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HomeMy WebLinkAboutMiscellaneous - 164 VEST WAY 4/30/2018 (2)i > Cf) t1 ro rt- o 't7 ti rt r (D .. P. (D � rr a••cn � w rr � •• C !D m rt, a ro a n m r North Andover Board of Assessors Public Access Page 1 of 1 M µORTy 2pf,t�.o „�ry0 k M ♦� �Sgt{NS �y Return to the Home page click on logo New Search Sales Summary Residence Detached Structure Condo Commercial Comparable Sales Tovm of Aicrth A dove c f as sses5xws Property Record Card Parcel ID: 210/104.D-0102-0000.0 Community: North Andover SKETCH PHOTO Click on Sketch to Enlarge Click on Photo to Enlarge _r 184 VEST WAY Location: 164 VEST WAY Owner Name: LAKOV, GERMAN & ALLA Owner Address: 164 VEST WAY City: NORTH ANDOVER State: MA ZIP: 01845 Neighborhood: 7 - 7 Land Area: 1.04 acres Use Code: 101 - SNGL-FAM-RES Total Finished Area: 3817 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 698,000 728,200 Building Value: 472,900 491,300 Land Value: 225,100 236,900 Market Land Value: 225,100 Chapter Land Value: LATEST SALE Sale Price: 496,000 Sale Date: 01/06/2002 Arms Length Sale Code: O-NO-PHYS-CHNG Grantor: MILLER, ROBERT J Cert Doc: Book: 06596 Page: 0009 http://csc-ma.us/NandoverPubAcc/jsp/Home.jsp?Page=3&LinkId=1180664 6/4/2008 AORTII Of 4��•o �•1�0 3+J, 0 F 9 . w Town of North Andover `,�'•�,; ;o ::,' HEALTH DEPARTMENT ,SSACHUStt CHECK #: 4PY DATE: LOCATION: H/O NAME: /_. - CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal ❑ Body Art Establishment ❑ Body Art Practitioner ❑ Dempster ❑ 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) ❑ Tit nspector Title 5 Report 10 7 ❑ Other: (Indicate) $ 2454 Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer R -r1 t d V c w a w y E a e R d w w 0 4) an d O 0 4) an u` z cn cc z S LO w a (D T ,y Q Co 22 w ci Q 70- yj o d w N ` LC y U tp 0 0 Q) O 40. m y d a w O w N O ami o C a o 0 3 o a, h c LO o o � �? O J z z z D U V E G1 @ y c aD m O 0 R z z z LO Co 'O p d N ` LC O m y d a O w N ami o C a o 0 3 c LO o y NORTH 01...... 4,, 3j .. ., . oL 1 o .. i F 9 Town of North Andover ��.'•�,,,,; :.�° �' HEALTH DEPARTMENT ,SSACMUStt CHECK #: DATE: LOCATION: H/O NAME: CONTRACTOR NAME: 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 Sustems: s ❑ Septic - Soil Testing $ e ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title,51nspector $ Title 5 Report $ �0 ❑ Other. (Indicate) $ 2454 He th Agent Initials White - Applicant Yellow - Health Pink - Treasurer Commonwealth of MassachtfsetS J,/4/ ��Z Title 5 Official Inspection Form ac�► D Subsurface Sewage Disposal System Form - Not for Voluntary Assessments W' q7 .` GfC� �o✓ �� 164 Vest Way Property AddressG�-y0 V, ' �5 Alla Lakov Owner Owner's Name information is required for No. Andover MA 01845 5/31/07 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. tab tetum A. General Information 1. Inspector: Benjamin C. Osgood Jr. Name of Inspector New England Engineering Services Inc. Company Name 1600 Osgood Street Suite 2-64 Company Address No. Andover MA City/Town State 978-686-1768 MAY 0 6 2008 FO' . r, Telephone Number License Number B. Certification 01845 Zip Code 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: IV/Passes Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority . - S A 0 Inspec 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. ****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. 164 Vest Way No Andover.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 official Inspection Form 9GUI,sC-D Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Li j 21jZ),3 164 Vest Way Property Address Alla Lakov Owner's Name No. Andover MA 01845 5/31/07 City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: �Ihave not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If "not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 164 Vest Way No Andover.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Insp Subsurface Sewage Disposal System Fo 164 Vest Way B. Certification (cont.) B) System Conditionally Passes (cont.): distribution box is leveled or replaced ND Explain: V ❑ The system required pumping more than 4 times a year due.to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 164 Vest Way No Andover.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 15 ection Form' 21 rm - Not for Voluntary Assessments Property Address Alla Lakov Owner Owner's Name information is required for No. Andover MA 01845 5/31/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): distribution box is leveled or replaced ND Explain: V ❑ The system required pumping more than 4 times a year due.to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 164 Vest Way No Andover.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 15 { Commonwealth of Massachusetts W Title 5 Official Inspection Form r. o�t��- � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 03 �k 164 Vest Way Property Address Alla Lakov Owner Owner's Name information is required for No. Andover MA 01845 5/31/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well`*. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ 51 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 164 Vest Way No Andover.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 164 Vest Way Property Address Alla Lakov Owner's Name No. Andover MA 01845 City/Town State Zip Code B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No k�'tvt>Fn q I zUlc?0 5/31/07 Date of Inspection ❑ [g Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ [29 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ S 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.] ❑ [N 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 ❑ QS the system is within 400 feet of a surface drinking water supply ❑ [N 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. 164 Vest Way No Andover.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 164 Vest Way Property Address Alla Lakov Owner's Name No. Andover City/Town C. Checklist K A A 01845 5/31/07 Zip Code Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ■I V 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)] 164 Vest Way No Andover.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 15 Owner information is required for every page. Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 164 Vest Way Property Address Alla Lakov Owner's Name No. Andover City/Town D. System Information Residential Flow Conditions: State 01845 Zip Code 5131/07 Date of Inspection Number of bedrooms (design): 4 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? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Last date of occupancy/use: Other (describe): '-IIvlos L.1 (.6.0 Lo &P c:;, ❑ Yes [& No ❑ Yes ® No ❑ Yes [S No ❑ Yes [L No POB 6 ­pp 7iD !2(0(, ❑ Yes ® No MJ�HaIVA/ Date ��ays.E (yAcdArt- oN y11-W6s Gallons per day (gpd) Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No 164 Vest Way No Andover.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 164 Vest Way Property Address Alla Lakov Owner's Name No. Andover City/Town D. System Information (cont.) Pumping Records: Source of information: 5/31/07 State Zip Code Date of Inspection General Information �u ryo p 6-0 j �t Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: gallons Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy �9AM ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): Approximate age of all components, date installed (if known) and source of information: 7,-, • lct vs PC- P. A-5-- RPO 6� �, a.tC s� S. Were sewage odors detected when arriving at the site? ❑ Yes 0 No 164 Vest Way No Andover.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 0 164 Vest Way Property Address Alla Lakov Owner Owner's Name information is l2rV lS�r �12� 1Jg required for No. Andover MA 01845 5/31/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer (locate on site plan): _ e 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): Depth below grade: Material of construction: concrete ❑ metal In feet ❑ 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: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? &77'C114 164 Vest Way No Andover.DOC - 08106 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ►�c o Iv og 164 Vest Way � Property Address Alla Lakov Owner's Name No. Andover MA 01845 5/31/07 City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): '�d1� ►�, c+� C��� t��.� 17�t�te . GDAsc 2�` i� TCL% i2�Lr4CEC� Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass 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 feet ❑ polyethylene ❑ other (explain): 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.): �l�Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): t Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): 164 Vest Way No Andover.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 15 Owner information is required for every page. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 164 Vest Way Property Address Alla Lakov Owner's Name No. Andover City/Town D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: Design Flow: Alarm present: Alarm level: �u 1ST l0 K1ZLCae MA 01845 5/31/07 State Zip Code Date of Inspection gallons gallons per day ❑ Yes ❑ No Alarm in working order: Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ❑ Yes ❑ No * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert -, 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.): tVI,+ Pump Chamber (locate on site plan): Pumps in working order: Alarms in working order: ❑ Yes ❑ No ❑ Yes ❑ No 164 Vest Way No Andover.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 164 Vest Way Property Address Alla Lakov Owner Owner's Name information is required for No. Andover MA 01845 5/31/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: El El leaching pits leaching chambers leaching galleries leaching trenches leaching fields overflow cesspool innovative/alternative system Type/name of technology: number: number: number: number, length: number, dimensions number: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 164 Vest Way No Andover.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 164 Vest Way t,5 C5, 912`10.? Property Address Alla Lakov Owner Owner's Name information is required for No. Andover MA 01845 5/31/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) /4 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.): UA- 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.): 164 Vest Way No Andover.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 164 Vest Way N Property Address Alla Lakov Owner Owner's Name information is required for No. Andover MA 01845 5131107 RE -0 ISG (> 4Lulc)s every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 164 Vest Way No Andover.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 15 41 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 N 164 Vest Way D. System Information (cont.) Site Exam: ®" Check Slope ❑ Surface water A) otj C ❑ Check cellar A., e> 5 ❑ Shallowwells Estimated de th to round water• nAA nA n A I 5/31/07 State Zip Code Date of Inspection W p g feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) K Accessed USGS database - explain: You must describe how you established the high ground water elevation: Pe? i &, r>--e--C oG-01 6ti-TLLtL IStd-D ij1211V 164 Vest Way No Andover.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 15 Property Address Alla Lakov Owner Owner's Name information is required for No. Andover every page. City/Town D. System Information (cont.) Site Exam: ®" Check Slope ❑ Surface water A) otj C ❑ Check cellar A., e> 5 ❑ Shallowwells Estimated de th to round water• nAA nA n A I 5/31/07 State Zip Code Date of Inspection W p g feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) K Accessed USGS database - explain: You must describe how you established the high ground water elevation: Pe? i &, r>--e--C oG-01 6ti-TLLtL IStd-D ij1211V 164 Vest Way No Andover.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 15 " A S • BU•I LT " lwla ,� SUB • SURFACE DISPOSAL SYSTEM IN WOP.TH A W VE 12,M ,&, FOR : W&mtaro, Plow- 4 120e EIZT M 1 LLEP. Scale: I'" = .40' Date: jul y 21,1585 RICHARD F. KAMINSKI AND ASSOCIATES , INC. ENGINEERS • ARCHITECT • SURVEYORS • LAND PLANNERS NORTH, ANDOVER , MASS. ELEVATIONS description design os built INV. PIPE OUT OF HSE. 15ZCo8 N . A, INV. PIPE INTO TANK I5?.46 INV. PIPE OUT OF TANK 157.23 (coi.is INV. PIPE INTO DIST. BOX 167.15 157,31 INV. PI PE OUT OF DIST. BOX 15cv.9Co 157,25 INV. END OF PIPE 15(o.$5 " A S • BU•I LT " lwla ,� SUB • SURFACE DISPOSAL SYSTEM IN WOP.TH A W VE 12,M ,&, FOR : W&mtaro, Plow- 4 120e EIZT M 1 LLEP. Scale: I'" = .40' Date: jul y 21,1585 RICHARD F. KAMINSKI AND ASSOCIATES , INC. ENGINEERS • ARCHITECT • SURVEYORS • LAND PLANNERS NORTH, ANDOVER , MASS. a t m c i O cwa i z z° N Q) d t 3 m c i O cwa 3 O m i O cwa z z° N Q) LO w a � � No T p Q tq O d Q c Nj N LL a U �; O 40. w m H d a d d N o y 3 O y 4; w o M p O J o z z z U d c LO w c_ d E m c a y 'c m O O i cwa z z° z° LO k y W No jO p 0 N LL a �; O w m H d a O d N 3 3 w o M p h a o 0 3 d c LO c a a � _ ai V � 3 t9 C O I� C9 O c�tlo Owner information is required for every page. Ummonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Asses: 164 Vest Way Property Address Alla Lakov Owner's Name No. Andover City/Town MA 01845 State Zip Code RBGEI JUN - 7 20 TOWN Or iaVlfei h i4x-u jVt:_R HEALTH DEPARTMENT i ('C' 5/31/07 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your Benjamin C. Osgood Jr. cursor - do not Name of Inspector use the return key. New England Engineering Services, Inc. Company Name 1600 Osgood Street Suite 2-64 Company Address No. Andover MA 01845 City/Town State Zip Code 978-686-1768 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes R Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority G d j "0 o7 Inspec 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. ****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. 164 Vest Way No Andover.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 164 Vest Way Property Address Alla Lakov Owner information is required for every page. Owner's Name No. Andover MA 01845 City/Town State Zip Code B. Certification (cont.) 5/31/07 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: CK One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If "not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): 7 broken pipe(s) are replaced obstruction is removed 164 Vest Way No Andover.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 15 Commonwealth of Massachusetts H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 164 Vest Way Property Address Alla Lakov Owner information is required for every page. Owner's Name No. Andover MA 01845 5/31/07 City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): NJ distribution box is leveled or replaced ND Explain: ptST9.1Bc.)'n0W% 30-4n 2EQ'uz0 A- N462T1-( ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 164 Vest Way No Andover.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 164 Vest Way Property Address Alla Lakov Owner's Name No. Andover MA 01845 5/31/07 City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ © Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ IN Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ [A Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑J Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ [�j Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 164 Vest Way No Andover.DOC • 06/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 15 IW Owner information is required for every page. CommonLalth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 164 Vest Way Property Address Alla Lakov Owner's Name No. Andover MA 01845 5/31/07 City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ [A Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ 29 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ N 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.] ❑ [X The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ [A 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 ❑ Q' 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 ❑ VS 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. 164 Vest Way No Andover.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 164 Vest Way Property Address Alla Lakov Owner's Name No. Andover City/Town C. Checklist RAA n,oAr- 5/31 /07 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? CK ❑ 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? 2 ❑ N ❑ ❑ M 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)] 164 Vest Way No Andover.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 15 Commonwealth of Massachusetts 4 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 164 Vest Way Property Address Alla Lakov Owner Owner's Name information is required for No. Andover MA 01845 5/31/07 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: y Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): & 0 L spa Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes Uk No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes © No Laundry system inspected? ❑ Yes ®, No Seasonal use? ❑ Yes S, No !O$ C -PP Water meter readings, if available (last 2 years usage (gpd)): 121o4O Iz1a4 N Sump pump? ❑ Yes ® No Last date of occupancy: c0 4-041,1,-TDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other (describe): 164 Vest Way No Andover. DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 15 CommonWealth of Massachusetts - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 164 Vest Way Property Address Alla Lakov Owner information is required for every page. Owner's Name No. Andover MA 01845 City/Town State Zip Code D. System Information (cont.) General Information 5/31/07 Date of Inspection Pumping Records: pv iM P eo y I o `1 F. em Source of information: ��' ac co R.fl S Was system pumped as part of the inspection? ❑ Yes X No If yes, volume pumped: How was quantity pumped determined? Reason for pumping: gallons Type of System: W Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): Approximate age of all components, date installed (if known) and source of information: 10k.,.W la%& Pet P, A -s- P>00 -T TLANs Were sewage odors detected when arriving at the site? ❑ Yes W No 164 Vest Way No Andover. DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 15 Owner information is required for every page. CommonVvealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 164 Vest Way Property Address Alla Lakov Owner's Name No. Andover City/Town D. System Information (cont.) MA 01845 5/31/07 State Zip Code Date of Inspection Building Sewer (locate on site plan): Depth below grade: Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): feet Distance from private water supply well or suction line: /V1#4 feet Comments (on condition of joints, venting, evidence of leakage, etc.): i t Pc; 4"-;,a 1'k S. 09% t N a F -e% Septic Tank (locate on site plan): Depth below grade: Material of construction: concrete ❑ metal ., 6 feet ❑ 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: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? � ��-►Q-C.IO�vS 4 41 Co /0e19Gu1Zj- bTCI4 164 Vest Way No Andover.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 164 Vest Way Property Address Alla Lakov Owner information is required for every page. Owner's Name No. Andover City/Town D. System Information (cont.) M4 r)1S2dF 5/31/07 State Zip Code 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.): TA4j iik trj (roofl Cavy rnon . ea N c et "lr —JL:�-rE /ti C-040 Ca © 0'rc.L's-" Po c- i J'PC%' C- Q.y3 fie -41 04N n ✓Ko.�c.D i-3 c= 'R.Tc'PAu2rc� Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): N'vight 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): 164 Vest Way No Andover. DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 164 Vest Way GSM SVey`�., Property Address Alla Lakov Owner Owner's Name information is required for No. Andover MA 01845 every page. City/Town State Zip Code D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: Design Flow: Alarm present: Alarm level: gallons 5/31/07 Date of Inspection gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): " Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert O •, Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): 0--�x rN 01/% "NI>t'nib^. 3c)X y+0' P,ec0 •e P11+ Pump Chamber (locate on site plan): Pumps in working order: Alarms in working order: ❑ Yes ❑ No ❑ Yes ❑ No 164 Vest Way No Andover.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 164 Vest Way Property Address Alla Lakov Owner Owner's Name information is required for No. Andover MA 01845 every page. City/Town State Zip Code D. System Information (cont.) 5/31/07 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 ❑ leaching chambers ❑ leaching galleries leaching trenches leaching fields overflow cesspool innovative/alternative system Type/name of technology: number: number: number: number, length: number, dimensions number: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): A '�A o F f%l 'CC. (7 Lo a Ky AJ c "AL. u G4 C74 IJ AJ - 164 Vest Way No Andover.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 164 Vest Way Property Address Alla Lakov Owner Owner's Name information is required for No. Andover MA 01845 every page. Cityrrown State Zip Code D. System Information (cont.) 5/31/07 Date of Inspection Nl& 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.): t4k 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.): 164 Vest Way No Andover.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 15 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 164 Vest Way Property Address Alla Lakov Owner information is required for every page. Owner's Name No. Andover City/Town D. System Information (cont.) MA 01845 5/31/07 State Zip Code 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. l 164 Vest Way No Andover.DOC • 08/06 1 / lTitle 5 Official a`. Inspect on Form: Subsurface Sewage Disposal System - Page 14 of 15 Commonwealth of Massachusetts u Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 164 Vest Way Property Address Alla Lakov Owner information is required for every page. Owner's Name No. Andover MA 01845 City/Town State Zip Code D. System Information (cont.) Site Exam: R Check Slope ❑ Surface water N oN G ❑ Check cellar ,v.9 /piL;p ❑ Shallow wells N614 Estimated depth to ground water: feet 5/31/07 Date of Inspection } (e Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record IN If checked, date of design plan reviewed: Date Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) N Accessed USGS database - explain: You must describe how you established the high ground water elevation: V SpCsp y b 1 y M xlfj fl t C 4-i17 &-atbyAV W A---M�i2 I> e ?_71W. 4;. Pry c 0 R "1IF Aq; 2. R, Fla Q'Me KT 4-'> IZV .� iva s -►.��. 164 Vest Way No Andover. DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 15 DATE 41- IR -0 y SYSTEM OWNER & ADDRESS L07 A�bJ 10 Y ew No1,qnbo� TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD SYSTEM LOCATION r 15. DATE OF PUMPING Y—I a G y/ QUANTITY PUMPED _ / O (� ?0j, CESSPOOL NO YES SEPTIC TANK NO NATURE OF SERVICE: ROUTINE V EMERGENCY OBSERVATIONS: /' GOOD CONDITION c/ FULL TO COVER HEAVY GREASE BAFFLES IN LACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLID CARRYOVER OTHER EXPLAIN SYSTEM PUMPED BY �nrp(�✓2 r S'2,�I t L St f3t2M Z21& COivsllb'�NTS: - CONTENTS TRANSFERRED TO a(� ✓, YES System Owner ('onu �onw alth of Massachusetts r� • Massachusetts System Pumping Record System Location (b llate of t'umping: r "' Quantity Pumped Cesspool: No H- - Yes U Septic Tank: No U System Pumped by: Varejea License # Contents transferrred to : Greater Lawrence Sanitary District - .Date: Inspector: gallons fpclo Yes [- --- System Owner Commonwealth of Massachusetts } �•, MassachugU stem �'urning Record System Location 16�lwo-ll Dale of pumping: Quantity Pumped: Cesspool: No IMS Yes H Septic Tank: No U System Pumped by: SQredort SNreTomed License Contents transferrred id : Gredter L6rencS S9nitary Distrlct Dale: Inspector: Yes F-4---� C TO: FROM: NORTH ANDOVER, MASS. July 22 1985 BOARD OF HEALTH DESIGN ENGINEER Re: Soil Absorption Sewage Disposal System This is to certify that I have reviewed' the construction materials of said disposal system at Lot 53A Vest Way Site Location North Andover, Mass. conformance to i The grades and.construction materials are in general plans and specifications dated Nov. 28 , 19 84 and As -Built July 21 , 19_� Reg.Prof--wee C3 LIA PLACE v CIVIL No. 31012 44 ST MAL .Sanitarian Board of Health North AndoverZN.a.as. OVED DATE SEPTIC SISTER INSTA.d.ATICK CHECK LIST easonst LOT 1. Distance Tot a. Wetlands b. Drains C., Well 2. Water Line Location 3. No PVC Pipe fit. Septic Tank a. Tees -_Length & To Clean Out Covers. b., Cement Pipe to Tank - On Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Floging Equal Amounts c. No Back Flow 60Leach Field or Trench a. Dimensions b. Stone Depth c. Capped Ends d. Clean Double Washed Stone 7. Leach Pits a. Dimensions b. Stone Depth c. Splash Pads d. Tees e. Can. ant Pipe to Pit - Both Side £. Clean Double Washed Stone 8. No Garbage Ili spo sal 9. Final Grading Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System c. Location with Regard -to Pere Test d. Elevations e: Water Table Board of Health Nor;.Y. A.,ddover,Mass SUBSURFACE DISPOSAL DESIGN CHECK LIST APPROVED DATE 12-b i Provided: 11191V av�n/ 17,0?e? i, P►S' AJ& WA'V UbC- MVSi Dr-_ R6toWgD Title V I FAIL 109 Reg 2.5 DISAPPROVED DATE_ Reasons: LOT f 53A vE3TItW The submitted plan must show as a minimum: a) the lot to be served -area dimensions lot Cabutters b location and log deep observation hoes -distance to ties c location and results percolation tests -distance to ties d design calculations & calculations showing required leaching area e) location --and dimensions of system -including reserve area f) existing and proposed contours g) location any wet areas within 100' of sewage disposal system or disclaimer -check wetlands mapping h) surface and subsurface drains within 1A0' of sewage disposal system or disclaimer i) location any drainage easements within 1001 of sewage disposal system or disclaimer -Planning Board files J) known sources of water supply within 2001 of sewage disposal • . system or disclairser k) location of any proposed well to serve lot -1001 from leaching facility 1) location of water lines on property -10' from leaching facility m) location of benchmark n) driveways of garbage disposals p no PVC to be used in construction q) profile of system -elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and other elevations - - r) maximum ground water elevation in area sewage disposal system s) plan mast be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Reg 6 Septic Tanks (a) capac t es -150 of flow, water table, tees, depth of tees, access, pumping (b) cleanout (c) lot from cellar wall or inground swimming pool (d) 25+ from subsurface drains Reg 10.2 Distribution Howes I(a) slope greater 0.08 Reg 10.4 1 jb) sum MB,cU .FACE DISPOSAL ME -d& CHECK LIST APPROM DATE /� L Provided: DISAPPROM DP.TE Reasonss LDT Title V FAIL CK Reg 2.5 Thp submitted plan must show as a minimum: the lot to be served -area, dimensions lot #..abutters location and log deep observation Mes-distance to ties location and results percolation tests -distance to ties d design calculations & calculations showing required leaching area location and dimensions of system -including reserve area rA existing and proposed contours g) location any wet areas within 1001 of sewage disposal system or disclaimer -check wetlands mapping (h) surface and subsurface drains within 100' of Is disposal system or disclaimer (i) location any drainage easements within 100' of sesage disposal system or disclaimer -Planning Board files J) knom sources of water supply within 200' of sewage disposal e system or disclaimer location of any proposed Kell to serve lot -1001 from leaching facilit. 1s) location of water lines on property -101 from leaching facility location of benchmark driveways garbage disposals - no PVC to be used in construction q) profile of system -elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and Other elevations maximum ground nater elevation in area sewage disposal system plan mast be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Reg 6 ( Septic Tanks (a) copacities-150�6 of flow, water table, tees, depth of tees, access, punging (b) cleanout c) 10t from cellar wall or i.nground swimming pool d) 25+ from subsurface drains Reg 10.2 7 Distribution Boxes (a) slope greater than 0.08 Reg 10.E b) mp 41 IN 4 'I5 � 5 O 6 6 7 1 7 1� �U 8 8 9 9 10 , 10 Benchmar er- % V Elevation DATES 4 5 6 7 8 9 10 Location Datum PERCO;,ATION TESTS 4 5 6 7 8 9 10 Pit Number 1 2 SOUL' PROFILE & PERCOLATION TEST DATA 4 _j Street No U� / Lot No North Andovss. Lac/Subdiv. Pland Owner �C.Z / Investigator 6 / ,► Observer Drop of 3" -Time Drop of 6" -Time vi100-C-le- SOIL PROFILE DATES l.tl.ev 2.Elev 3.Elev 4.Elev Mins.2nd " Drop 00 V, Percolation 0 0 7 Tres est Pit 2 2 2 2 3 3 3 3 41 IN 4 'I5 � 5 O 6 6 7 1 7 1� �U 8 8 9 9 10 , 10 Benchmar er- % V Elevation DATES 4 5 6 7 8 9 10 Location Datum PERCO;,ATION TESTS 4 5 6 7 8 9 10 Pit Number 1 2 3 4 Start Saturation Soak -Minutes ar e Drop of 3" -Time Drop of 6" -Time M&ns.lst 3" drop Mins.2nd " Drop Percolation /llo �c a. 2e cc,,,J w ( f a��f R SOIL PROFILE & PERCOLATION TEST DATA North.. i• .... T�Tn . Rgf,rAo+- _ T.rnt No. Loc./Subdiv. /OCI,,S Plan Owner Investi_gator-, �Observer,� SOIL ROFILES-DATE 1' Elev. 2. 3. 3' Elev. 4:Elev. 0 0 0 - 0 Ties to Test .Pits 2 2 2 2 3 3 3 3 -- -- '4 4 4 4 Benchmark Elevation 5 6 7 a' 9 10 5 6 7 s 0 10 Location Datum Perco]at/ion Tests -Date "/ ,,/ 1 /_i 5 6 s 9 10 �_T vale ----- Pit Number 2 3 4 5 Start Saturation Soak -Mins. 15N►� Start Test -Time ;ti3 Drop of 3" -Time - "-Time-Dro Drop of 6" -Time 5.1 Mins. 1st.3"Dro 4 3 Mins . 2nd 3"Drop 2013 Percolation Rate 06/97 1'NU 13:3U' FAX 1 5Ufi fiS3 55100 l':1}21.Rt1N w..-1N1)nVEx HISTORIC DISTRICT"COMMISSION Town of North Andover, Massachusetts APPLICATION FOR CERTIFICATE OF APPROPRIATENESS Application is hereby made for the issuance of a CERTIFICATE OF APPROPRIATENESS under Chapter 40C for proposed work as described below and on plans, drawings, or photographs accompanying,this application. CHECK CATEGORIES THAT APPLY: 1. Exterior building construction: ( ) New Building ( ) Addition ( ) Alteration Type of Building ( ) Home ( ) Garage ( ) Commercial. ( ) Other 2. Demolition or Removal of: 3. Signs or Billboards: ( ) New Sign ( ) Existing Sign { ) Ofher 4. Structure: { ) Fence ( ) Wal"1 ( ) Other TYPE OR PRINT LEG;BLY Address,of Proposed Work: Date: Owner: Telephone # Home Address (if different from above): Agent or Contractor: Telephone # Address: Assessors Map #: Assessors Lot #: Detailed Description of Proposed Work: Give all particulars of work to be done (see #8 below), including materials to be used, if specifications do not accompany plans. In _ase of signs, give locations of existing signs and proposed locations of new signs. `\(Attach additional sheet if necessary.) Q o0i 11/06/97 14:29 TX/RX N0.6328 P.001 E Owner (Agent, Contractor DO NOT WRITE BELOW THIS LINE RECEIVED FOR HISTORIC DISTRICT COMMISSION: TIME: DATE: BY: APPLICATION NO: THIS APPLICATION FOR CERTIFICATE OF APPROPRIATENESS: ( ) APPROVED ( ) DISAPPROVED Reason f -or Disapproval: ( ) NO CERTIFICATE OF APPROPRIATENESS REQUIRED A CERTIFICATE OF APPROPRIATENESS is for work described in the application above and attached documents. Chairman: Secretary: Members: 11/06/97 14:29 TX/RX N0.6328 P.002 ,4 Owner (Agent, Contractor DO NOT WRITE BELOW THIS LINE RECEIVED FOR HISTORIC DISTRICT COMMISSION: TIME: DATE: BY: APPLICATION NO: THIS APPLICATION FOR CERTIFICATE OF APPROPRIATENESS: ( ) APPROVED ( ) DISAPPROVED Reason f -or Disapproval: ( ) NO CERTIFICATE OF APPROPRIATENESS REQUIRED A CERTIFICATE OF APPROPRIATENESS is for work described in the application above and attached documents. Chairman: Secretary: Members: 11/06/97 14:29 TX/RX N0.6328 P.002 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PA' OTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 164 Vest Wa North Andover Owner's Name:Robert Miller & Wanda Dion Owner's Address: _164 Vest Way North Andover, MA Date of Inspection: 10/07/2000 Name of Inspector: (please print) Benjamin C. Osgood, Jr. CompanyName:New England Engineering Services, Inc Mailing Address: 60 Beechwood Drive North Andover. MA 01845 Telephone Number: (978) 686-1768 CERTIFICATION STATEMENT I certify that I have.personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training.and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector'sSignature: Dates 10/07/2000 i 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 Vppropriate 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 1 aK Page 2 of 11 as ti . OFFICIAL INSPECTION ;FORINT — NOT FOR VOLUNTARY AS.SSESSMENTS ' SU$SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A , —ZTIFICATION (continued) PROPERTY ADDRESS: 164 VEST WAY NORTH ANDOVER. i OWNER: ROBERT MILLER & WANDA DION DATE OF INSPECTION: 10/07/2000 Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D ! A. A System Passes: 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. Thr 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 exfrltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the: tank is less than 20 years old is available. ND explain: 'Observation of sewage backup or break out or high static water level in the distribution box due to broken or ,obstru( ted pipe(s) or due to a broken, settled or uneven distribution box.:§ystem will pass inspection if (with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced: i 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: T:.10 c T-...,.-..... T7.,.-.,, 411 rMinn 2 Page 3 of 11r'� OFFICIAL INSPECT=ION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM- ` ' PART A r RTIFICATION (continued) PRQPERTY ADDRESS: 164 VEST WAY NORTH ANDOVER OWNER: ROBERT MILLER & WANDA DION DATE OF INSPECTION: 10/07/2000 C. Further EvaluatioA is Required by the Board of Health: ! Conditions exist which require further evaluation by the Board of Health in o er to determine if the system is fail' g to protect public health, safety or the environment. 1. Sys will pass unless Board of Health determines in accordanc ith 310 CMR 15.303(1)(b) that the system. not functioning in a manner which will protect public ealth, safety and the environment: Cesspoo r privy is within 50 feet of a surface water Cesspool or ivy is within 50 feet of a bordering vege ted wetland or a salt marsh 2.. System will fail unless the Board of At and Public; Water Supplier, if any) determines that the system is functioning in a manner that prot s the public health, safety and environment: _ The system has a septic tank an soil absorp • n system (SAS) and the SAS is within 100 feet of a surface water supply or tributary t a surface water s ly. _ The system has a septic nk and SAS and the SAS is w in a Zone 1 of a public water supply. _ The system has a s tic tank and SAS and the SAS is within 5 eet of a private water supply well. The system h a septic tank and SAS and the SAS is less than 100 fe ut 50 feet or more from a private water su ly well". Method used to determine distance "This sys m passes if the well °water analysis, performed at a DEP certified laboratory, coliform bacteria d volatile organic compounds indicates that the well is free from pollution from that.facility and the pr ence of ammonia nitrog0' and nitrate nitrogen is equal to or less than 5 ppm, provided that'ino other 1 fail a chteria are triggered. iA copy of the analysis must be attached to thi§ form. i 3. Other: Tris c r-. fP ^. F,..-.., Kncnnnn 3 1 t Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS ; SUBSURFACE -SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) PROPERTY ADDRESS: 164 VEST WAY NORTH ANDOVER OWNER: ROBERT MILLER & WANDA DION DATE OF INSPECTION• 10/07/2000 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 /static ischar e or ondin of effluent to the surface of the round or surface waters due to an ove$ P $ g rloaded or logged SAS or cesspool liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or / cesspool _ l Liquid depth in cesspool is less than 6" below invert or available volume is less than '/� 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 ofa 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. rge:Systems: To be con . ` red a targe syskm the system must serve a facili ith a design flow of 10,0011 gpd to 15,000 gpd• 'You must indicate eith es" or ` no" to each of the fol ing: (The following criteria apply ge systems in ad ' on to tile:criteria above) yes no the system is within 400 fe of a surfac ' g water supply the system is wi 00 feet of a tributary to a surfac ing water supply the syst is located in a nitrogen sensitive area (Interim Wellhea tectioj I of a public water supply well Area — IWPA) or a mapped 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. .'.>_—u....Ursa*'.;+r�,,.•.r,,r•!!t7770.s!'•". _ Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEMINSPECTION-FORM =f PARI B CHECKLIST PROPERTY ADDRESS: 164 VEST WAY NORTH ANDOVLR i 1 OWNER: ROBERT MILLER & WANDA DION DATE OF INSPECTION: 10/07/2000 Check if the following have been done. You must indicate `yes" or "no" as to each of the following: Yed No umping 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 the were not available note as N/A ( Y ) Was the facility or dwelling inspected for signs of sewage back up i? l/ Was the site inspected for signs of break out ? 7- 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) gn the site has been determined based on: Yq� no i �_// 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 15302(3)(b)] Taal_ r r___ L1, c1�nnn 5 Page 6 of 11 OFFICIA;L:INSPECTION FORM - NOT FOR VOLUNTARY ASSESS. SUBSURFACE SEWAGE DISPOSAL; SYSTEM INSPECTION FO PART C "STEM INFORMATION PROPERTY ADDRESS: 164 VEST WAY NORTH ANDOVER OWNER: ROBERT MILLER & WANDA DION DATE OF INSPECTION: 10/07/2000 vj uW CONDITIONS RESIDgNTIAL i 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): N� Is laundry on a separate sewage system (yes or no): nJ- [if yes separate inspection required] Laundry system inspected (yes or no): Seasonal use: (yes or no): A) v Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or no): #V r Last date of occupancy: COMMERCIALANDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): Qnd 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: About 1 Yr. per owner Was system pumped as part of the inspection (yes or no): If yes, volume pumped: _gallons — How was quantity pumped determined? Reason for pumping: T�1E 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) Tight tank _ Attach a copy of the DEP approval Other (describe): Approximate age of all components, date installed (if known) and source of information: 1985 Were sewage odors detected when arriving at the site (yes or no):,") Title 5 insnertinn Fn,-.,, Ait tnnno 6 � : Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACg SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C QV4z-rVM INFORMATION (continued) PROPERTY ADDRESS: 164 VEST WAY NORTH ANDOVER OWNER: ROBERT MILLER & WANDA DION DATE OF INSPECTION: 10/07/2000 BUILDING SEWER (locate on site plan) Depth below grade: 18tv Materials of construction: X cast iron 40 PVC —other (explain): Distance from private water supply well or suction line: N/A Comments (on condition of joints, venting, evidence of leakage, etc.): Pipe looks good in basement SEPTIC TANK: _ (locate on site plan) Depth below grade: 411 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 9fj certificate) Dimensions: 1500 gallon Sludge depth: ?11 Distance from top of sludge to bottom of outlet tee or baffle: 3 C) Scum thickness: oil Distance from top of scum to top of outlet tee or baffle: 7 Distance from bottom of scum to bottom of outlet tee or baffle: J 7 How were dimensions determined: /V1 fw!5"j z C- -, P, Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evide Le of leakage, etc.): GREASE TRAP:Alocate 4site plan Depth below grade: Material of construction: —concrete __petal 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 Iiist 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.): 'r;tl- < TZ-- </I rrmnn 7 I Page 8 of 11 OFFICIAL INSPECTION FORM.= NOT FOR VOLUNTARY A�SESSME: -SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I PART C ' M INFORMATION (continued) PROPERTY ADDRESS: 164 VEST WAY NORTH ANDOVER OWNER: ROBERT MILLER & WANDA DION — DATE OF INSPECTION: 10/07/2000 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: - 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.): Distribution Box in good condition PUMP CHAMBER4 (locate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):(; i TiFle 5 Tncni-(-6— F,...,. Kiiciinnn 8 Page 9 of 11 OFFICIAL INSPECTION FORM' NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C cve'r RM INFORMATION (continued) PROPERTY ADDRESS: 164 VEST WAY j NORTH ANDOVER OWNER: ROBERT MILLER & WANDA DION DATE OF INSPECTION: 10/07/2000 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: 1 Field overflow cesspool, number: innovative/alternative system Type/name of technology: Co ments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Area of field looks good CESSPOOLS: A l^ (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, sins 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.): i Page 10 of i 1 7, Y OFFICIAL INSPECTION FORM — NOT; FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION. -FORM PART C SYSTEM INFORMATION (continued) PROPERTY ADDRESS- 164 VEST WAY NORTH ANDOVER _ OWNER' ROBERT MILLER & WANDA DION DATE OF INSPECTION: 10/07/2000 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. Page 11 of 11 r < OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS 'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 1 PART C l SYSTEM INFORMATION (continued) PROPERTY ADDRESS: 164 VEST WAY NORTH ANDOVER OWNER: ROBERT MILLER & WANDA DiON DATE OF INSPECTION: 10/07/2000 SITE EXAM i Slope S% Surface water N,�niE Check cellar .vo 3omr Shallow wells ,v�Nre Estimated depth to ground water feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: y 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) -,y Accessed USGS database -explain: You must describe how you established the high ground water elevation: SITE 5L.. ,R S f z> f2U VA lZo AA be to, aec- n V fq P5 10,1 O 1 C A -if w All -/L (,. 0 i Title 5 Inspection Form 6/15/2000 11