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Miscellaneous - 1601 SALEM STREET 4/30/2018 (2)
_ 1601 SALEM STREET 210/106.6-0006-0000.0 i r �e j r y y —a c c5— .o North Andover Board of Assessors Public Access Page 1 of 1 koRlr,4 Town of Worth Amdov—or 'ho $;oard CW Assessors. r n ZE��tl ap y Property �g���s�� � Return io the Home page click on logo Record Card Parcel ID:210/106.13-0006-0000.0 Community:North Andover SKETCH. PHOTO New Search Click on Sketch to Enlarge Sales N0, CI � WX Summary Residence Available Detached Structure Condo Commercial Comparable Sales Location: 1601 SALEM STREET Owner Name: MALLECK,REED Owner Address: 1601 SALEM STREET City:NORTH ANDOVER State: MA ZIP: 01845 Neighborhood: 6-6 Land Area: 1.01 acres Use Code: 101 -SNGL-FAM-RES Total Finished Area: 1236 sqft i ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 407,800 390,500 Building Value: 176,900 180,500 Land Value: 230,900 210,000 Market Land Value: 230,900 Chapter Land Value: LATEST SALE Sale Price: 419,000 Sale Date: 11/29/2004 Arms Length Sale Code:Y-YES-VALID Grantor: SYED,SOPHIA Cert Doc: Book: 9215 Page: 71 i i i http://csc-ma.us/NandoverPubAce/jsp/Home jsp?Page=3&Linkld=991022 9/14/2007 F ' Y f Lot & Street Map/Parcel�f} CONSTRUCTION APPROVAL a Has plan review fee been paid: YES NO Permit# / t5 Plan Approval: Date: a't _4Approved by:�,Q� -- Designer: 0560 J Plan Date: Conditions: _14—�� T 65 21 G 7210 0 S Water Supply: Town- Well -- Well Permit: Driller: Well Tests: Chemical Date Approved -- Bacteria I Date Approved -- - Bacteria H Date Approved Plumbing-Sign-Off Wiring Sign-Off: -Comments: -- Form"U" Approval: Approval to Issue: YES NO - - _Date Issued By: Conditions: Final Approval: All Permits Paid? YES NO Well Construction Approval? YES NO Septic System Construction Approval? YES NO Certification? YES NO Other YES NO Any Variance Needed? (�G a y`� YES NO 3,36 6 Pd FINAL BOARD OF HEALTH APPROVAL: DATE: J 00 APPROVED Bi(:- d� SEPTIC SYSTEM INSTALLATION T J Is the installer licensed? Type of Construction: -- P� J New Construction: Certified Plot Plan Review --- Floor Plan Review YES- NO —-- Conditions of Approval from Form U YES NO - \b . Issuance of DWC permit: NO DWC Permit Paid? YES NO -- =- DWC Permit _' Installer- c`ndy-l 7 r - Begin Inspection- - - =— - S - NO w Excavation Inspection: _ e Needed: Passed: 1 By; - - Construction Inspection: Needed: - It Plan Satisfactory,f YE Approval of Backfill: Date: `rh o By: - Final Grading Approval: Date: -,, < By: Final Construction Approval: Date: c By:_ Certificate of Compliance: Approval: f/C, /mate: _ C TRAhJSMISSION VERIFICATION REPORT TIME 08x'0612007 09:19 NAME : HEALTH FAX 9786888476 TEL 9786888476 SER. # : 000B4.J120960 I DATE.TIME 08!06 09: 16 FAX NO. 1.4-AAME 81877.-1299973 DURATION 00:02:07 PAGE;.S 06 RESULT OK MODE STANDARD E-M NORra North Andover Head#h_®e�ortrnent 1600 Osgood Street Letter of Transmittal 0 Building 2'0:, Suite 2-36 _ � North Andover, MA 01045 oLAMB 978.688.9540 - Phone Page of 970.688.0476 ® Fax g healthdept@tbwnofnorthandaue.r,cAm- E-mail www.townofnorthandover.com -Website T0: DATE; / COMPANY: FROM: Pamela DelleChiaie,Health Department Assistant w, -- }. y/ RE: / Fax: 7, We are sendhiq you. O Copy of Leffer O Plans P61her tfal/in below/ These are transmitted as checked below; > L74Tmwd#yNWbd ➢ azn&*_apt sfor i ®�Ragrtiie�d L7rwr&ri& > LyAdydt afiislbr&f REMARKS: COPY TO: TRANSMISSION +ERIFICATIOH REPORT TIME 00/06/2007 09:32 NAME HEALTH FAX 9786888476 TEL 9786888476 SER. # 000E4J120960 DATE,TIME 08/06 09:26 FAX NO./NAME 818773"99973 DHRATI Ohl t--i0:06:43 PAGE(4 19 RESULT OK: MODE STANDARD EC1,1 North Andover Health Department AOR'r#1 � 4��.11-1ko �6. tiG 1600 Osgood Streets �,,.,,< '^. 0 Building zo, surra 2-36 Letter of Transmittal � � -• North Andover, MA 01845 01845 � 9B 8.688.9540 - Phone � a*.teetie�..It.,�1� '� 978.688.$47b � fax Page / of •.� '�,� °qA*.s•*��� S�ACHU`3� htka.lihdep't a.townofnorth®ndc_v_C com-E-mail www.townofpoCthandover.com-Website TO: 11 DATE- 7�e 6-vi __- & - 1_9(1.�, _1�01 COMPANY: FROM: Pamela DelleChiaie,Health Department Assistant Phone: RE: j� f34AW We are seaafir g fox 0 6,vy of lefter O Plrxns gff,,ber(fill iv be/ow) These are transmitted as checked below: i5 ® rn►r�Nni�a► IJFvr4q ► ➢ L7� mpi�rl6ar > Orw wa ndavr w# amoral ©Qs m L7l�arYaG > > L71drrr't asibra�f. REMARKS: I COPY TO: ' I North Andover Health Department c� `ORT" qti 1600 Osgood Street Letter ®f Transmittal 3? - Building 20, Suite 2-36 ° 0 North Andover, MA 01845 . ey 978.688.9540 - Phone �j(� T � COCNKw�wNw y7 \J �� Page / of � qs 4�R^Tto �t 978.688.8476 — Fax Sq c►+US healthdept(CD-townofnorthandover.com-E-mail www.townofnorthandover.com-Website T0: DATE: ✓fr COMPANY: �� � FROM: Pamela DelleChiaie,Health Department Assistant a �4le,,' Lc Z'V_ f Phone: .r �J� L(/ Jl�CO� Alp 0 f Fax: �/ / • / / / / — We are sending you: O Copy of Letter O P/twu ther(fill in below) These are transmitted as checked below: ➢ L7*pwedarNbW ➢ Okr4Pad ➢ OResv*nt gpri sfar ➢ a4slWsft l ➢ OkrRbWvwamYwnv W aporard REMARKS: / COPY TO: COPY TO: COPY TO: SIGNED: COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS r d DEPARTMENT OF ENVIRONMENTAL PROTECTION yt TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A `` J) CERTIFICATION Property Address:' k /yt goi4 Owner's Name: ' Owner's Address: S Date of Inspection: 17 F-oJ a RECEIVED Name of Inspector: (please print)S/11" 3U.SQ AUG O s 2004 Company Name: 'e Mailing Address: A6 TOWN OF NORTH ANDOVER moI HEALTH DEPARTMENT Telephone Number: q'7gc -I CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority i F ils Inspector's Signature: 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.-This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I .r Page 2ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:1(,oQ 1 qol ph-) N C�/�)�'6W12 i rfla 1 s`. �Olwner.• �� �� Date of Inspection: "7—a�-� Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: 4- � 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. s 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'"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 �r =approval of Board of Health): broken pipes)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more'than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced 1 obstruction is removed ND explain: 2 a Page 3 of 11 a OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 11%0 0/ �qo/e m ��/ NO, Q/lll��t/PJ� f Owner:b�/e4p , Date of Inspection: 17 C. Further Evaluation is Required by the Board of Health: )`lk 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(i)(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 areirigiered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 Q OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 01 oTwovep,. Owner: q e-o _ Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No --Ifiackup 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 ''/z day flow _✓~Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. _ ✓�Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ ✓Any portion of a cesspool or privy is within a Zone 1 of a public well. 'Any portion of a cesspool or privy is within 50 feet of a private water supply well. --?,,'Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (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: —� `4 Tobe considered•a-large system the'system must serve a-facility with a design flow of 10,000gpd to 15,000 I. 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 trapped 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. 4 * Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: �J 1) ST, Owner: G,/e,0 Date of Inspection: r]- -D 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 ; . _ pt 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? _ ave 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: P� a Yes no r 3 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)[3 10 CMR 15.302(3)(b)] 5 Page 6 of l l r ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: ) 60/ S a l em S Owner: �] �/P Date of Inspection: —D y FLOW CNDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): Ho Is laundry on a separate sewage system(yes or no):Hp [if yes separate inspection required] Laundry system inspected(yes'or no):` Seasonal use:(yes or no): ` Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):ACS / Last date of occupancy: J /'u r�GG COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): =S If yes,volume pumped/r 12 gallons--How was quantity pumped determined? Reason for pumping: f /r e°cw« i �2_(/Ci c�LC ;s TYPE OF SYSTEM T t/Septic tank,distribution box,soil absorptian systiem _Single cesspool _Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Altemative 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: Were sewage odors detected when arriving at the site(yes or no): �! 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: l�n IP,tzST j j2. J� n/)✓elj'�, /L) � . Owners. "/ Date of Ins ection: � �g—b`t BUILDING SEWER(locate on site plan) Depth below grade: )"' Materials of construction:_cast iron L,-'40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on,condition of joints,venting,evidence of leakage,etc.): ." •� ,> v SEPTIC TANK://`S(locate on site plan) Depth below grade: Material of construction:concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: e r r Sludge depth: "' ?'' Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: / " f „ Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: 6 /-/ S / T/_= Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 10— / GREASE TRAP;` locate on site plan) A1 Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 A a OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: lla0Y7 S Owner: e�e-b Date of Inspection: 1-7 TIGHT or HOLDING TANKk(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:�I'�S(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: UJ 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.): L///f S 1--�Z ou..5 2�C/3 0 j- C d d r? Pe 7-7o I PUMP CHAMBERL'(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.): s 8 Page 9 of 11 M a y.. r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10n I �q/P��1 Owner: S\i e o h Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: 1 Type a f leaching pits,number:_ leaching chambers,number: leaching galleries,number: beaching trenches,number,length: L J-f 41 S -I—u t 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.): HO S/16-1 v`(c_ )CA14'ui2r—, — V,6G. /vl91211n :;;L CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): r 4 r / PRIVYd'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.): 9 Page 10 of 11 4 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION(continued) Property Address: C Owner: S\,-/ °LL NO. QIUDOVCLIX-4 Date of Inspection: f l—,:;V3 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. t t , jV- 4, / 7-a7�: 3. �a % T- `" r, 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ) 6 o I `_,II Pm�;l . n�(LQ8jy wl;M.11.Owner:�4 ��' Date of Insliection: SITE EXAM Slope Surface water Check cellar Shallow wells 1 Estimated depth to ground water feet ' Please indicate(check)all methods used to determine the high ground water elevation: LI/Obtained from system design plans on record-If checked,date of design plan reviewed: 4�I 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: ����c«-, o.� �'-�t�u, ��•� (�r fig �/��ra c -- vi' ' Qy t � �'�'a v�,� ivr�r�v 11 i R.J . INSPECTI Y NS , INC. HOME INSPECTION CO. 1 Osgood Street, Methuen, MA 01844 • 443 Toland Road, Dover, NH 03820 1-800-253-4402 t April 27, 1999 Town of North Andover Health Department 27 Charles Street North Andover,MA 01845 To Whom It May Concern: We are not sure if you have already received this paperwork for 1601 Salem Street,North Andover. If it is a duplicate,please disregard. Sincerely, S> < s F � Susan Van Meter Secretary .sVm ,. .. E Enclosure F TOWN OF NORTH ANDOVER/ BOARD OF HEALTH EAR 29 1999 1 RADON • LEAD • TERMITES COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET,BOSTON MA 02108 (617)292-5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUAS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION PropartyAddress: 1601 Salem St. , N. Andov@Pneafourne►p=i „H Q_ Rae Knowles Address of Owner- Date of Inspection: 2/25/99 , N.Andover Name of'l span (Please Prim) jim I on a DEP approved system inspector rsuarrt to Section 15.340 of roe 5(310 CMR 15.000) Company Name: R .T 1--n-SPP e t r e Maing Address: Telephone Number: Street, u e n, MA 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: _ Passes _ CF a f1s 'onaUy Passes _ urther Evaluation By the Local Approving Authority Inspector's Signature: Date: f The System Inspeofo hall submit a copy of this inspection report to the A p p pproving Authority(Board of Health or DEP)within thirty(30)days of completing this i� ection. 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. NOTES AND COMMENTS revi sed,'9;/2/9 S- Page.i of ti qD Punted on Reryded Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(cortlinued) Property Address: 1601 Salem Street, North Andover MA Owers: Ralph & Rae Knowles Daft of kopectim 2/25/99 eIISPECTION SUMMARY: Cued A, B, C, or D: A. SYSTEM PASSES: 1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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 exfiltration, 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) arereplaced 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 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Prole rtyAddress-- 1 601 Salem Street, North Andover MA Owner Ralph & Rae Knowles Data of Inspection: 2/25/99 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 N A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENIORONNI@LL- Cesspool or privy is within 50 feet of 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 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 I 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 (approximation not valid). 3) OTHER revised 9/2/98 Page 3.of11 _.-.---•. - SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued} PropertyAddrea- 1601 Salem Street, North Andover MA Owner: Ralph & Rae Knowles Data of Impecuon:2/25/99 D_ SYSTEM FAILS: You must indicate either"Yes" or"No" to each of thefollowing: I 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 intofacilityor system componentdoe"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 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 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 to a,vo ab a 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 targe 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 exist: Yes No the system is within 400 feet of a surface drinking water supply the system is.within 200 feet(if-e-tributary to a surface drinking water supply -••-a -- --.�- 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 4of11 ` f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1601 Salem Street, North Andover MA owner: Ralph & Rae Knowles Date of a"ecti°n: 2/2 5/9 9. Check if the following have been done:You must indicate either"Yes" or"No" as to each of the following: Y!!,,— No. Pumping information was provided by the owner,occupant,or Board of Health. • _ None of the system components havabeen pumpeddorat-least two weeks and-the system hasA"ww scaivingflow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. { The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components,excluding the Soil Absorption System,have been located on the site. 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:- 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) [1 5.302(3)(b)] -- _ The facility owner(and occupants.if different from-owner).were provided with infarmatioo.on tha.proper rnaintenaara-0f SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1601 Salem Street North Andover MA Owner: Ralph & Rae Knowles Dabs of Ynpectiorr 2/2 5/9 9 FLOW CONDITIONS RESIDENTIAL: Design flow—_____g—p.d./bedroom. Number of bedrooms(design): Number of bedrooms(actual)_ Total DESIGN flow Number of current residents: Garbage grinder(yes or no):...Y— Laundry(separate system) (yes or no):4; If yes,separateinspection-required _ Laundry system inspected (yes or no) Seasonal use(yes or no):_ _ Water meter readings,if available(last two year's usage(gpd): Sump Pump(yes or no): Last date of occupancy: COMMERCIALANDUSTRIAL• Type of establishment: Design flow:. qpd ( Based on 15.203) Basis of design flow Grease trap present:(yesi or ) Industrial Waste Holdin nk esent: as or no)_ Non-sanitary waste discharg to e 5 system: lyes or no)_ Water meter readings,if available: _ Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION. PUMPING RECORDS apd sourced o informati ` System pumped as part of inspection:(yes or no)_ If yes, volume pumped: gallons Reason for pumping: TYPE O STEM 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 instaNed{if known)-and source~ormadon: --- Sewage odors detected when arriving at the site:(Yes or no) revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART'C SYSTEM INFORMATION(continued) PropertyAddrej:601 Salem Street, North Andover MA owner: Ralph & Rae Knowles l Date of Impaction: 2/2 5 9 9 BUILDING SEWER: (Locate on site plan) Depth below grade:_ Material of construction:_cast iron_40 PVC_other(explain) Distance from p:,n1,f/Jn1/' tattar pply well or suction line Diameter Comments: onnting,evidence of leakage,-etc.) _.. SEPTIC TANK._ (locate on site plan) Depth below grader Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,.list age_ Is.age_confirmed by Certificate of Compliance_(Yes/No) Dimensions: S X (O Sludge depth: Distance from top of sludge to bottom of outlet tee or baffler r -- Scum thickness: 42 " Distance from top of scum to top of outlet tee or baffle:-2-L J{ Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: (1/-6 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.) GREASE TRAP: (locate on site plan) Depth below grade:_ I, Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(expiain) Dimensions: Scum thickness: Distance from top of scum t outlet tee or baffle: Distance from bottom of u o om 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 7of11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PravertyAddress: 1601 Salem Street, North Andover, MA 01845 Owren- Ralph & Rae Knowles Date of Impecaon: 2/25/99 TIGHT OR HOLDING TANK: (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' gallon Alarm present Alarm level: Alarm in wor in o er:Yes_ No Date of previous pumping: Comments:, (condition of inlet tee, condition f alarm and float switches,etc.) DISTRIBUTION SOX:_ (locate on site plan). Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of soli s carryover, evidencp of leakage into or out of box, etc.) — PUMP CHAMBER-_ (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes r ) Comments: (note condition of pump amber co on of pumps and appurtenances,etc.) revised 9/2/98 Pages of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropertyAddress: 1601 Salem Street, North Andover MA Owner: Ralph & Rae Knowles Data of kispead m: 2/2 5/9 9 SOIL ABSORPTION SYSTEM(SAS):— (locate on site plan,if possible;excavation not required,location may be approximated by non4ntrusive methods) If not located,explain: Type: leaching pits,number:_ leachitig chambers,number:_ leaching galleries,number:_ „ leaching trenches,number,length: p leaching fields,number,dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: . (note condition of soil signs of hydraulic failure,level of p ding, amp soil,condition of vegetation, etc.) AV CESSPOOLS:_ (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: 4 inflow (cesspool mui bqVpumped as part of inspection) 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 hydrauli/ilur I el of ponding, condition of vegetation, etc.) revised 9/2198 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: 1601 Salem Street, North Andover MA 0' Ralph & Rae Knowles Daft of Impeeoon. .. 2/25/99 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) �f Ae I 1 I a� I - I revised 9/21/98 Page 10 of 11 i Septic System Information w 1601 SALEM STREET Printed On:Friday, September 14, 200 System ID: BHS-2002-1531 General System Information Latest Permit Information Calcaluted Design Flow: Test Pits Septic Tank Disposal Trench Design Flow: One Two Capacity: Number: r Design Flow Provided: Minutes per inch: Width: Width: Total Flow: Depth: Length: Length: Seasonal: No No Depth to Water: Diameter. Leaching: Grinder: No No Soil Type: Depth: Laundry: No No Hauling/Pumping Listin Quantity Tvpe System Type Pumped Pumped By Transferred To Disposed At Date Pumped allons Routine Septic Tank Andover Septic 07/28/2004 1000 Routine Septic Tank Service Pumping&Drain Co., I GLSD 06/21/2006 1000 Inspections: Inspected: Expires: Inspector. Status: 08/08/2007 Charles Roux Passes Comments: Title 5 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Page 1 of 1 Vf . '. Ct 40RT",M r L ,; Town of North Andover HEALTH DEPARTMENT 'S CMU•+�� CHECK#: DATE: LOCATION: H/O NAME: 4. CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ? ❑ Funeral Directors $ ❑ Massage Establishment $ 'k ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ` ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title�5 Inspector $ :y°I"tle 5 Report $ k' ❑ Other. (Indicate) $ 2593 Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer COMMONWEALTH OF MASSACHUSETTS l ' EXECUTIVE OFFICE OF ENVIRONMENTAL .i, t i DEPARTMENT QF 1g& ENTAL PR ON AUG 2 7 2007 Tvw. �a HEAD TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM F ! ` ' PART A I CERTIFICATION !w 1 Property Address: ! b Owner's Name •. ... M.�:.�. p:G. ...., _.. .. , . ;,i;;.,� r ;;I7- �', Owner's Address: 4 a m Q Date of Inspection: " R —6-1 !c � I Name of Inspector: (Please print) _Qh gr l e S T R o we t ij i Company Name: Teviks6LLrW Cetoy-e r-ryl/•e_ Mailing Address: .IF3 2*+1ra Rd. Telephone Number: C974G CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and at ormation reported below is true,accurate and complete as of the time of the inspection. The inspection was erf9 m ., 'based on my training and,experience in the proper function and maintenance of on site sewage dispos syste, _ iI!,am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The yste Passes Conditionally Passes t Needs Fu valuation by the Local A rovin uthority _ Fails " Inspector's Signature: Date: ',-r v d: f , The system inspector shall submit a copy of this inspection report to the Approving Auth ity�(Bc�ard of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or ha a desigtl flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropr to regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if ap 'cable;And the approving authority. Notes and Comments 1' { 1 *»fir ia'�'.'I. .. This report only describes conditions at the time of inspection and under the c d16"ts'"of use at that time. This inspection does not address how the system will perform in the future detltl)e!same or different conditions of use: ",i',�.f a Title 5 Inspection Form 6/15/2000 page 1 1 ' Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTAR 'AtSSSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPE LRM PART A t } CERTIFICATION (continued) PropertyAddress: Owner: I i ` G ` . i r Date of Inspection. MT Inspection Summary: Check A,B,C,D or E'/ALWAYS.'complete all of Sectio A. System Passes: fi VI have not found any information which indicates that any of the failure criteria des 0CMIZ 15.303 or in;310 CMR 15.304.exists. An failure criteria not evaluated are indicated below omment F•,� �' � ,� N'A e (-s MVAAVA f -efwf 144 ���;h� I I, B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section nee to be placed or repaired. The system,upon completion of the replacement or repair,as approved by the arc. Eof Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the follow ng statements. If' of rmined"please explain. }: ' it i,I is•. The septic tank is metal and over 20 years old*or the septic nk(whether metal or ot)'4s, ylCturally unsound,exhibits substantial infiltration or exfiltration or tank f ure is imminent. Systei w; 'p f+ !inspection if the existingtank is replaced with a complyingse tic tank as a ro d b the Board of Health P P PP Y *A metal septic tank will ass inspection if it is structural) so d,not leaking and if a Ce ific f Compliance P P P Y S to indicating that the tank is less than 20 years old is available. P ND explain: k' r Observation of sewage backup or break out or gh static water level in the distrib ion bo due to broken or obstructed pipe(s)or due to a broken,settled or unev distribution box. System will pas ins l I`I'o'if(with approval of Board of Health): PP ) broken pipe(s) re replaced ' obstruction is emoved distribution ox is leveled or replaced ' ND explain: The system required pumping more an 4 times a year due to broken or obstructe pipes) The system will pass inspection if(with approval of the B rd of Health): f ', �bro en pipe(s)are replaced � t o; ob uction is removed ND explain: 2 � J i Page 3 of 11 ) r 'T ;OFFICIAL INSPECTION FORM-NOT FOR VOLUNTAR SMSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPE j ; , RM PART A t, CERTIFICATION (continued) S PropertyAddress: X4.61 � I`P N'( Owner: I t Date of Inspection: C. Further Evaluation is required by the Board of Health: Conditions exist which require further evaluation by'the Boar f Health in order !`' if the system J t . is failing to protect public health,safety or the environment. i 1. System will pass unless Board of Health determines in cordance with 310 CM 1 0 (lj(b)that the system is not functioning in'atmanner which will prot t public'health,safety d"tli a ivirbnment: !I _Cesspool or privy is within 50 feet of a surface w er Cesspool or privy is within 50 feet of a border' vegetated wetland or a salt n larsh! j '! it2. System will fail unless the Board of Health(and Public Water Su plier,if any)c eter' es;that the system is functioning in a manner that protects the public healt ,safety and en ronme t: —The system has aseptic tank and soil absorption system( S)and the SAS is ithui l , ;feet of a surface water supply or tributary to a surface water supply. { i. i The system has aseptic tank and SAS and the SAS is ithin a Zone I of a publi water supply. _The system has a septic tank and SAS and the SAS s within 50 feet of a privat water supply well. The system has a septic tank and SAS and the S is less than 100 feet but 50 f t orimPre from a private water supply well**Method used to deter ine distance **This system passes if the well water analysis performed at a DEP certified labor o for Icoliform �'� bacteria and volatile organic compounds ind' A/ "This that the well is free from polluti n#igrri that facility and ! the presence of ammonia nitrogen and nitra nitrogen is equal to or less than 5 pp ,provided that no other failure criteria are triggered. A copy of the nalysis must be attached to this form. 3. Other: :i 3 Page 4 of 11 K" OFFICIAL INSPECTION FORM-NOT FOR VOLUNTAR tS S,SMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPE ORM PART A CERTIFICATION (continued); PropertyAddress• J Owner: Date of Inspection: D. System Failure Criteria applicable to all systems: {1 You must indicate"yes" or"no" to each of the following for all inspections: " 64 I Yes Ng� ✓ t Backup of sewage into facility or system component due to overloaded or clo ge ,� icesspooI 1/— Discharge or t(^ verloaded or g. ponding of effluent to the surfaceof ground or,surface Ovate , ,„ clogged SAS or cesspool ' Static liquid level in the distribution box above outlet invert due to an overloaed or logged SAS or cesspool ! �lE Liquid depth in cesspool is less than 6"below invert or available volume is lest than%day flow /V Required pumping more than 4 times in the last year NOT due to clogged or pbs cted pipe(s). Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevatin. Any portion of cesspool or privy is within 100 feet of a surface water supply trip' '"to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. V Any portion of a cesspool or privy is within 50 feet of a private water supply ell: I/ Any portion of a cesspool or privy is less than 100 feet but greater than 50 fee fro a,.private water supply well with no acceptable water quality analysis.[This system passes if her rewater analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile mganic compounds indicates that the well is free from pollution from that facility and the pres a of ammonia nitrogen and nitrate nitrogen is equal to or less that 5 ppm,provided that n ofh f 'lure criteria are triggered. A copy of the analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above fail re c: `teria exists as described in 310 CMR 15.303,therefore the system fails. The system owner sl uld c (tact the Board of Y Y q Health to determine what will be necessary to correct the failure. "I E. Large Systems: ' I ilr, To be considered a large system the system must serve a facility with a design now o 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 e criteria above) f ;i yes no f it the system is within 400 feet of a surface dr' in water supply the system is within 200 feet of a tributa to a surface drinkingwater supplyI'r the system is located in a nitrogen se itive area Interim Wellhead Protection r ! Y g ( ea , A)or a mapped , Zone II of a public water supply w 1 rr: I . If you have answered"yes"to any question Section E the system is considered a signifi lint thre t,or answered "yes"in Section D above the large system D/ failed. The owner or operator of an large s s ,�; g Y p y g tern considered a significant threat under Section E or faile under Section D shall upgrade the system in ac ordark with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Departme t. �:�;I j , x ,14 4 ij , . Page 5 of 11 F� OFFICIAL INSPECTION FORM-NOT FOR VOLUNTAR ; S MENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEORM PART B1;R CHECKLIST' Property Address: Owner: Date of Inspection: Check if the following have been done. You must indicate"yes"or"no"as to each of th fol11 . Yes No �� } ✓ _ Pumping information was provided by the owner;occupant,or Board of Healt i . •+} ' r ✓ Were any of the system components pumped out in the previous two weeks? ' I ✓ _ Has the system received normal flows in the previous two week period? [I ✓_ Have large volumes of water been introduced to the system recently or as part f thisinspection? Were as built plans of the system obtained and examined?(If they were not av ilabl' note.4 N/A Was the facility or dwelling inspected for signs of sewage back up? _ Was the site inspected for signs of break out? ' I Were all system components,excluding the SAS,located on site? Were the septic tank manholes uncovered,opened,and the interior of the tanknspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,dep of'fudge and depth of scum? L _ Was the facility owner(and occupants if different from owner)provided with o tion on the proper maintenance of subsurface sewage disposal systems? i (' ij. The size and location of the Soil Absorption System(SAS)on the site has be n determined based on: Yep no i V _ 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 ippioximation of distance is unacceptable) [310 CMR 15.302(3)(b)] ij �i 5 �Fi' W, { Page 6 of 11 �4 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTAR tSs� 5SMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPE 1. 1Q' RM PART C 1SYSTEM INFORMATION Property Address: p , Owner: Date of Inspection: !. FLOW CONDITIONSWt 4 I RESIDENTIAL a ' h , m (design): Number of bedrooms(actual): + Number o�bedrooms(de gn)•� ( ) DESIGN flow based on 310 CMR 15.203(for example:110 gpd x#of bedrooms): Number of current residents: l i Does residence have a garbage grinder(yes or no): Is laundry!on a separate sewage system( es„or',no) [if es cepa ate inspection•regt�'retfi� l h Laundry system inspected es or no):w Wel( i Seasonal use:(yes or no): r � i . Water meter readings,if avail ble(last 2 years usage(gpd)): e A G e ►a t C7 Sump pump(yes or no): 1r l e p j/.Sft S Last date of occupanc COMMERCIAL,/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 1 03): gpd I I. Basis of design flow(seats/perso /sgft,etc.): Grease trap present(yes or no): I �' Industrial waste holding tank resent(yes or no): ! Non-sanitary waste discharg d to the Title 5 system(yes or no): Water meter readings,if av lable: Last date of occupancy/us : ;! j OTHER(describe): ! GENERAL INFORMATION Pumping Records ( i Source of information: Ivy - )rl,e r Was system pumped as part of the inspection(yes or no): AJ If yes,volume pumped/ gallons--Ho was quantity pumped determined? l Reason for pumping: 474 7Y E OF SYSTEM ' .�L Septic tank,distribution box,soil absorption system ! ti —Single cesspool —Overflow cesspools —Privy —Shared system(yes or no)(if yes,attach previous inspection records,if any) { # Innovative Alternative technology. Attach a co of the current r f / operation ation and mainle c ontract to be — g3' PY P ( obtained from system owner) I ' — Tight tank Attach a copy of the DEP approval — Other(describe): Approximate age of all components,date installed(if known)and source ofinf rmation• I ;, Were sewage odors detected when arriving at the site(yes or no): ,I All `I. I Page 7 of 11 1 7r!} OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY P SMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPE a ORM PART C SYSTEM INFORMATION (continued) , Property Address: Owner: a Date of Inspection: BUILDING SEWER(locate on site plan) 'I Depth below, grade: Material of construction: cast iron 40 PVC oth (explain): r I Distance from private water supply well or suction line: a' Comments(on condition of joints,venting,evidence of leakage,etc.): ,. Kk� SEPTIC TANK:�_(locate on site plan) Depth below grade: d j Material of construction:z concrete metal_fiberglasspolyethylene g I .' other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no (( + I a copy of certificate) Dimensions: X ( � a Gf'15- i Sludge depth: Distance from top ofudge to bottom of outlet tee or baffle: Scum thickness: ' 1. _ 1 Distance from top of scum to top of outlet tee or baffle: ;I Distance from bottom of scum to bolt of utlet ee o baffle: ' L,,J How were dimensions determined: 4 d — t 1 ' Comments(on pumping recommendations,iVdet and outlet tee or baffle condition,struc al 'te' ty,liquid levels as rel ted to outlet i vert,evidence of lea g etc.): ro -e(' b e(—c&)✓1 i y h" AVr vi 6=1, lv�„1 G:..; 112 I , GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: concrete_metal fiberglass_polyethylene $thee (explain): 1 , Dimension: ,I Scum thickness: j Distance from top of scum to top of outlet tee or baf e: Distance from bottom of scum to bottom of outlet t e or baffle: Date of last pumping: Comments(on pumping recommendations,inle and outlet tee or baffle condition,structural kerity,liquid levels as related to outlet invert,evidence of leakage, tc.): ,Ii,•,rl �, . ' t. IE 7 Page S of 11 r r , I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTAR MENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPE RM V PART C ;{ SYSTEM INFORMATION (continued) t f Property Address /b J `Q ✓� U I Owner Date of Inspection: TIGHT or HOLDING TANK:_(Tank must be pumped a 'me of inspection)(locarei Depth below grade: �! ,1 Material of construction:_concrete metal_fib glass_polyethylene_ t I ): Dimensions: .. ... �. /sor Capacity: gallonsDesign Flow: gallonsAlarm present(yes or no):Alarm level: Alarm in working or :Date of last pumping:Comments(condition of alarm and float sw l,i 1 j,;„•p l DISTRIBUTION BOX: (If present must be opened)(locate on site plan) hit'. Depth of liquid level above outlet invert: .L Comments(note if box is level and distribution to outlets equal,any evidence of solids car. oyI �; y evidence of aka into or out of box,etc.): L �- VL�Q11P6w 6le PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no):_ ni Alarms in working order(yes or no): /aer, Comments(note condition of pump ccondition of pumps and appurtenances,etc. : jI 1 i1 f� I ' 8 �{ff4r4r,1 I•I I Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY� a ,�SMENTS SUBSURFACE SEWAGE DISPOSALART C SYSTEM INSPEC 1 RM SYSTEM INFORMATION(continued) i' Property Address: Owner Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not,r If SAS not located explain why: • .i, -.i �>•fi:is'. Type leachingits,number: p � C' leaching chambers,number: leaching galleries,number:_ I leaching trenches,number,length: leachingfields,number,dimensions: d��4 C� overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil, nd}#ibh of vegetation, V 4i I'. ji CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan),, 1 1 Number and configuration: Depth-top of liquid to inlet invert: 4 ;,;•��'j' ".: Depth of solids layer: Depth of scum layer: ; I Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no 41, Comments(note condition of soil,signsof ydraulic failure,level of ponding,condition of vegetation,etc.): t . PRIVY:_(locate on site plan) Materials of construction: : Dimensions Depth of solids: Comments(note condition of soil,signs of hydr ulic failure,level of ponding,condition of'vegetation,.etc): (;11 9 1� Page 10 of 11 1 !s , OFFICIAL INSPECTION FORM-NOT FOR ; VOLUNTARX,AS SSMENTS i . ,i�,� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPE CORM PART C SYSTEM INFORMATION (continued) ai Z i� Property Address ( �Cl Owner: Date of Inspection: 1 SKETCH OF SEWAGE DISPOSAL SYSTEM , Provide a sketch of the sewage disposal system including ties to at least two permanent re r e17 Imarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters th .b .Pr'I r i I i I ( A IIj ,Iii ,. 10 . :I 11 f11 ' Page o OFFICIAL INSPECTION FORM-NOT FOR VOLUNTAR ! SMENTS ,1n SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPE FORM y. . PART C #,n.•:{ x ry SYSTEM INFORMATION(conten ued) Prop �� l � � e✓vl S�" erty Address: Owner: Date of Inspection: } 1 A � 1 SITE EXAM Slope Ij Surface water Check cellar Shallow wells 1 F Estimated depth'to ground water' 1 feet"" it ' 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: j r —Checked with local excavators,installers-(attach documentation) ;•,j Accessed USGS database-explain: You must describe howou established the hi ground w ' y high gd ater r elevation: 3, -� ( i i;}1,II I I ` I i' r�•jlj 'Ml;lii li }�jili . e� jl, Aug-06-07 07:3,2A"! e' lthWyse 877 329 9973 P. 12 OCT. 22. 2004 . ,1;:711P�! NO. 0255' P. 2 I� C , f j o g or c o� i i t Cr 40 r _ 102.3� c I,�� 3 I, � E �„• it h 3 il' f 1� I � I e f e , , I , .;li INSTRUCTIONS: This form u ' d to veri4 that all �" ' . fy necessary. approvals/pei-mits,fro`tt :. Boards Departments avtg j isdiction have been obtained. T ' �and Deartmethi his;does not relieve the applicant and/or.landowne fro compliance with any applicable or require; r�ents *******'"************''********�4PP ►C NT FILLS OUT THIS SECTION q A APPLICANT—EA �� IZ_ eD PHONE ! _ o 2-2.. LOCATION: Assessor's Map Number �.S'� ��� 6D'b?G PARCEL M A 2 ►v SUBDIVISION LOT(S) _ i STREET- DI �76 L.,eM 4,r , ST. NUMBER I O ************* *** *****************OFFICl1AL USE RE MMEiVDATIONS TOWN AGENTS: g CONSERVATION ADMINI ATOR DATE APPROVED DATE REJECTED COMMENTS "Rr,poK i a__S6oc. -u doo I -fy-1 vo TOWN PLANNER DATE—APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED L, �S 552 SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE- REJECTED _ COMMENTS �.�1�.� a►.D-� r r•,� � �� kAj PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT `RECEIVED BY BUILDING INSPECTOR DATE `ted 9197 jm '. J N.Andover Health Department • 27 Charles Street North Andover,MA 01845 • (978)688-9540 • • a z • � �. �4 a a s �;...,?,. �''`���C�I�C�Cl1✓ ���1�� �L� Y�. l...' �._. l. . ..`.�'�. z ...��.. .�. ,� ? t �.�. .`�� ,.. . .t� To: Mary Doherty Fax: (973)993-5944 From: Susan Ford,Health Insp. Date: 04/18/00 Re: 1601 Salem St.,N. Andover Pages: 3 CC: ❑ Urgent X For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle • • • • • • • • • • In reference to your questions regarding 1601 Salem Street,North Andover,MA. I am forwarding to you two additional pieces of information that may be of help. 1) The first page of the initial inspection which failed the septic stem P Y 2) A portion of the As-Built which shows the new location of the system components The Certificate that you already have indicates the systems compliance with the installation requirements of the MA regulations. I hope this will be sufficient information for your needs. r Sx +, e y # ' SrF is sx . . . . . . . T.P.# 1---,, P.T.#1 i DP OF SEPTIC 50 icssumed)----- T'P'#2 " 1000 GALLON SEPTIC TANK, C) �> c�' DISTRIBU TION 60X" 1 W G'�--- �� o� T.#.2 _� (MIT OF SAND \__20 MIL POLY BARRIER �---VENT F MAS V\ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WIIQTER STREET,BOSTON MA 02108. (617)292-5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Commissioner Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM MPEG ION FORM PART A CERTIFICATION of O-nw : 1601 Salem St. N. Andov��11e a Knowles Property Address , Ta�1 r,l, 4_ o Address of Owner: N.Andover Dat,of bnpwd= 2/25/99 Marine of Inspector:iPlses s Prirrtl JiM I am a DEP approved system irrspactorWr-j2ht rsusrrt to Section 15.340 of Title 5{370 CMR 15.0001 Ccmparw Name: . Maga"gs` , Methuen, MA Telapfwne IWmnber: CERTIFICATION STATEMENT I certify that 1 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: _ Passes Co onaily Passes _ s urther Evaluatjon By the Local Approving Authority F Is — Data- 4 inspector's Signature: The System Inspectrof�s/hail submit a copy of this inspection report to the Approving Authority (Board of Health or DEPlwithin thirty (30) days of completing this inspection. If the system is a shared system gr has a design flow of 10,000 gpd or greater,the inspector and the system owner 'shalt 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 COMMENTS revisedl'9/2/98. Pagel of 11 40 Printed on Recycled Paper ~-r JAN 6 2000 COVENANT We, Gary Silverman and Joan D. Silverman of 1601 Salem Street,North Andover, MA hereby covenant and agree as follows with the Town of North Andover as follows: I a. The Town of North Andover has allowed a variance to the separation of the leach field of the septic system located at 1601 Salem Street,North Andover, MA; b. In consideration of the aforementioned variance, Gary Silverman and Joan D. Silverman covenant with the Town of North Andover, that the dwelling located at 1601 Salem Street, North Andover, MA shall be limited to no more than three (3) bedrooms until such time as the said dwelling is tied into municipal sewer. C. This covenant is binding on all future owners and shall run with the land. For title to 1601 Salem Street,North Andover, MA; see deed of W. Ralph Knowles and Raymonde Knowles to Gary Silverman and Joan D. Silverman dated June 25, 1999, recorded at Essex North District Registry of Deeds Book 5491 Page 31. Dated this ��d Day of �uh���� , x•999- Z000 �.L ry verman iToan D. Silverman Commonwealth of Massachusetts Essex, SS January 3 ' 1999 Then personally appeared the above named Gary Silverman and Joan D. Silverman and acknowledged the foregoing of their free acts and deeds, before me, Notary Public My commission expires: F1Accu►vArn w 1 r3TATE OF MA � TE 01roeroe I ESSEX N©n-rH Re LAWRENCe 'Ass. of r)MDS A TRUE Copy:AT 4 LUV d TEsr-�-• TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE: January 6, 2000 This is to certify that the individual subsurface disposal system constructed () or repaired (X) by John Soucy at 1601 Salem Street has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations as described in the Design Approval Site System Permit# 1078 dated 6/29/99. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Board of Health Inspector I Dec-22-99 07:51A Law office 1 P.03 COVENANT We, Gary Silverman and Joan D. Silverman of 1601 Salem Street,North Andover,MA hereby covenant and agree as follows with the Town of North Andover as follows: a. The'rown of North Andover has alto-wed a variance to the separation of the leach field of the septic system located at 1601 Salem Street,North Andover,MA; b. In consideration of the aforementioned variance., Gary Silverman and Joan 1). Silverman covenant with the Town of North Andover,that the dwelling located at 1601 Salem Street,North Andover,MA shall be limited to no more than three(3)bedrooms until such time as the said dwelling is tied into municipal sewer. For title to 1601 Salem Street,North Andover, MA; see deed of W. Ralph Knowles and Raymonde Knowles to Gary Silverman and Joan D. Silverman dated June 25, 1999,recorded at Essex North District Registry of Deeds Book 5491 Page 31. Dated this Day of ' 1999 Gary Silverman Joan D. Silverman Commonwealth of Massachusetts Essex, SS - 1999 Then personalty appeared the above named Gary Silverman and Joan D. Silverrrian and acknowledged the foregoing of their free acts and deeds,before me, Notary Public My commission expires: I Dec-22-99 07: 51A Law office 1 P.02 Town of North Andover &ORTiq OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES o p 49 27 Charles Street North Andover,Massachusetts 01845SsACWcw us� WILLIAM J.SCOTT Director (978)688-9531 Fax(978)688-9542 June 25, 1999 Ben Osgood,Jr. New England Engineering Services,Inc. 33 Walker Road, Suite 23 North Andover,MA 01845 Re: 1601 Salem.Street Dear Mr.Osgood: This letter is to confirm that at their regularly scheduled meeting on June 24, 1999 the North Andover Board of Health granted the following variances for the repair of the septic system at the above-referenced site: • Reduction in the separation between the bottom of the soil absorption system and the groundwater table from 4 to 3 feet. e Use of a poly barrier in lieu of a concrete wail with a reduction in slope • Design of the soil absorption system for 330 gallons per day(3 bedrooms)instead of the minimum 440 gallons per day. Because of the variance to the separation of the leach field to the groundwater and the flow design for 3 bedrooms,a deed restriction must be filed at the Registry of Deeds stating that the dwelling is Iimited to 3 bedrooms unless the site is tied into municipal sewer. A copy of this filing shall be submitted to the Board of Health before the Certificate of Compliance is issued i Please do not hesitate to call the office at 978-688-9540 should you have any questions. I . Sincerely, �'3LL(JC.C� Sandra Starr,R-S. Health Administrator Cc: R.Knowles File CptySEAYACSON 6%%-9 sib LiE.Hl,"[li 68$AS� Pl�`t�� GRSA535 �d 6 ,9545 i I I I i Em I TOWN OF NORTH ANDOVER SEWAGE DISPOSAI. SYST N[ INSTALLATION CERTIFICATION The undersigned here.v certiry that the Sewage Dis csal System. i { cora - - - � p (� re^aired: ,Sc �cy located at rLop( t :'L_S-T 0,c was installed in confe.rnance with the North Andover Board of He with a:�provea plan, Svstem Desi_>n Pe-MA"L ,- dated wit h an approved desil-11) flow or,330 4allons per- day The matenials used were in conformance with those specmed on the appro\"ed plan; the system was instiled in accordance vJith the previsions of 3 10 C.MR- t5.000, Title 5 and local regulations, and the nnal Qrading agrees substantially with the approved plan. Ail work is accurate; v represented oc the As-wilt which has been submitted to the Board of Health, Bed inspection date: ZE o /L-- EnQlneer Rc ir�se :ative Final inspection d Emzinecr Represe^tat e tnstal:er: .'.m. Date: / Desivmn Engi peer: Date: RICHARD 9�y� G y TANGARD y A �S�OH ENG��I► AL 3o7. � �v I i '�:-�.•I- �j; - '.mfr-� o, ... :`�: �:.f�..��_ .7�5�...�•:`:i.;'"'5,:�'.,:.;.:,'::-.t`,•�,��?.,:�' .`.�:,Y,',.r;::' _ -.�_-.,.r L` ti•. I 1 - f TOWN OF NORTH ANDOVER SENVAGE DISPOSAL SYSTEM I 1N,STALLA•I'I0,1 CERTIFICATION The uncersiLned aere::v cmufv that the >ewaLe Discosal Svstem f 1 torsi,Jct;d; (� re^aired: located at !fin was installed in cornfprmance with the North Andover Board of He:ith acprovea plan, Svstem Design Pe:rit .. dated with ar. accroved design flow or 3230 gailons per day The materials used were in conformar.ce with [',lose specired on the approved plan; the system, was installed in accordance ,�ith the provisions of' 1 j CIvfR- t5.000, Title 5 and 'Local mniiations, and the anal szradir.2 agrees substantially with the approved plan. .--i1 work, is accurateiv represented :)r: the As-built wlh ch has been submitted to the Board of Health. Bed inspection date: yV2:: cr C U – Enszineer Re:)rts,:::auVe. Final inspection c _ �`�A:, _ �j- G ✓ �L— -.–—— L-ncir:ecr hepreser:tit :e Installer: _ f Date: _ -/� _ 957 Lesi�7r, En�/,eer: Date: - ?--- – RICHARD �y�! Qv C. N C TANGARD ti �V'/STERsp�<c tQ 3��ss�onra ��G`v : Town of North Andover, Massachusetts Form No.2 f NORTH BOARD OF HEALTH • 3 0 �...o,��y /� � 19 JL DESIGN APPROVAL FOR HUS SOIL SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant-2 Test No. 7�/r : Site Location —ILIL dA h�l� IZ&- Reference Plans and Specs. ENGINEER DE GN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. CHAIRMAN,BOARD OF HEALTH Fee Site System Permit No. O Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH Q APPLICATION FOR SITE TESTING/INSPECTION N°RATED>'Pp �y SSACHUS�� Applicant <-P)q1-'g!)51 NAME ADDRESS TELEPHONE Site Location ZED/ 5igG'e5w S En ineer :0V 656,044 NAME ADDRESS TELEPHONE Test/Inspection Date and Time Ap/e/z xC /'?W fI . zj CHAIR ,BO D OF HEALTR Fee�7� Test No d/ S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: CURRENT INSTALLER'S LICENSE4 LOCATION: d �GZ �Vt (:�4, 4-,, 4, �-� LICENSED 'ST LER v�.� v�c� SIGNATURE: TELEP ONES CHECK ONE: REPAIR:_L/ NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. Administrative Use Only TOWN OF NORTH ANOO�/f�R/ I BOA— Q OF HEALTH $75.00 Fee Attached? Yes _ No Foundation As-Built? Yes No AUG 13 1999 Floor Plans? Yes No Approval.".," � Date: l� _ 11192 SOUCY'S SEWER SERVICE, INC. 830 LIVINGSTON ST.,#5 PH. 978-851-8839 TEWKSB_URY, MA 0.1876_ 5-39/110 r PAY DATE TO THE ORDER OF D r- LLARS B � b BankBoston_ iBankBoston,NA.—Boston.Massach tts FOR % v t6101 ��� 1110119210 ' 1:011000390t: 31 2 [G=; 27 21, - - - --- ---- -------- Town of North Andover, Massachusetts Form No. 1 NORTH q BOARD OF HEALTH f + 19 r o„<Ew,. APPLICATION FOR SITE TESTING/INSPECTION apRA TED PPP' • ` ,C 9SSACHUS�� Applicant fi4 P NAME ADDRESS TELEPHONE Site Location Engineer 4;' 'L; NAME ADDRESS TELEPHONE Test/inspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee �' Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. i Town of North Andover o a NORTH OFFICE OF � `t t e D I °c COMMUNITY DEVELOPMENT AND SERVICES ° . A 27 Charles Street North Andover, Massachusetts 01845 WILLIAM J. SCOTT SSACHU Director (978)688-9531 Fax (978)688-9542 June 29, 1999 i Ben Osgood, Jr. New England Engineering 33 Walker Road, Suite 23 North Andover, MA 01845 Re: 1601 Salem Street,North Andover, MA Dear Ben: This letter will serve as your notification that the proposed septic repair plans for the lot specified above have been approved. If you have any questions, please feel free to contact the office at 978-688-9540. Sincerely, 1/1/z� Sandra Starr, R.S. Health Administrator S S/smc cc: ;RalP h Knowles File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 1 BOARD OF HEALTH TEL. 6$$_9540 NORTH ANDOVER, MASS. 01845 APPLICATION FOR SOIL TESTS DATE: LOCATION OF SOIL TESTS: )1,01 Assessor's map & parcel number. ,off, (S OWNER: �ZC,���.► K Ics TEL. NO.: �yl'- 4q 7 ADDRESS: ENGINEER: 2; Q C. t TEL. NO.: -7 g- o, 6 - i 7 8 CERTIFIED SOIL EVALUATOR: e„ Intended use of land: residential subdivision, single family home, commercial Repair testing Undeveloped lot testing N. A. Conservation Commission Approval: THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) 2. Plot plan 3. Fee of 1275.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of JZfj.00 per lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than 1"-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. Jun-17-99 10: 11A Paul D. Turbide, PE/PLS 508-465-0313 P.05 V June 17, 1999 Sandra Starr North Andover Board of Health Administrator Office of Community Development and Services 30 School St. North Andover, MA 01845 RE: Title V review for 1601 Salem Street Dear Sandra, I find that the design plans adequately address Title V and local regulations. Various local upgrade approvals and local variance requests are noted. In my professional opinion the requests seem reasonable for the conditions of the lot. If you have any questions or comments please feel free to contact me. Sincerely Carlton A. Brown, PE/PLS Salem l60 Ldoc 0 DFV ENGINEERING Civil Engineers& Land Surveyors One Harris Street Newburyport,M9 01950 (978)465-8594 NEW ENGLAND ENGINEERING SERVICES INC June 10, 1999 Sandra Starr,Administrator North Andover Health Department Town Hall Annex 27 Charles Street North Andover, MA 01845 Re: 1601 Salem Street septic system design Dear Sandra: Enclosed are the following documents regarding the application for approval of the septic system repair for the above referenced property. 1. 5 copies of design plans. 2. 2 copies of soil data sheets. 3. 2 copies of request for local upgrade. 4. Check to cover the fee. If you have any questions or need additional information please do not hesitate to contact this office. I Sincerely, Benjarpfm C. Osgood,\sJ ,I eT President 33 WALKER ROAD-SUITE 23-NORTH ANDOVER, MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 DATE: _5 ^`� LOCATION: d SOH WITNESS. FE 1 ^TION TEST „ a.COL v� SO i i ON1 DEPTH Or PLR(-- TEST: TIME OF SOAK: ' 3 �' (�� legis irutes Icnc) T I ME AT 12" ! �� TIME AT TIMEAT5 EVE;,NICHT SofA T1NiE ST,-.R T_D NE.'/"\/—i D,,,,,.. SOAK: (.At INIE A T 1 2" T iNIE AT TIME AT - 1 ^! fiIt r -�✓ __ - _ !. - I_ _ W/6 Iq ,1 - May-27-99 12 : 45P North Andover Com. Dev . 508 688 9542 P . 01 SEPTIC PLAN SUBMITTAL FORM LOCATION: I(nvt NEW PLAINS: YES $125.00/Plan___-- REVISED PLANS: YES $ 60.00/Plan SITE EVALUATION FORMS INCLUDED: YES NO DATE: � ---- - DESIGN ENGINEER_��s---��-�`� .A�-�_--_��.�----�►.,�;,..�cn�`� Se2�n`��� DATE TO CONSULTANT: *If you want your plans expedited, please submit three plans and included a stamped envelope with the correct amount of postage to mail plans to Port Engineering. When the submission is all in place, route to the Health Secretary. t400f- NEW ENGLAND ENGINEERING SERVICES ik- INC June 17, 1999 Sandra Starr,Administrator North Andover Health Department Town Hall Annex 27 Charles Street North Andover, MA 01845 Re: 1601 Salem Street,Septic system design Dear Sandra: Please accept this letter as a request to have the above referenced plan considered for approval at the Board of Health meeting on June 24, 1999. Specifically, the board needs to approve the following local upgrade approval requests and local bylaw variances. LOCAL UPGRADE APPROVAL REQUESTS: 1. Allow the reduction in the offset distance between the bottom of the soil absorption system and the water table from the 4 feet required by Title 5 section 15.212 to 3 feet. LOCAL BYLAW VARIANCES: 1. Allow the use of a poly barrier in lieu of a concrete wall with a reduction in slope and fill extension at the breakout elevation in lieu of the concrete wall required. 2. Allow the leach field to be designed for 330 gallons per day of flow in lieu of 440 gallons per day of flow. If you have any questions or need additional information please do not hesitate to contact this office. Sincerely, i� Benj C. Osg Jr.,EIT President i a BOARD OF HEALTH TEL. 688-9540 NORTH ANDOVER, MASS. 01845 APPLICATION FOR SOIL TESTS DATE: LOCATION OF SOIL TESTS- )1'_01 �e ivy Sfi Assessor's map & parcel number: ;opo R OWNER: TEL. NO.: ADDRESS: /Lf tli.t rtt (_JO t k5; nee .'Z ENGINEER: TEL. NO.: 4>- � 6 CERTIFIED SOIL EVALUATOR: ��r., ;�_ C Intended use of land: residential subdivision, single family home, commercial Repair testing `"C Undeveloped lot testing N. A. Conservation Commission Approval: N\—) THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) 2. Plot plan 3. Fee of$275.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of$75.00 per lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than V-1 shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. 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"+^. y' v ' J r•. '-• r;. R 7' + )THE, Wi L; ?'r;d. n'v/r_ plf��* � ,�•.�.'�,�'h+. 1 ti r l+ 1 /�A'� 1 ! '<� 4 .e 1 r L„ �'f _'FE r i t t t 7 rY: oaf ,k' C+ � r + �,S;4d. ,; N.'. t '5 ,, t r<r'a�' I I Sit it,75 s" .,'rd, :„ k lA a ti.5- i ya r d. Sf i ,t'.= XE 'u5 :? '7>F 1 of;{ `• u4 r r3k {-" r i J � ([J/� n .,.CC. y�' .... r � :., t• ... ..1 ,.ijYP 5 ,,,.,i. a .�, ...it r• is :'; :: , iy, R: Ut:r t. .n-• `; + � t vt� .I-� jv ,,.. � ,..r I f,..p• sl! ir�. ki� ..;. ...,.,�2,, ,,{�+�fi,.,. ,,` � .t: rp .r ':. t+,. r.,.da•' 7 .��5..1 ,�+ rt; 't 'r t,t tI-: a. t t t Lc�'. 13' inl �. tfi .:f, t�]F '�M`?ry ,/� :bth i.:'.,MUMS a,; •i`.FL•./1 - F. 't.y;. ret £ t a s i.. '__ �a i a. (•$5 low"!fi iP a,, ar L1 4, 3� r -3,•_:� t rt a - ' f_. .� nY'K.:;•i i9": .q r s.,' s ev� �.::.a , .�:. a'5: ,fi '.i'�Rn4Y: �S rr.:;j� '+. ' c �..,r-.,, ", ., ,y`.1r+ ,Q .'...�...�„rt��'y�K „r's �I:. ;ly k r+,+x r w. yy�� S r-� 5 G�. , •.o- b-�.eb.F:.� r l , Tay 3::ir'. fr Y,+se<: y , wt,v, X do ., tt I r a, \i a c a, r v tip ,7 ,� *,• q h: .r�"st.: ...r., ..yn,. .,,c _:y, -.1+ l ? P }y.� ,., a P.t ,; �s,.,TWA d t{! �r v- ..2JS zn �`.,{t' .,S,Ft. ,k` .1 ft r '�•t1. ^.fir. � .1 r,•. n �ii: t .�. ..��^ .1 s 1� �e bLl '4�e,s. y'Pv „T f r' 1 .l A t � -'.�,.• f' 7 irµµ : } r 515 I �•',.a. f �..{i.. '�+P , n � MY led.. W. �� y. e[ ', t � t'� t° - �3 5•`,a .. ,a.. � ytl + Cs��,ltY _.� + - 6 `3 5 ,.r {a� i� r lL �y� ;47 �f,...N ..iii-•ry ,.;tir � 'r -, t -:: ,.I� � {:s _s& k.' ri, f'• 'ns:t'f��kl l+ >~ 'r�o. .v f, tit 1. , r .:1 h 4 Ix i'n 1 j _ ,: ..e ?{F '1 r .�� ,• t �:� '��? y. I), :.;sN r.4 ._ V�L - t 5 t u � t � I f8 � �.�• ,i'41{_ �.� 1. r r('Y4t`•: Ir.•c.k X r t P+' ro J' .r: d .o} f 7' , :I; ,q' P .+'J p �-�x / •b'i .r. , :r. , �- -�. 7G£.: .i :;�$' a .qiy {� A a..G .�ly•4 )y� r h t S tt :7 :p • �j (y r,G'"Y s >F.,-�1,;� :. � 31��. '� 3 ,j r i• : ,,�� I i. NEW ENGLAND ENGINEERING SERVICES INC April 5, 1999 Sandra Starr, Administrator North Andover Board of Health 27 Charles Street North Andover,MA 01845 Re: 1601 Salem Street Soil Testing Dear Ms. Starr: Enclosed is an application for soil testing at the above referenced property. Also enclosed are the following supporting documents. 1. Deed as proof of ownership. 2. Contract signed by the owner for proof of authorization. 3. A lot plan with proposed soil testing location indicated. 4. Copy of assessor's map with parcel indicated. 5. Check for 75 dollars for the fee. Please schedule soil testing for the first available date. If you have any questions or concerns please do not hesitate to contact this office. Sincerely, Benjimin C. Osgood .,EIT, President 33 WALKER ROAD-SUITE 23-NORTH ANDOVER, MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 I'— . * j,j,�.�,%J.,,, --I' -_�i- W1 -1� I .. , t.i$, ,.:.- �.�. .�.j,..-!,. . . I 1.t.t I{. 11;I . *e 61 . ,:, I . ? I.. . . � .#-.I "'k., ." , .� 14. , ,�, . . , :; - ,��. , . . � �l. . , ., . ..., .." - A " 0, - , '), ,�:: . I z_!-:..�;�!�j,�, . . . ..__. ., . '� , "_4� -I". v, ,.,. ,..:�'t�,� . , , . . ,�7.1, _.A�,', , . .., , . � . v,'" .. I i. , i.., . `?�� .. , '..:!�.�., '. � , . ',,�,�ir:,. -`.�� . � .t 1, � "I"N' :�, I.1; � __ , , 'N � t ) ',f I', -� - -p,�rv_ . � � ,� 11 ,_� "V41 71 . If S, !��,k 71 �A.i-; , . . �.!",I., �,.�,;K,-,-,-,�� I '��o :1V1.1 . m 1. -- h JS I . , I I liqzo,.�l � I. - , ,�,'�,ly..��, . � . - . ...... ,, �t m o�. I hP, if " 1� ". : _zw&-r " —, . . S ,*1'- . .. . .4 - , ll� , , �'.-�Pl� � . 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Ralph xrwrlee Raynotde Knowlesas tenants by the entirety E of 1601 saiem Street, North Andover, MA with quiltfamt roAtrnards �: the land to said North Andover, desclbed an fol].a+st Being Lot 12 shown On 'Plan of Lend, North Andover, Massachusetts. owned by Revised Lots f11 and 12,' said plan being recorded in the Essex (] 4 Nort District Registry of Deeds as Plan Noj 59831 to which plan referenoe is hereby made for a carplete desariptian of the prselisea hereby conveyed. Being the sono pztruises conveyed to ue by deed of John W. Ostrowski and Kristine 'u C. Ort--wski dated October 1, 1984 and recorded at the Essex North Registry of Deeds in Book 1874 Page 255. c E Ju 1; 06 31 TAX and tacnaaQu thu 13th day of Deco benl9 94 . Jarttea Youree r �otamartfarslff( of tents Es96% ` Dao&*ar 13 1, 94 Thfp �^Oa� &PPI-rd th,,b— e_d Janne F. Yotreee and Dorothy D. Yan'ee 1p Id"'Wdled tb,foreloml m,Uuaa l to he their feat ref and deed, Nro�-y Adh My oommu,ioo exPhu MEGAN I TAYLgyUH its 4. My Co wdWon Evku 8.23-96 8,I! i t i; i m NEW ENGLAND ENGINEERING SERVICES INC CONTRACT COPY PROPOSAL FOR SEPTIC SYSTEM DESIGN February 17, 1999 Ralph Knowles 160.1 Salem Street North Aildover, MA 01845 Dear hon Knowles: The following is a proposal'to complete a septic system design, and permitting for the design, at your property located at 1601 glMrf=r Street, North Andover, MA. A breakdown of the price is as follows: 1. Deep hole soil testing $ 2. Percolation testing 3. Design Plans and Specifications 4. Site Survey 5. Backhoe for soil testing 6. Board of Health fee Total Price Any fees due to the North Andover Board of Health other than those listed above are not included. These fees may be fees for a variance request to the Town, advertising fees, certified mail fees, or fees for a submittal to the state DEP Fees for a submittal to the conservation commission submittal are not included. A submittal is not anticipated as being necessary. 33 WALKER ROAD-SUITE 23- NORTH ANDOVER. MA 01845-(978)686-1768-(888)359-7645- FAX(978)685-1099 PAGE 2 PAYMENT TERMS: 3. Any additional charges are due upon invoicing. NOTE: Unpaid balances subject to a 1.5 % service charge per month plus all costs of collection including reasonable attorneys fees. PROJECT SCHEDULE: Commencement of work will be upon receipt of the initial deposit. Final plans will be completed and submitted to the Town within three weeks of completion of on site soil testing. Soil testing will be done at the availability of the Town inspector. All plans produced will be given to you for review and comment prior to release to contractors or the town. Kindly advise if further information or clarification is required. Thank you for the opportunity to present this proposal to you. If acceptable, please indicate by signing below and returning the deposit and a copy of this letter in the envelope provided. Sincerely, A- Ben—Ja2n g C. Os o)d2J E.f.T. President This proposal is acceptable as written: Ralph Knowles: Date: MAV 21 '99 07:58 P.02 NEW ENGLAND ENGINEERING SERVICES INC May 21, 1999 Sandra Starr, Administrator North Andover Board of Health 27 Charles Street North Andover, MA 01845 Re: 1601 Salem Street Dear Sandra: I am writing this letter to inform you that this firm no longer is working for the owner of the above referenced property. Apparently I do not return his phone calls soon enough so he has hired someone else to complete the' p e Job. Please cancel my appointment with Rudy today to do percolation testing. 1 will submit all of the test data as soon as my final bill has been paid_Until that time I do not authorize the use of information obtained by this office for the design. If you have any questions please do not hesitate to contact this office. Thank You B4-2n C.Cos 904;?.,�EfT President 33 WALKER ROAD-SUITE 23-NORTH ANDOVER,AAA 01845-(978)686-1768-(M8)359-7646-FAX(978)685-1099 MAV 21 199 07:57 P.01 NEW ENGLAND ENGINEERING SERVICES INC HVTORTANT FAX FAX TO : S e,4 r S R DATE: A 2 k l q I FAX FROM: Ben Osgood, Jr., New England Engineering Services Inc. OPERATOR: BCO JR. PAGES IN FAX INCLUDING THIS SHEET: IF THIS TRANSMISSION IS UNCLEAR, CALL SENDER AT(508-686-1768) MESSAGE: 33 WALKER RD. — SUITE 22 — NORTH ANDOVER, MA 01845 — (508) 686-1768 1 Page 1 of 5 9A-APPLICATION FOR LOCAL UPGRADE APPROVAL Commonwealth of Massachusetts /V. Massachusetts Application for Local Upgrade Approval Title 5, 310 CMR 15.000 DEP approved form required by 310 CMR 15.403(1) To be submitted to Local Approving Authority/Board of Health: For the upgrade of a failed or non-conforming system with a design flow of<10,000 gpd, where full compliance, as defined in 310-CMR 15.404(1), is not feasible. To be submitted to DEP: For the upgrade of a failed or non-conforming system with a design flow of 10,000 up to 15,000 gpd and/or for upgrade of state of federal facility, where full compliance, as defined in 310 CMF 15.404(1), is not feasible. NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of new design flow to a cesspool or privy or the addition of new design flow above the existing approved capacity of a system constructed in accordance with either the 1978 Code or 310 CMR 15/000. 1) Facility/System Owner: Name: �q/f,C, /�in0 wlPs Address: xa/Cr>-, sf,-51, , A/. Phone#: 978- y 9 9-v 6 Address of facility: /(-,Cl S f ,t/. 2) Applicant (if different from above) Name: Address: Phone #: 3) Type of Facility: K Residential Commercial School Institutional (Specify) 5, /-6,»� xri f. Page 2 of 5 4) Type of Existing System: _privy . cesspool(s) conventional system other(describe) Type of soil absorption system (trenches, chambers, pits, etc.) 4eee-1,- 5 Design Flow Based on 310 CMR 15.203: a) Design flow of existing system _ gpd Approved: 7 yes Approval date. no Why: b) Design flow of proposed upgraded system 3 gpd Why c ,� c) Design flow of facility 33,:D gpd 6) Proposed upgrade of existing system is: a) Voluntary required by order, letter, etc. (attach copy) -, —Required following inspection required by 31 CMR 15.301 (provide date inspection form was submitted to the approving authority) v;I (date) i b) Describe the proposed upgrade to the system: c) Which of the following are applicable to the proposed upgrade? Reduction of setback(s) (list setbacks to be reduced with proposed setback distances) Percolation rate of 30-60 minutes per inch(state actual perc rate) Up to 25% reduction in subsurface disposal area design requirements (state required & proposed size) Relocation of water supply well (identify well, describe relocation) I Reduction of required separation between bottom of SAS & high groundwater(specify proposed reduction & perc rate) n . .y Page 3 of 5 Other requirements of 310 CMR 15.000 that cannot be met(specify sections of the code) System upgrades that cannot be performed in accordance with 31 CMR 15.404 & 15.405, or in full compliance with the requirements of 310 CMR 15.000, require a variance pursuant to 310 CMR 15.410-15.417. 7) If the proposed upgrade involves a reduction in the required separation between the bottom of the soil absorption system and the high groundwater elevation, an Approved Soil Evaluator must determine the high ground water elevation pursuant to 310 CMR 15.405(1)(1)(1). The evaluator must be a member or agent of the local approving authority: Distance from soil absorption system to high groundwater feet As determined by: . Evaluator's name: S,U 5,g19 u Evaluator's Signature: Date of evaluation: 8) Notice to Abutters: No application for upgrade approval in which the setback from property lines or a private water supply well is reduced shall be complete until the applicant has notified all abutters whose property 9or well is affected by certified at least ten days before the Board of Health meeting at which the upgrade approval will be on the agenda. Such notice shall include the date, time and place where the upgrade approval will be discussed. Af the department is the approving authority, then such notice to abutters must be completed prior to the date of submission of the application to the department. The notices to abutters shall include a copy of the completed application form and shall reference the standards set forth in 310 CMR 15.402 through 15.405. Page 4 of 5 List of affected abutters: Abutter Name Date notified Address Abutter Name Date notified Address Abutter Name Date notified Address Abutter Name Date notified Address 9) Explain why full compliance, as defined in 310 CMR 15.404(1), is not feasible (each section must be completed): a) An upgraded system in full compliance/_with 310 CMR 15.000 is not feasible.: Skc'i7 -Cloge3 e,17 Si/e- ,7�vlh� Sti<s fnm T�Z rr1 b) An alternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible. �0st /5 lacIr- c) A shared system is not feasible. L �J SC3/A aN sX �PV IZ /4f V^ G cc e,41 l�S Y d) Connection to a sewer is not feasible. /V CSc,�lyJ4<C /'� Ci✓L 10) An application for a disposal system construction permit, including all required attachments (e.g. plans & specifications, site evaluation forms), must accompany this application.; Is the DSCP application attached? dyes no Page 5 of 5 11) Certification "I, the facility owner, certify under penalty of law that this document and all attachments, to the best of my knowledge and belief, are true, accurate, and complete. I am aware that there may be significant consequences for submitting false information, including, but not limited to, penalties or fine and/or imprisonment for knowing violations." Fac' ty Owner's e ate 7' Print N me Oc � G t ' Name o Preparer Date 8 6 —176& Telephone No. & Address of Preparer NOTE: Title 5, 3101CMR 15.403(4) requires the system owner or operator to submit to the Department a copy of the local upgrade approval upon issuance by the Board of Health and prior to commencement of construction. DATE: l� LOCATION: ENGINEER: BOH VVI T NcSS. PERCOLATION TEST � -_ - BC i 0 N DEPT-i 'Or PLRC TcST: TIME OF SOAK: 9`33 (At Ieast minutes Icnc) T W E: AT 12" -!M TIME AT 9" T IME A T E_" �/s OVE ,NIC'r,T SOAK IME R =J NE/XT D,^," SU iK. ees; 1 E 15-L, TIME AT 12" T i IVi E ^. I r F TIME ATE" i DATE: LOCATION: 160 �NGINE=D _ " -- - BOH WITNESS. NESS. PERCOLATION TEST COT T OM DEPTH H OF PERC TEST. TIME OF SOAK: ` 0� �� (A� minutes Icrc) l TIME -,'\T 12" TIME AT c" TIME AT . :�,FRNIG�T �OA,K TIiv1E S T APT= NEXT D,�,Y SO,-,;K: egis, TrvIEA.T9 ; 3. d T1NIE AT ., r Town of North Andover NORTH OFFICE OF Oy S t o ,c 110 COMMUNITY DEVELOPMENT AND SERVICES A 27 Charles Street North Andover, Massachusetts 01845 WILLIAM J. SCOTT 9SSACHuSE� Director (978)688-9531 Fax(978)688-9542 June 25, 1999 Ben Osgood, Jr. New England Engineering 33 Walker Road, Suite 23 North Andover, MA 01845 Re: 1601 Salem Street Dear Ben: This is to confirm you that on June 24, 1999, at their regularly scheduled meeting the North Andover Board of Health considered variances requested for the repair of a septic system at 1601 Salem Street,North Andover. The following variances were granted by a vote of the Board. 1. Allow the use of a poly barrier in lieu of a concrete wall with a reduction in the slope and length of fill extension. 2. Allow the leach field to be designed for 330 gallons in lieu of 440 gallons per day. Please feel free to call the Health Department at 978-688-9540 if you have any questions concerning this action. Sincerely, Sandra Starr, R.S. Health Administrator cc: Ralph Knowles File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 1106D 010 ��e �T- J �UiruceNzd �57larGs f,- yT�M 15 �iJ i Town of North Andover, Massachusetts Form No.3 • HORT/., BOARD OF HEALTH 1 �j 19 DISPOSAL WORKS CONSTRUCTION PERMIT SACMU50 Applicant / J; 7__e__) NANTE ADDRESS TELEPHONE Site Location C�j fL7, Permission is hereby granted to Construct ) or Repair an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No.�/1��� op CHAIRMAN, BOARD OF HEALTH 4'e D.W.C. No. 7 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: � �� CURRENT INSTALLER'S LICENSE# LOCATION: LICENSED INSTALLER: G V C 2 CJ SIGNATURE: c TELEPHONE# 702— CHECK O REPAIR: NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION(4S----BUILT. Administrative Use Only $75.00 Fee Attached? Yes �'`"Y No Foundation As-Built? Yes ,,,, No Floor Plans? Yes , No Approval - Date: `/rrJ i VOW APPLICATION FOR SEWAGE DISPOSAL INSTALLATION HEALTH DEPARTMENT - NORTH ANDOVER, MASS. "7 �'/l� dT /:2 I hereby make a 4ication for a permit for a sewage disposal installation at I will install this system in ac- cordance with all the laws of the Commonwealth of Massachusetts and regulations of the Board of Health of the Town of North Andover. Further, I will construct the house sewer of bell and spigot pipe, the minimum diameter being 4 inches, and will maintain a minimum grade of 1/ until 10 feet pre- ceding the septic tank, where the grade shall not exceed 29o. I will install a con- crete septic tank of in size. A manhole (s) permitting easy cleaning will be provided with removable cover (s) of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with 4 inch perforated or open jointed pipe and laid in a series of trenches, the bottom of which will pro- vide a minimum of lineal (square) feet of effective absorption area. The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 .inches (dia. ) and the pipes will be surrounded by similar material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling the trench, 2 inches of gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single tile line will exceed 100 feet in length and in any case, two lines of tile will be installed. A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No part of the installation will be less than 100 feet from any private water supply, 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. I further agree not to cover any portion of this installation until approved by the inspection officer, as provided below, and to incorporate any additional requirements that may be at:7ed to the permit. Plot Plans must be 'submitted with application. DATE / D 0 Si ture of Applicant I hereby issue the above permit for: the Board of Health of the Town of North Andover, Massa& usetts. DATE / d /7 L) Signatu a of ealth Agent I have inspected the uncovered system indicated above and find everything done as describ d. DATE j / n Signature of I s &ting Officer Percolation Test_ Garbage Grinder � BOARD OF HEALTH �i TOWN OF NORTH ANDOVER, MASS. Sd q 0 +" ryIV 3 a� �ol 1. NAMEZZ �rr DATE / �D 2. APD LOT NO. '/zTEL. 6 `tel 7 3. NO. OF BEDROOMS DEN YES NO 4. GARBAGE GRINDER YES NO 5. SHOW DIMENSIONS OF HOUSE 6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES 7. SHOW DIMENSIONS OF LOT ` 8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL e9l ,) 9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM 10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC. 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY. �3 � x q N u Igo i BOARD OF HEALTH OF NORTH ANDOVERY MASSACHUSETTS SEWAGE DISPOSAL DATE 1�>/IC)T 70L, NAME OF APPLICANT �:AnygA Es, LOCATION 1593 Sa'1 em Ft.. Address of lot no. BUILDING: Dwelling X Other SYSTEM: New X Repair GENERAL DESCRIPTION OF LAND high SUBSOIL: Clays Gravel Sand PERCOLATION TEST 7 minutes per inch, MINIMUM INSTALLATION RECOMMENDATIONS I CONCRETE SEPTIC TANK 1.000 gallon capacity. LEACH FIELD 200 lineal feet of drain pipe, illiam J. D scoll, Engineer Board of Hea lop 9,4 97 EE PLAT 105.A ,f, by SG 5s JI \' e ti A7 Ab 14 47 47 r a .�•7te �S b r' M' y 218 ZD4AC. O L 1 2t'1 1 t�yt Ne ot \ 0 17 a%• 2.0 AC. .8 L7 126!6 t+ N.E.R. 219 Q do c O —--�` Z22 220 D"` ; +.Y✓ w tab .2D Z03AC. U) <AC -tsip `D` 2L W 221 s \ ` ,. �• L 2.OAC. L4 � .G `D� e ✓ 9a A %OIr �' \ s1 `i � s c FI, vo A. ; A.m Isi .\ +p I Y' S q w 0 i e 6 co b' \c • \ N«d�ld Ac. j� � 2 � s.ez A� lJD +t+" os,aw 1.Z28AG 1.03AG 1.8ZAC. 0 28 2.0 3A7 L320 239LZ 240 LZ2 L2A E. 0.4Pf2695 1oAc �b, "• L 75AG L19 BRDOK Ftp 1.071AC. v. 236 L= 2AG L 18 '.12AC. 7LOAG L47AC. 1 2300 _ L4 f.53 32 231 L 12 L 22 AC. 1.07 L14 L13229 2 05� 1.0217E Z33 a LII LSA 224 % Z34 L I L6A \\ %L I Ion '+yrs 1D AC. 1 22 6 225 I.0 AC, \� L?)o 1.04AC L 8 L7 2Z7 �\ L9 �r SEE PLAT 106 r-> I lig f' I. X- 'v? ----- ,,. J i; I I FORM 11 - SOIL EVALUATOR FORM " Wage 1 of 3 No. Date: Commonwealth of Massachusetts Massachusetts Soil Suitability Assessment for On-site Sewage Disposal • i � Date: .99.. .. ... Performed By: ��......... ...... �/�� U .. -D. . Witnessed B - ......_......................... .. .............. _. .... .... owner's Name. Location Add,-- Address,and Lot I Telephone I pew Construction ❑ Repair © � � .Office Review Published Soil Survey Available: No ❑ Yes /Q�� ��� �� Soil Ma Unit Year Published Publication Scale p _. __._.... Drainage Class Soil Limitations -7.... 1- - Surficial Geologic Report Available: No Q Yes ❑ Year Published _._ Publication Scale Geologic Material (Map Unit) ........................................ _.......... .... .............................................................. Landform ............ ....................................I..........._......... _........__..... ..................................................................................... Flood Insurance Rate Map: Above 500 year flood boundary No ❑Yes Within 500 year flood boundary No ❑Yes ❑ Within 100 year flood boundary No ❑Yes ❑ Wetland Area: National Wetland Inventory Map (map unit) ............. - .. .......•. ..................................... Wetlands Conservancy Program Map (map unit) Current Water Resource Conditions (USGS): Month Range :Above Normal ❑Normal ❑Below Normal Other References Reviewed: 1)EP APPROVED FORM.12/07/95 FORM 11 - SOIL EVALUATOR FORM Page 2 of,3 Location Address or Lot No. (O� On�site :Review 0 Deep Hole Number Date:.. /7 Time: Weather �� Location (identify on site plant 5� .. - CiGT..::...... ...::.: Land Use c�77�L Slope M Surface Stones . J1 Vegetation : Landform Position on landscape (sketch on the back) ,6 Distances from: _ �a � � Open Water Body/� -.feet Drainage way feet Possible Wet Area � feet Property Line ....¢ feet Drinking Water Well feet Other DEEP OBSERVATION HOLE LOG' Depth from Soil Horizon Soil Texture Soil Color Soil Other surface(Inchesl (USDA) (Munsell) Mottling (Structure,Stones, Boulders, Consistency, % Gravel) Z-4 2 - YZ MINIMUM01-2 HOLES REQ01RE0 AT EVERY PRMOSED DISPOSAL AREA m5 C Parent Material (geologic) —/r/—L L- DepthtoBedrock: DDgpth to Groundwater: Standing Water in the Hole: Weeping from Pit Face: r� Estimated Seasonal High Ground Water: 46 ^_ —•— – DEP APPROVED FORM-12107195 FORM 11 - SOIL, LVALUATOR F01W Page 3 of 3 Location Address or Lot No. ,Determination or Seasonal High Water Table Method Used: ❑ Depth observed standing in observation hole...... inches ❑ Depth weeping from side of observation hole .. .... inches El Depth to soil mottles inches T 014 3 ❑ Ground water adjustment ................. feet Index Well Number ... .......... Reading Date .................. Index well level . . Adjustment factor ..... Adjusted ground water level Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? � If not, what is the depth of naturally occurring pervious material? Certification I certify that on �qs (date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. ��"Signature Date I , DEP APPROVED FORAt-12/07/95 ? s� O� Ol �� recce Rd ' s f . 109 Forest St 109 Forest St c North Andover,MA 01845 a ` 0 1601 Salem St < . 1601 Salem St k T Z: North Andover,MA 01845 223 Fo�Vdover t Ut 223 Fo ' North 01845/S Y 1� Sufi ''.' ,use;. n::.. cA n r 4 Ip Cl\,a( \\41s >P Omi 0.2 0.4 0.6 0.8 1 12 Streets% Copyright 0 1988-1997,Microsoft Corporation and/or its suppliers.All rights reserved. Please visit our web site at http://maps.expedia.com. Page 1 FORM II - SOIL EVALUATOR FORN-1 Page 2of3 7- Location Address or Lot No. Ort-site Review 'J Deep Hole Number / Date:... Time:.. Weather CS . Location (identify on site plan) .. �.�� �•`% '.F,. '�� r Land Usef�` ` Slope (%) Surface Stones Vegetation Landform Position on landscape (sketch on the back) Distances from: Open Water Body feet Drainage way feet Possible Wet Area :. feet Property Line ... .:.. ... feet Drinking Water Well feet Other :..::. DEEP OBSERVATION HOLE LOG* Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (Inches) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, Consistency, % Gravel) L l / — c/,� - ,tet•% f �z Z / 5 L �oy,z41;� kt orxVNC•(% �xG/z_ qOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA Parent Material (geologic) _ DepthtoBedrock: _. Depth to Groundwater: Standing Water in the Hole: / Weeping from Pit Face: Estimated Seasonal High Ground Water: 442 -- �;�GI DEP APPROVED FO"I•12/07/95 a" FORM 11 - SOIL EVALUATOR FORM Page I of 3 �I Z Date: No. , 1 h � ; Commonwealth of Massachusetts , Massachusetts Soil Suitability Assessment for On-site Sewage Disposal U Oocx --/Z. Date: Performed By: J 4mr� _ .... Witnessed By: Location Address a /6G/ Sa��ryl Sf /I/f�r+c�vc/P2 oWrcr:N. �<��Li J�s?v LA-;/e Address.and La X 7elephom New Construction ❑ Repair Office Review Published Soil Survey Available: No ❑ Yes Year Published /9,5i.........- Publication Scale Soil Map Unit Drainage Class Soil Limitations L. '. "'........... /Gi......... Surficial Geologic Report Available: No El Yes ❑ Year Published Publication Scale Geologic Material (Map Unit) .... ................. . Landform e Flood Insurance Rate Map: Above 500 year flood boundary No El Yes IS] Within 500 year flood boundary No ❑Yes ❑ Within 100 year flood boundary No ❑Yes ❑ Wetland Area: National Wetland Inventory Map (map unit) ...............-........ - - ........ Wetlands Conservancy Program Map (map unit) Current Water Resource Conditions (USGS): Month lqj Range :Above Normal ❑Normal ❑Belc�v Normal Other References Reviewed: DEP APPROVED FORM. 12/07/95 FOIZM 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot leo. 1601 S"/rrrl S7 /V- R•+O���e2 Orc-site Review Deep Hole Number -1-P Date: /� fit Time: ' Weather Location (identify on site plan) R Land Use Slope M Z Surface Stones c w Vegetation Gipsy. Landform �T2J✓.vvvr� �,ti'c% Position on landscape (sketch on the back) Distances from: Open Water Body /�00 feet Drainage way feet Possible Wet Area feet Property Line feet Drinking Water Well ..71 feet Other DEEP OBSERVATION HOLE LOG* Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (Inches) (USDA) (Munsell) Mottling (Structure, Stones,Boulders, Consistency, % GraveDISI 191 �/j^ 1�. e, P '"l/Zi^c5 v (Z S ,36 S .. i l s n rd *--MINIMU 2 [40-LES R=RED AT EVERY PROPOSED DISPOSAL ARE i Parent Material(geologic) MP -C DepthtoBedrock: Depth to Groundwater: Standing Water in the Hole: — Weeping from Pit Face: — Estimated Seasonal High Ground Water: 3 1� -- DEP APPROVED FORM-12/07/95 FORM II - SOIL EVALUATOR DORM Page 2 of 3 Location Address or Lot No. G/ SAS —� &Ioe �)e'2 On-site Review Deep Hole Number Date: '505-, Time: ��=` ' Weather S"n.ty -So Location (identify on site plan) Land Use Slope M Z Surface Stones Vegetation CTrzc SS Landform C �«v /Y1o,2r9/�✓C Position on landscape (sketch on the back) Distances from: Open Water Body 6-00 feet Drainage way 300 feet Possible Wet Area Z°0 feet Property Line 2r'. feet Drinking Water Well 70 feet Other DEEP OBSERVATION HOLE LOG Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(Inches) (USDA) (Munsell) Mottling (Structure,Stones, Bounders, Consistency, % Grav 36" 36 - y C�a r S, �� %3 0 r-l",0e At,;-k5 /U t SCO p.�T /i>�.::� (.JAG✓ �c7� ('t,��,5 e n,✓t. C' '51 IV3 Iveo O y Parent Material(geologic) L-0r?_v�et / �� _ DepthtoBedrock: Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face: Estimated Seasonal High Ground Water: DEP APPROVED FORM-12/07/95 FORM I I - SOIL LVALUATOR FORM Page 3 of 3 r Lot No. D/ Sal.-h9 S71: r/✓tc�.�vC2 Location Address o /r7 N Determination Lor Seasonal High Water Table Method Used: ❑ Depth observed standing in observation hole inches ❑ Depth weeping from side of observation hole _ ... inches ❑ Depth to soil mottlesi?�/36 inches j:;2z ❑ Ground water adjustment feet Index Well Number ..._............. Reading Date .................. Index well level ..... ..... Adjustment factor .......... Adjusted ground water level _... _. . .................... ......... Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? �s If not, what is the depth of naturally occurring pervious material? Certification I certify that on 4,10L/ lg9.S� (date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature & Date DEP APPROVED FORM- 12/07/95 MASSACHUSETTS U141FORM APPLICATIOWFOR PERM 1' TO:pp'pLg g� (Type or Print) .�' ;i: ., . . ;•;� NORTH ANDOVER Mass. ,,.4: Oate:' y Building Location t�t!��/ S/ -��'''r Permit c3Gn9 . Nov Owners Name �(e� / '� S ti v New Renovation r] Replacement C1 Plans Sybmitted FIXTURFS sn O Z m Y -i o. a- V a N a d r a . m CC z 0 a ac ~ = o z eD a s Ot— U Y < �' d• z ~ a W to _ t,• a < _ < 3 >t! v a• ac o a azi W �- t- v o a m a o► ac o M. o v o„ sr I < W .v a 40 Z to � .Q �. m x �' r- W o o -' 1•- a le M- < Z z Z. Y a 0 d W IL !L W Y 1 O N N 7 v, F' 2 O O v1 X Y ul H O U X SUB—,BSMT. BASEMENT IST FLOOR 2ND FLOOR , 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR ' 8TH FLOOR (Print or Type) _ ! Check one: Certificate Installing Company Name P,,6A f,(/ /7t✓ �� FW I"(, 0 Corp. Address Partner.` kir /(d I - E�Firm/Co. Business Telephone Name of Licensed Plumber: i�t/Z Insurance Coverage: Indicate the type of insurance coverage by checking the i . appropriate box: Liability insurance policy �ther type of indemnity D Bond Insurance Waiver: I, the undersigned, have been made aware- that the licensee of this application does not have any one of the above three insurance coverages. • Signature of owneriagent of property Owner Agent`s I baebr eettifr that all of Ilse dclails and information 1 leas subinittcd(or cntcrcd)in a1Mo.e application ice tcrrc asrd�alt to an btd 4N ly knowledge and that all plumbing work and installst'ions lice fnrmcd undcr Pc1411it iuued for this applicsliost will be M oothyrWthp h-ilk ell OcfllNW pwo I osis"of On Masisehusetls Stale Plumbing Codc and Cluplcr 142 of 111e(:cnuat UWL sib By i ` Title . Signature of Licensed Plumber a*j pe of Plumbing License !` .. City/Town. /�7� � ry . --- r"� ------- ----- TITLE 5 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSL SYSTEM FORM PART A CERTIFICATION Property Address: 1601 Salem Street North Andover,MA 01845 Owner's Name: Robert Kasischke Owner's Address: 1601 Salem Street North Andover,MA 01845 Date of Inspection: January 8,2002 Name of Inspector:(please print) George Norris Company Name: D.F.Clark,Inc. Mailing Address: P.O.Box 265 Ipswich,MA 01938 Telephone Number: (978)356-5638 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 Approval Authority Fails 011�1 Inspector's Signature: Q,_��M Date: I Nica 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 kithoctt$�r:NORTH ANDD,c .%- BOARD OF HEALTH Notes and Comments ii ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6115100 page 1 r Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1601 Salem Street North Andover,MA 01845 Owner: Robert Kasischke Date of Inspection: January 8 2002 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 conditions 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`hot 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. f Compliance indicating * leaking and if a Certificate o C g A metal septic tank will pass inspection if rt is structurally sound,not g p 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: 2 Y Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1601 Salem Street North Andover,MA 01845 Owner: Robert Kasischke Date of Inspection: January 8,2002 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(l)(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: 3 1 V Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1601 Salem Street North Andover,MA 01845 Owner: Robert Kasischke Date of Inspection: January 8,2002 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no" to each of the following for all inspections: Yes No _ X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than''/2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s) Number of times pumped X Any portion of the SAS,cesspool or privy is below the high ground water elevation X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply X Any portion of a cesspool or privy is within a Zone 1 of a public well _ X Any portion of a cesspool or privy is within 50 feet of a private water supply well _ X 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 the 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 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1601 Salem Street North Andover,MA 01845 Owner: Robert Kasischke Date of Inspection: January 8,2002 Check if the following have been done: You must indicate"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 Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined? (If they were not available note as N/A) X Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X Were all system components,excluding the SAS,located on site? X 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? X 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 X _ Existing information. For example,a plan at the Board of Health. X _ 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)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1601 Salem Street North Andover,MA 01845 Owner: Robert Kasischke Date of Inspection: January 8,2002 FLOW CONDITIONS -- RESIDENTIAL —_ Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system (yes or no): No ; [if yes,separate inspection required] Laundry system inspected(yes or no): No Seasonal use: (yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Well Water Sump Pump(yes or no): No Last date of occupancy: Currently Occupied COAL ERCIAL/MUSTRIAL 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 reading,if available: Last date of occupancy/use: OTHER: (Describe) GENERAL INFORMATION Pumping Records Source of information: System has never been pumped according to owner Was system pumped as part of 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 inspection records,if any) InnovativeJAlternative 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 gh approval Other(describe): Approximate age of all components,date installed(if known)and source of information: System was installed in December 1999/January 2000 according to Certificate of Compliance Were sewage odors detected when arriving at the site(yes or no): No 6 - -- Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1601 Salem Street North Andover,MA 01845 Owner: Robert Kasischke Date of Inspection: January 8,2002 BUILDING SEWER(locate on site plan) Depth below grade: 17" Material of construction: X_cast iron 40 PVC_other(explain): Distance from private water supply well or suction line: 23' Comments:(on condition of joints,venting,evidence of leakage,etc.): Unable to inspect building sewer pipe because it goes into a slab floor. SEPTIC TANK: Yes (locate on site plan) Depth below grade: 4" 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: 4'/2'W x 8'L x 4'D Sludge depth: 14" Distance from top of sludge to bottom of outlet tee or baffle: 20" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: N/A Distance from bottom of scum to bottom of outlet tee or baffle: N/A How were dimensions determined: Measured 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 and outlet baffles are in lace li uid is at outlet invert,tank is in good condition and does not require p Q ert, g Q -pumping. GREASE TRAP: No (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments:(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1601'Salem Street North Andover,MA 01845 Owner: Robert Kasischke Date of Inspection: January 8,2002 TIGHT or HOLDING TANK: No (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: gallonsiday 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: Yes (if present must be opened)(locate on site plan) (Depth below grade= 16") 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.): No evidence of solids carryover,distribution is equal d-box is in great condition. PUMP CHAMBER: No (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): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1601 Salem Street North Andover,MA 01845 Owner: Robert Kasischke _ Date of Inspection: January 8,2002 SOIL ABSORPTION SYSTEM(SAS): Yes (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 leach field—20'x 50' overflow cesspool,number: r_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.): Ground was frozen and snow covered over SAS no signs of ponding or hydraulic failure present. CESSPOOLS: No (cesspool must be pumped as part of inspectionxlocate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: No (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.): 9 i } �l Page 10 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1601 Salem Street North Andover,MA 01845 Owner: Robert Kasischke Date of Inspection: January 8,2002 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. A- 1 = 19'4" B- 1 = 57' A—2 =42'6" #2—D-box B—2 = 39'2" Well to SAS = 105'4" O Vent #1 —Septic Tank B =4"x 4" support for deck Deck A sewer Garage water Well O Salem Street 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1601 Salem Street North Andover,MA 01845 _ Owner: Robert Kasischke Date of Inspection: January 8,2002 SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated depth to ground water_feet Please indicate(check)all methods used to determine the high ground water elevation: X Obtained from system design plans on record—If checked,date of design plan reviewed: January 18,2002 _Observed Site(abutting property/observation hole within 150 feet of SAS) _Checked with local Board of Health-explain: _Checked local excavators,installers—(attach documentation) _Accessed USGS database-explain: You must describe how you established the high ground water elevation: Bottom of SAS is 28"below grade According to soil testing performed on April 15 1999 by Ben Osgood ESHGW was determined at 36"below grade in Test Pit#T.P. 1 11 Date 3`_. .. . . . N 3-629 f.. i ".0 oT; +tio TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING j f This certifies t . .C :`% . . . . has permission to perform r- ". .-�1- . . . . . ... . . . . . . . . plumbing in the buil gs of/ . a-- . . . . . . . . . . . . . . : . at. . :. . . ., North Andover, Mass. Fee Lic. No. . PLUMBING INSPECTOR 03/03/98 09;32 15.00 PAID WHITE: Applicant CANARY: Building Dept. PINK:Treasurer �' T01" OF NORTH'ANDOVE-R,mC- SYSTEM PUkPING RECO RaD- FF s '51-57EM OWNER-&- ADDRESS r, SYSTEM LOCATION S yE� (example: left fr at of ho sr) . Sal s�-- ` r /6 vA'J'E OF PUINPINC: QUANTITY PUMP ED CESSPOOL:.»1 UUL: NO YES SEt' IC TANK: NO YES a NATURE OFSERYICE; ROUTINE EMERGENCY • a uIJSFRVAT10N3r s' ' GOOD CONDMOM FULL TO COVER HEAVY GREASE BAFFLES IN PLACL ROOTS LEACHFIELD RUM3ACK— EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOY$R -sp;HRR (EXPLAJN) t = s,I.v.M PUMPED P MPC BY: «-.• Vfy 4177 C'U 11 kf FttTS: c U17'IsN'J'S TRA NSPC,It R R0 TO: TOWN OF R,rFl ANDOVER, RECEIVED DAll: U SYS ,M MPING RECORD AUG 0 9 2004 SYSTEM OWNER ADDRESS SYSTEM.LOCATION T6 HEALTH DEPARTMENT e— /v,Anclo DATE OF PI.IMMNG:^ .-----.—QtJANTITY PtJMPEID NATURE OF slaRvI E: ROUTtlrlE---..._.__EMERGENCY OJISE,RYA I'It)N& GOOD CONDITION FULL TO COVER vY G SSE BAFFLES IN PLACL ROOTS LEACIMELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLID CARRYOVER,' OTHER EXPLAIN CON TI N I,� FKANSF R D TO a d k Commonwealth of Massachusetts North Andover, Massachusetts System Pumping Record System Owner & address: Reed Malleck _ 1601 Salem Street RECEIVED North Andover, MA Location of system: Rear JUL — 7 2006 TOWN OF NORTH ANDOVER Date of Pumping: June 21, 2006 HEALTH DEPARTMENT li _ Type of system: Septic tank Gallons Pumped: 1000 Gallons System pumped by: Service Pumping &Drain Co., Inc. License #: BHP-2005-0649 Contents transferred to: Greater Lawrence Sanitary District Date: June 23 2006 Pumping Technician: MW This is PROPRIETARY and CONFIDENTIAL information that may be used only by the Board of Health for regulatory purposes Commonwealth of Massachusetts North Andover, Massachusetts System Pumping Record System Owner& address: RECEIVE.,-rr Y Matt Merrill/Erin Tholen SEP 2 2 2008 1601 Salem Street i North Andover, MA TOWN OF NORTH ANDOV�- HEALTH DEPARTMENT Location of system: Rear yard Date of Pumping: September 12, 2008 Type of system: Septic Tank Gallons Pumped: 1000 Gallons System pumped by: Service Pumping& Drain Co.,Inc. 5 Hallberg Park North Reading,MA License#: BHP 2007 0728, 0725, 0727,0722, 0724, 0726 I Contents transferred to: Greater Lawrence Sanitary District Date: September 12, 2008 Pumping Technician: PD This is PROPRIETARY and CONFIDENTIAL information that may be used only by the Board of Health for regulatory purposes I I Commonwealth of Massachusetts North Andover, Massachusetts r° System Pumping Record RECE 'D3 System Owner& Address: 7"T Matthew Merrill TOWN OF NORTH ANDOVER 1601 Salem Street HEALTH DEPARTMENT North Andover, Ma 01845 Location of system: Rear Date of Pumping: September 23, 2010 Type of system: Septic Gallons Pumped: 1000 gallons System pumped by: Service Pumping& Drain Co.,Inc. S Hallberg Park North Reading,Ma License#: BHP-2010-0359,0373,0374,0375,0376,0377,0378 Contents transferred to: Greater Lawrence Sanitary District Date: September 23, 2010 Pumping Technician: FA This is PROPRIETARY and CONFIDENTIAL information that may be used only by the Board of Health for regulatory purposes i I