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Home My WebLink AboutMiscellaneous - 160 Olympic Avenue \ ��o O '� Commonwealthof assac usetts City/Town of Y System Pumping Recor 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 fro n the PUMDipq diale accordance with 310 CMR 15.351. RECEIVED -flity Information JUL0 2008 Importan When f' Ing out System Location: TO OF NORTH ANDOVER form n the HE TH DEPARTMENT corn uter,use onl the tab key Ad ess to ove your u O I "" curs -do not City/Town State Zip Code use the turn key. S stem Owner: Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank XGrease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes X0 If yes, was it cleaned? ❑ Yes ❑ No 5. ConditioSyst f m: 6. Syste Pumped B : � Name Vehicle License Number Company 7. Location wire contents were disposed: Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06' System Pumping Record•Page 1 of 1 / 163 OLYMPIC LANE 210/106.6-0132-0000.0 Y � s i I I 1 i Residential Property Record Card PARCEL ID:210/106.B-0132-0000.0 MAP:106.13 BLOCK:0132 LOT:0000.0 PARCEL ADDRESSA63 OLYMPIC LANE PARCEL INFORMATION Use-Code: 101 Sale Price: 273,500 Book: 04118 Road Type: T Inspect Date: 06/10/2002 Tax Class: T Sale Date: 08/30/1994 Page: 0001 Rd Condition: P Meas Date: 06/10/2002 Owner: Tot Fin Area: 2240 Sale Type: P Cert/Doc: Traffic: M Entrance: X ESTERKES,JEFFREY R Tot Land Area: 1.01 Sale Valid: Y Water: Collect Id: RRC ROBIN SUE ESTERKES Grantor: AUGUSTINOS, ROBERT Sewer: Inspect Reas: C Address: 163 OLYMPIC LANE Exempt-B/L% / Resid-B/L% 100/100 Comm-B/LM Indust-B/L% 0/0 Open Sp-B/L% 0/0 NORTH ANDOVER MA 01845 RESIDENCE INFORMATION LAND INFORMATION Style: CL Tot Rooms: 7 Main Fn Area: 1120 Attic: NBHD CODE: 7 NBHD CLASS: 7 ZONE: R2 Story Height: 2 Bedrooms: 4 Up Fn Area: 1120 Bsmt Area: 1120 Seg Type Code Method Sq-Ft Acres Influ-Y/N Value Class Roof: H Full Baths: 2 Add Fn Area: Fn Bsmt Area: 1000 1 P 101 S 43560 1 215,186 Ext Wall: FB Half Baths: 1 Unfin Area: Bsmt Grade: 2 R 101 A 0.01 47 Masonry Trim: Ext Bath Fix: Tot Fin Area: 2240 VALUATION INFORMATION Foundation: CN Bath Qual: T RCNLD: 282262 Current Total: 525,700 Bldg: 310,500 Land: 215,200 MktLnd: 215,200 Kitch Qual: T Eff Yr Built: 1987 Mkt Adj: 1.1 Prior Total: 490,800 Bldg: 291,700 Land: 199,100 MktLnd: 199,100 Heat Type: HW Ext Kitch: Year Built: 1980 Sound Value: Fuel Type: G Grade: G Cost Bldg: 310,500 Fireplace: 1 Bsmt Gar Cap: Condition: A Att Str Val 1: Central AC: N Bsmt Gar SF: Pct Complete: Att Str Va12: Att Gar SF: 552%Good P/F/E/R: /100/100/91 Porch Type Porch Area Porch Grade Factor W 216 SKETCH PHOTO w 12 IL GL 216 Sq.Ft. 12 AlEkk 'in 2_R P wpm= 1 n 0 Ct FUff FM 6 11 0 Sq.R. 552 Sq.R. 2$ 24 24 4111 b I A v a I 4 ' 40 Parcel ID:210/106.6-0132-0000.0 as of 11/2/06 Page 1 of 1 Commonwealth of Massachusetts u Title 5 Official Inspection Form RECEIVE® Subsurface Sewage Disposal System Form-Not for Voluntary Assessm is AUG -1 Z911 163 Olympic Lane i Property Address HEALTH DEPARTMENT Jeff Esterkes Owner Owner's Name information is required for North Andover MA 01845 7/20/2011 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the comuter,use only the tab key 1. Inspector: to move your Neil James Bateson cursor-do=t use the return Name of Inspector key. Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover MA 01810 City/Town State Zip Code 978-475-4786 S115 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 7/20/2011 Insp ct s 'gnature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts w v Title 5 Official Inspection Form a Subsurface Sewage Disposal System Fong-Not for Voluntary Assessments 163 Olympic Lane Property Address Jeff Esterkes Owner Owner's Name information is required for North Andover MA 01845 7/20/2011 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 t indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y 0 N ❑ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts a m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 163 Olympic Lane Property Address Jeff Esterkes Owner Owner's Name information is required for North Andover MA 01845 7/20/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 l Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 163 Olympic Lane Property Address Jeff Esterkes Owner Owner's Name information is required for North Andover MA 01845 7/20/2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. } ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 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 1/day flow t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 163 Olympic Lane Property Address Jeff Esterkes Owner Owner's Name information is required for North Andover MA 01845 7/20/2011 every page. CityTown State Zip Code Date of Inspection B. Certification (cont.) Yes No El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ . the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to:a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection ❑ ❑ Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts w wTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 163 Olympic Lane Property Address Jeff Esterkes Owner Owner's Name information is required for North Andover MA 01845 7/20/2011 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ElDetermined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 600 t5ins•11/10 Title 5 official Inspection Forth:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 163 Olympic Lane Property Address Jeff Esterkes Owner Owner's Name information is required for North Andover MA 01845 7/20/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: -Number of current residents: 3 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage Yes 9 ( y 9 (gPd))� Detail: Sump pump? ® Yes ❑ No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: I Design flow(biased on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 163 Olympic Lane Property Address Jeff Esterkes Owner Owner's Name information is required for North Andover MA 01845 7/20/2011 every page. Citylrown State Zip Code Date of Inspection D. System-Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped last year, owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Measured tank Reason for pumping: Inspect tank&tee 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 I ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 163 Olympic Lane Property Address Jeff Esterkes Owner Owners Name information is required for North Andover MA 01845 7/20/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 31 years old, 10/4/1980, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): 4"Cast iron thru wall. 3" PVC in house, no leaks visible Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x5'x 4' Sludge depth: 2 l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts w m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 163 Olympic Lane Property Address Jeff Esterkes Owner Owner's Name information is required for North Andover MA 01845 7/20/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 25" Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Tape Measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumped septic tank. Outlet tee ok, Depth of liquid at outlet invert. No evidence of leakage Y Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 163 Olympic Lane Property Address Jeff Esterkes Owner Owner's Name information is North Andover MA 01845 7/20/2011 required for every page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of lastum in p p g Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts MW Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments I 163 Olympic Lane Property Address Jeff Esterkes Owner Owner's Name information is required for North Andover MA 01845 7/20/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box level&distribution equal. No evidence of leakage. Evidence of carryover, pumped d-box to ' clean. Pum (locate ovate on site Ian Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 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: t5ins-11110 Title,5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17- Commonwealth of Massachusetts afa-IFTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 163 Olympic Lane Property Address Jeff Esterkes Owner Owner's Name information is required for North Andover MA 01845 7/20/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 field 20'x 45' ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M s.•''y 163 Olympic Lane Property Address Jeff Esterkes Owner Owner's Name information is North Andover MA 01845 7/20/2011 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M .•''t 163 Olympic Lane Property Address Jeff Esterkes Owner Owner's Name information is required for North Andover MA 01845 7/20/2011 every page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately [0S i V-) --V-cL&AN-_ _ Lq'g�� - - q 3 tl t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 I Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 163 Olympic Lane Property Address Jeff Esterkes Owner Owner's Name information is required for North Andover MA 01845 7/20/2011 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water. ® Check cellar ® Shallow wells Estimated depth to high ground water: >4 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 5/18/1977 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: Design plan ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: As per test pit data on design plan. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection . Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 163 Olympic Lane Property Address Jeff Esterkes Owner Owner's Name information is required for North Andover MA 01845 7/20/2011 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 i Summary Record Card generated on 7/19/2011 1:56:23 PM by Karen Hanlon Page 1 Town of North Andover Tax Map # 210-106.6-0132-0000.0 Parcel Id 17536 163 OLYMPIC LANE ESTERKES, JEFFREY 163 OLYMPIC LANE N. ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residentia Size Total 1.01 Acres FY 2011 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until ESTERKES,JEFFREY Payor 163 OLYMPIC LANE N.ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 1751.0.0-163 OLYMPIC LANE Last Billing Date 7/13/2011 3170180 03 Cycle 03 Active UB Services Maint. Account No.3170180 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 57.00 /1 UB Meter Maintenance Account No.3170180 Serial No Status Location Brand Type Size YTD Cons 363880743 a Active ERT HH b Badger w Water 0.63 0.63 175 Date Reading Code Consumption Posted Date Variance 6/8/2011 168 a Actual 15 7/20/2011 4% 3/8/2011 153 a Actual 14 4/13/2011 -61 12/9/2010 139 a Actual 36 1/12/2011 -53% 9/10/2010 103 a Actual 81 10/15/2010 3220/c 6/7/2010 22 a Actual 18 7/15/2010 26% 3/10/2010 4 a Actual 4 4/14/2010 -100% 2/13/2010 0 n New Meter 0 4/14/2010 -100% 2/13/2010 3424 r Replacement 11 4/14/2010 -43% 12/10/2009 3413 a Actual 27 1/12/2010 -27% 9/10/2009 3386 a Actual 38 10/15/2009 87% 6/8/2009 3348 a Actual 19 7/20/2009 16% 3/12/2009 3329 a Actual 18 4/29/2009 8% 12/5/2008 3311 a Actual 15 1/20/2009 -62% 9/9/2008 3296 a Actual 44 10/10/2008 97% 6/5/2008 3252 a Actual 20 7/16/2008 53% 3/11/2008 3232 a Actual 14 4/11/2008 -49% 12/10/2007 3218 a Actual 29 1/22/2008 -39% 9/4/2007 3189 a Actual 40 10/12/2007 107% 6/15/2007 3149 a Actual 22 7/20/2007 59% 3/15/2007 3127 m Manual estimate 14 4/16/2007 -9% 12/12/2006 3113 a Actual 14 1/19/2007 -69% 9/18/2006 3099 a Actual 48 10/20/2006 136% Trouble Code:03 6/19/2006 3051 a Actual 23 7/10/2006 41% 3/8/2006 3028 a Actual 12 4/17/2006 -39% Trouble Code:03 Commonwealth of Massachusetts u City/Town of System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location a front of hot right front of house, left side of house, right side of house, Left rear of house, right-r-e-a—r6TF5use, left side of building, right rear of building, under deck. Cityrrown State Zip Code 2. System Owner: Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 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 0'<o If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: V\, ti U 6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Loci where contents°were disposed: G. .9J' Lowell Waste Water Signatu e o au r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 f' Gelinas 5 ructural �ngineerinq Phone 978.465.6436 Daniel L. Gelinas,P.E. Fax 978.465.5160 579A North End Blvd. Email danl elinas@,comcast.net - Salisbury, MA 01.952-1738 T ;. Letter, 08138-E a . October 7,2008 .,. 7Andove cell 978.590.0695 163 Lane NortA 01845 jresterkes@comcast.net' Subject: addition/enclosed porch { f' C Dear Mr. Esterkus E P.^ PI I' You have requested Gelinas Structural Engineering LLC (GSE) review and comment regarding the structural adequacy of the recent enclosed q Y porch/deck/rear room. p meet� GSE you on site made observations and office analysis,and it is GSE's Y opinion: s 1. the LV I f" 1. s installed satisfy code loading conditions , 2. the framed enclosure and foundations satisfy the structural requirements of the Massachusetts State Building Code, 7TH Edition, One and Two Family Dwellings provided the recommendations shown on drawings SG-1, SG-2, SG-3 are implemented °w i !f Very Truly Yours, OF Le 6A Daniel L. Gelinas DANIEL aim ': B E L ramin 10-7-08 08138.doc �" -TC tt�fV�.S 4 g SIR CTURAL v I ' A n y .1.. VAL q I 9 I `T Ig ,z sI I R i I fT�1' coa M an u�i a o L b�Io I' } �;T1�3?o- cs rn(0 7M .. ., a ___..__.Q EC ) CO _.. .. (S( -0 Lo-Fu ¢ C/)ST o i i Z, pT, Pi,YW19a" _ jAU �Gtr- I f" I' '. ;�;3 I� t" N N L` St ori; ` -��- "� �• 1/I1 Wit./ :.� 1a"o�[w+t��.+. � �r�'ir`� � I ---� `� 9.tr-moi�•.- � "ail firs �Y r — _ lknara t �:;r• .4 �`e �1,.',�1 �t ``� i,pias` . JCB NOO��3. W3994 SHEET NO. !ice i` i i 'ON 133HSOr - j �39llA� oy SI t �1 Io i Re w p jE2 w g m a t "19 N alp W..+ ". Z4 n m . . ......... ._ ... m a,Co + i v.. k\ i l 9+ T, "T �3 T- I � � Ta \ r " m w a6UNA5 ST UCTURAL ENG(NEERINC,LCC .6 aniel L.Gelinas,F.E. o y 140$ Oty H Flee LAO I�- 579A North End Blvd. Salisbury,MA 01952-1738 i Phone 978.465.6436(Fax 5160) Own it tl. v i Sam € s 4 �z SAKE%Jj .Eli \ z ky 4c Do t •� C � fi , 'b 5_..,.,. ;:. F .,tin c':c b .. .� :• A::',.? �` '. ,.:_. ,,.1 ., „': �'>., .. Y .; . �, .. .. SAM,. ,3 MI 21 kit > h G• ,�.. -�, �, ?„gib y S c • ..e '�. 3 •�. ,,, � \�:�` ��° .:_ , I �"9 `�� baa ,ffi. '.'.o,p R �x Yx 3 A .,da � +'� .c 1 .x� •,a., � �' "'e C ��`�w:2s'„v:�-,' k:.. .s�m.�.»¢L-:,Ksn.+Wx+,.umi•;;,aia .,vnt,-`+n.n-c,w..u..... .mwxa-,,:> i. a<41 c FIR 5RAY, r s � y� .. • } -, e i �fiy C1 .fir 3r'F f � "i _ i• •.' 7 -�� r Y �r d B ��e Y - �t ii s. �d v �i z n' s }✓ �rw,; � �. , , ,:..��, . . .: � a� .,,.. � �... acs.,,, �' �<." d:'Y'.. �e r,"w.-» $•-- 1, 4;'yxsa Gwx` J:'�. /y • NrY a < Via ,. v Q d. 3 Y rf 5 l b Y y „ T?. y COMMONWEALTH OF MASSACHUSETTS ID EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS t d DEPARTMENT OF ENVIRONMENTAL PROTECTION See TITLE 5 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A I CERTIFICATION Property Address: 163 Olympic Lane _North Andover_ RECEIVED Owner's Name:_Jeff Esterkes Owner's Address:_163 Olympic Lane _North Andover,MA 01845_ NOV 0 12006 Date of Inspection:_10/20/2006_ TOWN OF NORTH ANDOVER Name of Inspector: Neil J Bateson HEALTH DEPARTMENT Company Name: Bateson Enterprises Inc._ Mailing Address:_111 Argilla Road_ _Andover,MA 01810_ Telephone Number:_(978)475-4786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority F ''so A tA� Inspector's Signature: Date: _10/20/2006_ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments: I ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 L •FFICIAL INSrECTION FARM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property hAddress: 163 Olympic Lane _ _North Andover_ Owner:_Esterkes_ Date of Inspection:_10/20/206_ Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain . The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_163 Olympic Lane_ _North Andover_ Owner:_Esterkes Date of Inspection:_10/20/2006 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: — The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other:_ i I Page 4 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_163 Olympic Lane_ _North Andover_ Owner: Esterkes_ Date of Inspection:_10/20/2006_ D. System Failure Criteria applicable to all systems: You must indicate"yes"or`no"to each of the following for all inspections: No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool No Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool No Liquid depth in cesspool is less than 6"below invert or available volume is'h day flow. No Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped No Any portion of the SAS,cesspool or privy is below high ground water elevation. _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. No Any portion of a cesspool or privy is within a Zone 1 of a public well. No Any portion of a cesspool or privy is within 50 feet of a private water supply well. No Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forma _No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or`no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:_163 Olympic Lane_ _North Andover_ Owner:_Esterkes Date of Inspection:_10/20/2006 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Yes_ _ Pumping information was provided by the owner,occupant,or Board of Health No Were any of the system components pumped out in the previous two weeks? _Yes_ — Has the system received normal flows in the previous two week period? _ No Have large volumes of water been introduced to the system recently or as part of this inspection? Yes_ ` Were as built plans of the system obtained and examined? Yes ` Was the facility or dwelling inspected for signs of sewage back up? Yes_ _ Was the site inspected for signs of break out? _Yes_ _ Were all system components,excluding the SAS,located on site? _Yes_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the d, , _ P P P condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _Yes_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No _Yes_ __ Existing information. _Yes_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_163 Olympic Lane_ _North Andover– Owner:_Esterkes Date of Inspection:_10/20/2006_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_4_ Number of bedrooms(actual):_4_ DESIGN flow based on 310 CMR 15.203_600_ Number of current residents: 3 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no):_No Laundry system inspected(yes or no): _ Seasonal use: (yes or no): No Water meter reading:Yes_ Sump pump(yes or no): Yes_ Last date of occupancy:— Current-COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203):_gpd Basis of design flow(seats/persons/sqft,etc.):— Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:_Pumped ed this year,owner_ Was system pumped as part of the inspection(yes or no):_No If yes,volume pumped: gallons--How was quantity pumped determined?_ Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool_Overflow cesspool _Privy _Shared system(yes or no)(if yes attach previous s ins ection records if any) _ i Alternative technology.Attach a co of the current operation and maintenance contract(to be Innovat ve/ gy copy P obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe):_ Approximate age of all components,date installed(if known)and source of information:_26years old,10/4/1980, as built plan _ Were sewage odors detected when arriving at the site(yes or no):_No_ Page 7 of 11 V � OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_163 Olympic Lane_ _North Andover_ Owner:_Esterkes Date of Inspection:_10/20/2006_ BUILDING SEWER_X_ (locate on site plan) Depth below grade:_24"_ Materials of construction: _X_cast iron —X-40 PVC_other Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.) _4"Cast iron thru wall,3"PVC in house, no leaks. SEPTIC TANKS: X Depth below grade:_12"_ Material of construction: X_concrete—metal_fiberglass_polyethylene _other(explain) If tank is metal list age:` Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 10' x S'x 4' Sludge depth 0"_ Distance from top of sludge to bottom of outlet tee or baffle: 27"_ Scum thickness:_0" Distance from top of scum to top of outlet tee or baffle:-8"— Distance affle_8"Distance from bottom of scum to bottom of outlet tee or baffle: 21"_ How were dimensions determined:_Tape Measure_ Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc _Inlet tee ok.Outlet tee ok. Depth of liquid at outlet invert. No evidence of septic tank leaking._ GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_163 Olympic Lane_ _North Andover– Owner: Esterkes Date of Inspection:_10/20/2006 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: Depth below grade 20"_ Depth of liquid level above outlet invert: 0_ Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.)_D-box level&distribution equal.No evidence leakage.No evidence of carryover. PUMP CHAMBER:—(locate on site plan) Pump in working order(yes or no):— Alarm in working order(yes or no):— Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):_ Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_163 Olympic lane_ _ North Andover_ Owner:_Esterkes Date of Inspection:_10/20/2006_ SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: _ leaching chambers,number: leaching galleries,number: _ leaching trenches,number,length: _X_ leaching field,number,dimensions:_1 field 20'x 45'_ overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.):_Soil ok.Vegetation ok.No sign of ponding to surface. CESSPOOLS: Number and configuration:_ Depth—top of liquid to inlet invert:— Depth of sludge layer:_ Depth of scum layer:_ Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no):_ Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): I PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation;etc.): Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_163 Olympic Lane_ _North Andover- Owner:_Esterkes Date of Inspection: 10/20/2006 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 House Garage WaterMeter A B ��,hDriveway A to Tank=14'8" A to D-Box=30'8" Septic Tank B to Tank=40' B to D-Box=48'3" D- Box Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_163 Olympic Lane_ _North Andover— Owner:_Esterkes Date of Inspection:_10/20/2006_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water_616"_ Please indicate(check)all methods used to determine the high ground water elevation: _X_ Obtained from system design plans on record-If checked,date of design plan reviewed:_5/18/1977_ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain:_ Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: _ You must describe how you established the high ground water elevation:_As per design plan_ Town of North Andover • J Tax Map # 210-106.6-0132-0000.0 163 OLYMPIC LANE ESTERKES, JEFFREY 163 OLYMPIC LANE N. ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 1.01 Acres FY 2007 US Mailing Index Name/Address Type Loan Number Active/inact. From Until ESTERKES,JEFFREY Payor 163 OLYMPIC LANE N.ANDOVER, MA 01845 US Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 17510.0- 163 OLYMPIC LANE Last Billing Date 10/16/2006 3170180 03 Cycle 03 Active US Services Maint. Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 198.12 /1 US Meter Maintenance Serial No Status Location Brand Type Size YTD Cons 0027321888 a Active ENC L ? w Water 0.63 0.63 0 Date Reading Code Consumption Posted Date Variance 9/18/2006 3099 a Actual 48 10/20/2006 136% Trouble Code:03 6/19/2006 3051 a Actual 23 7/10/2006 41% 3/8/2006 3028 a Actual 12 4/17/2006 -39% Trouble Code:03 12/22/2005 3016 a Actual 24 1/17/2006 Trouble Code:03 9/21/2005 2992 a Actual 36 10/14/2005 154% Trouble Code:03 6/27/2005 2956 a Actual 16 7/15/2005 2% 3/22/2005 2940 a Actual 16 4/5/2005 38% 12/13/2004 2924 a Actual 23 1/14/2005 -30% Trouble Code:03 9/16/2004 2901 a Actual 32 10/8/2004 69% Trouble Code:03 6/22/2004 2869 a Actual 15 7/30/2004 25% Trouble Code:03 4/15/2004 2854 a Actual 22 5/17/2004 0% Trouble Code:03 • Tel: (978) 475-4786 ' Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating-Water.& Sewer Lines-Septic Systems&Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 163 Olympic Lane, North Andover Owner. Esterkes Date of Inspection: 10/20/2006 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Neil J. Bateson Bateson Enterprises, Inc. Town of North Andover, Massachusetts ` Form No. 3 f NORTH BOARD OF HEALTH • o ,t�.° ,,�.yO J tJ 3a e•, ._ ..< ori p � 19 °��..o • DISPOSAL WORKS CONSTRUCTION PERMIT CHUSE� Applicant 2z NAME AD RESS TELEPHONE Site Location /Z, � . lC ' ' Permission is hereby granted to Construct ( ) or Repair ( L)1 Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN, BOARD OF HEALTH 7 Fee ` 7-5 D.W.C. No. i 4 BOARD OF HEALTH NORTH ANDOVER, MA 01845 978-688-9540 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: CURRENT INSTALLER'S LICENSE# LOCATION: ��e�j Q ,.� G fw, LICENSED INSTA ER:_ SIGNATURE: TELEPHONE 7 �l d'�s3 CHECK ONE: REPAIR: NEW CONSTRUCTION.: IF -CONSTUCTION, PLEASE ACH FOUNDATION AS-BUILT. Administrative Use Only �J 7 Fee Attached? Yes No Project Manager Ob. Yes t/ No Foundation As-Built? Yes No Floor Plans? Yes No Date: Approval I INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at Z6 3 01y^- ,L relative to the application of L-A �5dr✓ dated for plans by and dated with revisions dated I understand the following obligations for management of this project: 1. As the installer I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer I must call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item three shall be applicable. 3. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Tile 5 and the Board of Health Regulations may result in a$50.00 fine being levied against my company. a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As-built or verbal OK from engineer must be submitted to Board of Health, after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be read and able t y o cause pump to work and alarm to function. c) Final Grade Installer must request inspection when all grading is complete. Does not have to be on site. 4. As the installer I understand that only I may perform the work (other than simple excavation) required to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation or suspension of my license to operate in the Town of North Andover; significant fines to all persons involved are also possible. 5. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached. b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff or consultant. d) Installation of tank, D-box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other Persons shall absolve me of this obligation. Undersi icensed Septic Installer Date: Disposal Works Construction Permit# COMMONWEALTH OF MASSACHUSETTS Z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS n r a d DEPARTMENT OF ENVIRONMENTAL PROTECTION F I � 9 Sy0 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_163 Olympic Lane_ _North Andover_ Owner's Name:_Jeff Esterkes Owner's Address: 163 Olympic Lane_ North Andover,MA 01845_ Date of Inspection:_11/15/2002_ Name of Inspector: Neil J.Bateson_ Company Name:Bateson Enterprises Inc._ Mailing Address:_111 Argilla Road_ Andover,Ma.01810_ Telephone Number:_(978)475-4786 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: �X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fail Inspector's Signature: Date: 11/15/2002 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments:After permit from B.O.H.,install new D-Boz,inspection from B.O.H.,septic system now passes Title 5 Inspection. ****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. A r i COMMONWEALTH OF MASSACHUSETTS z g EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS � d DEPARTMENT OF ENVIRONMENTAL PROTECTION 142002 TITLE 5 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_163 Olympic Lane_ _North Andover Owner's Name: Jeffrey Esterkes_ Owner's Address:_163 Olympic Lane_ _North Andover,MA 01810_ Date of Inspection:_10/26/2002_ Name of Inspector: Neil J.Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address:_111 Argilla Road_ _Andover,Ma.01810_ Telephone Number:_(978)475-4786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes X Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: _10/26/2002_ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the-inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments:Needs D-Boz. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection,does not address how the system will perform in the future under the same or different conditions of use. r Page 2 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_163 Olympic Lane_ _North Andover_ Owner: Esterkes Date of Inspection:—10/26/2002_ Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D I 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: �I B. System Conditionally Passes: _X_ 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. Needs D-box, Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. _N_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: _N_ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: N_ 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: i Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_163 Olympic Lane_ _North Andover— Owner: Esterkes Date of Inspection:_10/26/2002_ 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 i 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well's*.Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: i Page 4 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_163 Olympic Lane_ _North Andover— Owner: Esterkes Date of Inspection:_10/26/2002_ D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _No_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool —No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool —No— Static liquid level in the distribution lox above outlet invert due to an overloaded or clogged SAS or cesspool _No_ Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/i day flow No Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _No_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well. No Any portion of a cesspool or privy is within 50 feet of a private water supply well. _No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] _No_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large.Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone ll of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:_163 Olympic Lane_ _North Andover— Owner: Esterkes Date of Inspection:_10/26/2002_ Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Yes _ Pumping information was provided by the owner,occupant,or Board of Health No Were any of the system components pumped out in the previous two weeks? Yes_ — Has the system received normal flows in the previous two week period? _ _No Have large volumes of water been introduced to the system recently or as part of this inspection? _Yes_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) Yes _ Was the facility or dwelling inspected for signs of sewage back up? Yes_ — Was the site inspected for signs of break out? Yes_ _ Were all system components,excluding the SAS,located on site? _Yes_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _Yes_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Yes _ Existing information.For example,a plan at the Board of Health. _No_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] I Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_163 Olympic Lane_ _North Andover– Owner: Esterkes Date of Inspection:_18/26/2002_ FLOW CONDITIONS RESIDENTIAL 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:_3 Does.residence have a garbage grinder{yes or no): Yes_ Is laundry on a separate sewage 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: Sump pump(yes or no): Yes_ Last date of occupancy: Current I – COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER{describe): GENERAL INFORMATION Pumping Records j Source of information: Pumped last year,owner Was system pumped as part of the inspection(yes or no):_No If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _3 Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) __._Tight tank _Attach a copy of the DEP approval —Other{describe): Approximate age of all components,date installed(if known)and source of information: 22 Years old. 9/4/1980 As built plan. Were sewage odors detected when arriving at the site(yes or no): No_ Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION{continued) Property Address:_163 Olympic Lane_ _North Andover— Owner: Esterkes Date of Inspection:_10/262002_ BUILDING SEWER(locate on site plan)X Depth below grade: 24" Materials.of.construction:_X cast iron _X_40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.):_4"Cast iron thru wall. 3"PVC in house. No leaks. -SEPTIC TANK: X locate on siteplan) Depth below grade:_12" Material of construction:_X_concrete_metal_fiberglasspolyethylene _other(explam) If tank is metal list age:_ is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 10'x 5'x 4' Sludge depth 1" Distance from top of sludge to bottom of outlet tee or baffle: 26" Scum thickness: 0 Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: " _21 _ How were dimensions determined:_Subtract scum&sludge depth to tee length._ Comments(on pumping recommendations,.inlet and.outlet tee or baffle condition,structural integrity,.liquid levels as related to outlet invert,evidence of leakage,etc.):_Inlet tee ok.Outlet tee ok.Depth of liquid at outlet invert. No evidence of leakage_ GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass___polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_163 Olympic Lane_ North Andover— Owner: Esterkes Date of Inspection:_10/26/2002 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) I Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:_X_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_-2" Comments note if box is level and distribution to outlets equal,an evidence of solids carryover,an evidence of ( �l � Y Y � Y leakage into or out of box,etc.): Liquid level in d-box 2"below inverts.Evidence of leakage.Evidence of carryover. Needs d-box replaced._ PUMP CHAMBER: (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.): I Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_163 Olympic Lane_ _North Andover_ Owner:_Esterkes_ Date of Inspection:_10/26/2002_ SOIL ABSORPTION SYSTEM(SAS):_X (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: _X_leaching fields,number,dimensions:_1 field 20'x 401 _ overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.):_Soil ok.Vegetation ok.No sign of ponding to surface. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_163 Olympic Lane_ _North Andover_ Owner: Esterkes Date of Inspection:_10/26/2002 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. House Garage Water Meter Ar"A B Driveway A to Tank=14'8" A to D-Bog=30'8" Septic Tank B to Tank=40' B to D-Bog=48'3" D-Bog 20' 40' i Page 11 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_163 Olympic Lane_ _North Andover— Owner: Esterkes Date of Inspection:_10/26/2002_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water >6 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) X Accessed USGS database-explain: Essex County Soil Map_ You must describe how you established the high ground water elevation:_Essex County Soil Map,Sheet#37, Canton Soil,Water>6'deep, • Tel: (978) 475-4786 • Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating-Water.& Sewer Lines-Septic Systems &Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 163 Olympic Lane, North Andover Owner: Esterkes Date of Inspection: 10/26/2002 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. C r Neil J. Bateson Bateson Enterprises, Inc. r • r " r 0 WATER BILLING HISTORY 3170180-ESTERKES, JEFFREY METER 11111 : 3170180 utloC3k °': --------------------- 163 OLYMPIC LN = - o 0 CYCLE SERUICE PRIOR CURRENT USE WATER SEWER FEES TOTAL y 1 2000-13 10/01/1999 2151 2279 128 349.44 0.00 0.00 349.44amt w 2 2000-23 01/06/2000 2279 2312 33 90.09 0.00 0.00 90.09rte'<� °v Mi 3 2000-33 03/30/2000 2312 2328 16 43.68 0.00 0.00 43.6B t:r ,Go 4 2000-43 06/20/2000 2328 2353 25 68.25 0.00 0.00 68.25 5 2001-13 09/20/2000 2353 2397 44 120.12 0.00 11 .00 131 .12 6 2001-23 01/02/2001 2397 2421 24 65.52 0.00 11.00 76.52 w 7 2001-33 04/02/2061 2421 2441 20 54_60 0.00 11.00 65.6 8 2001-43 06/19/2001 2441 - 2477 36 98.28 0.00 11.00 109.28 " 9 2002-13 09/16/2001 2477 2543 66 214.S4 0.00 5.55 220.09_ r _ .:;.:;�;- -_ x;10 2002-23 01/30/2802 2543 2592 49 135.59 0.00 5.55 "141.14_ 11 2002-33 04/04/2002 2592 2615 23 60.17 0.00 5.55 65.72 rrtoad.hd{ ."- �_ _ z 12 2002-43 06/87/2802 2615 2648 25 67.35 0.00 5.55 72.90 ---- " 13 2003-13 69/13/2002 2640 2709 69 226.70 0.00 5.97 232_67 -_ .�::•-.cam.>-- '� I Computer _ tl REVIEW CHOICE 8 or <ENTER> MORE HISTORY: ei WOM ip Excel Work_ _ Orme Outlook -:}Deltnet Signup Games - y W°� Sress ervices Ex _ _-- p - --_ - ;. - t -- .rte. -- - - :� •:� ... _ --r:^rif .._ :: ,•E'l;.i _ max-._. __. 2 r • `:.�•,�.'AY�::'. ^=a'1.:'- .. . ..:.. . .:'.. : "mac,: n..�';..::' i7- - 4.u1:::tlT� �:..y_i ..___,___ _ +J�4�i+..L.J S I� -r_::s=__3G�'t-`SeT-. _ __._-_ :i". -. -•�-• " _ .. - . - "• .. ti - it _ 4.410 q5r , a a, Y 1 -=•••-- ,r ;f ��'• �Uf,•'+`l� �,�it,�C:v��, � fit �i ] . - l • •_ ` z�:n. 2 _-fid► .r�: PA-r -j S"T ., ,tom mw _ _ /� Y F% .� 4 1 � 11 _ � � � � a7 �� y �- . � �, �� C� L � w� p ► L. 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