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Miscellaneous - 162 STONECLEAVE ROAD 4/30/2018 (2)
162 STONECLEAVE ROAD pad 210,10-A.B-0128=0000.0 -f ti r v l 162 STONECLEAVE ROAD JS-2009-000017 Proiect Detail Report Printed On:Tue Jul 08,2008 Project Name: GIS#: 5941__Project No: JS-2009-000017 Owner of Record BOOTHBY, STANTON R SANDRA t wo**� 4 Map: 104.6 Date Submitted: Jul-07-2008 162 STONECLEAVE ROAD o .v�ao 0 r q oD Block: 0128 Status: - Open --- —NORTH.ANDOVER, MA 01845 — Lot: Work Category: Work Location. 162 STONECLEAVE ROAD Zoning: Proposed Use: _ —___ _ - ---_ District: S'�`'•��••'`gfi' land Use: 101 Proposed Use Detail Subdivision Description Septic D-Box Comments: of Work: Department Status GeoTMS Module: Status File No. Comments: LCDate: Board of Health GREEN FLAG BHJ-2008-000023 7/7/08-DWC application received via fax for a D-Box replacement from John Divincenzo. �. Called Stewarts to confirm receipt. Need check and obligation form. 7/8/08-Worker came in to pick up permit. Still need obligation form. Faxed to Roxanne at office to complete and send back. 1 asked for a copy of the recent T-5 to show need of D-Box replacement. She said R.Kimball did it. I called the number. R. Kimball is deceased. Called ` h/o and left message to call me back re:permit issued. I need a copy of T-5,and find out who did it,when,etc. Who determined need to replace d-box. Waiting to hear from h/o.--p.d. Permit History Type: Permit No: Issue Date Status Work Category Contractor Project No: Description of Work: DWC Component Repair - BHP-2008-0165 Jul-08-2008 SIGNED OFF JS-2009-000017 Repair-Individual Components GeoTMS®2008 Des Lauriers Municipal Solutions,Inc. Page 1 of 1 NorthAndoverBoarcl01Assessors PublicAccess rage 1 or 1 s ]Board of A4ssessorR. F. A 4't 8i �4�sneNul�' Property Return to the Home pace click on loco Record Card Parcel ID:210/104.13-0128-0000.0 Community:North Andover SKETCH PHOTO New Search Click on Sketch to Enlarge Click on Photo to Enlarge Sales Summary Residence Detached Structure s: Condo Commercial Comparable Sales 182 STONECLEAVE ROAD Location: 162 STONECLEAVE ROAD Owner Name: BOOTHBY,STANTON R SANDRA L BOOTHBY Owner Address: 162 STONECLEAVE ROAD City:NORTH ANDOVER State:MA ZIP:01845 Neighborhood:7-7 Land Area:1 acres Use Code:101-SNGL-FAM-RES Total Finished Area: 1400 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 445,600 460,100 Building Value: 220,800 223,600 Land Value: 224,800 236,500 Market Land Value:224,800 Chapter Land Value: LATESTSALE Sale Price: 1 Sale Date:05/18/1988 Arms Length Sale Code:A-NO-FAMILY Grantor:BIALOSKY SANDRA L Cert Doc: Book:02731 Page:0233 http://csc-ma.us/NandoverPubAcc/jsp/Home.jsp?Page=3&Linkld=l 180317 7/8/2008 Commonwealth of Massachusetts �tECElVED City/Town of NORTH ANDOVER JUN 10 2014 System Pumping Record TOWN OF NORTH ANDOVER HEALTH DEPARTMENT M yv6 Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, ��ne C t euuse only the tab ko? ye- key to move your Address cursor-do not NORTH ANDOVER Ma use the return City/Town State Zip Code key. 2. System Owner: Z0c 71 Name renes Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping V , 2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: X 6. Systn Pumped By: acne'^'^-- Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: a s r - ent Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Date-- Signature of Receiving Facility Date 4 t5form4.doc•03/06 System Pumping Record•Page 1 of 1 Sawyer, Susan From: Sawyer, Susan Sent: Monday, April 28, 2014 10:32 AM To: Sawyer, Susan Subject: 162 Stonecleave potential buyer questions Received phone message Called Melissa back in regards to 162 Stonecleave.They are looking to put in an offer, but want an addition. Info shared: Insp report done by John DiVincenzo;Stewarts septic; provided phone# Looks like tank is @ 10 from house; if the addition comes too close it would have to be relocated. Cannot confirm the distance to the field;as-built is not specific though it was designed for 25 feet to field from proposed foundation. System can sustain a 5-bedroom home or 11 room max based on 600 gallon per day design (150 gpd x 4 bedroom) To gain approval for the addition; 1) The title v inspection is passing; system is @ 36 years old. 2) Suggest locating the leaching field and d-box to determine if the required distances can be maintained a. If on columns must be>5 feet to tank and > 10 feet to leach area b. If on foundation must be >10 feet to tank and >20 feet to leach area 3) Could contact Stewarts or an engineer for advice and cost estimate for design and installation depending on the answers to#1 4) Health would review any information submitted. Susan Sawyer Public Health Director Town of North Andover 1600 Osgood Street Suite 2035 North Andover,MA 01845 Phone 978.688.9540 Fax 978.688.8476 Email mailto:ssawver@townofnorthandover.com Web www.TownofNorthAndover.com Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records.For more information please refer to:http://www.sec.state.ma.us/pre/preidx.htm. Please consider the environment before printing this email. ' 1 of NORT.,y 6646 O i Town of North Andover e r s,�'•>;,;p:: HEALTH DEPARTMENT ,SSACNUSt1 CHECK#: ` � DATE: LOCATION: br? w c H/O NAME: CONTRACTOR NAM04-, Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ Title 5 Report $� ❑ Other. (Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer Of,NORTH 1y 6646 ; O i � • 9 Town of North Andover HEALTH DEPARTMENT ,SSACMUS�S CHECK#: Z5-p� DATE: LOCATION: H/O NAME: CONTRACTOR NAMELA, Type of Permit or License:(Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ Title 5 Report $��JV�, ❑ Other. (Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer 12752 Town of North Andover \ 11/18/18 ' 0,00 \- I Haverhill Bank 9613 title 5 162 Stone Cleave Rd 50.00 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 162 Stone Cleave Property Address Sandra&Stanton Boothby Owner Owner's Name information is North Andover MA 01886 October 16, 2013 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not John DiVincenzo use the return Name of Inspector key. Stewarts Septic Serive r� Company Name 58 South Kimball street Company Address 2�, Bradford MA 01835 City/Town State Zip Code 978-372-7471 S113386 Telephone Number License NumberJD RECEIVED B. Certification NOV 19 20 I certify that I have personally inspected the sewage disposal system at t iSOffl�s D 'dN information reported below is true, accurate and complete as of the time .2 6S)" ction was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ !Need Further E a nation by/the Local Approving Authority tesystem 's ignature Date Tinspector shall sub it of this inspection report to the Approving Authority (Board of Health or DEP)within 30 da s of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 162 Stone Cleave Property Address Sandra&Stanton Boothby Owner Owner's Name information is required for every North Andover MA 01886 October 16, 2013 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Tanked pumped 6/24/13 B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20,years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 162 Stone Cleave Property Address Sandra& Stanton Boothby Owner Owner's Name information is North Andover MA 01886 October 16, 2013 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Tale 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 162 Stone Cleave Property Address Sandra& Stanton Boothby Owner Owner's Name information is required for every North Andover MA 01886 October 16, 2013 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less ❑ ® than %day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 162 Stone Cleave Property Address Sandra&Stanton Boothby Owner Owner's Name information is required for every North Andover MA 01886 October 16 2013 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate r regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 162 Stone Cleave Property Address Sandra& Stanton Boothby Owner Owner's Name information is required for every North Andover MA 01886 October 16, 2013 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ❑ ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ^M 162 Stone Cleave Property Address Sandra& Stanton Boothby Owner Owner's Name information is required for every North Andover MA 01886 October 16 2013 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Occupied 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 162 Stone Cleave Property Address Sandra&Stanton Boothby Owner Owner's Name information is required for every North Andover MA 01886 October 16, 2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Stewarts septic Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: 1000gallon tank pumped 6/24/13 gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Tale 5 Official Inspection forth:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 162 Stone Cleave Property Address Sandra&Stanton Boothby Owner Owner's Name information is required for every North Andover MA 01886 October 16, 2013 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 10/10/79 34 years as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 23"feet Material of construction: ® cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: 114' Plus feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 14"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3113 Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 "<L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 162 Stone Cleave Property Address Sandra&Stanton Boothby Owner Owners Name information is required for every North Andover MA 01886 October 16, 2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness .5 Distance from top of scum to top of outlet tee or baffle 5 1/2" Distance from bottom of scum to bottom of outlet tee or baffle 14.5" How were dimensions determined? Tape measure&sludge judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): liquid levels are good, no leakage both baffles are in good condition. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;* 162 Stone Cleave Property Address Sandra&Stanton Boothby Owner Owner's Name information is required for every North Andover MA 01886 October 16, 2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: , gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of lastum in p p 9 Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ;M 162 Stone Cleave Property Address Sandra&Stanton Boothby Owner Owner's Name information is required for every North Andover MA 01886 October 16, 2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): New box installed 7/15/08 equal distribution, no leakage, no solids carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 162 Stone Cleave Property Address Sandra&Stanton Boothby Owner Owner's Name information is required for every North Andover MA 01886 October 16, 2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1-20'X 45' ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No hydraulic failure, no ponding. We also camered lines and there was no ponding in laterials. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 162 Stone Cleave Property Address Sandra&Stanton Boothby Owner Owner's Name information is required for every North Andover MA 01886 October 16, 2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 i ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 162 Stone Cleave Property Address Sandra&Stanton Boothby Owner Owner's Name information is required for every North Andover MA 01886 October 16, 2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 162 Stone Cleave Property Address Sandra& Stanton Boothby Owner Owner's Name information is required for every North Andover MA 01886 October 16, 2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 4.5 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked date of design Ian reviewed: November 3,1977 p Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: pulled files ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Water table taken from design plans water at elevation 119.50. Bottom of bed 123.50. 4' seperation from water to bottom of bed. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 162 Stone Cleave Property Address Sandra& Stanton Boothby Owner Owner's Name information is required for every North Andover MA 01886 October 16, 2013 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 o � N W J c J 1 0 O ¢ o fJ) Z D •�Z pta C 18 •_ ' c 77ViV-Z Zo •� r _ 9S-;,7V1-71 IV c/ E/ >/N W1 P 41 c/-$ •/ n o �� •�'S vim. 1 1 c � S "7. /�. 1 iloc- hl L07 , 0 ' � �� / ' c� e •� ,�[ p ' Commonwealth of Massachusetts PECE71VED9tjjV City/Town of No Andover System Pumping Record UL 1 Foram 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Heap. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form,check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information important:When riling out tomo 1. System Location: on the computer, / use only the tab 6 e C t' Lle- key to move your Address cursor-do not No andover use the return Ma key. City/Town Site Zip Code 2. System Owner. Name tunr Address(if different from iocationj City/Town State Zip code Telephone Number B. Pumping Record 1. Date of Pumping Date C (Un 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) �] Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: ex n! �l 6. System Pumped By: Name Vehicle License Number StewartsSeptic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant 20 So. Mill Bradford Ma 01835 Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03106 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts IJ City/Town of No Andover System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your j local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: 2,2 013 on the computer, //�� use only the tab 6 p C� TOWN OI=Ntri l ht,�NnnVCR Ile— key to move your Address na I r r i3l.r nig 1 YYIL.IY 4 cursor-do not use the return No Andover Ma key. City/Town State Zip Code 2. System Owner: 0 Name _ mann Address(if different from location) City/Town State Zip Code i Telephone Number B. Pumping Record 1. Date of Pumping Date 0C_ /� 2.• Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight TankGrease Tr ❑ ap ❑ Otherdes ( crlbe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Name Vehicle License Number Stewart's Septic Se �ce Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Date Signature of Receiving Facility Date ` t5form4.doc•03/06 System Pumping Record•Page 1 of 1 .r }1u 1/� Y � it `..A' t,•) r 1 1 ... �r:+;,,, l ; ,.r�r,gi1�'1��;';w'<' '•f`y;'1',��;;,1 ;'.,;0,11,:, . OCT 0 6 2009 paP.hi I plpYldl'd IhN ro/rn 1�/ r t 1 b1111 0 1' p,;01 6 b r floc to of IQW aqw: I „ �JW°I�,r�'p>tTllaal gv�R �� OJIIn p/ Cl )pry - A ART' N� •eel ; A, Faclllty In(ormon - S� sm i;lr '.''11V•.110 ,��i•,,,r,.'i;'I.JiIN '.'.'��I� `,�r,' , S W-4.0111 1 !2 r1:.Q 'rJ 'I•/ �' r) )!•'�1451�;}`.I'�jirll 1 !ry�!.' ot Y;I,�.pU•.IpL�lb�d'�.P,rr��'I ,.,.,, 1�''1 ir•r'1�,�v'u..'r.;�,1.5),1 ' �2Ys 4 I/IAI IM11b �. uVo 1 . . 10�07�On1 n,mo11 �� [IJ A r1g'�e�ord • `'t .. �/r�y}'I v'�I,.�'i'��'4Jr��ls II'rl�ll��"rel", Oalo of Pum�inp'. ,, � ; ,, •, ► . 01,1 ? �•:d r:', r, ;6 C .�=—__ �► ' ' ' ,:rY� o +y�lOm;,. C1 C91��001(�) optic Ten, v1:. „ Tim rs 1r/�Fille( ,I,R,aonf7 [' Yoe n'o u • .. ,'•j'; �'+I"L,��;?rx,�,r'�Jn,At?•'Irr1.u�,�'�,1'���ij'r ��'Ir�: � Y87. n•81 {� C•'08n00� � Y�5 — I L/'l.�,il`'%.tl�1 •� •�,j i.,r ,�r:,ll'.+'h'JY+•I to 11;;v1'1\" PVmped 8Y,",.. _. '• •.�r;,1�N�f�' )1,I��yy� �i',.+4 J(; �,1; ' i C� �I llld I '.1 A I 1 h'1•�,. . ;•�,:f:�ar�,�a..�,,�`�'N�Gli� h'h�('vl�,/. � +''i11�l;tllr;•� � � • . •. :r, '1;,,,,,; , heli ooAl�ny,�ero dl�posev: • ' , ,1 •r; of ,1 ,',r 1 www���ttt �. ,r.masa.pov/dep�.I, ,Oppoyi/allbtorm3,rvnam pORTil O tt�e o 16'gti O IL V ey o o` -1p4 cocwc c«c.V ��SSACHUS PUBLIC HEALTH DEPARTMENT Community Development Division RVEITC3rrE O F CO.�Vl�1',GIA�II�CE As of: ,duly 1S, 2008 This is to cert that the indviduafsu6surface d�sposafsystem received a SAV FACYIORTINSPEMOYof the: Distribution Bo,-�replacement By- John 1DiVincenzo At: 162 Stonecleave lead Map 104-B; (Parcel 128 North Andover, qvq 01845 The Issuance of this certifi*cate shaff not 6e construed as a guarantee that the system wilt function satisfactorify. a 2'. Sawyer ,f 1 , u.ffeafth Director 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 918.688.9540 fax 978.688.8476 Web www.townofnorthandover.com NORTi4 O��tLEC 16 3� h� 6 0 o O c""Ic" K• 1` �74p°R�re�rPa�y�(9 9SSACHUS�� PUBLIC HEALTH DEPARTMENT (ommunity Development Division C' 2�A—J -� 'IC.A`1- O ' CO�I�1�1'�I.ANC2 As of: ,duly 15, 2008 This is to certify that the individualsu6suiface di osal stem received a SA`ITSE,gCT01RT1-1VSITECgY0Xof the: Distribution Bo.V Refacement B ,john DiVincenzo At: 162 Stonecleave load Wap 104. 3; (Parcel128 North Andover, 9YIA 01845 The Issuance of this certificate shaft not be construed as a guarantee that the system wilt function satisfactorily. Z-Llen ja 1 SawyerPtic Ifealth Director 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 fax 978.688.8476 Web www.townofnorthandover.com NORTH O� �SLEo 16 - 3'? OL O t A �14Q°'IATED �SSACHUS�� PUBLIC HEALTH DEPARTMENT Community Development Division C RTIElC.�T� Off' C0-(14 I.�NCE As of: Jufy 15, 2008 r1his is to cert that the individualsu6surface dzsposa[system received a SA`ITSFAC OR,YIT�STECg7oTl'of the: (Distribution Bo,-�RepCacement By• ,john 1DiVincenzo At: 162 Stone&ave load 9Yap 104.B; (Parce[128 North Andover, qvA 01845 The issuance of this certificate shall not 6e construed as a guarantee that the system wiff function satisfactorify. 17 ssaw 1Y. Sawyer,/ j Mlfic IfeaCth Director 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Page I of 1 DelleChiaie, Pamela From: DelleChiaie, Pamela Sent: Thursday, July 10, 2008 10:27 AM To: Grant, Michele Subject: 162 Stonecleave- Ready for D-Box inspection HI, Stewarts called and said this is ready for a D-Box inspection. There is a bucket of water there. Can you do it today sometime? File is on your desk. NOWRagavds, P4#10.44 Da lelolo tlalo Health Department Assistant Town of North Andover 16o0 Osgood Street Building 20,Suite 2-36 North Andover,MA 01845 9978.688.9540-Phone 978.688.8476-Fax http-.//Ns,",w.tow-nofnorthandover.com healthdept@townofnorthandover.com 7/10/2008 t TOWN OF NORTH ANDOVER t NORTH Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 1600 OSGOOD STREET;Building 2-36 NORTH ANDOVER,MASSACHUSETTS 01845CHs" �cMug Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX D-BOX ❑ Installed on stable stone base ❑ nlet tee (if pumped or >0.08'/foot) ❑ Hydraulic cement around inlet & outlets Observed even distribution ❑ Speed levelers provided (not required) Comments: SOIL ABSORPTION SYSTEM ❑ Bottom of SAS excavated down to soil layer, as provided on plan ❑ Size of SAS excavated as per plan Title 5 sand installed if specified on plan ❑ P ❑ 3/4-1 Y2" double washed stone installed ❑ 1/8-1/2" (peastone) double washed stone installed ❑ Laterals installed and ends connected to header ❑ Laterals vented if impervious material above ❑ Orifices @ 5 & 7 o'clock positions ❑ Gravel-less disposal systems: type, number and location asp er Ian P ❑ Elevations of laterals installed as on approved plan ❑ 40 Mil HDPE barrier installed ❑ Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: Wastewater System Documentation—Feb 2006 Page 3 of 6 i 3384 Town of North Andover ° HEALTH DEPARTMENT s34CNUSE CHECK#: "W - DATE: lv� LOCATION: Ito "?� .tr�'/��`�• H/O NAME: OF CONTRACTOR NAME: 4 Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type. $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ > ❑ TrashlSolid 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 $ ❑ Title 5 Report $ ❑ Other. (Indicate) $ a Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer VritrI -'Ul1,S U:J:41 PAA M10 )1J 0011 o Ass) 7 t1hiLori=N1 WjUUI Noses, o Application for Septic Disposal System 717 1,0f •�'° ' ' _ -Construction Permit— TOWN Cts TODAY' DA TEf � - IIA 01$4 $250. 0-Fuji Repair ORTH M DOVER 9 --- r ofient� Important: Application is hereby made for a pemtit to' When filling out ❑Construct a new on-site sewage disposal system* forms on the computer,use ©Repair or replace an existing on-site sewage disposaonly the tab keyto movedo n Repair or replace an existing system component—W � cursor•do not � 'J 1_;�a kuse eylheretum A Facility Information w Address or Lot# Citylfewn 2.-*TYPE CF SEPTIC SYSTEM' Q Pump ❑Gravity(choose one) "T pump system,attach copy of electrical permit to application"* ❑Conventional System(pipe and stone system) ❑Infiltrator or Blodiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system. U Pressure Distribution S.A.S.(No D-Box)(Attach Draft Maintenance Agreement) ®Pressure Dosed(D-Bax Present)S.A.S. 2, Owner Information Name. 14_7 P . Address(rf difiere t from ate vej &1/7, 414 �� _14 CltylfOWn state��r ` �� ,.,�lp COd9 ll/+ffl{' JG/-//rJ0ry Telephone Number 3. Installer In"ation Name Name of Company LZ Add ' #U. . ID Cdylfown State Zip Code Tolephone Number(Cell Phone N ff possible please) 4. DeSioner Information Name Name of Company Address Ctty/fewn -- State — - Zip Code Telephone Number{best t)to Reaelt) Application r[?ispo6al system Construction Permit•Page 1 of 2 i i a ' pRr►� Commonwealth of Massachusetts Map-Block-Lot p tjil0 �� S' Op 10--B 0128- a Board of Health ___ ____________ Permit No BHP-2008-0165 North Andover __________-___________ P.I. FEE ,SSCNUSE� F.I. $125.00 ----------------------- Disposal Works Construction Permit Permission is hereby granted John-D1Vincenzo to(Repair)an Individual Sewage Disposal System. at No 162 STONECLEAVE ROAD as shown on the application for Disposal Works Construction Permit No. BHP-2008-016 Dated July 08,2008 II ---------------------- ------ --------- -L-iff -------- ------------------ Issued On:Jul-08-2008 Boao ealth „oxr" Commonwealth of Massachusetts Map-Block-Lot p:o 4�,90 ,., p� 104.B-0128- Board of Health ----------------------- s i s North Andover • *a 's Certificate of Conce ,Ss�cwust� THIS IS TO CERTIFY,That the I ' ' ual Sewage Disposal System (Repair) by John DiVincenzo ------------- ------------------------------------------------------------------------------------------------------------- Installer at No 162 STONE AVE ROAD has been insta in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the ap lica ' or Disposal Works Construction Permit No. BHP-2008-016 Dated July_08,2008........ ----------------------------------------------------------------- Printed On:Jul-08-2008 Board of Health 07/07%008 09:47 KU 978 373 U1511 i M) 7 llL4LLIFAILlv1 qfjUU.L r Q'r•°��':. Application for Septic Disposal System 1, 1 & ' �'' '.:•.' oc S TE Construction Permit® T® OF TOD NORTHTDOVE MA 01845 .$250.00-FUII Repair ....�" $125.00-Component 'ssuw�' PAGE 2OF2 A. Faciiitv Inform tion continued.... 5. Type of Building: Residential Dwelling or[]Commercial B: Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Conde,as well as the Local Subsurface Disposal Regulations for the Town of No An ver, d n to pla. the system in operation until a Certificate of Compliance has b iss ed by his rd o ealth. Te 717 INV Na e, Date Applicati Approved By, and of Health Representative) am � Date Application Disapproved for the following reasons: For Office Use only• - I Fec Attached. YCS7 _ c Z. Project Manager Obligation Farm Attachcd? f�"es No 3. Pump S s��.aa? If.5a. ttaeh c�0�S vLofE'lecrrical it Yes No 4. Foundation As-Built?(clew construction root y). Yes n 1110 (Same scale as approcedplan) ,5. noor Plans?(new construction only): Yes _ No Application for Disposal System Conatn+ction Permit Page 2 of 2 11:Dy rAA 11110 0/J UU11 _i 31VL ,7 l/r,l•LvriU Ni WJvul �i7i'09!2QQb 11:5E 9786888476 HEALTH PAGE , 01/01 «- SEPTIC SYSTEM INSTALLER PROTECT M-4NA,('x31MENT OBLIGATIONS As the North.Andover licensed in-t&--T for t11e constmr-tion for the septic system.fdr the ploPe at: 67 . _ For .Iasis by (rlddz�FF pf BEphC SS13Cft7l) l�`�a"'---T� !/.�! Relntizc to the npplicatlon of ! Aq11 dared (Installer's nainc) ate Dated revisions Mated q _ s ate (�+st rfied date X lundetstgiod the flonoatix3g obligations for xna.na MEnt Of this ptojgct; 1. A_s the installer„ X am obligated to obtaix7 ail,permits and Board of klealdl approved plans Ili=to perfozming abp work on a site. T Ln t 1 a e C spproved pla.tns anrn�it o site mhcn any wow ' done. 2. As the!�staller.,I Prittst call fax any and all ii,apections. If hots wvmer,COMPactor,project manager,or any �vlYll my cobrpai�y sclicdrtles an inspection and the system is �,ot ready,then other person not associated item three s1,.0 be applicable-. 3. Assthe Inst ll,cT,I am required tohave the n.eces%,ty works co,.mpieted prior to the applicable inspections as indicated.belacv, I underst d a c tin a cti ' out c tion o e+ s in aaeorda �t�i Ti e 5 c Board a t c= tions m i a � 00t1ag tmng levied agaig Meqnor a. 15o f Bed-Gmetally,tlxis is the first(V)iitispectiM,1less there is a retaining wall,which, should be doge fust. '1,110,hjstaljer dust request the inspection but does nut knave to be present. b, Eat Construction Ing -Engtmcr must first do their iaspection fot. evations,ties,etc s-built of verbal OIC(or a-til to:hca ' e t t day com from the Gzxginccr must be subi nitted to the Board of health,aftea:kvEch installer calls for az iu$TCC6On tune. Installet must be present fur this i,rnspection,. With a pump systenxa,all•clectrical work must be ready and able to cause pump to wo-tk and alae-0 ro function. c. Final Gr -In€tallet tmist request inspection when all grading i.s cox'npkete Installer does not have to be on-site, erfo n the work olber:tbav rin le exca field)and I am required m 1. As the smUer,I understand that only ,i zzta y t' to complete the Wsta.-I.tatiazt.of tlxe system idc:ntificd in the attached application fax installatim I fiuth ,x under s w 1 S xs uxihccn cd to 1n9tall septic s�stem5 '�To covet constitute rPacnnc fele-den131 t-6,-.fiy'gtam.nndlor rev cation or s,� e n of m c e to o be wn f North 1lttdoy� s• can,.+ ,nem to�l��r�a�ap it�yo��d nxe�i sz.p Ss' E. ti As the installer,I unldexststad that I must be oft-site dutizng the performance of the following construction steps: a Detem'zirnt on tfist the ptopeJt elevatio$of the excavation has been reached. ,b. raspection ofthe satsd and stone to be used c. Fibal inspection lav Board oflYealrh 0990'r consuhant d. IfM&vllatiott of tapjs D--Box.pipe,stone, vcn4 pump c,4gmhcx,xctaWjW scall and other 6. As the ins•caller,I undczata,t7. lbat I an-,,play xeMonsible for the ju,,Aallation of the Z iserrs as per the apptovcd:plany Ne.,is coons hLtham homed mrt.g• mat conox M 2LW%7-0—tb-et pexsa:as shall absolve the of this_ l , -dsw, Undetstgn.ed.Licensed Septic Intone.,: (To s t Az elfo-'�Pzv (Name-- rrnt 7 - Sigac 41 TRAfdSMISSIOH VERIFICATION PEPOPT TIME 07/06/2006 11:56 NAME HEALTH FAX 9766666476 TEL 9766666476 SEP.# 0004J120960 DTE.TIME 0:/06 11:56 FA' 110./NAME 697637 6111 DURATION 00:00:22 PAiaE(:- 01 RESULT OK MODE STANDARD EM SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North.Andovet licensed installcr. for the construction for tb,c septic s'j'steta.for the property at: A, d _ For pl,aas by (address of septic.system) (j1n. ineex) Relative ro the aPplicarion of (lAnd dated nsta.11cr's namc) �IOVgMalafi Darted Wit])revisions dated — ay s atc j (Last.rfivised date) I understand the following obligations for Management Of this, project: 1.. As the installer., i am obligated to obtain all permits anal Board of Health approved plans pij-01 to performing anywork on a site. II mustt,c approved p,ons and d e permit on site-w en any wo being done. 2. As the instaUei,,I must call.for any acid all io)spcc-dons. If hamco-,veer,con.ttactor,project%?aanager,or any other person not associated with my company schedules an inspection and the system is not ready,then item thtee Shall be applicable. 3. As the installer,I am required to have the necessixy work completed prior to the applicable inspections as indicated.below. I understand, a re c ttesti]a'An iii ection,without cc�rrzt�letion of tl��% � ig in accordat�c 'Vith-Tithe Board ofReMu ations may resMjt in a 550 00 fine b���'levied mains riac and/ox -H rny compa�zt� inspection a. Botta f Bed--Generally,tbls is the first inspectionunless there is a.tera'n'_ng wall,which shouldbe deme first. The installer ti ust request the inspection but does not have to be present. b. jitial Constructton_Instlection—F—Mmcer must first do their inspection for elevations,ties,etc. As-built ofverbal OIC(or e-mail.to: hcalthdeptQ %-th ndover.corn) from the eo,ginccr must be submitted to the Board of Health.,after which installer calls tot an inspection time. Installer must be present tot this inspection. With a pump system., all,electrical work must be teady and able to cause pump to work and a4,n):i to function. c. Final Gtade–Installer gust teguest inspection when allgrading is complete. Installer does not have to be on-site. 4. As the installer,I undersuind ttut only I may perform the-work (o117er thxi,rune/exeiawtioyt�and I am required to complete the b..stal ati.ota,of the system identified in the attached application fox.installation. I further understand that work done by others nnlicenscd to install.septiC Sj:stems_in oCr can constitute SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: (address of septic system) For plans by (Engineer) Relative to the application of Vw ,P/���� � (Installer's name) And dated ngma ate Dated ©� o av s ate With revisions dated / (Last revised date) I understand the following obligations for management of this project: 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner, contractor,project manager, or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection,without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or my compaW. a. Bottom of Bed—Generally, this is the first (VS inspection unless there is a retaining wall,which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection—Engineer must first do their inspection for elevations, ties, etc. As-built of verbal OK (or e-mail to: healthdeptQa townofnorthandover.com) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system,all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade—Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation)and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used c. Final inspection by Board ofHealth staff or consultant. d. Installation of tank,D-Box,pipes, stone, vent,pump chamber,retaining wall and other components. 6. As the installer, I understand that I am solely responsible for the installation of the system as per the Q12r�plans. No instructions by the homeowner,,general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: �g (Today's Date) //171"If A9 �� � 0 ame—Print) (Name—Signed) :~ Town of North Andover Health Department Date: y o1 Location• (Indicate Address,if Residential,or Na`m�e of Business) Check#: �� Type of Permit or License:(Circle) ➢ Animal $ ➢ Dumpster $ ➢ Food Service-Type: $ ➢ Funeral Directors $ ➢ _Massage Establishment $ i. ➢ Massage Practice $ 4 ➢ Offal(Septic)Hauler $ ➢ Recreational Camp $ ➢ SEPTIC PERMITS: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC)$- ❑ Septic Disposal Works Installers(DWI) $ z, ➢ Sun tanning $ ➢ Swimming Pool $ ➢ Tobacco $ ➢ Trash/Solid Waste Hauler $ ➢ Well Construction $ ➢ OTHER(Indicate) f/A Health Agent Initials. 1492 White-Applicant Yellow-Health Pink-Treasurer Commonwealfh of.Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6115/2000.Inspection forms may not be altered in any way. A. Certification Important: When filling out 1. Property Information: forms on the computer,use 162 Stonecleave Road only the tab key Property Address to move your Stan Boothby cursor-do not Owner's Name use the return key. 162 Stonecleave Road Owner's Address vQ North Andover MA 01845 Citylrown State Zip Code �,M Date of Inspection: 3/23/06 Date 2. Inspector: Robert Kimball Name of Inspector R Kimball Excavation, LLC Company Name 21 Clifton Avenue Company Address Salem NH 03079 City/Town State Zip Code 978-375-1055 Telephone Number 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 ❑ Fails ❑ Ne ds Fu er atio b e Lo p roving Authority A� A InsoWdrs 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. ****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. boothby no andover.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 � Commonwealth of Massachusetts man . Title 5 Official Inspection Form Not for Voluntary Assessments M SV a Subsurface Sewage Disposal System Form A. Certification (cont.) 162 Stonecleave Road Property Address North Andover MA 01845 City/Town State Zip Code Stan Boothby 3/23/06 Owner's Name Date of Inspection Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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: boothby no andover.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts . Title 5 Official Inspection Form ° Not for Voluntary Assessments M Sv y. Subsurface Sewage Disposal System Form A. Certification (cont.) 162 Stonecleave Road Property Address North Andover MA 01845 Cityrrown State Zip Code Stan Boothby 3/23/06 Owner's Name Date of Inspection B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh boothby no andover.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 � i i � Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form N A. Certification (cont.) 162 Stonecleave Road Property Address North Andover MA 01845 CitylTown State Zip Code Stan Boothby 3/23/06 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health(cont.): 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for 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: boothby no andover.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 � Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments y � Subsurface Sewage Disposal System Form A. Certification (cont.) 162 Stonecleave Road Property Address North Andover MA 01845 Cityrrown State ZipCode Stan Boothby 3/23/06 Owner's Name 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 ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® 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 6 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. boothby no andover.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 � Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M S+o d A. Certification (cont.) 162 Stonecleave Road Property Address North Andover MA 01845 City/Town State Zip Code Stan Boothby 3/23/06 Owner's Name Date of Inspection E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. YES NO ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. boothby no andover.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 • Commonwealth of Massachusetts 9 Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Checklist 162 Stonecleave Road Property Address North Andover MA 01845 Cityrrown State Zip Code Stan Boothby 3/23/06 Owners Name Date of Inspection Check if the following have been done. You must indicate"yes"or"no"as to each of the following: YES NO ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ® ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] boothby no andover.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information 162 Stonecleave Road Property Address North Andover MA 01845 Cityrrown State Zip Code Stan Boothby 3/23/06 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ® Yes ❑ No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump? ❑ Yes ® No Last date of occupancy: Dateent CommerciaUlndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): boothby no andover.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 8of16 Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form ' M C. System Information (cont.) 162 Stonecleave Road Property Address North Andover MA 01845 City/Town State Zip Code Stan Boothby 3/23/06 Owners Name Date of Inspection General Information Pumping Records: Source of information: owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How'was quantity pumped determined? Reason for pumping: Type of System: ® Se tic tank distribution box soil absorption s stem ❑ 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: 11/1977 plan on record Were sewage odors detected when arriving at the site? ❑ Yes ® No boothby no andover.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments 41M SV � Subsurface Sewage Disposal System Form C. System Information (cont.) 162 Stonecleave Road Property Address North Andover MA 01845 Cityrrown State Zip Code Stan Boothby 3/23/06 Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of ❑ Yes ❑ No certificate) Dimensions: 8'6"Lx5'4"W Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle 4'+/- Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? field measurement boothby no andover.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 l . Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments M $Ve Subsurface Sewage Disposal System Form C. System Information (cont.) 162 Stonecleave Road Property Address North Andover MA 01845 City/Town State Zip Code Stan Boothby 3/23/06 Owner's Name Date of Inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness I Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): i i i Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: I Material of construction: I ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): boothby no andover.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M y+ y C. System Information (cont.) 162 Stonecleave Road Property Address North Andover MA 01845 Citylrown State Zip Code Stan Boothby 3/23/06 Owner's Name Date of Inspection Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): poor condition : concrete deteriated. Recommend replacement Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No boothby no andover.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 162 Stonecleave Road Property Address North Andover MA 01845 City/Town State Zip Code Stan Boothby 3/23/06 Owner's Name Date of Inspection Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 4, 45'x20' ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: design plan on record/iron bar Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): boothby no andover.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 L . Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 162 Stonecleave Road Property Address North Andover MA 01845 Cityrrown state Zip Code Stan Boothby 3/23/06 Owners Name Date of Inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): boothby no andover.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 Commonweafth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 41M SV,y`v C. System Information (cont.) 162 Stonecleave Road Property Address North Andover MA 01845 Cityrrown State Zip Code Stan Boothby 3/23/06 Owner's Name Date of Inspection 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. See c � boothby no andover.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 L j[F.STw.a .p rs C/Q �oYNFST ST• Lot #/y ' •�o'_ , • o &o -S 13 E 0,0 v /• S " 7l d TlN/ X - Jtv.c,/liNG L -s L.ZXI QL ax /Ae Z N p O: sli. v . Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 162 Stonecleave Road Property Address North Andover MA 01845 City/Town State Zip Code Stan Boothby 3/23/06 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: 17°S�� Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 11/77 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Design plan on record boothby no andover.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 16 of 16 b cEoN :ovv a M.A k SETTS DEPART'IVEI`TT o EI� IRtNM E1I'TA PROTECTI41v I3EIAC' KNOWN 7 HAT Robe' rt .L. Kimball Sr. I-las satisfied; the ]Depar�.zaZent's .clizali��icatiotxs as required and: is hereby by to use the .title CEWrIFIED TITLE 5 SYSTEM INSPECTOR as provided in. 310 CMR '15 `340 and Section 13 of Chapter 21 A of .the General Laws. Issued by Z,he Department' of Environmental Protection. Junc 12, 1995 AciinA Director oC the Tori at 1Natex Pott6fion Control ,, �� ` f z •A l��OVER�`�M�� ��'T'S � • 11114Weu.1 6 .TTp� : cc.ord' � � ''Y;{• '�' + til?(�:,r,:• AUGa- 2 2007 ,.{•�1' !,v•.' jS OVA"},,a/•�yp,A A.1,5:at(y J,.,.rv11 ••,��.p;;Y!:1f;' �1,1�-�'"1w'_,f1i �'.,5�,i,it r�.•o•1'ri �tv' ,. <a ;11'r V ry:., •.r , DER has provided rhls:form for use b local B be's.ubRll6d the �st�fli loQ g d must y Boards of H &' M, nTk#\6 Record to .local;Board of Health or other appro In , �J i!'�''.i(t(.v(,'•I:�"^t:r'%,1�y',Y',i:Lt•i'1••/ln,n• 1r • A', Facility,.InfQrmation < .il:.r: �,Ortirlt+i! ::°i••'L'. :.,�.';1,,,`• ;14f':.;', ?,��'. ,,,�:',;t: • . ,��rWhan'twyipout '•':1,.::, 3ystam�t.ocatlon; ���',�, �, � , , -f,"o�mpUtOr,'(JSe 4,i , . �� U l• --��CC o*the tab key Addnas 1 to move your:: •, ,.ar:or•do Vit;:�,,:,: ,, -' ..:� 1�---', � ����'�-�7, �'�.`.uiithi•rotum.�;y ;:��;�!�,CItY(T ; ...,:: r;,.. .,: . �. .. 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Dae 4 tlty Pumped: Gallons '.Typo 9t•systemt '' ❑ Cesspools) C�'S�eptic Tank ❑ Tight Tank • �,;• ' ;`'� ` (Other descrlbe��;°'� ' • :,: '''' ! .•,`i; ..*Lt Too Fllte(.pr$sont?.❑ Yes o If yes was It cleaned? ❑ Yes ❑ N :�9� ,.,..,.`.'.;i,Vii:''•''•{,�,,,,,�,,Ai��p[Yf"•,r:,'�/':,,.ty}'',Vj•'Ir�rh f;'\:{�{ m A. ,,� .; .� on of .. . ,;...L:,:y, � ;.a�;,•'tir'{J'11,�1i(t�(:r};idrdw�i:,tt1`N rrtil r _ :ti:r .�t'�y.+.,;(,/. r) /t�'I�'y:i•�1�')I•�':: /. 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'•'+•'r:.`.ri.r:�.i,••:�•'.1j,('`.'';°t.• r !i'�11,+.,�/',{�::`sof.Yr f,•,' , :' :;i.C.•il:�i'it� tri t,;t•'� d,'•Pv� lVI ai{i' . .'ri;,•••:it':�'}:,'•:+;.o\:%,:C:'� ' rtii: i{: �'►d'{1't!',..•, .fY.rr�,,�r.fi•1•/.,,•', t, :.�; . : :;+•�,;;yr>,�:1N, '.!� ':::G?,+}• �t�j:.l",;eQ�H��Ie�, !{)�!aYti•,�,..;•,.,,:• oat$ /www.mass, ov/do at er%�pprovaJ37t6forms,htm#Inspect .i.,.., ,,,7,; +ij.:l:�.a�'�� •,., ••�, '.,. ••'fir. .. t5forrMrdop 0"3 System Pumping Record Page i or i TO: NORTH ANDOVER, MASS �� 19 7F BOARD OF HEALTH FROM: DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at s7—o1yF6'2,!Fx11E /ca - North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated 19 coMMON�l � 9y. c. Reg. Df oneeKeg ririan '41 ��, S 11' 0-/,q o - v V 0 7 13) t 1 f I t ZOo G S,rPric TIgA//< . /� I�PRaX � tv a L —S .1C Ok 7 ILL ax /Au t 24'�4 © u.7- 7 �a cosr�o/ 9�•P�40 • t 1 V. Distribution Boxes Reg. 10.2 (a)ooOOIS-1ope greater than 0.08 Reg. 10.4 (b 1,,,"'S-ump VI. Leaching Pits 1I Leaching pits are preferred where the installation is possible. Reg. 11.2 (a) Calculations of leaching area (minimum 500 S.F. ) Reg. 11.4 (b) Spacing Reg. 11.10 (c) Surface drainage 2% Reg. 11.11 (d) Cover material I VII'. Leaching Fields Reg. 15.1 (a�')'�Gr--eater than 20 minutes/inch Reg. 15.1 (b)lArea (minimum 900 S.F. ) Reg. 15.4 (c) Construction of field Reg. 15.8 �dSurface drainage 2% I IX. Downhill Slope (a)Slope y/x = (to be shown) ' c/ (b) y/x X 150 = (to be shown) { I ,j NORTH AITDOVER BOARD OF .HEALTH INSTALLATION CHECK LIST APPROVED DATE DIS ' PROVED DATE EXCAVATION OK AIL OK 1 . Distance To: Wetlands (/ Drains �,� HC,11-V 2. Water Line Location W 3, VC Pipe �Z l` 4. Septic nk ), .Teees - Length & To Clean Out Covers Cement Pipe to Tank - On Both Sides of Tank 5. Distributi Bax Cove Box - No Cracks A Li-fees Flowing Equal Amounts L.o Back Flow a0 6. each Tield or Trench mensions Stone Depth Capped Ends Clean Double Washed Stone 7. Leach Pits Dimensions Stone Depth Splash Pads Tees Cement Pipe to Pit - Both Sides Clean Double Mashed Stone . No Garbage Disposal Final Grading Inspection Barracading Covered System 11 As - Built Submitted Lot Location Dimensions of System Location with Regard to Pere Test Elevations Water Table NORTH ANDOVER SUBSURFACE DISPOSAL SYSTEM CHECK LIST ` l µ�a� "- ' AP I. General Information 4AA�� 0 Reg. 2. 5 The submitted plan must show as a minimum: (a) he- lot to be served ( /location and dimensions of the system (including serve area) (c)/des-ign calculations (d) •calculations showing required leaching area (e) o-15sting and proposed contours I (f) ilo ation and log of deep observation holes - distance to ties (g) ,.--l-ocation and results of percolation tests - distance to ties (h),e o ation of any wet areas within 100' of the sewage disposal system or disclaimer (i) oo8t'r"face and subsurface drains within 100 ' of he sewage disposal system or disclaimer location of any drainage easements within 100 . of the sewage disposal system or disclaimer (k).o�nown sources of water supply within 200 ' of the sewage disposal systeri or disclaimer (1 )ee'T'�cation of any proposed well to serve the lot (m) e"T';�cation of water lines on the property (n maximum ground water elevation - in the area of t-e-sewage disposal system (o)-ol< profile of the system (p)--no PVC is to be used in construction (9) occation of benchmark (r lan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans. II. ,-Ga b qe Disposers III. SepticcTT"a��nks + Reg. 6. 1 (a).oO a;'acities - 150% of flow Reg. 6. 7 (b).�ater table Reg. 6.8 (c) --f��s Reg, 6,9 (d) �D�th of tees Reg. 6. 12 (e) Ac ess Reg. 6. 18 (f) 'Pumping (g) ,e6eanout IV. Pumps Reg. 9. 1 (a) Approval Reg. 9.6 (b) Stand-by power TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) U� Ovt cls i DATE OF PUMPING: S`-���� QUANTITY PUMPED /06t) GALLONS CESSPOOL: NO 51LYES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE _ EMERGENCY OBSERVATIONS: GOOD CONDITION X— FULL TO COVEIZ HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: COM MENTS: CONTENTS TRANSFERRED TO: r f d ORIT� ' HUSE TT.. SEP 08 2008 DFpWN OF h©a provided Inl, torr:) y T H � IFbCefTHyANOV l?��DE ER -o c !Q t") ;�•_. 9', ^ raclllry Iniorrr,G; o;� — -- .41 ;'a -1)'.Irn i-l'',1 Oflrinl rcrn lOuum ~Pumping Record /066 .'Yfla GI eysl@m; '� �@95�00;19) M:c Te . r•� •_ � _ I n n i T a•,l EMivanl 1'@@ FlHo(,Prosan�? _ e5 _ r;; - :•1.,i,,,�;r r•n','".t.� i its$ �S •�^d:� c ;,.,...r.i r?... it v!' Il,�fl'•r, it O C �'!'''Sr!'�ly / �w r,• t M�n ��J .1%j'J, .^. n i ^ nYOAIG'9 'icT44 r,. :4 7. .oca�Cn� ,hei 9 conlenl9 wet@ c.s, sac Y l r 1 1 t �7 c -.=•''^'^'n "'ss�•.;o'r'/0@;fNel@r/8�,�(OY8�3/I�'Io(Tr9 `''-^'; '�y,��• - - 77-7 Commonwealth.of Massachusetts j V'City/Town`pf.N RTH A DOVER, MAETTS System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. The System Pumpfrtg Record must be submitted to the local Board of Health or other approving authority. X Facility Information Important: "1e„ out 1. System Location: `� Ga ���� forms on theffiLe� computer,use only the tab key Address to move your cursor-do not y� State Zlp Code use the return own key. 2. System Owner. Y ' Name �w Address(If different from location) City/Town State Zip Code Telephone Number B. Pumping Record /akIl a 1. Date of Pumping Date 2. Quantity Pumped: Gauons 3. Type of system: ❑ Cesspool(s) ,�] Septic Tank ❑ Tight Tank ❑ Other(describe): 4, Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: 'ooccl e. System Pumped By: Vehicle Uoense Number %y 7. Location wh a contents were disposed: M/ Sii;in# ra of Hauler Date http://www.mass.gov/deptwaterlapprovalstt5forms.htm#4nspect t5fom)4 dos 060 System Pumping Record-Page 1 of 1 Commonwealth of Massachusetts W City/Town of North Andover -i if System Pumping Record Sc1, 25 Form 4 [ui2 TOWN OF Iq DEP has provided this form for use by local Boards of Health. Other forms may b 'edAfffb theTHANDVER information must be substantially the same as that provided here. Before using this form, c�kvi#h yo""ur local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, , C eo use only the tab /� / key to move your Address cursor-do not north andover Ma use the return key. -`City/Town - State _ Zip Code 2. System Owner: ad Name mam Address(if different from location) north andover City/Town State Zip Code Telephone Number B. Pumping Record 1Y 1. Date of Pumping LDAte antity Pumped: Ga' ns 3. Type of system: ❑ Cesspool(s) [�Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): / 4. Effluent Tee Filter present? ❑ Yes , No If yes, was it cleaned? ❑ Yes ❑ No 5. Con i o f System: _ r j 6. System P e By: Name Vehicle License Number Stewart's Sep is Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1
