB. ABSORPTION SYSTEM (SAS): xx pocate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number. leaching galleries, number leaching trenches, number, len leaching fields, number, dime �� l , �51 f met each overflow cesspool, number, . innovative/alternative system ;fy*=e of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): CESSPOOLS: DILA (cesspool must be pumped as part of inspectionxlocate 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: W a (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note conditionof soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ' a Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 5 Wintergreen Drive N. Andover. MA 01845 Owner: M;4nuI Ski Date of Inspection:09 / 2 7 / 01 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. ri Rubs P c1�4.�,6CA r f� CAAAaQ_jL i T/�EF Page 11 of 1 I :V OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 15 Wintergreen Drive N. n over, 1845 Owner: Ma cul s k i Date of Inspection0 9 2 7 SITE EXAM Slope Surface water.. W Check cellar x_x Shallow wells Estimated depth to ground water Z2_+ feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: yy _ 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: Diiq trzaf hnl a with angr_r 1 nAH dreL nff a-rea i nrnnn re nn wafAr at 48"innh (elevation different from frnni- fn roar 11 .f t -s :III' ja� y a 401. 1 J W �?4 ,s � E• � q s z sal¢ n s � z. I- C7vI�MMvC4 . P uj �. ©©0.0vv0v LLJ W � W . . . . IP- OD D©h.4 70.N ' CO:3 C9T 7x y Z Z 0 W M©NTT©O+P7 LIj T" W TMNNMNNNZz • C9 in z x t D�•Z MCID 0NMN0m O k k Q LA rl ci �f c O" a •O -DP.ODOti W ,f OD O rrrTTTTT +. ti 's C6 W } I avvvvvt-T = 2; IM I }v©©©cc= y.1 - .O I W Q.vvvvvvv TNNNNNNN� S I CC 0TNTNT0T�"�� :4D 1 y a .0 a.N-'.0 y , Cm yj rr I �k J I co Ch C9 0 C9 m I W 11 I I I I I 1 v x a ©©© W NNNNNN©NN a iau S v 3 I ii TN0 LA.0Ncm y� ql 17m 140+ /4' I ,E L.. /S'DO GR % SEP tJk LSNl1 3 7ARPALC! Es 74'x 3t L o f 7A �AZ/ZV I- 4ER GRFE/V s�-4RF-6�t- f r k� YII X, top "t A) tlry e�4 1. INV, - v et sr T V1 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD 1,; 1 r 't -1 a A "k: t, 1 7. siDt4Cr� j v ? ',1'P1!-'.','SYSTEM'OWNEk &ADDRESS t'.SYSTEM LOCATION (example: left front of house) tv N frX q;, • SATE OF PUMPING: *-'QUANTITY PUMPED GALLONS �_:YES I'M PTI C TANK: NO YES :OF ROUTINE THU EMERGENCY Urw gg K,W?, _01 S QNRIU, CONDITION FULL TO COVER 0 HEAVY'.GREAS 4 E -BAFFLES IN PLACE o, ;1EACHFIELD RUNBACK EXCESSIVE SOLIDS _44; FLOODED -SOLIDS CARRYOVER OT R (EXPLAIN) HE �10_k NIA f' -S I _S�) A .1 11 P I TOWN OF NORTH ANDOVch/ BOARD 05t -WEALTH JUL 1 6,•2R J., TOWN OF NORTH ANDOVch/ BOARD 05t -WEALTH JUL 1 6,•2R .(X13D of N5& ' Noll"FfN AnJPNLE)-�, MA, ,4pMovtD Coy j-nw5 w,a-r6 CAS I $� UJEU- AP fouCD D4 f -C sCPT"�c. sysiEM VES►<-� .. �15APPP4vEp DgiE R�4SoNS D4x- q 79- S1 pr(6 SY STEM w S ►A U,,QT IOAJ =-'X4V4T(o1-1 ),vc I'�.G ► �OtiJ V4rC 5 -z --7-i2 �sS ❑ F41L- �rNA� l�SP�TIon� APPROOED 04TC 'j,12 -�7 APflr�vrNG A�r�tor��-ry v RuM� DiWP)�o\j&D R�J50 NS FK4L APPF�jvAL 1\ DAIFe- APP3alvJ6 6u i Hold t y C� 7 6 ,, 5 Date. . L / ........ TOWN OF NORTH ANDOVER Ir ' PERMIT FOR GAS INSTALLATION Y .1.0 •`t, �,SSACMUSEt h This certifies that r..... { l'' y ....... � �G has permission for gas installation ....71-.1 . . T .............. in the buildings of . . ` .��.? �z. �.!t J ................... at . f ..�'` `` y.' .::.:.... t�� :. , North Andover, Mass. Fee.. 7............. �Lic. No..... GASINSPECTOR Check # 1311 J A MASSACHUS ET I ,UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) V/—Mass. Date Q Permit # Building Location_ Owner's Namee,46 f)jPr / % cp . Type of Occupancy Residential New ❑ Renovation ❑ Replacement Plans Submitted: Yes 11 No ❑ FIXTURES Installing Company.Name Heritage 'Htg: &Pig. Co. Inc. Check one: Certificate Address 35 Pleasant `Street IX Corporation 714 Stoneham; Ma`02180 ❑Partnership Business Telephone Z81 —438-7776 n Firm/Co. Name of Licensed Plumber Gordon ` SWitZer INSURANCE 60VtRAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ® No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all . pertinent provisions of the Massachusetts State Plumbing Co a and Chapter 142. f the Peneral Laws. Title Sig re ol LicensedPlumber Type of License: Master [g Journeyman ❑ City/Town8 3 2 2 APP 0 S NL Ucense Number N N N z O Nd Z Q Z W Y J (n �' V Q �� ' W b cc O Z W H W 2 ~ x ¢ N Z W U. Z Z ' d Q) -j N - m N x K W N Z a WO 7 Cr a (n Cr r: y W O S J = aOCr w=Q x 3 3 0 z> Y N a F a X W U x < u> f- O x az m ►- z o o N z z Q W H o 3 rl 3 X J m N O O J 3 = F w LL 0 O O a i m a1 SUB—BSMT. BASEMENT IST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company.Name Heritage 'Htg: &Pig. Co. Inc. Check one: Certificate Address 35 Pleasant `Street IX Corporation 714 Stoneham; Ma`02180 ❑Partnership Business Telephone Z81 —438-7776 n Firm/Co. Name of Licensed Plumber Gordon ` SWitZer INSURANCE 60VtRAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ® No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all . pertinent provisions of the Massachusetts State Plumbing Co a and Chapter 142. f the Peneral Laws. Title Sig re ol LicensedPlumber Type of License: Master [g Journeyman ❑ City/Town8 3 2 2 APP 0 S NL Ucense Number C. ti m V CL S IL_ O O J LL cc F d LL O LL ; ¢ 3 LL O f0 ,., W4 Y JO O W o. u p LU W IL LL L .SL C. ti SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) VUY6 n l e i � feel 5 �A S -f . DATE OF PUMPING: QUANTITY PUMPED A17-0 GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES .« NATURE OF SERVICE ROUTINE EMERGENCY OBSERVATIONS: 'p ' GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK _ EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: e � �e_ oc. r. Y. COMMENTS: , CONTENTS TRANSFERRED TO: C�_f . LQ,0J(_eytLe 0- V7i i S ��— �;