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Home My WebLink AboutMiscellaneous - 160 CARLTON LANE 4/30/2018 (2) .- i N J J � 0 0 V � b D �/ �2 �� J N � (' Z r� �I��J1 � Z .��--� - � ��s �� _�� North Andover Board of Assessors Public Access Page 1 of 1 NOR7M North Andover Board of , assessors Of•��ao .�•yG �,SSACMUS � roperty Record Card Click Sea]To Return Parcel ID:210/107.A-0192-0000.0 FY:2009 Community:North Andover SKETCH PHOTO Click on Sketch to Enlarge Click on Photo to Enlarge �y Search for Parcels Search for Sales Summary Residence Detached Structure Condo 160 L-17A CARLTON LANE Commercial Location: 160 CARLTON LANE Owner Name: WINNIE,DARREN S LAURA L WINNIE Owner Address: 8 JAMES MILLEN ROAD City: NORTH READING State: MA Zip: 01864 Neighborhood:7-7 Land Area: 1.06 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 2881 s ft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 627,100 648,200 Building Value: 401,900 423,000 Land Value: 225,200 225,200 Market Land Value: 225,200 Chapter Land Value: LATEST SALE Sale Price: 445,000 Sale Date: 05/25/1999 Arms Length Sale Code: Y-YES-VALID Grantor: DONALD THOMAS Cert Doc: Book: 05443 Page: 0216 http://csc-ma.us/PROPAPP/display.do?linkld=1465823&town=NandoverPubAcc 11/2/2009 1 04"'4 , Commonwealth of Massachusetts Map-Block-Lot 4,'`u ' <a t0a 107.A0192 3 Board of Health - -- o •-- *p Permit No North Andover BHP-2009-0690 --------------- "'�.�:�c,..'�•._^�' P.I. FEE �Ss�cNu �� F.I. $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted James-Kellett ----------------------------------------------------------------------------------------------------- to(Repair-D-BOX ONLY)an Individual Sewage Disposal System. at No 160 CARLTON LANE ---------------------------------------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP-2009-069 Dated November 02,2009 ------------------------ ---------------------------- ----------------------- Issued On:Nov-02-2009 Board of Health ,j4RTN Map-Block-Lot +.,•g� + Commonwealth of Massachusetts 107.A0192 o? •� bad Board of Health ----------------------- A A North Andover are' .•' �►,S••Ts�••'sem CERTIFICATE OF COMPLIANCE $�4C Mtl�St THIS IS TO CERTIFY,That the Individual Sewage Disposal System (Repair-D-BOX ONLY) by James Kellett at No 160 CARLTON LANE Installer — !-'- -!__ _-- _' �r has been installed in accordance with the provisions of TITLE 5 of the StaYdbronm ntal Code as described in the application for Disposal Works Construction Permit No. -BHP-2009-069- - -- Dated---November 02,_2009 ---- ---------- ---- ----------------------------------------------------------------- Printed On:Nov-02-2009 Board of Health ti f 9 • Town of North Andover �+�'• HEALTH DEPARTMENT ,SS�CMUSES CHECK#: �31vATE: LOCATION: A"O � H/O NAME: CONTRACTOR NA �/ ✓ ME•. 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 � W�e $� Septic Disposal Works Cp IO truc'tio (D C) $ S ' ❑ Septic Disposal Works I7tallers(D ) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer v _ Application for Septic Disposal System 7 -Construction Permit - TOWN OF TODAY'S DATE '' ••�� ' ORTH ANDOVER MA 01845 $250.00—Full Repair skM„se ✓$125.00-Component Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the g P Y computer,use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key C to move yourRepair or replace an existing system component—What? k cursor-do not use the return A. Facility, Information key. `7 VQ — j(00 Cq 14n o',4 Address or Lot# Ol/ar4 City/Town 2.-*TYPE OF SEPTIC SYSTEM*: ❑ Pump ❑ Gravity(choose one) ***If pump system, attach copy of electrical permit to application*** J] Conventional System (pipe and stone system) ❑ Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D-Box)(Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D-Box Present)S.A.S. 2. Owner Information Poi-/-e i A/r Name 1(00 Ca( Lvti1 Address(if different from ab e) Ai, Ah,Dc"--" In A 0/q Y1- City/Town State Zip Code Telephone Number 3. Installer Information Na a 5� Name of Company Alda ��, 5� Address City own State Zip Code Telephone Number(Cell Phone#if possible please) 4. Designer Information Name Name of Company Address f City/Town / State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 r � 6 s Application for Septic Disposal Svstem MONTN . 3��++ �• ori AConstruction Permit — TOWN OF TODAY'S DATE •- ' • ' ORTH ANDOVER, MA 01845 $250.00-Full Repair ♦.�J.n�s� - sK, $125.00 -Component PAGE 2OF2 A. Facility Information continued.... S. Type of Building: (Residential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover,and not to place the system in operation until a Certificate of Compliance has bee sued by this Board of Health. 0/0 Date 1 Na ' Date Applicat' n Approved By: ( oard of Health Representative) Z l z a N e 1 Date •• 1 Application Disapp oved for the following reasons: i For Office Use Only: f 1. Fee Attached. Yes v No 2. Project Manager Obligation Form Attached. Yes No 3. Pump System? Ifso,Attach copy of Electrical Permit Yes No 4. Foundation As-Built. (new construction ronly): Yes No (Same scale as approved plan) 1 5. Floor Plans?(new construction only): Yes No Application for Disposal System Construction Permit-Page 2 of 2 TOWN OF NO.IkT.H ANDOVER ° NoerH q Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 1600 OSGOOD STREET;Building 2-36 4. NORTH ANDOVER,MASSACHUSETTS 01845 �'"Ssgc"„Stip°y Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION J ADDRESS: 1A� 2'I'�7D 4IAP: LOT: INSTALLER: DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS ,�jU / �� ✓ TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑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 ❑ 1500 gallon 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) ❑ Inlet tee installed, centered under access port ❑ Outlet tee (gas baffle or effluent filter) installed, centered under access port ❑ 24" inch cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present ❑ Hydraulic cement around inlet & outlet Wastewater System Documentation—Feb 2006 Page 1 of 6 TOWN OF NORTH ANDOVER t10RTN Office of COMMUNITY DEVELOPMENT AND SERVICES 3 ,t •° ti°L HEALTH DEPARTMENT A 1600 OSGOOD STREET;Building 2-36 NORTH ANDOVER,MASSACHUSETTS 01845 SgCHUs¢ Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ Combo Tank installed. Size: ❑ 1000 gallon Pump Chamber installed H-10 loading Monolithic construction) ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ 24" inch cover to within 6" of final grade installed over pump access port ❑ Water tightness of tank has been achieved Visual testing ❑ Hydraulic cement around inlet & outlet Comments: ADVANCED TREATMENT TECHNOLOGY ❑ Type of treatment device: ❑ Installed per manufacturers requirements ❑ All components working in accordance with manufacturer's requirements Comments: Wastewater System Documentation—Feb 2006 Page 2 of 6 TOWN OF NOKTH ANDOVER NORTH q Office of COMMUNITY DEVELOPMENT AND SERVICES o HEALTH DEPARTMENT « _ 1600 OSGOOD STREET;Building 2-36 NORTH ANDOVER,MASSACHUSETTS 01845An.Uf Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX D-BOX ❑ Installed on stable stone base Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets [� Observed even distribution [�Speed levelers provided (not required) ) Comments: SOIL ABSORPTION SYSTEM ❑ Bottom of SAS excavated down to soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 3/4-1 Y2" double washed stone installed ❑ 1/8-1/2" (peastone) double washed stone installed ❑ Laterals installed and ends connected to header ❑ Laterals vented if impervious material above ❑ Orifices @ 5 & 7 o'clock positions ❑ Gravel-less disposal systems: type, number and location as per plan ❑ Elevations of laterals installed as on approved plan ❑ 40 Mil HDPE barrier installed ❑ Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: Wastewater System Documentation—Feb 2006 Page 3 of 6 TOWN OF NORTH ANDOVER F N°RTh Office of COMMUNITY DEVELOPMENT AND SERVICES or HEALTH DEPARTMENT p 1600 OSGOOD STREET; Building 2-36 NORTH ANDOVER MASSACHUSETTS 01845 �'"S' ` '°�<�h ' SACNUS Susan Y. Sawver,REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX PRESSURE DISTRIBUTION ❑ -- inch manifold ❑ laterals installed with end sweeps size: material: ❑ Squirt test ft in height ❑ Equal distribution to all laterals ❑ orifice size inch as per plan Comments: CONTROLPANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: ❑ Rated for exterior if placed outside Comments: Wastewater System Documentation—Feb 2006 Page 4 of 6 TOWN OF NORTH ANDOVER VtORTH Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT p 1600 OSGOOD STREET;Building 2-36 "►� . ,P+' NORTH ANDOVER,MASSACHUSETTS 01845 "SsaCHuse�{y Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback Tank SAS Sewer ❑ Property line 10 10 -- ❑ Cellar wall 10 20 -- ❑ Inground pool 10 20 -- ❑ Slab foundation 10 10 -- ❑ Deck, on footings, etc 5 10 -- ❑ Waterline 10 10 101 ❑ Private drinking well 75 1002 50 ❑ Irrigation well 75 100 ❑ Surface Water 25 50 ❑ Bordering Vegetated Wetland , Salt Marsh, Inland/Coastal Banka 75 100 ❑ Wetlands bordering surface water supply or trib. (in Watershed) 150 . 150 ❑ Trib. to surface water supply 325 325 ❑ Public well 400 400 ❑ Interim Wellhead Prot. Area ❑ Reservoirs 400 400 ❑ Drains(wat. supply/trib.) 50 100 ❑ Drains(intercept g.w.) 25 50 ❑ Drains(Other)Foundation 10(5) 20 (10) ❑ Drywells 20 25 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54,and 10.30,respectively,pursuant to 15.211(3),also by NA wetland bylaws Wastewater System Documentation—Feb 2006 Page 5 of 6 TOWN OF NORTH ANDOVER poRrk Office of COMMUNITY DEVELOPMENT AND SERVICES "e "k°L HEALTH DEPARTMENT A 1600 OSGOOD STREET; Building 2-36 w� . ,P*K NORTH ANDOVER,MASSACHUSETTS 01845 ,,,,S�T�y Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX SYSTEM ELEVATIONS INVERT ON DESIGN PLAN FIELD INVERT ELEV. Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 HIGH Lateral 1 LOW Lateral 2 HIGH Lateral 2 LOW Lateral 3 HIGH Lateral 3 LOW Lateral 4 HIGH Lateral 4 LOW Lateral 5 HIGH Lateral 5 LOW Wastewater System Documentation—Feb 2006 Page 6 of 6 Commonwealth of Massachusetts _ W City/Town of NORTH ANDOVER a System Pumping Record M SV Form 4 SI 1L 3L 5 �%IER DEP has provided this form for use by local Boards of Health. Other fon>MYt1 YTtPd%6d, but-Ithe information must be substantially the same as that provided here. Before utr*AQ orm, 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 within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab 160 CARLTON LANE key to move your Address cursor-do not NORTH ANDOVER MA 01845 use the return key. City/Town State Zip Code 2. System Owner: DARRIN WINNY Name 8 JAMES MILLEN ROAD Address(if different from location) NORTH READING MA 01864 City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date/15 2. Quantity Pumped: G 1 500S 3. Component: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank E; Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes j No 5. Observed condition of component pumped: GOOD CONDITION _ 6. System Pumped By: JAMES H CURRIER II H79 406 Name Vehicle License Number X SEPTIC & DRAIN Company 7. Location where contents were disposed: GLSD j� 7/27/15 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts ECEIVED R Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessmeni s DEC 2 1 2009 160 CARLETON LANE, NORTH ANDOVER, MA 01845 TOWNLT I r)FP M ANDOVER Property Address DARREN AND LAURA WINNIE Owner Owner's Name information is required for NORTH ANDOVER MA 01845 10/20/09 AND 11/12/09 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your HAROLD T. LINCOLN, JR. cursor-do not Name of Inspector use the return key. RAGGS, INC. Company Name P.O. BOX 1027 Company Address CONCORD MA 01742 City/Town State Zip Code 978-369-1100 4162 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority /Z—Is-� pec Date The stem 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. WINNIENANDOVER20091NSP.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 160 CARLETON LANE, NORTH ANDOVER, MA 01845 Property Address DARREN AND LAURA WINNIE Owner Owner's Name information is required for NORTH ANDOVER MA 01845 10/20/09 AND 11/12/09 every page. City/Town 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: DISTRIBUTION BOX REPLACED AFTER FIRST VISIT. RE-INSPECTED ON 11/12/09. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed WINNIENANDOVER20091NSP.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c�M 160 CARLETON LANE, NORTH ANDOVER, MA 01845 Property Address DARREN AND LAURA WINNIE Owner Owner's Name information is required for NORTH ANDOVER MA 01845 10/20/09 AND 11/12/09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. WINNIENANDOVER20091NSP.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 160 CARLETON LANE, NORTH ANDOVER, MA 01845 Property Address DARREN AND LAURA WINNIE Owner Owner's Name information is required for NORTH ANDOVER MA 01845 10/20/09 AND 11/12/09 every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® 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. WINNIENANDOVER20091NSP.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 160 CARLETON LANE, NORTH ANDOVER, MA 01845 Property Address DARREN AND LAURA WINNIE Owner Owner's Name information is required for NORTH ANDOVER MA 01845 10/20/09 AND 11/12/09 I every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): i Yes No ❑ ® 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. WINNIENANDOVER20091NSP.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM ,•'' 160 CARLETON LANE, NORTH ANDOVER, MA 01845 Property Address DARREN AND LAURA WINNIE Owner Owner's Name information is required for NORTH ANDOVER MA 01845 10/20/09 AND 11/12/09 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] WINNIENANDOVER20091NSP.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 160 CARLETON LANE, NORTH ANDOVER, MA 01845 Property Address DARREN AND LAURA WINNIE Owner Owner's Name information is required for NORTH ANDOVER MA 01845 10/20/09 AND 11/12/09 every page. City/Town State Zip Code Date of Inspection 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 Number of current residents: 4 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 233.53 AVGGPD 9 ( Y 9 (gpd)): 9/14/07-9/11/09 Sump pump? ❑ Yes ® No Last date of occupancy: OCCUPIED Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): WINNIENANDOVER20091NSP.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts 10 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 160 CARLETON LANE, NORTH ANDOVER, MA 01845 Property Address DARREN AND LAURA WINNIE Owner Owner's Name information is required for NORTH ANDOVER MA 01845 10/20/09 AND 11/12/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: JUNE, 2009 PER OWNER Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1,500 gallons How was quantity pumped determined? FIELD ESTIMATE Reason for pumping: TANKA ND TEE INSPECTION Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: CIRCA 23 YEARS -OWNER & RECORD; DISTRIBUTION BOX REPLACED IN FALL, 2009 Were sewage odors detected when arriving at the site? ❑ Yes ® No WINNIENANDOVER20091NSP.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts F W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 160 CARLETON LANE, NORTH ANDOVER, MA 01845 Property Address DARREN AND LAURA WINNIE Owner Owner's Name information is required for NORTH ANDOVER MA 01845 10/20/09 AND 11/12/09 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 1.17feet 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.): GOOD; OK; NONE Septic Tank(locate on site plan): Depth below grade: .83 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 10'X 6'X 5'10" Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 34" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? FIELD ESTIMATE WINNIENANDOVER20091NSP.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 160 CARLETON LANE, NORTH ANDOVER, MA 01845 Property Address DARREN AND LAURA WINNIE Owner Owner's Name information is required for NORTH ANDOVER MA 01845 10/20/09 AND 11/12/09 every 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.): RECOMMEND ANNUAL PUMPING; BAFFLES INTACT; APPEARED STRUCTURALLY SOUND; LIQUID LEVEL AT OUTLET INVERT; NO LEAKAGE Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 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): WINNIENANDOVER20091NSP.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 160 CARLETON LANE, NORTH ANDOVER, MA 01845 Property Address DARREN AND LAURA WINNIE Owner Owner's Name information is required for NORTH ANDOVER MA 01845 10/20/09 AND 11/12/09 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 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.): 11/12/09- NEW BOX WAS IN PLACE; APPEARED LEVEL WITH EQUAL DISTRIBUTION AND NO LEAKAGE Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No WINNIENANDOVER20091NSP.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 160 CARLETON LANE, NORTH ANDOVER, MA 01845 Property Address DARREN AND LAURA WINNIE Owner Owner's Name information is required for NORTH ANDOVER MA 01845 10/20/09 AND 11/12/09 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate 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, length: 2 @ 52 RECORD ❑ 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.): LOAM; NO SIGNS OF HYDRAULIC FAILURE OR PONDING ABOVE GROUND; DRY; NORMAL (GRASS) WINNIENANDOVER20091NSP.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts f.o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 160 CARLETON LANE, NORTH ANDOVER, MA 01845 Property Address DARREN AND LAURA WINNIE Owner Owner's Name information is required for NORTH ANDOVER MA 01845 10/20/09 AND 11/12/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 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.): WINNIENANDOVER20091NSP.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts _ z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 160 CARLETON LANE, NORTH ANDOVER, MA 01845 Property Address DARREN AND LAURA WINNIE Owner Owner's Name information is NORTH ANDOVER MA 01845 10/20/09 AND 11/12/09 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. THIS SKETCH IS NOT TO SCALE. DESCRIPTION A B C TANK 20' 67'5" D D-BOX 2614" 5914" LOT / 7A 433S 0 A CS, K co, YlE � ; I- '98-jr Ar z0' I ; f0' Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 160 CARLETON LANE, NORTH ANDOVER, MA 01845 Property Address DARREN AND LAURA WINNIE Owner Owner's Name information is required for NORTH ANDOVER MA 01845 10/20/09 AND 11/12/09 every page. City/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: 41+ 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: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: CHECKED CELLAR- DRWY WITH NO SUMP PUMP; SYSTEM DESIGNED IN ACCORDANCE WITHT TITLE 5 (1978)WHICH REQUIRED A MINIMUM FOUR FOOT OFFSET BETWEEN THE BOTTOM OF THE SOIL ABSORPTION SYSTEM AND GROUNDWATER. CHECKED OLD REPORTS AND SOIL LOGS. NO INDICATION OF GROUNDWATER WITHIN ACCEPTABLE OFFSETS. WINNIENANDOVER20091NSP.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 Sep 28 09 11 : 03a DPW 9786889573 p. 1 Sunmaq Re=d Card Sonaraied on BJ2& 00910,34:05 AM by Karen Hanlon Page 1 Town of North Andover Tax Map # 210-107.A-0192-0000.0 Parcel Id 18018 160 CARLTON SANE WINNIE, DARREN 8 JAMES MILLEN ROAD NO. READING,MA 01864 _ Class 1b1 Single Family Property Type 1 Residential Size Total 1,06 Acres FY 2010 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until WINNIE,DARREN Payor 8 JAMES MILLEN ROAD NO.READING,MA 01864 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 14196.0.160 CARLTON LANE Last Billing Date 9/2/2009 2100186 02 Cycle 02 Active UB Services Maint. Account No.2100188 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.62 1/ WTR WATER 01 ALL METER SIZE 92.65 /1 UB Meter Maintenance Account No.2100188 Serial No Status Location Brand Type Size YTD Cans 13242098 a Active ERT MH METE METE w Water 0.63 0.63 145 Date Reading Code Consumption Posted Date Variance 8/3/2009 769 a Actual 23 9/1112009 -10% 51712009 746 a Actual 27 6/1612009 -1% 21312009 719 a Actual 27 3/16/2009 -5% 11/312008 692 a Actual 29 1217012008 -270A 8/1/2008 663 a Actual 39 9/1212008 50% 5/1/2008 624 a Actual 24 6/1812008 5% 216.2008 600 a Actual 26 3/142008 -22% 11/112007 574 a Actual 31 1/15/2008 348% 8/3,12007 543 a Actual 7 9/14/2007 -1000/0 5/4/2007 536 a Actual 0 62612007 -100% 22112007 536 a Actual 0 3/23/2007 -100% 11/1/2006 536 a Actual 30 12/2212006 -37% 8/1/2006 506 a Actual 46 9/13/2006 54% 5/4/2006 460 a Actual 29 6120/2006 0% 2/1/2006 431 a Actual 29 3/1312006 -74% 11/1/2005 402 a Actual 108 12/1412005 78% 8/4/2005 294 a Actual 64 9112/2005 152% 522005 230 a Actual 24 6/82005 -19% 2/2/2005 206 a Actual 31 3115/2005 -46% 11/112004 175 a Actual 51 12/172004 -24% 8/102004 124 a Actual 72 9/2012004 140% 5/1312004 52 a Actual 31 6114/2004 -8% co i 17 1 I L-(L 3 '�01Z:i so.5� 01. 11,01, � yti I i! is :',OIL f'ROFTI,E & pf.RrO 4'TI2TE;S ATA. Vlort5 And:)ver,1:?99. No.&Street Lot No.l Loc./Subdiv. Plan Owner Investigator Observer w SOIL PROFILES-DATE 1' Elev, 2. Eley.,____-. 3' Elev. 4=-Eley. 0 0 0 0 ------ 2 2 - -2 lies to Test . _ 2 3 //3 / - 4 .4 4 4 5 5 5 5 6 6 6 6 7 7 7 7 8 `` ' 8- - 8 _ g 9 9 9 - 9 L0 10 10 10 _ Benchmark Location Elevation Datum Percolation Tess-Date ' Pit -- pit Number 1 2 3 4 5 Start Saturation Soak-Min - -- - _ Start Test-Time -- - ----. . --- -- - - - - - ---- -- - Dr_2 of 3"-Time - Dt� of 6"-Time ISins. lst 71s-t- . 3-'Drop Mins _3 5, _ Fereolation Rate -- -- - --- (976) 666-7653 `L TEAMS: 1'19�CE CHARGES C AI INVOICE NUMBER/DESCRIPTION I BALANCE FORWARD DANIEL A. GIARD /y\/1 7 J U �enB r Since 1�� *�GGSt G1� General Maintenance Recommendations Proper maintenance of your septic system can help prevent premature failure of your soil absorption system. RAGGS, INC. recommends the following: 4 DO PUMP your system on a regular basis, preferably ANNUALLY for most households. Larger systems, such as those serving multi-family locations or commerical properties, may require more frequent pumping. The purpose of pumping is to remove solid material and scum material from the tank. This will help prevent unwanted material floating out to the leaching facility. 4 DO OPEN your D-Box every THREE TO FOUR YEARS. This is a good way to spot little problems before they grow into bigger ones. DO ensure that your VENT PIPES are INSTALLED properly. Vent pipes are used to allow oxygen into the system, thereby allowing bacteria to breathe and grow. 4 DO make sure you know WHERE your TANK is LOCATED. Check the covers to make sure that they are not deteriorating and causing a potential hazard. DO make sure you know WHERE your LEACHING FIELD is LOCATED. If the field ever goes into failure and break out", it would be necessary to isolate the area for health protection. DO look for GREEN STRIPES over leaching field. If you see this, it is indicative a field starting to back-up. Act immediately when you see this warning sign. + DO check to determine if you can smell any ODORS from field location. Odors can indicate that the leaching facility is having a problem. 4 DO raise the tank COVERS up to WITHIN 6" OF GRADE. -� DO USE LIQUID DETERGENTS and USE SMALL AMOUNTS OF BLEACH when cleaning toilets, etc.. DO USE NON-ABRASIVE HOUSEHOLD CLEANING PRODUCTS. RAGGS SEPTIC SERVICE,INC. d.b.a. E.A.COMEAU SEPTIC P.O.Box 1027 Concord,Massachusetts 01742 (978)369-1100 (800)287-5541 FAX(978)897-3848 website:http://www.raggsinc.com e-mail:info@raggsinc.com J seT lig YOU Sine 1 G GGS, 11`� + DO USE ENVIRONMENTALLY SAFE PRODUCTS. + DO INSTALL WATER SAVING DEVICES, where appropriate. + DO AVOID having roof gutters and downspouts DRAIN ONTO the LEACHING FIELD. THE DON'TS 4 DON'T DISPOSE any,NON-BIODEGRADABLE MATTER IN TOILETS. Foreign items can cause blockages in the lines and back-ups. (i.e.: cigarettes, sanitary napkins, diapers) 4 DON'T wash paint brushes used in latex or oil PAINT. Paint residues are not broken down by a leaching system. In fact, they will travel out to the leaching facility and impede its ability to function. 4 DON'T allow any PAINT, THINNERS, OR ANY OTHER TOXIC OR CAUSTIC LIQUIDS, to go down sink or toilets. 4 DON'T allow ANY GREASE or FAT to enter system. Residential sites do not have grease traps. Therefore, if grease is allowed into the system it will congeal and travel out to the leaching facility leading to damage. + DON'T DISPOSE BONES, EGG SHELLS, COFFEE GROUNDS, DENTAL FLOSS, OR FIBROUS MATERIAL, etc. when using a garbage disposal. However, it is recommended that garbage disposals aren't used at all. 4 DON'T use POWDERED DETERGENTS with phosphates. They don't break down and can re-solidify. 4 DON'T use any DRAIN CLEANERS, such as Drano®, LiquidPlumbr®. Call a rooter professional or buy a small rooter snake at the hardware store. Drain cleaners KILL bacteria. Bacteria keeps your system alive. RAGGS SEPTIC SERVICE,INC. d.b.a. E.A. COMEAU SEPTIC P.O.Box 1027 Concord, Massachusetts 01742 (978)369-1100 (800)287-5541 FAX(978)897-3848 website:http://www.raggsinc.com e-mail:info@raggsinc.com Seng you Sine G GGS, 1� (D THE DON'TS DON'T use any ENZYMES or BACTERIAL ADDITIVES. These products usually have too low a pH to be effective. Often they are sitting on a shelf too long. Normal activity and proper use of a septic system should provide plenty of bacteria naturally. 4 DON'T use any GREASE DISSOLVERS. Degreasers allow grease to flow out of the tank and into your field. + DO NOT ADD ANY ADDITIVES TO YOUR SYSTEM FOR ANY REASON. In the event of a clog or other plumbing problem, contact your local plumber, rooter or pumper. + DON'T PLANT any trees or shrubs WITHIN 10 FT. OF THE LEACHING FIELD. Root systems can cause damage to the piping in the leaching facility. 4 DON'T ALLOW SPRINKLER SYSTEMS or other WATERING DEVICES OVER the LEACHING FIELD. Doing so will saturate the field, damaging the system's performance. Systems are designed to handle up to a certain quantity of flow. 4 DON'T DRIVE any VEHICLES or place any HEAVY OBJECTS ON TOP of the LEACHING FIELD. Damage to piping could result. + DON'T INSTALL a swimming pool, a patio, or a driveway over the tank or leaching field. If installing a swimming pool, ensure that the backwash does not enter the leaching system. Do not obstruct access to the tank otherwise it will be difficult to maintain. i + DON'T CONNECT a basement SUMP PUMP to a household DRAIN. + DON'T ALLOW WATER USAGE to EXCEED the DESIGN FLOW OF YOUR SYSTEM. 4 DON'T ALLOW a WATER SOFTENER TO BE HOOKED UP to a SEPTIC SYSTEM. Check with the local authority to see if an alternative place for the backwash can be used. RAGGS SEPTIC SERVICE,INC. d.b.a. E.A.COMEAU SEPTIC P.O.Box 1027 Concord, Massachusetta 01742 (978)369-1100 (800)287-5541 FAX(978)897-3848 website:http://www.raggsinc.com e-mail:info@raggsinc.com r Commonwealth of Massachusetts Map-Block-Lot 107.A0192 R _____________________ Board of Health Permit No a s BHP-2009-0690 : . North Andover --------_-_-- ` P.I. * . „-:...�. FEE � F �Ss4 � 5�i F.I. $125.00 DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted James Kellett to(Repair-D-BOX ONLY)an Individual Sewage Disposal System. at No 160 CARLTON LANE as shown on the application for Disposal Works Construction Permit No. BHP-2009-069 Dated November 02 2009 ----------------------------------------------------------------- Issued On:Nov-02-2009 Board of Health aRT a + Commonwealth of Massachusetts Map-Block-Lot 107.A0192 Board of Health ----------------------- North Andover CERTIFICATE OF COMPLIANCE THIS IS TO CERTIFY,That.the Individual Sewage Disposal System,(Repair-D-BOX ONLY) by James Kellett - Installer at No 160 CARLTON LANE has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. -BHP--200-9---069- Dated---November_02,-2009 ------ ----- - ---- - Printed On:Nov-02-2009 Board of Health SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: f (� e Ccl--ate LmG (Address of septic system) For plans by /. (Engineer) Relative to the application of , 1 p, Kt lie�4 (Installer's name) And dated ngma ate Dated l L d 1 —/ o ay s ate With revisions dated (Last revised date) 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 manager, or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection,without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or my company. a. Bottom of Bed—Generally, this is the first (ls� inspection unless there is a retaining wall,which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection—Engineer must first do their inspection for elevations, ties, etc. As-built of verbal OK (or e-mail to: healthdept(2townofnorthandover.com) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system, all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade—Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation)and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board ofHealth staff 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. Undersigned Licensed Septic Installer: �t/z�d (Today's Date) TT arae—Print) —Signed) Commonwealth of Massachusetts `City/Town of.NORTH ANDOVER MASSACH S T g 2Q06 System Pumping Record TOWN Cir �H r• Form 4 HEALTHUtrH�„�,CNr DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: forms on the computer, use Cl/ only the tab key Address to move your ��, e14't/[J cursor-do not State te� use the return City/Town Zip Code key. 2. System Owner: Name fe0'A Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Dat/ 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Name Vehicle License Number J-9 cSd. �ey�cGO�Sf- CL� Company 7. Location where contents were disposed: C;�o Signature of Hauler Date http://www.mass.gov/dep/water/approvals/t5forms.htm#in ect t5form4.doc•06/03 System Pumping Record•Page 1 of 1 3 Commonwealth of Massachusetts City/Town of NORTH ANDOVER, MASSACHUSETTS System Pumping Record a Form 4 DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving ; on r ��C� iy A. Facility Information Important: SEP 2 5 2000 When filling out 1. System Location: forms on the TOWN O?= 1n,:ZTH ANDOVER computer,use 160 CARLTON AVENUE HEALTH DEPARTMENT only the tab key Address to move your NORTH ANDOVER MA 01845 cursor-do not City/Town State Zi Code use the return P key. 2. System Owner: _ DARRFN & T,ATJRA WTNNTk _ Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of PumpingDate 8/01/0 E'2 Quantity Pumped: al 00 0 ns 3. Type of system: ❑ Cesspool(s) :E] Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? [3 Yes ❑ No If yes, was it cleaned? [ Yes ❑ No 5. Condition of System: GOOD 6. System Pumped By: RAC GS SEPTIC SERVICE INC. Name Vehicle License Number Company 7. Location where contents were disposed: WATER SOLUTIONS GROUP, TAUNTON 9/15/06 Signature of Hauler Date http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect t5form4.doc•.06/03 System Pumping Record•Page 1 of 1 • ri TO F`NO$TH ANDOVER r SY T PUMPING RECORD � r DATE SYSTEM OWNER&ADDRESS SYSTEM LOCATION 0j) 1)n le_ DATE OF PUMPINQ QUANTITY-PUMPED �(�O CESSPOOL NO .ms,�_ � SEPTIC TANK NO YES V .. V NATURE OF SERVICE;;,RQI1P WE ' •tivMROENCY OBSERVATIONS; GOOD CONDITION :': FULL TO COVER H$AVY GREASE „ BAFFLES IN LACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS_ ;-FLOODED SOLID CARRYOVER__ OTHER EXPLAIN SYSTEM PUMPED BY D�/ COMMENTS; CONTENTS TRANSFERRED TO_ '''Y � ✓,f/i/� —�> TOWN OF NORTH ANDOVER SYSTEM PUMPING RECO (ZD b - 5202 I'EM OWNER & ADDRESS SYSTEM LOCATION - , l'l � (example: left from uf housc; h � S, CI C OF PUMNINC; /(,Y -0"� QUANTITY f UMPCD of - j . � :.:)SPOOL: NO L//YES SEPTIC' TANK : NO YES A1'URE OF SERVICE: ROUTINE ✓ EMERGENCY ) )3>FRv \TIONS: COOD CONDITION BULL TO COVE � HEAVY CREASE BAFFLL;S IN PIACI: _ ROOTS LEACHFICLD IZ NUACK .. CXCESSIYE SOLIDS FLOODED � SOLIDS CARRYOVER Oj�HFR (EXPLAIN) > 1 > I LNI PUMPED BY cl /A (j Vert e Bf U ,IvdFNTS: U �' I r� TItANSFCIZRED TO North Andover Board of Health Andover Septic 120 Main St. 47 Railroad St. North Andover Ma.01845 Bradford Ma. 01835 Haul Lic. #151-OOH Install Llc. # 128-0 Date Address Gallons Comments 11/1/2000 303 Chester St 1000 11/1/2000 50 Willow Rd 1000 11/1/2000 160 Carelton Ln 1500 11/1/2000 165 Bridal Path 1500 11/4/2000 174 Ingals St 1000 11/4/2000 1062 Salem St 1250 11/6/2000 373 Raligh Tavern Ln 1000 11/6/2000 252 Boxford St 1000 Leachfield Run Back/ Ex. Solids 11/6/2000 150 Liberty St 1500 11/6/2000 149 Osgood St 1000 11/712000 255 Haymeadow 1500 11/7/2000 850 Winter St 1250 11/8/2000 25 Windsor Ln 1500 11/912000 249 Carlton Ln 1500 11/9/2000 767 Johnson St 1500 11/10/2000 56 Academy Rd 1500 11/14/2000 Sugar Cane Ln 1500 11/14/2000 250 Abbott St 1000 Extra Solids 11/15/2000 195 Winter St 1500 11/15/2000 187 Winter St 1500 11/16/2000 85 Laconia Cir 1500 11/16/2000 86 Willow Ridge 1000 11/17/2000 2135 Turnpike St 1500 11/20/2000 203 Grandville Ln 1000 Flooded 11/2012000 391 Pleasant St 1500 11/20/2000 124 Tucker Farm Rd 1500 11122/2000 394 Boston Rd 1500 11/22/2000 728 Forest St 1500 11/22/2000 18 Johnney Cake St 1500 11/24/2000 106 Rockey Brook Rd 1500 11/24/2000 258 Rea St 1000 11/28/2000 1815 Great Pond Rd 1000 11/28/2000 1420 Great Pond Rd 1500 11/29/2000 266 Lacy St 1000 11/29/2000 155 Laconia Cir 1500 A' Commonwealth of Massachusetts Massachusetts System Pumping Record System Owner System Location 1 1,7 11 G�1 Date of Pumping: Y P t ` Quantit Pumped. gallons Cesspool: No Yes ❑ Septic Tank: No ❑ Yes System Pumped by: 64&d" & License# Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. ************ """APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT ��'��S/� /��`�/ r PHONE LOCATION: Assessors Map Number PARCEL Cf I SUBDIVISION LOT (S) STREET lle!!�-ST. NUMBER OFFICIAL USE ONLY "E IONS O WN AGENTS: LAY NSERVATIori ADMINISTRATOR DATE APPROVED DATE REJECTED A COMMENTS ' l � TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HfALTH DATE APPROVED • l / ( DATE REJECTED E TIC INSPECTO LTH DATE APPROVED o DATE REJECTED COMMENTS V, PUBLIC WORKS -SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm Y MAR 2 4 10 4 GeanOe rWwW�wllw+yW..urwip� SEPTIGTANK t Water Ta b)e, Septic Compliance, Inc. E. Paul Cardone, Soil Evaluator March 23, 1999 North Andover Board of Health 27 Charles Street North Andover, MA 01845 Attn: Sandra Starr Re: Sanitary Disposal System Inspection `L160 Carlton Lane -Delores Thomas, Dear Ms. Starr: In accordance with the Commonwealth of Massachusetts, Department of Environmental Protection, State Environmental Code (Title V), 310 CMR 15.301, paragraph 7, please find attached a"Subsurface Sewage Disposal System Inspection Form" for your records. If you have any questions regarding this report or any of its contents please do not hesitate to contact this office. We thank you, in advance, for your continued cooperation in these matters. Very truly yours, SEPTIC COMPLIANCE, INC. Paul Cardone Certified Septic Inspector Attachment PC/JMP title5 thomasmps • TITLE 5 SYSTEM INSPECTORS D.E.P. SOIL EVALUATORS • 447 Boston St., Topsfield, MA 01983 371/2.Baremeadow St.,Methuen,MA 01844 Tel (978) 887-8586 Fax (978) 887-3480 (978) 681-0726 FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: % Phone LOCATION: Assessor's Map Number Parcel Subdivision ✓✓II Lot(s) Street �� C-/r�l �/�i� L��/7� St. Number ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Date Approved Conservation Administrator Date Rejected Comments Date Approved Town Planner Date Rejected Comments Date Approved Food Inspector-Health Date Rejected J, Date�'1' !.. Date Approved 2 . /Z J Septic Inspector-Health Date Rejected Comments I/ C ll Public Works - sewer/water connections - driveway permit Fire Department .�/� �'��- � ,/�'�` J G� �•' �j �� O �� (�J Received by Building Inspector G Date C td3t2!`19111E Septic Compliance, Inc. F Paul Cardone, Soil Evaluator UWCOMMONWEALTH OF MASSACHUSETTS ExEcunvE OFFICE OF ENVIRONMENTAL AFF.4dRs DEPARTwm OF ENVIRONMENTAL PROTECTION ONE WINTER STREET,BOSTON MA 02108 (617)292-5500 TRUDY CORE Secretary ARGEO PAUL CELLUCCI DAVID B.STIZIJI-IS Governor Commissioner SU13SURFACE SEWAGE DISPOSAI,SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: eNo-AAndover, v .10 Th... Address of Owner.Same Date of Inspection:March 20,19" Name of Inspector.Paul Cardone I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name:Septic Compliance,Inc. Mailing.Address:447 Boston Street Topsficid,Ma.01983 Telephone Number(978)4887-8586 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 inspection. The inspection was performed based on my train and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passesxx Conditionally Passes Needs Furtfic by the/ Authority Fails c Inspector's Sigr1!t!r7e1e=��_ _z 1, The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30.)days of completing this inspection. If the system is a shared system or has a design flovk,of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the System owner and copies sent to the buyer.if applicable,and the approving authority. NOTES AND comtwrs •TITLE 5 SYSTEM INSPECTORS • D.E.P. SOIL EVALUATORS • 447 Boston St.,Topsfield.MA 0198"s 37 V2 Baretneadow St.. Methuen,MAO 1844 Tel (978)887-8586 Fax (978) 887-3480 (978) 681-0726 Revised 9/2/98 Page 1 of 11 • � ff COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STRI;'ET,BOSTON MA 02108(617)292-5500 X TRUDY COXE Secretary ARGEO PAUL CELLUCCI Govemor DAVID B.STRUI-IS Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address:160 Cartton Lane No.Andover,Ma.09845 Name of Owner:Delores Thomas Address of Owner.Same Date of Inspection:March 19,1999 Name of Inspector:(Please Print)Paul Cardone 1 am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000)Company Name:Mailing Address:Telephone Number. CERTIFICATION STATEMENT I certify that I have personalty inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: XX Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority inspectors Signatu e ..GJ—� L/ Date' 7 The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP within thirty(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 Department of Environmenta Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM IINSPECTION FORM PART A CERTIFICATION(continued) Property Address:Owner:Date of inspection:160 Carlton Ln.No.Andover,Ma.01845 3-19-99 Delores Thomas INSPECTION SUMMARY:check A,B,C,or D. A.SYSTEM PASSES:XX I have not found any information which indicates that any of the failure conditions described in 310 CMR 16.303 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.if"not determined",explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfittration, or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping-more than four 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 revised 9/2/98 Page 2 of 11 0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:160 Cartton Lane No.Andover,Ma.01985 Owner:Delores Thomas Date of Inspectlon:March 19,1999 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 the public health,safety and 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 PROJECT THE PUBLIC HEALTH.AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetlend 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 PRO T ECTS i HE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone 1 of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply weft,unless a well water analysis 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.Method used to determine distance (approximation not Valid). 3) OTHER revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:160 Cartton Lane No.Andover,Ma.01985 Owner:Date of Inspection:Delores Thomas March 19,1999 D.SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: 1 have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of-sewage into facility or system component-due to an overloaded dogged 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 112 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 Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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 then 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for-coliform bacteria,volatile organic-compounds,ammonia nitrogen-and nitrate nitrogen. E.LARGE SYSTEM FAILS: 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: The system servos a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety an, the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the systemAs-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 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART 8 CHECKLIST Property Address:Owner.Daft at Inspection:160 Carlton Lane No.Andover,Ma.01845 Check if the following have been done:You must indicate either'Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the.owner,occupant,or Board of Health. X None of system components have at least two weeks and has been flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: X Existing information.For example,Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (15.302(3)(b)) X The faa—iity owner land occupants,if different owner)were provided information on the proper maintenance f SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:160 Carlton Lane No.Andover,Ma.01845 Owner.Delores Thomas Deft of tnspection:March 19,1999 FLOW CONDITIONS RESIDENTIAL: Design flow: 150 g.p.d./bedroom. Number of bedrooms(design): 4 Number of bedrooms(actual): 4 Total DESIGN flow 600 Number of current residents: 4 Garbage grinder(yes or no): No Laundry(separate system)(yes or no): No If Yes,separate inspection required Laundry system inspected(yes or no): Seasonal use(yes or no):No Water meter readings,if available(last two year's usage(gpd): Sump Pump(yes or no): No Last date of occupancy: Occupied COMMERCILA/INDUSTRIAL: Type of establishment: Design flow: qpd(Based on 15-203) Basis of design flow 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: OTHER:(Describe) Lest date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: _The system was pumped 18 months ago pump slips were provided. System pumped as part of inspection:(yes or no) Yes If yes,volume pumped: 1200 gallons Reason for pumping: To inspect baffles,tocheck for any excessive runback,to check for any apparent crack or leaks in tank. TYPE OF SYSTEM XX 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank_Copy of DEP Approval Other APPROXIMATE AGE of all components,date installed(if known)and source of information: 12 years of age 2-10-86 on file Sewage odors detected when arriving at the site:(yes or no) No revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC71ON FORM PART C SYSTEM INFORMATION(continued) Property Address:160 Cartton Lane No.Andover,Ma.01845 Owner:Delores Thomas Deft at Inspection:March 19,1999 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: cast iron_40 PVC_other(explain) Distance from private water supply well or suction line Diameter_ Comments:(condition of joints,venting,evidence of leakage,etc. SEPTIC TANK Yes (locate on site plan) Depth below grade:6" Material of construction: X concrete_metal_Fiberglass—Polyethylene—other(explain) If tank is metal,list age_Is age confirmed-by Certificate of Compliance (Yes/No) Dimensions: 10'x 6'x 5'10" Sludge depth: 5" Distance from top of sludge to bottom of outlet tee or baffle: 1'5" Scum thickness: V Distance from top of scum to top of outlet tee or baffle: 9" Distance from bottom of scum to bottom of outlet tee or baffle: 1'5" How dimensions were determined: on-site septic diD-stick Comments: (recommendation for pumping,condition of inlet and outlet toes or-baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage.etc.) We recommend tank should be pumped once every two years baffles were in good shape liquid levels good structural integrity was good no evidence of leaks GREASE TRAP: N/A (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 too or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc,) revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 160 Carlton Lane No.Andover,Ma.01845 Owner:Delores Thomas Date of Inspection:March 19,1999 TIGHT OR HOLDING TANK: NIA (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: Material of construction:--concrete -metal_-Fiberglass_-Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes_ No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX:Yes (locate on site plan) Depth of liquid level above outlet invert: Even—good ieval Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) Box was level distribution appeared to be equal,no solids carryover,no apparent leaks in or out of box. PUMP CHAMBER: NIA (locate on site plan) Pumps in working order:(Yes or No)_ Alarms in working order(Yes or No)_ Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) Revised 9/2/94 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:160 Carlton Lane No.Andover,Ma.01845 Owner:Delores Thomas Date of Inspection:March 19,1999 SOIL ABSORPTION SYSTEM(SAS):Yes (locate on site plan,if possible:excavation not required,location may be approximated by non-intrusive methods) If not located,explain: Type: leaching pits,number:__ leaching chambers,number. leaching galleries,number: leaching trenches,number,length: 2-trenches 4'x 52'each 102.7 total leaching caoacity leaching fields,number,dimensions: overflow cesspool,number: Alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure,Level of ponding,damp soil,condition of vegetation,etc.) normal none _ none no grassy side yard area CESSPOOLS: N/A (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(cesspool must be pumped as part of inspection) Comments: (note condition of soil,signs of hydraulic failure,level of pending,condition of vegetation,etc.) PRIVY: N/A (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.) I revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMAY10N(continued) Property Address:160 Carlton Lane No,Andover,Ma.01845 Owner:Delores Thomas Date of Inspection:March 19, 1999 SKETCH OF SEWAGE DISPOSAL SYSTEM: (include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) 335- • �C �S�o �T � I j ,o. revised 9/2/93 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:160 Carlton Lane No.Andover,Ma.01845 Owner.Deiores Thomas Date of Inspection:March 19,1999 NRCS Report name. -)o/-L 5..�•�L(_ o//„.�5,�= �� Sal Type, ?y_ r,Z' Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater dapth Shallov. Moderate— Deep SITE EXAM Slope'3 "i8 Surface water i✓�'✓�- Check Cellar Shallow wells i✓'N� G' Estimated Depth to Groundwater L_ Feet Please indicate all the methods used to determine High Groundwater Elevation: XX Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) XX Determined from local conditions Checked with iocal Board of health XX Checked FEMA Maps XX Checked.pumping records Checked local excavators,installers XX Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) revised 9/2/98 Page 11 of 11 E--vent Y Y yWLiN ' ° n�Y'gL�l'Ih,4 � uc i 4q• u pN4UimY.uiwnWiO Geano �ury,,,,,,1'eL� /j�IUG 13 11997 SEPTIGTANK LEACH`IELO miter-Table, t. Septic Compliance, Inc. affilliate of Thomas E. Neve Assoc., Inc. August 11, 1997 North Andover Board of Health 146 Main Street North Andover, MA 01845 Attn: Sandra Starr Re: Sanitary Disposal System Inspection 160 Carlton Lane - Robert Krueger Dear Ms. Starr: In accordance with the Commonwealth of Massachusetts, Department of Environmental Protection, State Environmental Code (Title V), 310 CMR 15.301, paragraph 7, please find attached a "Subsurface Sewage Disposal System Inspection Form" for your records. If you have any questions regarding this report or any of its contents, please do not hesitate to contact this office. We thank you, in advance, for your continued cooperation in these matters. Very truly yours, SEPTIC PLI CE, INC. Paul Cardone Certified Septic Inspector Attachment N.Andlet.sam • SYSTEM INSPECTORS • • SOIL EVALUATORS • • ENVIRONMENTAL ENGINEERS • 447 Old Boston Rd., US Route 1, Topsfield,MA 01983 Tel (508) 887-8586 Fax (508) 887-3480 T Vent Y Y `r P Ge3noLtiWy2rwMwWllaRMYn.YwPWPM• SEPTIG;ANK LEACH FIELD v>Ja Tai)e, Septic Compliance, Inc. affilliate of Thomas E. Neve Assoc., Inc. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: Robert Krueger Address of Owner: 160 Carlton Lane No.Andover,Ma.01845 (if different) Date of Inspection: August 5, 1997 Name of Inspector: Paul Cardone I am a DEP approved septic inspector pursuant to Section 15.340 of Title 5(3 10 CMR 15.000) Company Name, Septic Compliance,Inc. Address and 447 Old Boston Road,Topsfield,MA 01983 Telephone Number: (508)887-8586 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X Passes Conditionally Passes Needs further Evaluation By the Local Approving Authority ails Inspector's Signature: Date: Z/- The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Page 1 of 18 • SYSTEM INSPECTORS • • SOIL EVALUATORS • • ENVIRONMENTAL ENGINEERS • DEP on the World Wide Web: hq://www.magnet.state.ma.us/dep (revised 04/25/97) 447 Old Boston Rd., US Route 1, Topsfield, MA 01983 Tel (508) 887-8586 Fax (508) 887-3480 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 160 Carlton Lane No.Andover,Ma.01845 Owner: Robert Krueger Date of Inspection: August 5, 1997 INSPECTION SUMMARY: Check A,B,C,or D: A) SYSTEM PASSES: X I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. 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. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced Page 2 of 18 (revised 04/25/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 160 Carlton Lane North Andover,MA 01845 Owner: Robert Krueger Date of Inspection: August 5, 1997 B) SYSTEM CONDITIONALLY PASSES(continued) The system required pumping more than four 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 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 the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS THE BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis 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. Method used to determine distance (approximate not valid.) Page 3 of 18 (revised 04/25/97 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 160 Carlton Lane No.Andover,Ma.01845 Owner: Robert Krueger Date of Inspection: August 5, 1997 C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH(continued): 3) OTHER D) SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s) Number of Times Pumped Page 4 of 18 (revised 04/25/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued Property Address: 160 Carlton Lane No.Andover,Ma. 01845 Owner: Robert Krueger Date of Inspection: August 5, 1997 D) SYSTEM FAILS(continued) Yes No Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exists: Page 5 of 18 (revised 04/25197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CHECKLIST Property Address: 160 Carlton Lane No.Andover,Ma.01845 Owner: Robert Krueger Date of Inpsection: August 5, 1997 E) LARGE SYSTEM FAILS(continued): 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). The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. Page 6 of 18 (revised 04/25/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CHECKLIST Property Address: 160 Carlton Lane No.Andover,Ma.01845 Owner: Robert Krueger Date of Inpsection: August 5, 1997 Check if the following have been done: You must indicate either"Yes"or"No"as to each of the following: Yes No Yes Pumping information was provided by the owner,occupant,or Board of Health.Owner had pumping slips pumps it every year. Yes None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. Yes Asbuilt plans have been obtained and examined. Note if they are not available with N/A. Yes The facility or dwelling was inspected for signs of sewage back-up. Yes The system does not receive non-sanitary or industrial waste flow. Yes The site was inspected for signs of sewage breakout. Yes All system components,excluding the Soil Absorption Syste,have been located on the site. Yes The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of SCUM. Yes The size and location of the Soil Absorption System on the site has been determined based on: Yes The facility owner and occupants(if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System. Yes Existing information. Ex.Plan at B.O.H. Determined in the field(if any failure criteria related to Part C is at issue,approximation of distance is unacceptable)[15.302(3)(b)] Page 7 of 18 (revised 04/25/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 160 Carlton Lane No.Andover,Ma.01845 Owner: Robert Krueger Date of Inpsection: August 5, 1997 FLOW CONDITIONS RESIDENTIAL Design flow: 600 g.p.d./bedroom for S.A.S. Number of bedrooms: 4 Number of current residents: 2 Garbage grinder(yes or no): no Laundry connected to system(yes or no): yes Seasonal use(yes or no): no Water meter readings,if available (last 2 year usage(gpd): Sump Pump(yes or no): no Last date of occupancy: occupied COMMERCIALANDUSTRIAL: Type of establishment: Design flow: gallons/day 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: OTHER(Describe): Last date of occupancy: Page 8 of 18 (revised 04/25/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 160 Carlton Lane No.Andover,Ma.01845 Owner: Robert Krueger Date of Inspection August 5, 1997 GENERAL INFORMATION PUMPING RECORDS and source of information: Owner had pumping slips; pumped every year System pumped as part of inspection(yes or no): yes If yes,volume pumped: 1,500 gallons Reason for pumping: In order to do complete inspection of the interior of the tank. TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)[If yes,attach previous inspection records,if any] UA Technology etc. Copy of up-to-date contract? Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source of information: 11 years of age 2-10-86 B.O.H. installation check list Sewage odors detected when arriving at the site(yes or no): no BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction cast iron 40 PVC other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints,venting,evidence of leakage,etc.) (revised 04/25/97) Page 9 of 18 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 160 Carlton Ln.No.Andover,Ma.01845 Owner: Robert Krueger Date of Inspection: August 5, 1997 SEPTIC Yes TANK: (locate on site plan) Depth below grade: 6" Material of construction: X concrete metal Fiberglass Polyethylene Other(explain) If tank is metal,list age Is age confirmed by Certificate of Compliance (Yes/No) Dimensions: 10'x 6'x 5' 10" Sludge Depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: 1'6" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 9" Distance from bottom of scum to bottom of outlet tee or baffle: 1'6" How dimensions were determined: on-site Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) We recommend tank be pumped once every two or three years. Baffles in good condition,liquid level good,structural integrity good-no apparent leaks. Page 10 of 18 (revised 04/25/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: - 160 Carlton Lane No.Andover,Ma.01845 Owner: Robert Krueger Date of Inpsection: August 5, 1997 GREASE TRAP: none (locate on site plan) Depth below grade: Material of construction: Concrete Metal Fiberglass Polyethylene Other(Explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (Recommendations for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) TIGHT OR HOLDING TANK: none (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: Material of construction: Concrete Metal Fiberglass Polyethylene Other(explain): Page 11 of 18 (revised 04/25/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 160 Carlton Ln.No.Andover,Ma.01845 Owner: Robert Krueger Date of Inspection: August 5, 1997 TIGHT OR HOLDING TANK(continued) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in working order Yes; No Date of previous pumping: Comments: (Condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: yes (Locate on site plan) Depth of liquid level above outlet invert: even Comments: (Note if level and distribution is equal evidence of solids carryover,evidence of leakage into or out of box,etc.) Box was level, liquid level good,no evidence of leaks. Page 12 of 18 (revised 04/25/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 160 Carlton Ln.No.Andover,Ma.01845 Owner: Robert Krueger Date of Inspection: August 5, 1997 PUMP CHAMBER: none (Locate on site plan) Pumps in working order: (Yes or No) Alarms in working order(Yes or No) Comments: (Note condition of pump chamber,condition of pumps and appurtenances,etc.) SOIL ABSORPTION SYSTEM(SAS): yes (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain Type: Leaching pits,number: Leaching chambers,number: Leaching galleries,number: Leaching trenches,number,length: 2-trenches 4'x 52'each 102.7 total leaching capacity Leaching fields,number,dimensions: Overflow cesspool,number: Alternative system: Name of technology: Page 13 of 18 (revised 04/25/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 160 Carlton Ln.No.Andover,Ma.01845 Owner: Robert Krueger Date of Inspection: August 5, 1997 SOIL ABSORPTION SYSTEM(SAS)(continued): Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) normal none none good grassy area CESSPOOLS: none (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(cesspool must be pumped as part of inspection): Comments(Note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 14 of 18 (revised 04/25/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 160 Carlton Ln.No.Andover,Ma.01845 Owner: Robert Krueger Date of Inspection: August 5, 1997 PRIVY: none (Locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(Note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): Page 15 of 18 (revised 04/25/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 160 Carlton Ln.No.Andover,Ma.01845 Owner: Robert Krueger Date of Inspection: August 5, 1997 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent references, landmarks or benchmarks. Locate all wells within 100': (Locate where public water supply comes into house). L a T 4 6, 3 3 50, ( Lin,., s•I Ye- I , ( I o' Page 16 of 18 (revised 04/25/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 160 Carlton Lane No.Andover,Ma.01845 Owner: Robert Krueger Date of Inspection: August 5, 1997 DEPTH TO GROUNDWATER Depth to groundwater: 10' feet Please indicate all methods used to determine High Groundwater Elevation: X Obtained from Design Plans on record X Observation of Site(Abutting property,observation hole,basement sump etc.) X Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators,installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) By looking at local conditions and checking existing B.O.H.records,it is clear that there is no indication of groundwater. Page 17 of 18 (revised 04/25/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Paul Cardone Company Septic Compliance,Inc. Address 447 Boston Road,Topsfield,MA 01983 (508)887-8586 Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and maintenance of on-site sewage disposal systems. Check one: I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15.303. Any failure criteria not evaluated are as stated in the XX FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15.303. The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector's Signature: Date: August 6, 1997 Copies to: Board of Health Buyer(if applicable)Approving authority: (revised 04/25/97) P , Board of Health . North AndnvarLN.aae. SEPTIC SZSTEH INSTAMATICK CHECK LIST LOT'J '17 J O HNNYa K�______ �P r�OVED DATE DI W PR t X A-V ATION OK 11IL 1)10 eauonst FAIL og 9.��S �'rro✓ , 1. Distance To s 4Q1nd l S ��e w�� s�owh ' Fid 1 i ns7r - a. wetlands lwX s 1 ��, mss_ CkVVVV'5TY�T-<S IT ro b�f b. Drains Z c.. Well 2. Water Line Location 3- No PPC Pipe 4. Septic Tank a. Tees -_Length & To Clean Out Covers b. Cement Pipe to Tank- On Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines.Flowing Equal Amounts c. No Back Flow 6. Leach Field or Trench a. Dimensions ` b. Stone Depth c. Capped Ends d. Clean Double'Washed Stone 7. Leach Pits a. Dimensions b. Stone Depth c. flash Pads d. Teas e. Cunt Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. No Garbage Ili spo sal 9. Yinal. Grading Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System c. Location with Regard-to Perc Test d. Elevations e.' Water Table Bot.rd of Health y Nce.) Andover,,Mass SUBSURFACE DISPOSAL DESIGN CHECK SST LOT 1-7 CAP__rOA1 APPROM DATE__LZ--/ -d DIS APPROPID DATE Provided: �1,� POW L-r Reasons s vg� _ 13 RLL, na AlRF09`/ti u AILC. 1244v 0- Title V FAIL Ob -MOT'S w l-9 TrfiC g9VIS00 Reg 2.,5 The submitted plan must show as a m4n1mum: a) the lot to be served-area,dimensions lot #,abutters b location and log deep observation hoes-distance to ties c location and results percolation tests-distance to ties d design calculations k calculations a)-wing required leaching area (e) location and dimensions of system-inc''uding veserve area f) existing and proposed contours (g) location any wet areas within 1001 of sewage disposal system or disclaimer-check wetlands mapping (h) surface and subsurface drains within .AO' of sewage disposal system or disclaimer (i) location any drainage easements withi. 1001 of sewage disposal system or disclaimer-Planning Boaz- ' fAes T 0) know sources of water supply wit,.= 001 of sewage disposal e system or disclaimer (k) location of any proposed well to serve lot-100, from leaching facilit (1) location of water lines on property-101 from leaching facility (m) location of benchmark (n) driveways --.- (o) garbage disposals (p no PVC to be used in construction (q) profile of system-elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and Otter elevations (r) maximum ground water elevation in area sewage disposal system (s) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Reg 6 Septic Tanks (a) capacities-15076 of flow, water table, tees, depth of tees, access, pumping (b) cleanout (c) 101 from cellar wall or inground swin tng pool (d) 251 from subsurface drains Reg 10.2 Distribution Boxes (b) �e greater 0.08 Reg 110.4 , CACI j,TJJ�I �Qr�MS 05C LOT 17 Iri k 12"�n-5 9 IZ=11''@ 12: 1 bYlk. cat 30- � .5= l2 i 5 �� - 56 I,,';T { 74 r . r.� SOIL PRUFIL,E & �'f RCOLI,TIO TES ATA. V.cA_ North Andover,liass. Ne.&Street Lot No.1 Loc ./Subdiv. Plan Owner Investi-gator - Observer . S0IL PROFILES-DATE - 1. Elev. - 2. "Elev,.. — 3' EElev. 4'Elev. 0 0 0 0 } Ties to Test Pith 2 2 2 2 IIIT 3 3 3 _ 4 4 4 4 5 5 5 5 6 6 6 6 7 7 7 7 9 9 - 9 .. 9 _ 10 10 10 10 Benchmark Location - Elevation Datum Percolation Tests-Date - - - Date--=-= .! � - • Pit Number- 1 2 3 4 5 Start Saturation.- Soak-Min S aturationSoak-Mins _- - - --- -- - - - - =-- -- Start Dr_p of 3"-Time Dro of 6"-Time Mins . 1st . 3"Dro Mins . 2nd 3"Dro p _ Percolation Rate �L\ Commonwealth of Massachusetts RECeIVED City/Town of NORTH ANDOVER MASSA USETTS System Pumping Record ' U8N UU U10 Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. The System Pump ng Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: forms on the computer,use only the tab key Address to move your cursor-do not use the return City/Town State Zip Code key. 2 System Owner: r1>11 ry-.t 4-1 k La V f M W n H Name til Address(if different from location) Cityrrown State Zip Code Telephone Number B. Pumping Record in/ Zo/Zoav/ /saw 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: (".10 0 6. System Pumped By: -r?vh L ;&q r:d r ,ti Name Vehicle License Number V-y iG-2 Compa y 7. Location where contents were disposed: - Signature of Hauler Date hftp://www.mass.gov/dep/Water/approvals/t5forms.htm#inspect t5forrn4.doc-06/03 System Pumping Record-Page 1 of Commonwealth of Massachusetts W City/Town of NORTH ANDOVER 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 within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: `�1 N�0 on the computer, use only the tab 160 CARLETON LANE key to move your Address 0``SS�Q cursor not ret use the return NORTH ANDOVER MA ��'U1845 key. City/Town State Zip;ode 2. System Owner: DARREN WINNIE Name remm Address(if different from location) City/Town State Zip Cc-le Telephone Number B. Pumping Record 1. Date of Pumping Date 1/30/17 1500 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: GOOD CONDITION 6. System Pumped By: JAMES H CURRIER II H79 406 Name Vehicle License Number S SEPTIC & DRAIN Company 7. Location where contents were disposed: GLSD _ 1/30/17 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1