The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 1500 Forest Street 1500 FOREST STREET 21-0/105,B-0004-0000.0 <, 7=777- ' All UPC 1 408 t i ' HA8IFINQB�MN x 1 Residential Property Record Card PARCEL ID:210/105.B-0004-0000.0 MAP:105.B BLOCK:0004 LOT:0000.0 PARCEL ADDRESSA500 FOREST STREET PARCEL INFORMATION Use-Code: 101 Sale Price: 307,000 Book: 04241 Road Type: T Inspect Date: 05/25/2004 Owner: Tax Class: T Sale Date: 04/17/1995 Page: 0344 Rd Condition: P Meas Date: 05/25/2004 MYERS,JOHN L Tot Fin Area: 3036 Sale Type: P Cert/Doc: Traffic: M Entrance: C LISA M MYERS Tot Land Area: 1.25 Sale Valid: Y Water: Collect Id: RRC Address: _ T Grantor: PEARL,JEFFREY R Sewer: Inspect Reas: M 1500 FOREST STREET EXT. Exempt-B/L% / Resid-B/L% 100/100 Comm-B/L@ZO Indust-B/L% 0/0 Open Sp-B/L% 0/0 BOXFORD MA 01921 RESIDENCE INFORMATION LAND INFORMATION Style: CL Tot Rooms: 8 Main Fn Area: 1716 Attic: NBHD CODE: 5 NBHD CLASS: 5 ZONE: R1 Story Height: 2 Bedrooms: 3 Up Fn Area: 1320 Bsmt Area: 1616 Seg Type Code Method Sq-Ft Acres Influ-Y/N Value Class Roof: G Full Baths: 2 Add Fn Area: Fn Bsmt Area: 1 P 101 S 43560 1 168,577 Ext Wall: FB Half Baths: 1 Unfin Area: Bsmt Grade: 2 R 101 A 0.25 1,175 Masonry Trim: Ext Bath Fix: Tot Fin Area: 3036 VALUATION INFORMATION Foundation: CN Bath Qual: T RCNLD: 307438 Current Total: 471,700 Bldg: 324,500 Land: 147,200 MktLnd: 147,200 Kitch Qual: T Eff Yr Built: 1987 Mkt Adj: 1.1 Prior Total: 486,400 Bldg: 324,500 Land: 161,900 MktLnd: 161,900 Heat Type: HW Ext Kitch: Year Built: 1986 Sound Value: Fuel Type: O Grade: G Cost Bldg: 338,200 Fireplace: 2 Bsmt Gar Cap: Condition: A Att Str Vall: Central AC: Y Bsmt Gar SF: 384 Pct Complete: Att Str Val2: ' Att Gar SF: %Good P/F/E/R: /100/100/91 Porch Type Porch Area Porch Grade Factor W 454 SKETCH PHOTO M z 17 W 10 454 Sq.R. 12 4 4 F 13 0 S� §I1: 384I Sq.Ft. l e 24 24 30 -s 16 4 44 44 1500 FOREST STREET •' Parcel ID:210/105.B-0004-0000.0 as of 5/4/05 Page 1 Of 1 i f "--Dellechiaie, Pamela From: health department[healthdept@townofnorthandover.com] on behalf of Dellechiaie, Pamela Sent: Friday, April 15, 2005 11:36 AM To: 'Daniel Ottenheimer(E-mail)'; 'Lisa LeVasseur(E-mail)'; 'McBrearty Andrew(E-mail)' Cc: errill, Pamela�Grant, Michele; Sawyer, Susan Subject: 1500 Forest Str bt-Soil Test Application i I� Hello, ! There is some confusion about the location of this property. I spoke with Bill Dufresne, and he gave me the following direction ---- ou must get to Boxford Street in Boxford. Take a Right onto Main Street and then a Right on Town Road. Take anothe Right onto Hollow Tree Lane, and then a Left on Stonecleave Road. Follow this until you get to Forest Street, which i really a"Paper Street" referred to as Forest Street Extension. I will send the property card information separately as erence. --------------------- Thank you. $6sf R0010--ds, A414044 AW0000.41ai¢ Health Department Assistant Town of North Andover 400 Osgood Street North Andover,MA o1845 978.688.9540-Phone 978.688.8476-Fax http://www.townofnorthandover.com healthdept@townofnorthandover.com i Dellechiaie, Pamela.vcf I ! I 1 Driving Directions from 400 mood St,North Andover, MA to [990-1P"91 ] Forest St,No... Page 1 of 3 Y 1 .•. Y Q4 A Qszi(no. CHEM Start: 400 Osgood St North Andover, MA 01845-2909,us Vvatecuon ""'""" " T from the momerit End: [990-1099] Forest St you turn the key. North Andover, MA 01845, US +.nrClick Here to Learn More! `:+� Directions Distance 1: Start out going SOUTHWEST on OSGOOD ST toward 0.7 miles MILL POND. ' 2: Turn LEFT onto MASSACHUSETTS AVE. 0.2 miles 3: MASSACHUSETTS AVE becomes SALEM ST. 2.5 miles 4: Stay STRAIGHT to go onto BOXFORD ST. 0.2 miles 5: Turn RIGHT onto FOREST ST. 2.4 miles raE� 6: End at [990-1099] Forest St North Andover, MA 01845, US Total Est. Time: 17 minutes Total Est. Distance: 6.20 miles http://www.mapquest.com/directions/main.adp?do=prt&mo=ma&2si=gdt&1 gi=0&un=m&... 5/4/2005 Driving Directions from 400�ood St,North Andover, MA to [990-]t A9] Forest St,No... Page 2 of 3 r rim - "$lftfdnfsI10� r �4s1 O?ct�orld r` - ikm t �mkr GIG 4 _ ` 4r _Attevon Crass AndOvrrCerdsi 133 artiN Ridgs Stgtbn •"'� tis n It 11 >f f , iS,l04, :arl `�E3istsh oxford ' i t OVer 5 c h~ d+ 80 Ion • �P f `ryj� < �r,,�, �ay r A X , 2005 Ph pQuest.com,inev, 02005 Ni4VT_Q Start: End: 400 Osgood St [990-1099] Forest St North Andover, MA 01845-2909, US North Andover, MA 01845, US ►P�V6S►rTa� OfOtm 0000 1 ft 11C ` q I ��sa` 5� 0' N Cid a ,o 'Q I is ant Sr a .. �� Stevens�rossin�gc j � a, 133 Bay 02005_MapQuestcom,Inc, Q100S`AVTEQ 102006WpQuest,com,Inc. _ ._ 02005 Ni4VTEQ Notes: FR-A-V—TE-0] All rights reserved. Use Subject to License/Copyri-ht These directions are informational only. No representation is made or warranty given as to their content, road conditions or route usability or expeditiousness. User assumes all risk of use. MapQuest and its suppliers assume no responsibility for any loss or delay resulting from such use. http://www.mapquest.com/directions/main.adp?do=prt&mo=ma&2si=gdt&1 gi=0&un=m&... 5/4/2005 Commonwealth of Massachusetts Title 5 Officia inspection Form 4 Subsurface Sewage Disposal System Form-Not for Voluntary AssessmentsY�j1500 Forest Street Extension Property Address Mark Jackson Owner Owner's Name information is required for every North Andover MA 01845 7/2/2015 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 filling out forms A. General Information RECEIVED on the computer, use only the tab 1. Inspector: JUL 16 2015 key to move your cursor-do not Neil J. Bateson TOWN use the return OFT ��( NEI� key. Name of Inspector HEALTH DBYARTMENT Bateson Enterprises Inc. e6 Company Name 111 Ar ills Road Company Address Andover MA 01810 Cityrrown 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 ❑ e s Further Evaluation by the Local Approving Authority 7/2/2015 InspM6r'kSignatJVj 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. r t5ins•3113 Tide 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 " 1500 Forest Street Extension Property Address Mark Jackson Owner Owner's Name information is required for every North Andover MA 01845 7/2/2015 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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•3113 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 1500 Forest Street Extension Property Address Mark Jackson Owner Owner's Name information is required for every North Andover MA 01845 7/2/2015 page, City/Town 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•3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1500 Forest Street Extension Property Address Mark Jackson owner Owner's Name information is required for every North Andover MA 01845 7/2/2015 page. Cityfrown 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: ms: 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 0 ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/Z day flow t5ms-3113 Tice 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments " 1500 Forest Street Extension Property Address Mark Jackson Owner Owner's Name. information is � required for every North Andover MA 01845 7/2/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ 0 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 r Section E or failed under 9 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. !Sins•3!13 Title 5 Official Ins peclion Form:Subsurface Sewage Disposal System•Page 50117 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1500 Forest Street Extension Property Address Mark Jackson Owner Owner's Name information is required for every North Andover MA 01845 7/2/2015 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms(actual): 4 `DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins•3113 Title 5 official Inspection Porth: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 " 1500 Forest Street Extension Property Address Mark Jackson Owner Owner's Name information is required for every North Andover MA 01845 7/2/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 5 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): On well water> 100 from tank Detail: Sump pump? ❑ Yes N No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No R 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 a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1500 Forest Street Extension Property Address Mark Jackson Owner Owner's Name information is required for every North Andover MA 01845 7/2/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped last year, owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Measured tank Reason for pumping: Inspect tank tees Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (Yes or no) Cif 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1500 Forest Street Extension Property Address Mark Jackson Owner owner's Name information is North Andover MA 01845 7/2/2015 required for every page. City/Town 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, 11/5/2005, 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 I Material of construction: ® cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >100 feet Comments(on condition of joints, venting, evidence of leakage, etc.): 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 10'x 5'x4' 4' Dimensions: Sludge depth: 1" 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 1500 Forest Street Extension Property Address Mark Jackson Owner Owner's Name information is required for every North Andover MA 01845 7/2/2015 page. City/Town 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 33" Scum thickness 1" 1811 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum'to bottom of outlet tee or baffle 14" Tape measure 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. Inlet&outlet covers has riser 2"deep Grease Trap(locate on site plan): Depth below grade: feet Material of construction: 0 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-3113 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 1500 Forest Street Extension Property Address Mark Jackson Owner Owner's Name information is required for every North Andover_ MA 01845 7/2/2015 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 tSins•3/13 Tide 5 Official lnspection Form:Subsurface Sewage Disposal System•Page 11 of 17 h Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1500 Forest Street Extension Property Address Mark Jackson Owner Owner's Name information is required for every North Andover MA 01845 7/2/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): , D-box 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 ok. Floats ok. Pump started& pumped to d-box. Alarm has both audible&visual alarm. Riser cover over pump &floats 2"deep. *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•3113 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 1500 Forest Street Extension Property Address Mark Jackson Owner Owner's Name information is required for every North Andover MA 01845 7/2/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 28 ❑ leaching galleries number: ❑ leaching trenches number, length: i ❑ 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.): i Soil ok. Vegetation ok. No sign of ponding to surface. 28 infiltrator chambers. Four rows of seven chambers per row 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•3113 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 1500 Forest Street Extension Property Address Mark Jackson Owner Owner's Name information is North Andover MA 01845 7/2/2015 required for every I page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1500 Forest Street Extension Property Address Mark Jackson Owner Owner's Name information is required for every North Andover MA 01845 7/2/2015 page. City1rown 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 1N-tic . 19. `C">7 W-PU Dell Uk' 3 a P -� - t Qe3c� r 3 C 3 ` �� fc t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments " 1500 Forest Street Extension Property Address Mark Jackson Owner Owner's Name information is required for every North Andover MA 01845 7/2/2015 page. Cfty Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 4 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 6/9/2005 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with�local Board of Health-explain: Design plan ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: As per test pit data on design plan. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 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 r 1500 Forest Street Extension Property Address Mark Jackson Owner Owner's Name information is required for every North Andover MA 01845 7/2/2015 page. City/Town 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 I M t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 vvl rlt llUl lVVW0lLl i til lVlc1,5c Ul IU*=L* 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. i A. Facility Information 1. System Location: Left/Right front of house, Left/Right rear of house,�righ gside;:ofnous LeftRight side of building, Left/Right front of building, Left/Right rear of building, Un Address ( s �{�� T I cy\ City/rown ` �✓'� State Zip Code 2. System Owner. Name' Address(if different from location) Cityfrown State Zig Cod Telephone Number t a i B. Pumping JRecord r 1. Date of Pumping Date 2. Quantity Pumped: Gallons ` 3. Type-of system: ❑ Cesspool(s) 9_<PtIc Tank E3 -right Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes 2-46 If yes, was it cleaned? ❑ Yes ❑ No ' 5. Condition of tem: II /OS \IV 1 � 6: System Pumped By: Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Ina Company 7. Location ere contents-were disposed: S: Lowell Waste Water Sig qt Haul Date f t5form4.doo-06/03 System Pumping Record•Page 1 of 1 Town of North Andover Office of the Health Department Community Development and Services Division +� 400 OSGOOD STREET North Andover,Massachusetts 01845CHU CHU e 9 SAS t Susan Y. Sawyer,REHS/RS 978.688.9540-Phone Public Health Director 978.688.8476-Fax I C29 ; I FICAqtF OT C0�I�1�1 J-PA_1 919V-CE As of. September 21, 2005 This is to cert that the individualsu6surface disposal system Repaired� /" by ,john Soucy At 1500 Forest Street North Andover, M,4 01845 9fas been installed in accordance with the provisions of Title v of the State Sanitary Code and with the North Andover(Board of ifealth regulations. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Sus n 7 Sawyer, 1� S, S 6lic Ifealth Director BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 _ C/1 TOWN OF NORTH ANDOVER °R*M Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 400 OSGOOD STREET NORTH NDO UCnRSS�'A� HU ETTS 01845 s�c►+uge 978.688.9540—Phone Susan Y.Sawyer,RENS/RS 978.688.8476—FAX Public Health Director SEP 16 2005 E MAIL:healthdeptgtownofnorthandover.com TOWN OF NORTH ANDOV W BSITE:htip://www.townoftiorthandover.com iorthandover.com HEALTH DEPARTMENT TOWN OF NORTH AND SEPTIC DISPOSAL SYSTEM - INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System ( ) constructed; (yj repaired; by o So,,e (Prin ame) locatedat moa �Qc�s S i�'� 6r X TF,✓s i0^ (Installation Address) was installed in conformance with the North Andover Board of Health approved plan, originally dated 4,-/3- v S and last Revised on 7--Z. 45-S , with a design flow of 4-1 -� 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: Engineer Representati (Signature) And-Print Name Final inspection date: .5131ft- tq 1 E77n g-sneer Represen ative(Signature) ftt` .�:w C Ot�ooQJ•L And-f1rint Name Installer. (Signature) Date: t And-Pri Name Engineer: a* I c� ' (Signature) Date: � BENJAW C. '; T v 0© And-Pr' t Nam Id" dg681 p Ap �n `�FGISTE� •�u' C- J NEW ENGLAND ENGINEERING SERVICES INC September 15, 2005 - RECEIVED 'EP 1 6 2005 Susan Sawyer North Andover Board of Health 1' HEALTLT NQE- EH DEP�r 400 Osgood Street - North Andover, MA 0l 845 Ile: 1500 Forest Street .Extension, North Andover, MA Septic System .,ks-Built Plan Submittal ],rear Ms. SwNryer, The following Selitic. As-Built plans for the above referenced property are being submitted for approval. Enclosed are the following: 1 . (3; Copies of ttic septic System As-Built Plan. 2. Copy of.Desig,cr's/Installer's Certification Form. Please contact this „fl ice. with any questions or concerns. Sincerely, Thomas Hector Project En;;ineer cc: Homeowner 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645- FAX(978)685-1099 0 Page 1 of 1 DelleChiaie, Pamela From: Andy McBrearty [amcbrearty@millriverconsulting.com] Sent: Wednesday, August 31, 2005 5:22 PM To: Sawyer, Susan; Grant, Michele; DelleChiaie, Pamela Cc: Daniel Ottenheimer(info@millriverconsulting.com); Lisa Kozel LeVasseur Subject: 1500 Forest St Ext Const Inspection Here is construction inspection from Wed at 1500 Forest st. No problems. Soucy did have to replace the 1500 tank and 1000 gal pump chamber with a single 2500 combo tank because of the amount of ledge encountered.Not a problem with that. Could not access house as owners were away. Was not able to check on electric and plumbing, so need you to do that at final grade inspection, if possible... thanks, -andy I 9/2/2005 0 0 TOWN OF NORTH ANDOVER a NORTI{ Office of COMMUNITY DEVELOPMENT AND SERVICES Fr e�y�`" •"O° HEALTH DEPARTMENT 400 OSGOOD STREET NORTH ANDOVER,MASSACHUSETTS 01845 "S-"CHU Susan Y.Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.9542—FAX ADDRESS: 1500 Forest St Ext. MAP: LOT: INSTALLER: Soucy Septic DESIGNER: NEE PLAN DATE: 9/1 161< BOH APPROVAL DATE ON PLAN: gll I OJ DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION- 8/ /05 DATE OF FINAL GRADE INSPECTION: q' �b SITE CONDITIONS IF] Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged 0 1500/1000 gallon combo tank has been installed H-10 loading Monolithic construction ❑ Water tightness of tank has been achieved (Visual or Vacuum Test or Water held for 24hrs) 0 Inlet tee installed, centered under access port 0 Outlet tee (gas baffle or effluent filter) installed, centered under access port El 24" inch cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present El Hydraulic cement around inlet & outlet Comments: Due to ledge encountered on site, Installer replaced Septic tank and pump chamber with a 2500 gallon combo tank (1500/1000). i Page 1 of 3 a b TOWN OF NORTH ANDOVER E NORTH Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 400 OSGOOD STREET `►", .�� 4"D•� NORTH ANDOVER, MASSACHUSETTS 01845 'Ss�CMUset Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.9542—FAX PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged 0 1500/1000 gallon Combo tank installed H-10 loading 2 piece construction) 0 Inlet tee installed, centered under access port 0 Pump(s) installed on stable base 0 Alarm float working 0 Pump Ori/Off float working 0 Drain hole in pressure line 0 24" inch cover to within 6" of final grade installed over pump access port ❑ Water tightness of tank has been achieved (Visual testing 0 Hydraulic cement around inlet & outlet Comments: Combo tank (see Septic notes) D-BOX 0 Installed on stable stone base 0 Inlet tee (if pumped or >0.08'/foot) 0 Hydraulic cement around inlet & outlets 0 Observed even distribution Comments: SOIL ABSORPTION SYSTEM ❑ Bottom of SAS excavated down to soil layer, as provided on plan 0 Size of SAS excavated as per plan 0 Title 5 sand installed, if specified on plan 0 laterals installed and ends connected to header (and vented if impervious material above) 0 Gravelless disposal systems: type, number and location as per plan 0 Elevations of laterals installed as on approved plan 0 40 Mil HDPE barrier installed ❑ Final cover as per plan Comments: Page 2 of 3 TOWN OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 400 OSGOOD STREET ::.. •� NORTH ANDOVER,MASSACHUSETTS 01845 ?'�Ss�CHU ` Susan Y. Sawyer,REHS/RS 978.688.9540-Phone Public Health Director 978.688.9542-FAX CONTROL PANEL ❑ Alarm & Pump are on separate circuits 0 Alarm sounds when float is tripped D Location of control panel: Basement ❑ Rated for exterior if placed outside Comments: Could not access Basement-Try to enter at final grade inspection SETBACK DISTANCES Tank SAS Sewer El Property line 10 10 -- [H] Cellar wall 10 20 -- SYSTEM ELEVATIONS Benchmark: 100.89 Rod at Benchmark: 3.79 Height of Instrument: 104.68 INVERT ON DESIGN PLAN INVERT ELEVATION Building Sewer OUT 99.35 98.50 Septic Tank IN 98.83 97.08 Septic Tank OUT 98.58 *see note Pump Chamber IN ---- *see note Pump Chamber OUT --- 98.00 Distribution Box IN 100.39 100.48 Distribution Box OUT 100.22 100.32 Lateral 1 HIGH 100.58 100.68 Lateral 1 LOW 100.58 100.70 Lateral 2 HIGH 100.58 100.69 Lateral 2 LOW 100.58 100.70 Lateral 3 HIGH 100.58 100.70 Lateral 3 LOW 100.58 100.70 Lateral 4 HIGH 100.58 100.69 Lateral 4 LOW 100.58 100.70 Lateral 5 HIGH 100.58 100.69 Lateral 5 LOW 100.58 100.70 Page 3 of 3 Commonwealth of Massachusetts Map-Block-Lot 105.B-0004 �. Board of Health s Permit No p North Andover BHP-2005-0260 P.I. t�S4CHs`+E` F.1. FEE - $250.00 Disposal Works Construction Permit Permission is hereby granted J0114 SOucq to(Repair)an Individual Sewage Disposal System. at No 1500 FOREST STREET - ------- ----- as shown on the application for Disposal Works Construction Permit No. BHP-2005 026 Dated August 11,2005. Issued On:Aug-11 2005 _ Iioa� liiwth .......................... .i... ... ... ..I/..................................................... . .. _ . ., . ......................i .....*.,F.. ....a.... ...................... 1 TOWN OF NORTH ANDOVER O !NORT10 Office of COMMUNITY DEVELOPMENT AND SERVICES 3:;�'',`" HEALTH DEPARTMENT A 400 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845 swcNus� 978.688.9540—Phone Susan Y.Sawyer,REHS/RS 978.688.9542—FAX Public Health Director healthdept@townofnorthandover.com-e-mail www.townofnorthandover.com-website APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: LOCATION: + LICENSED INSTALLER NAME: C,n PLEASE PRINT SIGNATURE: ELEPHONE# �I CHECK ONE: FULL SYSTEM REPAIR: ($250) COMPONENT REPAIR(indicate what parts): ($125) * NEW CONSTRUCTION: * If NECONSTRUCTION lease attach the Foundation - p at on As Built Plan. r: $250.00 or$125 Fee Attached? Yes No Project Manager Obligation From Attached? Yes�� No Foundation As-Built? Yes > No Floor Plans? Y No Approval of Health Agent Date: i f E O INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at `S� elative to the application of ITSA, Lnwzk dated for plans by AX, and dated!'_--/3-6t7 with revisions dated I understand the following obligations for management of this project: 1. As the installer I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer I must call for any and all inspections. If homeowner, contractor, project manger,or any other person not associated with my company schedules an inspection and the system is not ready then item three shall be applicable. 3. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Tile 5 and the Board of Health Regulations may result in a$50.00 fine being levied against my company. a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As-built or verbal OK from engineer must be submitted to Board of Health, after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade—Installer must request inspection when all grading is complete. Does not have to be on site. ' 4. As the installer I understand that only I may perform the work(other than simple excavation) required to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation or suspension of my license to operate in the Town of North Andover; significant fines to all persons involved are also possible. 5. As the Installer I understand that I must be on site during the performance of the following construction.steps: a) Determination that the proper elevation of the excavation has been reached. b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff or consultant. d) Installation of tank, D-box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Under ' tied icensed Septic taller i Date: I Dispo Works Construc on Pe 0 NEW ENGLAND ENGINEERING SERVICES ik -- INC July 28, 2005 Mrs. Susan Sawyer North Andover Board of Health 400 Osgood Street RECEIVED North Andover, MA 01845 JUL 2 8 2005 WN OF NORTH ANDOER Re: 1500 Forest Street Extension, North Andover, MA TO HEALTH D PARTM NT Septic System Design Plans - REVISED Dear Mrs. Sawyer, The following plans for the above referenced property are being submitted for approval. + 1. (3) Copies of the REVISED Septic System Design Plans. Revisions to the enclosed plans consist of lot line changes to the rear and West lot line only. The system was previously located on the abutting lot to the rear of the subject property in a proposed easement area. However, since the original plan submittal an ANR (Approval Not Required) plan was executed swapping the proposed easement area with land on the West side of the subject property with the abutter. Therefore, the septic system is now located on the subject property. Please contact this office with any questions or concerns. Sincerely, f: Steven E. Pouliot Project Engineer 60 BEECHWOOD DRIVE-NORTH ANDOVER, MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 TOWN OF NORTH ANDOVER 0 NORTq Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT a 400 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845 Susan Y. Sawyer, REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476-FAX June 28, 2005 Lisa&John Myers 1500 Forest Street Extension North Andover, MA 01845 I RE: Subsurface Sewage Disposal System Plan for 1500 Forest Street Extension, Man 10513, Lot 4,Map 10413, Lot 115 Dear Mr. &Mrs. Myers The North Andover Board of Health has completed review of the septic system design plans for the above referenced property submitted on your behalf by New England Engineering Services dated June 13, 2005 and received by this office on June 13, 2005. The design has been approved for use in the construction of an upgrade onsite septic system. This approval is valid for threeears from the date e of this letter and during this time a licensed septic system installer must obtain a permit and complete this work, and a Certificate of Compliance must be endorsed by the installer, designer and the Town of North Andover. This approval is subject to the following conditions: 1. Since the location of the new leaching field requires an easement for the purposes of access for construction and maintenance, an easement as depicted on the design plan must be recorded at the Registry of Deeds prior to issuance of a Disposal Systems Construction Permit. 2. If site conditions are found in the field to be different from those indicated on the design plan and/or soil evaluation, the originally issued Disposal System Construction Permit is void, installation shall stop, and the applicant shall reapply for a new Disposal Systems Construction Permit(3 10 CMR 15.020(1)). 3. It is the responsibility of the applicant and/or the applicant's septic system designer, septic system installer or other representative to ensure that all other state and municipal requirements are met. These may include review by the Conservation Commission, Zoning Board, Planning Board, Building Inspector, Plumbing Inspector and/or Electrical Inspector. The issuance of a Disposal System Construction Permit shall not construe and/or imply compliance with any of the aforementioned requirements. 4. The plan does not call for installation of a septic tank effluent filter but one is recommended. Please be advised that only certain brands of filters are permitted for use in Massachusetts and each is required to follow certain approval criteria. Your designer 1500 Forest Street Septic Plan Approval Pagel of 2 or installer should work with you to assure a licensed brand is selected for use, if you choose to install one. Your effort to provide a properly functioning septic system for your dwelling is greatly appreciated. The Health Department may be reached at 978-688-9540 with any questions you might have. Sincerely, S san Y. Sawyer,{EHS/RS Public Health Director encl: List of licensed septic system installers cc: New England Engineering Services file 1500 Forest Street Septic Plan Approval Page 2 of 2 o NEW ENGLAND ENGINEERING SERVICES INC RECEIVED June 13, 2005 JUN 13 2005 Susan Sawyer TOWN OF NORTH ANDOVER HEALTH DEPARTMENT North Andover Board of Health - 400 Osgood Street North Andover, MA 01845 Re: 1500 Forest Street Extension,North Andover, MA Septic System Design Plan Submittal Dear Ms. Sawyer, The following plans lans and enclosures for the above referenced property are being submitted for approval. 1. (3) Copies of the Septic System Design Plans. 2. (2) Copies of the Form 11 Soil Evaluator Sheets. 3. (2) Copies of the Form 12-Percolation Test Sheets. 4. (1) Copy of Septic Submittal Form 5. Check for the Town approval fees. The septic system design is located on the adjacent lot, to the rear of the aforementioned property. An easement plan is currently being drawn up and will be submitted to the Board of Health at a later date. Any approval of the plans will be subject to the property easement being drawn, prepared, and recorded. Please contact this office with any questions or concerns. Sincerely, l Thomas Hector Project Engineer 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 <. Town"of North Andover HEALTH-DEPARTMENTv 27 Charles Street North Andover,MA 01845 O 978.688.9540 JUN 1 3 2005 healthdepWownofnorthandover.com TOWN OF NGRM ANDOVER HEALTH DEPARTMENT SEPTIC PLAN SUBMITTAL FORM DATE OF SUBMISSION: rp SITE LOCATION: 15-OD F reCl- Sit ICx ENGINEER: 1 JSae NEW PLANS: YES $225.00/Plan Check#: (Includes 1 W and one Re-Review Only) REVISED PLANS: YES $75.00/Plan Check#: O SITE EVALUATION FORMS INCLUDED: YES NO LOCAL UPGRADE FORM INCLUDED: YES NO Telephone#:=6 9) 10 1766 Fax#: 6a) 6X- 1099 E-mail: HOMEOWNER NAME: ahn. iud Lisa- OFFICE USE ONLY When the submission is complete(including check): 1. ✓Date stamp plans and letter 2. Xomplete and attach Receipt .O 3C� •py File, Forward to Consultant 4. ;7 Enter on Lo heel Log S and Database o o y ECE1V RM 11.- SOIL EVALUATOR FORM Page 1 of 3 JUN 1 3 2005 TP l TOWN OF NORTH ANDOVER HEALTH DEPARTMENT No. Tfa. aj 1105 Date: A 13 vS Commonw alth of Massachusetts /Var�rh �t�c�qer ,, Massachusetts Soil Suitability Assessment for On-site Sewage Disposal Performed B Q.en :1M,tn.. C• . Q- �# Sr,.. By: .. .. .............. �goa...,.....,. ............... Date: ,q�oS Witnessed By: .........».. !'e ..../ c... ..... j•1.s.�'... , ........................:`--._.............. London Address or 15100 Fbre4t 6- . C,wf M5% w, Owner's Name, Dh� 1Lac e(�,5 - ! jor+v\ A xA*dQ/j MA Tekplane!Ades:.aid ]-Too 1=0r454 -<At�k�'tAS<<OY) 0WF_6rA,J' A OIgaI Pew construction ❑ Repair (q7S) 887 - 15a, Office Review Published Soil Survey Available: No ❑ Yes Year Published Publication Scale • .$49 Soil Map Unit A.5- Drainage Class ..... Soil Limitations A.oIer44r.......S.�O.�....QkrY1A.;.e 46.;J!1'Y-- 46.; !1'Y.----- _... Surficial Geologic Report Available: No Er Yes ❑ Year Published Publication Scale n....k...w. GeologicMaterial (Map Unit) .........................................................................................:..... ............................................................. Landform. ............................................................................................. Flood Insurance Rate Map: Above 500 year flood boundary No ❑Yes Within 500 year flood boundary No El Yes ❑ Within 100 year flood boundary No ❑Yes ❑ Wetland Area: _ National Wetland Inventory Map (map unit) . JQt.............................................. .......... Wetlands Conservancy Program Map (map unit) N A.........................................._.-.._................ ._......__.._._ Current Water Resource Conditions(USGS): Month Ag3(_oioo.� Range :Above Normal Normal ❑Belcw Normal ❑ Other References Reviewed: DEP APPROVED FORM-12/0719S . o 0 :FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot i4o. J"5'0o Forwa+ a er On-site Review Deep Hole Number .: Date:.....bf RIPS 9Mt Weather 1n; 86 .00 Location (id ntify on lite plan) .::...l�.Q6tf!'�....:.�e.-A::..:....::.:.:..:::...:.,.::.:.:::.:.-.::...v;::::...::..:..: M...r.:._.......:.....r:,.. ............:..:......:... Land Use :.....45.... - .�Arr1........:.:......:: Slope (%) -. .::�D.. Surface Stones...:. fie........_.. ... Vegetation ... :Q.Q.c Ql�.:.::..::::.:..:.. .:.. _:......:.::::.::..::.::.::..:.:...-::....::._:... _.... ...... ... ...... .._. Landform ..:::::.:.,.o.�..,:-. ....:...:.::.. Position on landscape (sketch on the back) :.... ',:.. .: Distances from: Open Water Body ::.: feet Drainage way_..5.00 feet Possible:Wef1 Acea >.`�....:., feet Property Line .:.. :....:.. feet 'Drinking Water Well 13 :.w,. feet Other DEEP OBSERVATION HOLE LOG* Depth from Soil Horizon Soil TextureSnil r1n12F S_il (.:.er Surf ace.(Inches) (US.DA) (Munsell) Mottling (Structure,Stones,Boulders,Consistency, % Gravel) L JOYRa�� ` l q !aYR5 3 1 ol'o -- ` ao1*la Cabbs iblro MINIMUM OF 2 HO Parent Material(geologic) llf I) QQ2f 1;f t'.. .. DepthtoBedrock: Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face: Estimated Seasonal High Ground Water.___ DEP APPROVED FORM-12107/95 . o 0 ..... .: :.. FORM 11 - SOIL EVALUATOR FOR M Page 2 of 3 Location Address or Lot No. 15'00f o' r-v,* On-site Review TPI- q 9 f o� - 'r r Deep Hole Number .:::.::::.:...:.:. Date:...61 �5 Time:.:� :.<OO Weather 1p,,d.,.go� Location (identify on site plan) ta+Glr.:: .:.:.::. +. o/ Land Use :R� -� t '��y1. C�.:.. Slope M .3. `o Surface Stones Vegetation :. +► .6:�rdd..::.:.::...::.::..:,.._ Landform Position on landscape (sketch on the back) ...1 .S� . ....... Distances from: Open Water Body :..:504,... feet Drainage way,.�!,.. feet Possible'.Wet Area 5, :.: feet Property Line ...::1.7....:, feet Drinking Water Well _119.............. feet Other DEEP OBSERVATION HOLE LOG* Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(Inches) (USDA) (Munsell) Mottling (Structure,Stones,Boulders,Consistency, °k Gravel) -a� 10YR 9011 loyR C/3 109'0 'v�tLes L3 SY Y1q . rY` l.' JO 4a C,�bb3 jD % Civ. /h Parent Material(geologic) .. DepthtoBedrock: "f L Depth to Groundwater: StandingWater in the Hole: "' Weeping from Pit Face: Estimated Seasonal High Ground Water: r 9 t). DEP APPROVED FORK!-12/07/95 i o FORM 11 - SOIL LVALUATOR FORM Page 3 of 3 Location Address or Lot No. /J _Oftl >L c`�f Determination for Seasonal High Water Table Method Used: Depth observed standing in observation hole................... inches ❑ Depth weeping from side of observation hole .................. in hes " ® Depth..to soil mottles inches[Tpl' C4`� 3t`J TPa-�t`�aS ❑ Ground water adjustment ................... feet Index Well Number .................. Reading Date ................... Index well level ................... .Adjustment factor ................... Adjusted ground water level ........................................................ Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in I areas observed throughout the area proposed for the soil absorption system? YC5 If not, what is the depth of naturally occurring pervious material? '— Certification I certify that on,oL✓ l4Q,S` (date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature C r Date / p-" DEP APPROVED FORM-12/07/95 0 a Commonwealth of Massachusetts City/Town of A)or4�\ "'Jer _ Percolation Test o Form 12 ^M Percolation test results must be submitted with the Soil Suitability Assessment for On-site Sewage Disposal. 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 the local Board of Health to determine the form they use. Important: A. Site Information When filling out forms on the John Myers computer, use only the tab key Owner Name to move your 1500 Forest Street Extension cursor-do not Street Address or Lot# use the return MA 01845 key. North Andover City/Town State Zip Code (978) 887-9529 Contact Person(if different from Owner) Telephone Number B. Test Results rewn 6/9/05 9:07 Date Time Date Time PT1 Observation Hole# 37"/14" Depth of Perc 9:07 Start Pre-Soak 9:22 End Pre-Soak 9:22 Time at 12" 9:49 Time at 9" Time at 6" 12:21 Time (9"-6") 32 11 MIN/INCH Rate (Min./Inch) Test Passed: ® Test Passed: ❑ Test Failed: ❑ Test Failed: ❑ Benjamin C. Osgood, Jr. Test Performed By: Andrew McBrearty, Mill River Consulting Witnessed By: Comments: t5form12.doc•06/03 Perc Test•Page 1 of 1 BOARD OF HEALTH NORTH ANDOVER,MASS. 0184 978-688-9540 RECEIVED / APPLICATION FOR SOIL TEST MAY 2 3 2005 DATE: Z3 �S MAP&PARCEL: Q �-4 -GQ184 1-4�NE;F44-H ANDOVER HEALTH DEPARTMENT .., LOCATION OF SOIL TESTS: 1,00 )rwArui X-, rte- -1W4d1a-,7 OWNER: �t�/v LISA- NAye-ZS TEL.NO.: 9)9` 9529 ADDRESS: /SrDD ��ri f, �,r; liiJjan� ENGINEER:/� �/I� rJii'( iiU TEL..NO.: CERTIFIED SOIL EVALUATOR: Gy/� f/� intended use of land: Residential Subdivision Ingle Family Home Commercial Is This: . Repair testing .� Undeveloped lot testing Upgrade for addition In the Lake Cochichewick Watershed? Yes No �( THE FOLLOWING MUST BE INCLUDED WrM THIS FORM: 1. Proof of land ownership(Tax bill,deed,or letter from owner permitting tests) 2. Plot plan 3. Fee of$4425.00 per lot for new construction. This covers the minimum two deep holes.and two percolation tests required for each disposal area. Fee of$360.00 per lot for repairs or upgrades. GENERAL INFORMATION 1. 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. Rill 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"-100')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 W This Linel I N.A.Conservation Commission Approval Date Received: Check Amount: Check Date: C . lis �bk. bbl Z S 4he- 6�AJ F}��j�cc=� T Piz ^ p� ✓2��. nc Li 1 �7) 7 May 24 05 02:48p SPAUI-DING & SLYE COLLIERS p•2 RECEIVED VIA FACSIMLE and MAIL MAY 2,,4 2005 978-688 9542 TOWN OF RJT�-4 AVrnbVERZ HEMI i May 23, 2005 North Andover Board of Health 400 Osgood Street North Andover, MA 01845 Re: 1500 Forest street Extension, North Andover,Massachusetts Gentlemen: We are writing to notify you of a change in licensed engineer r our necessary prodocposed to New England Engineering Services has been engaged t prepare the erp and monitor the installation Engineeringgstem for act ngn our behalf. ously Please note of thisinitial changetests exploration, Merrimack was Ben Osgood will be contacting you to schedule additional soil tests on an adjacent area where we om will be granted an easement by the neighbor. You will receive un essaer rpletterarate cover a tests and to ndaterthat our neighbor authorizing access to the property to perform the in y granting of an easement is in process. if you have any questions,you may contact us at 978-887-9529 (home) or on John's cell phone at 617-650-6810. Thank you for your continued support. Sincerely, Y. John and Lisa ers . Forest Street Extension (Note: Property is in North Andover, Boxford mailing address) Boxford, MA 01921 (N• � Y I i I i f Page 1 of 1 DelleChiaie, Pamela From: Lisa LeVasseur[lisal@millriverconsulting.com] Sent: Thursday, May 26, 2005 12:51 PM To: Sawyer, Susan; amcbrearty@millriverconsulting.com; DelleChiaie, Pamela; dano@millriverconsulting.com Subject: Soil Test Dates Here are some additional dates: June 9 9:001500ForestStreet,then.82-Paddock-Lane—� June 29 9:00 55 Oakes Drive Lisa LeVasseur Mill River Consulting Your Complete Source for Onsite Wastewater Management 2 Blackburn Center Gloucester, MA 01930-2259 978-282-0014 or 1-800-377-3044 fax: 978-282-0012 www.millriverconsulting,-porn �I 5/26/2005 I' - M2c(.jA �.M(CtP,>c�.,7 0V.G r�O [fix e Af An,-A.. �gnT . X77"114-11 S?AR ?R% $IUAI(_ ;g=off ii STA2T ©IT Q' A�, l O� 'i ,I +tom S• j 1 2 Blackburn Cer --' 1-800-377-301 info@millriverc it I 10 BOARD OF HEALT _ NORTH ANDOVER, MASS. 01845 r 978-688-9540 APPLICATION FOR SOIL TESTS DATE: 4' I 7 MAP&PARCEL: b ®v LOCATION OF SOIL TESTS: �00 �TO 1 fir. OWNER: — �4 f:':: �C f4EL.NO.: eJe-f7'9 5�e—7 ADDRESS:_ ENGINEER: kiK" r456 LKkUZW'&L.NO.: 41 CERTIFIED SOIL EVALUATOR: 7 Intended use of land: Residential Subdivision ngl Family Pe Commercial Is This: Repair testing Undeveloped lot testing Upgrade for addition In the Lake Cochichewick Watershed? Yes THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: RECEIVE 1. Proof of land ownership(Tax bill,deed,or letter from owner permitting tests) 2. Plot plan �PR 1 1 2005 3. Fee of 425.00 per lot for new construction. This covers the minimum two deep hol s and wo percolation tests required for each disposal area. Fee of$360.00 per lot for repairs or upgrades. TOWN OF NORTH ANDOVER HEALTH DEPARTMENT GENERAL INFORMATION 1. 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"-100')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: pproval: Date Received: Check Amount: Check Date: i i I b Y' . L o ,l �: d py p 1.2485 AC m 'o I O . /l4zS FORES r S r [MORTGAGE LOAN INSPECTION SCALE: 1 IN.= 4o FT. DATE: fE�T. IiAV7 PLAN REFERENCE: BEING LOT �a�� ON A PLAN BY 6SSE,Y sa«'Y SELli�CE DATED RECORDED IN ,E"SS-cX. *0A5E °EGISTRY OF DEEDS BOOK_ izT9 PAGE 42 , `ERESYCERTIFYTHATTHE BUILDING SHOWN ON THIS PLAN IS LOCATED ON THE GRO HOWN, CONFORMS'TO THE ZONING.LAWS OF THE TOWN OF NORTH ANDO TIFYTHATTHIS LOCUS DOES NOT LIE oP •� THE-FLOOD HAZARD ZONE AS G 1 l It i ' T`Ev ON MAP --E D.�r�i�::-SCi :�r�-YA SSS. - o•Z��_ ' ;. ),.OMMUNITY zs°o 9A 76 NENOIDEN ST.+ NEEDHAM R oQ 1Q1Yp S�Rv�+ NOT MADE FROM AN INSTRUMENT SURVEY, NOT TO BE•USED S, ETC. FOR USE OF BANK ONLY. Q Dellechiaie, Pamela From: Lisa LeVasseur[lisal@millriverconsulting.com] Sent: Wednesday, May 11, 2005 12:00 PM To: 'Pamela Dellechiaie'. Cc: millrivercon Iting.com; 'Andy McBrearty' Subject: 1500 Forest Street afid 72 Paddock Lane-Soil Test Results Importance: High Forest Street #1500.tif Here are soils for 1500 Forest Street and 72 Paddock Lane. Lisa LeVasseur Mill River Consulting Your Complete Source for Onsite Wastewater Management 2 Blackburn Center Gloucester, MA 01930-2259 978-282-0014 or 1-800-377-3044 fax: 978-282-0012 www.millriverconsulting.com I -----Original Message----- From: health department [mailto:healthdept@townofnorthandover.com] Sent: Wednesday, May 11, 2005 8:53 AM To: 'Daniel Ottenheimer (E-mail) ' ; 'Lisa LeVasseur (E-mail) ' ; 'McBrearty Andrew (E-mail) ' Cc: Osgood Ben (E-mail) Subject: 1500 Forest Street - Soil Test Results Importance: High I i Hi Guys, Ben Osgood was asking about the Soil Test results for this address, particularly the water table. He has a •staff person coming in this morning for something else, and I would like her to be able to pick this up also. Any chance? Thanks! P Best Regards, Pamela DelleChiaie Health Department Assistant Town of North Andover 400 Osgood Street North Andover, MA 01845 978. 688. 9540 - Phone 978. 688.8476 - Fax http: //www.townofnorthandover.com healthdept@townofnorthandover.com 1 r" /mo, sAA n T 1 c-'rA. 0-10 �N,YLt, � �t5; Q1$xett3au.l,d'q� ��IG•�•a�-� i_� ilJ I. wU-cP © �r QIP IS14 6 L-i Q 31.E Nonni ",IS 144 V'- ills t e d i-n �,n ti j S r.�c 41 r O �9p:_l'"► �c ( /�,��n� G 's� r s hey/ �^v s-v�'�7�v �„�a c-•� �+I r��"vr�d xa �e a.1 i��oN•9r3 'vF��nc�+�x � 'rj cl ')aIPV Yb cr X5,3✓�"�'y,,, COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION RECEIVED Property Address: 1500 Forest Street Extension,North Andover,MA 01845 Owner's Name: John and Lisa Myers �JUl 1 2 2005 Owner's Address: 1500 Forest Street Extension,Boxford,MA Date of Inspection: June 6,2005 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Name of Inspector: (please print) Benjamin C.Osgood,Jr.Certified Title 5 Inspector Company Name: New England Engineering Services Inc. Mailing Address: 60 Beechwood Drive North Andover,MA 01845 Telephone Number: 978-686-1768 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of the on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15340 of Title 5(3 10 CMR 15.000).The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority (_Fails Inspector's Signature: Date: (:::,/6 The system inspectionshall 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 Continents ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. i O 2of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1500 Forest Street Extension,North Andover,MA 01845 Owner's Name: John and Lisa Myers Date of Inspection: June 6,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: JVQ 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: NOne 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: 0 3of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1500 Forest Street Extension,North Andover,MA 01845 Owner's Name: John and Lisa Myers Date of Inspection: June 5,2005 C. Further Evaluation is Required by the Board of Health: 00 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 i 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 (SAS)Soil Absorption System and the(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 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 stem asses if the well water analysis, armed at a DEP certified laboratory,for coliform bacteria and system P y ,P� �', volatile organize compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: I 0 0 4of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1500 Forest Street Extension,North Andover,MA 01845 Owner's Name: John and Lisa Myers Date of Inspection: June 6,2005 D. System Criteria applicable to all systems: You must indicate"yes or No"to each of the following for all inspections: Yes No Y. Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool — Discharge or ponding of effluent to the surface of the ground or surface waters due to an overload or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overload or clogged SAS or cesspool -A_ Liquid depth in cesspool is less than 6"below invert or available volume is less than%2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumper X 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 C 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 fret from a private water supply well with no acceptable water quality analysis. (this system passes if the well water analysis,performed at a DEP certified laboratory for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrogen is equal to or less than 5ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) AEs (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 c nsidered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You ratate either"yes"or"no"to each of the following: (The followin teria apply to large systems in addition to the criteria above) Yes No The system is 400 feet of a surface drinkin er supply The system is within 20 of utary to a surface drinking water supply The system is 1 in a nitrogen nsitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a p ' water supply well If you answer "yes"to any question in Section E the system is 'dere)a significant threat,or answered"yes"in Section D above the large system has failed The owner or operator of any large syste 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 0 0 5of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1500 Forest Street Extension,North Andover,MA 01845 Owner's Name: John and Lisa Myers Date of Inspection: June 6,2005 Check if the followinit have been done. You must indicate"Yes"or"no"as to each of the following: Yes No _Z Pumping information was provided by the owner,occupant,or Board of Health x 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? x Have large volumes of water been introduced to the system recently or as part of an inspection? Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? X Was the site inspected for sign of break out? Were all system components,excluding the SAS,located on site? Were all 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 difference from owner)provided with information on the proper maintenance of the subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No X 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) 1310 CMR 15,302(3)(b)] 0 0 6of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1500 Forest Street Extension,North Andover,MA 01845 Owner's Name: John and Lisa Myers Date of Inspection: June 6,2005 FLOW CONDITIONS . RESIDENTIAL Number of bedrooms(design) Number of bedrooms(actual): !?� DESIGN flow based in 310 CMR 15.203(for example: 110 gpd x #of bedrooms): Number of current residents: y Does residence have a garbage grinder(yes or no): /.-a Is laundry on a separate sewage system(yes or no): [if yes separate inspection required] Laundry system inspected(yes or no): — Seasonal use: (yes or no): No . Water meter readings,if available(last 2 years usage(gpd):w E L Sump Pump (yes or no): Al Last date of occupancy L., COMMERCIAL/1"USTRIAL 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(ves or no) Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records _ Source of information: r E127 2 �d c t&a P E12 ow "YL Was system pumped as part of the inspection(yes or no): Aro If yes,volume pumped: gallons-How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ? Septic tank, distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) InnovativelAlternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attached a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected wen arriving at the site(yes or no): N D 0 0 7of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1500 Forest Street Extension,North Andover,MA 01845 Owner's Name: John and Lisa Myers Date of Inspection: June 6,2005 BUILDING SEWER(locate on site plan) I Depth below grade: Materials of construction: cast iron 40 PVC other(explain? Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): D�9 .iv�T t its PC's r SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: 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: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 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 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.): P1 0 ,/va j (NSIpCr-i GREASE TRAP:N ,- (locate on site plan) Depth below grade: Materials 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 sludge to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc. E 0 Q 8of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i PART C SYSTEM INFORMATION (continued) Property Address: 1500 Forest Street Extension,North Andover,MA 01845 Owner's Name: John and Lisa Myers Date of Inspection: June b,2005 TIGHT OR HOLDING TANK: /V 14 (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Materials of construction: concrete metal fiberglass polyethylene other (explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(Imate on site plan) Depth of liquid level above outlet invert: O 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.): 80X w otti cz->tij P IT)13N PUMP CHAMBER: N A (locate on sire plan) Pumps in working order(yes or no) Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): I F 0 9of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1500 Forest Street Extension,North Andover,MA 01845 Owner's Name: John and Lisa Myers Date of Inspection: June 6,2005 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required I If SAS not located explain why TYPE ✓ leaching pits number ! s leaching chambers, number _,leaching galleries number leaching trenches,number in length leaching fields,number,dimensions: overflow cesspool,number innovativetalternativestem T name of technology: sY Type /name (note condition of soil,signs of hydraulic failure.Level of ponding,damp soil,condition of vegetation,etc) f0r-RE,4 ON- :?1—15. L—"K,� neo a /--4 L 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: /4'" — (locate on site plan) Material of construction: Dimensions: Depth of solids Comments(note condition of soil signs of hydraulic failure,level of ponding,condition of vegetation,etc. O O 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1500 Forest Street Extension,North Andover,MA 01845 Owner's Name: John and Lisa Myers Date of Inspection: June 6,2005 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. i w -T �ocwnoniS $au PO xi.w �lY I i . I . 0 0 O 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1500 Forest Street Extension,North Andover,MA 01845 Owner's Name: John and Lisa Myers Date of Inspection: June 6,2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water .3 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: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health—explain: Checked with local excavator,installers—(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: TES-1-1 Aj 6- Da ti l-�- '7U 17 e TeR u+ter 45- k.✓✓,►-TEYL ;"7"167- A-T) 67-A-T)mit-/< TSU r� cD t—( -S N