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Home My WebLink AboutMiscellaneous - 165 MILL ROAD 4/30/2018 165 MILL ROAD - 2101107 0000.0 1 r \ 1 . 1 1 I y 6630 Town of North Andover ','•�,; :: �� HEALTH DEPARTMENT ,s$ACMUSf1 CHECK#: DATE: LOCATION: H/O NAME: M! ofr1P CONTRACTOR NAME-1 ^ 5y� 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 G' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 165 Mill Road Property Address Michael Odiorne Owner Owner's Name information is required for North Andover MA 01845 11/19/2013 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Neil J. Bateson cursor-do not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover MA 01810 Cityrrown State Zip Code 978-475-4786 S115 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority F� C EV16D 11/19/2013 Drc 2 *' In e r s ignature Date TOWN 01-N'wk;i The system inspector shall submit a copy of this inspection report to the A1"�r6vin9 AutottY`,(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts A Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .° 165 Mill Road Property Address Michael Odiorne Owner Owner's Name information is required for North Andover MA 01845 11/19/2013 every page. Cityrrown 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: After permit from B.O.H.,replace d-box&pipe to d-box, inspection from B.O.H., septic system now passes Title 5 Inspection. 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): i t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a• - J Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 165 Mill Road Property Address Michael Odiorne Owner Owner's Name information is required for North Andover MA 01845 10/28/2013 every page. CityfTown 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. I Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key j to move your Neil J. Bateson RECEIVED cursor-do not use the return Name of Inspector key. Bateson Enterprises Inc. NOW 4 Company Name 111 Ar ilia Road TOWN OF NORTH ANDOVER HEAL1uE4 TMENT Company Address Andover MA 01810 Citylrown State Zip Code 978-475-4786 S115 j Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Need Further Evaluation by the Local Approving Authority 10/28/2013 Inspect rs t3ignature 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. I I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 I I I I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 165 Mill Road Property Address Michael Odiorne Owner Owner's Name information is required for North Andover MA 01845 10/28/2013 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described j in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are ! indicated below. i Comments: I 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): II t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System Page 2 of 17 Po Y - 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 165 Mill Road Property Address Michael Odiorne Owner Owner's Name information is North Andover MA 01845 10/28/2013 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.): I ® 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): i i ® broken pipe(s) are replaced ® Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): I ® 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): I 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 165 Mill Road Property Address Michael Odiorne Owner Owner's Name information is required for North Andover MA 01845 10/28/2013 every page. City/Town 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 Y2 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 165 Mill Road Property Address Michael Odiorne Owner Owner's Name information is required for North Andover MA 01845 10/28/2013 every 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 regional office of the Department. t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts 9-3 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 165 Mill Road Property Address Michael Odiorne Owner Owners Name information is required for North Andover MA 01845 10/28/2013 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 600 t5ins•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 165 Mill Road Property Address Michael Odiorne Owner Owner's Name information is required for North Andover MA 01845 10/28/2013 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 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 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 I I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 165 Mill Road Property Address Michael Odiorne Owner Owner's Name information is required for North Andover MA 01845 10/28/2013 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped 2012, 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: ® 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 Title 5 Official Inspection Form: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 .yr< 165 MITI Road Property Address Michael Odiorne Owner Owner's Name information is required for North Andover MA 01845 10/28/2013 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 35 years old, 11/21/1978 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1 feet Material of construction: ® cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4"Cast iron through walls, 3" PVC in house no leaks visible Septic Tank(locate on site plan): Depth below grade: •5 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene y El other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10' x 5'x 4' Sludge depth: 4" t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 165 Mill Road Property Address Michael Odiome Owner Owner's Name information is required for North Andover MA 01845 10/28/2013 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 23 Scum thickness 6 Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene F-1 other(explain): Dimensions: Scum thickness c ess 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 165 Mill Road Property Address Michael Odiorne Owner Owner's Name information is required for North Andover MA 01845 10/28/2013 every page. Cityfrown 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 last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Forth: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 'r 165 Mill Road Property Address Michael Odiorne Owner Owner's Name information is required for North Andover MA 01845 10/28/2013 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc:): D-box level &distribution not equal. Evidence of carryover. D-box has corrosion holes needs to be replaced. Liquid above pipe, found pipe pitched wrong. 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 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 165 Mill Road Property Address Michael Odiorne Owner Owner's Name information is required for North Andover MA 01845 10/28/2013 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 field 20'x 45' ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 17 1 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 165 Mill Road Property Address Michael Odiorne Owner Owner's Name information is required for North Andover MA 01845 10/28/2013 every page. Cityrrown 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.): i t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "< 165 Mill Road Property Address Michael Odiorne Owner Owner's Name information is required for North Andover MA 01845 10/28/2013 every page. Cityfrown 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 w� !4 � o a 1zv�l� a f 4©<q Ic ✓ 4S C> a � t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r` 165 Mill Road Property Address Michael Odiorne Owner Owner's Name information is required for North Andover MA 01845 10/28/2013 everypage. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells >4' Estimated depth to high ground water: feet Please indicate all methods used to determine the 9 high round water elevation: plans design Obtained from system® y g on record If checked, date of design plan reviewed: 5/31/2013 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Design plan ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: I You must describe how you established the high ground water elevation: As per design plan no water 4' below field Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 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 165 Mill Road Property Address Michael Odiorne Owner Owner's Name information is required for North Andover MA 01845 10/28/2013 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist E 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 Forth:Subsurface Sewage Disposal System•Page 17 of 17 Summary Record Card generated on 10/11/2013 9:56:08 AM by Karen Hanlon Page 1 Town of North Andover Tax Map # 210-107.C-0070-0000.0 Parcel Id 18353 165 MILL ROAD MICHAEL ODIORNE KRISTEN COMEAU 165 MILL ROAD NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zonirl 1 Residential Size Total 1.01 Acres FY 2014 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until MICHAEL ODIORNE Owner KRISTEN COMEAU 165 MILL ROAD NORTH ANDOVER,MA 01845 HOUT, DAVID Previous Customer Inactive 11/30/2007 HOUT,JENNIFER 165 MILL ROAD N.ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 14325.0-165 MILL ROAD Last Billing Date 9/9/2013 2100326 02 Cycle 02 Active UB Services Maint. Account No.2100326 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 76.00 /1 UB Meter Maintenance Account No.2100326 Serial No Status Location Brand Type Size YTD Cons 34769949 a Active ERT RT b Badger w Water 0.63 0.63 279 Date Reading Code Consumption Posted Date Variance 8/2/2013 301 a Actual 20 9/18/2013 70% 5/6/2013 281 a Actual 12 6/18/2013 -1% 2/5/2013 269 a Actual 13 3/13/2013 4% 10/31/2012 256 a Actual 11 12/13/2012 -4% 8/7/2012 245 a Actual 13 9/26/2012 3% 5/3/2012 232 a Actual 12 6/20/2012 2% 2/2/2012 220 a Actual 12 3/14/2012 30% 11/1/2011 208 aActual 9 12/15/2011 -51% 8/2/2011 199 a Actual 18 9/14/2011 115% 5/4/2011 181 a Actual 8 6/13/2011 -9% 2/7/2011 173 a Actual 10 3/15/2011 -24% 11/1/2010 163 a Actual 12 12/13/2010 -11% 8/4/2010 151 a Actual 14 9/13/2010 -23% 5/4/2010 137 a Actual 18 6/9/2010 -9% 2/2/2010 119 aActual 20 3/11/2010 40% 11/2/2009 99 a Actual 14 12/11/2009 2% 8/4/2009 85 a Actual 14 9/11/2009 26% 5/4/2009 71 a Actual 11 6/16/2009 -9% 2/2/2009 60 a Actual 12 3/16/2009 2% 11/4/2008 48 a Actual 12 12/10/2008 -16% 8/4/2008 36 a Actual 14 9/12/2008 9% 5/6/2008 22 a Actual 13 6/18/2008 10% 2/5/2008 9 a Actual 9 3/14/2008 -100% Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 DEP has provided this form for us&by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left 1 ht front of hou , Left/Right rear of house, Left/right side of house, Left/ Right side of building, Left/Rig ron of building, Left/Right rear of building, Under deck Address Citylrown — 1`lA, State Zip Code 2. System Owner. Name Address(if different from location)'' - City/Town �"`- ! �� State �--�-�-�Zip-`t oe. Telephone Number r-a, pow ac�NpEpPa'(M� ',,. B. Pumping Record 1. Date of Pumping pate 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes L-No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of stem: ` I C 4� 6. System Pumped By.- Neil y:Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatio contents were disposed: G... S. Lowell Waste Water Sign a Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 FILE COPY RATED AQ ' PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF. COMPLIANCE As of: 11/19/13 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: D-Box By: Todd Bateson At: 165 Mill Rd. Map 107.0 Lot 0070 North Andover, MA 01845 lt su ce of this c if hall no e construed as a guarantee that the system will function satisfactorily. W � ele Grant Public Health Agent FILE COPY 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com i f 1 F 'R4 DX North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 165 Mill Rd. MAP: 107.0 LOT: 0070 INSTALLER: Todd Bateson DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONSZ(L _ 11/19/12 D BOX: 11/19/12 TANK INSPECTION: DATE OF BED B TTOM INS ECNNNSPECTION: DATE OF FINAL C STRUCTI DATE OF FINAL GR E INSPE SITE CONDITIONS ❑ Co\bing ny changes to design plan ❑ Exiproperly abandoned ❑ Intel to one building sewer ❑ Topreciably altered Comments: SEPTIC TANK ❑ Buil •ng sewer in continuous grade, on comp ted firm base ❑ Cleano s per plan ❑ Bottom o tank hole has 6" stone base ❑ Weep hole lugged ❑ 1500 gallon nk has been installed H-10 loading ❑ Monolithic tank c struction E . Water tightness of k has been achieved by visual testing ❑ Inlet tee inst led, centered under access port ❑ Outlet tee inst ed, centered under access port (gas baffle/efflue t filter) ❑ inch cover within 6" of finish grade installed over one a ess port ❑ Hydraulic cement aro d inlet & outlet Comments: PUMP CHAMBER ❑ Bo m of tank hole has 6" stone base ❑ Weep ole plugged ❑ 1500 Ilon Pump Chamber installed ❑ H-10loa ing ❑ Monolithic nk construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) instal d on stable base ❑ Alarm float work\gra ❑ Pump On/Off flog ❑ Separate on/off f ❑ Drain hole in pre ❑ cover at fiinstalled over pump access port ❑ Water tightness of tank has en achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of controlp anel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX Installed on stable stone base H-20 D-Box ❑ Inlet tee (if pumped or >0.08'/foot) [;]/�ydraulic cement around inlet & outlets Observed even distribution ❑ Speed levelers provided (not required) Comments: �I Map-Block-Lot Commonwealth of Massachusetts P �k` • 107.co070 BOARD OF HEALTH Permit NO North Andover BHP-2013-1021 P.I. FEE F.I. $125.00 ------------------------ DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby-granted Todd-Bate-son to(Repair)an Individual Sewage Disposal System. b-b} at No -165 MILL ROAD - - - - - - ------------------- - ----.----------.- -- -------------�3-1.02 F- ---- -- ------------- --- -------- as shown on the application for Disposal Works Construction PermitNo. BHP-20i �' DadNo tuber 06,2013 ----------------- ----------------------------------------------------------------- Issued On:Nov-06-2013 --------- --------------------------------------------------------------- BOARD OF HEALTH i ................................................................ .............................................................................. .....................� 165 MILL ROAD Reference No: BHJ-2013-000081 Permit No: BHP-2013-1021 Department: •---------------------------------- North Andover BOARD OF HEALTH Fee Type: Account No: 1001001.1.5.0510.00 DWC-Component Repair PERMIT Receipt No: REC-2014-000586 .................... .................................... Paid By: Paid in Full On: Wed Nov 06,2013 Odiorne,Michael .................................... ------------------------------------------------------------------------------•----- Check No: 7731 Received By: Lisa Blackburn ..............................•-• ••----.......-,-----•------ -•-•....-- ---•- DEPARTMENT'S COPY Amount: $125.00 ----------------------------------------------------------------------------------------------------------- .......-.-......................... s ° ;. Application for Septic Disposal System 13 TODAY'S DATE Construction Permit - TOWN OF NORTH ANDOVER, MA 01845 $2s oo-comp enent Important: Application is hereby made for a permit 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 disposal system* @� only the tab key epair or replace an existing system component—What? �� y .Q to move your cursor-do not use the return A. Facility Information key. [o-5 f l A o Address or Lot# I RECEIVED rob Cityrrmn �d �(r''s NOV 0 b 2013 2.-*TYPE OF SEPTIC SYSTEM*: TB WPl OF NORTH ANDOVER ➢ ❑ Pump ravity(choose one) HEALTH DEPARTMENT ***If pumps tem, attach copy of electrical permit to application*** . ➢ Conventional System (pipe and stone system) ➢ ❑ Infiltrator or Biddiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system.) ➢ ❑ Pressure Distribution S.A.S.(No D-Box) ➢ ❑ Pressure Dosed(D-Box Present)S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No if yes, does plan specify make and model of filter? YES=(no further info. needed) NO=(installer must specify brand of filter before DWC issuance) What is the Make? What is the Model? 2. Owner Information Name Address(if different from above) I/o, A-,> A,+- City/Tow State Zip Code Telephone Number 3. Installer Information Name Name of CoMNFrjLJUN ENTERPRISES,INC. 111 ARGILLA ROAD 9 Address ANDOVER,h ^181 L- , Cityrrown State M Zip Code 67 7 -470 Telephone Number(Cell Phone#if possible please) 4. Designer Information Name Name of Company Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 Application for Septic Disposal System Construction Permit - TOWN OF TODAY'S DATE 250.00-Full Repair e air NORTH ANDOVER, MA 01845 $125.00-Component PAGE 2OF2 A. Facility Information continued.... 5. Type Of Building: esidential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover. l understand that until a final Certificate of Compliance has been issued by this Board of a/th, the installed system is not approved. Name Date Application Approved By: (Board of Health Representative) p ) Name Date Application Disapproved for the following reasons: i For Office Use Only: 1. Fee Attached. Yes No 2. Project Manager Obligation Form Attached. Yes No I Pump System? Ifso,Attach copy ofElectrical Permit Yes_ No 4. Reviewed approvalletter, all paperwork received. Yes No Missing.• 5. Foundation As-Built. (new construction only): Yes_ No (Same scale as approved plan) I 6. Floor Plans?(new construction only): Yes No Application for Disposal System Construction Permit•Page 2 of 2 SEPTIC SYS'Y'EM.INSTALL-Ek-PRO18Cr MA�IAGEMEN'Y'''�BLIGATIONS As the North Andover.lice awed uistaller for#lie.construction forthe septic Sys.teip-if6r.the property at —�— T For plans by (Address of septic system) eer) Relative to tht.application of !° ��4��Sofa-� (installer's name) And dated 21 date . Dated —S_13 With revisions dated o a s date!.) est revised date) I understand the following obligations for management of-this project: 1. As the installer,I am.obligated to obtain.aff permits and Board of-Health approved plans:pAot to ;perflans and the orming any work on a site: T must h ve the a�rove�i �erinit:on site when any work is bring done. 2. As the installer;.Imust-c0i -for.any' and alliaspt'�ons: 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,shail.br:applicable. 3." As•tlie:instafltr,I atn rtgL1ired to,have.the pecss$ ry work completed piio�;to the.applicable inspections as indicated b.elowr• T.,grief land that reguesfine dn inspectiQn,without completion•of theitemis in,accordarice yith le 5 an ' p Ro "' of eaitli&61&hs yie6dr1n a.1k Erre,brinis�l1eviedagainst me and/or BonOW bf.13.6d; Generally,this is thet.(.1"�,'ii�'speotioiz unless.there is a'retaiiung wad c lick. shout •be done rst: The nstall r iriust#eguest the ii specd6a but sloes-not have to be pttsent. . .�.b. FinjjjQdnsi�}ctidO.Itispectiori—Eng�aeermtus't'firstdotheminsj�ection for elevations;•tie¢,etc. As-built of verbal OK dor a-maEil to:}iealtlidp_p �towno o�handover.Q m1 from the engineer must be stibiriitfedto'-.the.Boar&ofHealth,after:wl eliinstialEer,ca�Is for:an inSp'ectipn time. Installer must be present for this.inspection, With•a puirtp,&p$tem,it..eleatical wvtk;must:be ready and able to cause, .un4 .tri fivork and talarm':to function.. P P • c. Fina�,�G —installermust request inection wh ea all•gradtng•is complete: .Installer does not have to be•on ite. 4. As-the installer,•I un%kta and that only I. perform the work'(other than:cimpk.excavafisx)and'I ai a '-req to complete the•installatitin of the system identified in xlie attached application for installation. Ad understand:that work•done by.otliers uiiiccfised. instaii i-. _-' tic, stems-in North Andover caii constitute reasons for dehial•of the-system and lorT vocation•or susnension Qty lieense•to operate in the Town of North Andover.sigficant fines to a ly&- te.. •••o Visible.' 5.. ,As th .instiller,I understand that.I tnt3§t`he oii=site during th .perfostziance of the following constructitm. steps: . a: DeterrninatiorY that.the proper efevatlon ofthe ekcalvabron has been reached b. Inspection ofthe'sand and stone-to be used C. Find inspeciYoa by Board of.Uealth staffor consuhaut. d. Installatiotr.•6f tank,DBox p3rpes,stone, vent,primp chamber,retail waif and other components. , 6. As the installer'i•11 derstand that I On S61 y resRpnsime for the installation of they'ts em as per the ti arts, No instructions by thAii e4 general con+raM L=AM-Othftj2ersons sha'u absolve me 4f:d11+s 6bHp.d . Undersigned :icensed Septic.In$tallez: (Tpda 's Date) /— RECEIVED IL Commonwealth of Massachusetts City/Town of AUG 3 2008 System Pumping Record TOWN OF NORTH ANDOVER r Form 4 HEALTH DEPARTMENT , I DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form,check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. Syst Location: forms on the computer,use only the tab key Address to move your cursor-do not Citylrown State Zip Code use the return key. 2. System Owner. Name i ISI Address(if different from location) City/Town Stat Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. SysteRn PYmpced Fs-g7�r Name '�'"� Vehicle License Number Company 7. Locatiorlohere contents VVM disposed: .S. _ � S Sign re H u er Date t5form4.doc•06/03 System Pumping Record.Page 1 of 1 Commonwealth of Massachusetts -RECEIVED City/Town of SUN Z0�p System Pumping Record Form 4 MW TOWN OF NORTH ANDOVER wM HEALTH DEPARTMENT 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 tQ determine the form they use. The System Pumping Record must be submitted to the local Board of Health orother approving authority. A. Facility Information 1 System Location: Left side of house, Right side of house, Left front of house, fight front of house, Left rear of house, Right rear of house. Left rear of building. Right rear of building. Address 16,5 / 5 M) City/Town State Zip Code 2. System Owner: Name Address(if different from location) C' /Town p �Y Stay � � vC�^��Z Telephone Numbers 1� B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: canons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes [4—M6-� If yes, was it cleaned? ❑ Yes ❑ No 5. Conditi n of System: 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locati a contents were disposed: G.L.S. LoI Wa Water 6, .—/y!v Signal of aul Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 j Commonwealth of Massachusetts RECEIVED City/Town of System Pumping Record MAY - 8 201 Form 4 TOWN OF NORTH ANDOVER HEALTH PEPARTN.T, ,, DEP has provided this form'for use by local Boards of Health. Other Turn to I I Say 0W 1.10cui-MUMM information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/41i "t front of hous Left/Right rear of house, Left/right side of house, Left/ Right side of building, Left/Rigrjit front of building, Left/Right rear of building, Under deck (- &5 lel 1V led Address Cityrrown State Zip Code 2. System Owner. 1 Name Address(d different from location) Cityrrown State Zip Code (e) �2q0 z Telephone Number B. Pumping Record 1. Date of Pumping I �- 2. Lanti Pum 50 Date lam: Gallons 3. Type of system: ElCesspool(s) Septic Tank ❑ Tight Tank. ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes 2 No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: 4fvVid 1�ey'd 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: L Lowell Waste Water ` 1 L& signAtufe 4 Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 .y Septic System Information 165 MILL ROAD Printed On:Friday, October 19, 2007 System ID: BHS-2002-1167 g . General System Information Latest Permit Information Calcaluted Design Flow: Test Pits Septic Tank Disposal Trench Design Flow: One Two Capacity: Number: Design Flow Provided: Minutes per inch: Width: Width: Total Flow: Depth: Length: Length: Seasonal: No No Depth to Water: Diameter. Leaching: Grinder: No No Soil Type: Depth: Laundry: No No HaulinjVPumping Listing Quantity Type System Type Pumped Pumped By Transferred To Disposed At Date Pumped (gallons) Routine Septic Tank Bateson Enterprises 12/08/2004 1500 Routine Septic Tank Bateson Ent GLSD 05/19/2006 2000 Comments: normal level in tank Routine Septic Tank Bateson Ent GLSD 08/03/2007 1500 Comments: clogged inlet tee-heavy solids Inspections: Inspected: Expires: Inspector: Status: 09/14/2007 Neil J.Bateson Passes Comments: Title 5 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Page 1 of 1 E 7i Of"ORT"1� w O •-r F Town of North Andover -•T.,,,,.. �, HEALTH DEPARTMENT ,SSwCHustt CHECK#: DATE: LOCATION: H/O NAME: CONTRACTOR NAME: x Type of Permit or License: (Check box) 0 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) $ ��irtie 5 I pector $ 5 Report ❑ Other:(Indicate) $ 2623 Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer ,w COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONME �OTECTION R��9l�f�� ` " SEP 2 7 2007 TOWN OF NORTH ANDOVER HEALTH DEPARTMEiNT TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_165 Mill Road_ —North Andover_ Owner's Name:_Jennifer Hout_ Owner's Address:_165 Mill Road_ —North Andover,MA 01845_ Date of Inspection:_9/14/2007_ Name of Inspector: Neil J Bateson Company Name: Bateson Enterprises Inc._ Mailing Address:_111 Argilla Road_ _Andover,MA 01810 Telephone Number:_(978)4754786_ 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 ils Inspector's Signature: r Date: _9/14/2007_ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments: ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. , z Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_165 Mill Road_ _North Andover— Owner:_Hout Date of Inspection: 9/14/2007_ Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.Answer yes,no or not determined(Y,N,ND)in the for the following statements.If`not determined"please explain._ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicatingthat the tank is less than 20 ears old is available. Y ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Pdge 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_165 Mill Road_ _North Andover_ Owner: Hout Date of Inspection: 9/14/2007_ C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**.Method used to determine distance_ **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_165 Mill Road_ _North Andover— Owner: Hout Date of Inspection: 9/14/2007_ D. System Failure Criteria applicable to all systems: You must indicate"yes"or`no"to each of the following for all inspections: _ No Backup of sewage into facility or system component due to overloaded or g! ed SAS or cesspool _No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool No_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool No Liquid depth in cesspool is less than 6"below invert or available volume is'/z day flow. _No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ No Any portion of the SAS,cesspool or privy is below high groundwater elevation. _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _ _No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ _No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either`yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply J 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. Pdge 5 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:_165 Mill Road_ _North Andover_ Owner:_Hout Date of Inspection: 9/14/2007 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Yes_ , Pumping information was provided by the owner,occupant,or Board of Health No Were any of the system components pumped out in the previous two weeks? Yes_ _ Has the system received normal flows in the previous two week period? No Have large volumes of water been introduced to the system recently or as part of this inspection? N/A _ Were as built plans of the system obtained and examined? Yes , Was the facility or dwelling inspected for signs of sewage back up? Yes_ _ Was the site inspected for signs of break out? Yes _ Were all system components,excluding the SAS,located on site? _Yes_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _Yes_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No _Yes Existing information.Old Title 5 Inspections _Yes _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_165 Mill Road_ _North Andover— Owner:_Hout Date of Inspection: 9/14/2007 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_4_ Number of bedrooms(actual):_4_ DESIGN flow based on 310 CMR 15.203_600_ Number of current residents:_4 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): No_ Laundry system inspected(yes or no): _ Seasonal use: (yes or no):_No_ Water meter reading:_Yes_ Sump pump(yes or no):_No Last date of occupancy:,Current COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/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 meta readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped this year,owner_ Was system pumped as part of the inspection(yes or no): No_ If yes,volume pumped: gallons--How was quantity pumped determined?_ Reason for pumping: _ TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool_Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous 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_29 Years old,Nov.21 1978,old title 5 report Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_165 Mill Road_ _North Andover_ Owner:_Hoot Date of Inspection:_9/14/2007 BUILDING SEWER_X_ (locate on site plan) Depth below grade:_18"_ Materials of construction: X cast iron _X 40 PVC_other Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.) _4"Cast iron thra wall,&3"PVC in house.No leaks visible _ SEPTIC TANK: X Depth below grade:_6" Material of construction:—concrete_metal_fiberglass—polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions:_10'x 5'x 4' Sludge depth:—0_ Distance from top of sludge to bottom of outlet tee or baffle: 27"_ Scum thickness:_1" Distance from top of scum to top of outlet tee or baffle: " _8 _ Distance from bottom of scum to bottom of outlet tee or baffle:_20"_ How were dimensions determined:_ Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc Inlet tee ok.Outlet tee corroded on top.Depth of liquid at invert.No evidence of leakage._ GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_165 Mill Road_ _North Andover_ Owner•_Hout Date of Inspection: 9/14/2007_ TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: i Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX_X_ Depth below grade _12"_ Depth of liquid level above outlet invert:_0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.)_D-box level&distribution equal.No evidence of leakage.Light carryover._ PUMP CHAMBER:—(locate on site plan) Pump in working order(yes or no):— Alarm in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): I J Paige 9 of 11 A OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:_165 Mill Road_ _North Andover_ Owner:_Hout Date of Inspection: 9/14/2007_ SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type _ leaching pits,number: _ leaching chambers,number:_ leaching galleries,number: _ leaching trench,number,length:_ X_ leaching field,number,dimensions: _1 field 20'x 451 _ overflow cesspool,number: innovativelalternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.):_Soil ok.Vegetation ok.No sign of ponding to surface._ CESSPOOLS: Number and configuration:_ Depth—top of liquid to inlet invert:, Depth of sludge layer:_ Depth of scum layer: Dimensions of cesspool:_ Materials of construction: Indication of groundwater inflow(yes or no):_ Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) I� Materials of construction: Dimensions: Depth of solids: I� Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): i 4 drynecordGardgenerated on 9/13/2007 2:39:32 PM by Elaine Barclay Town of North Andover Page 1 Tax Map # 210-107.C-0070-0000.0 165 MILL ROAD HOUT, DAVID HOOT, JENNIFER 165 MILL ROAD N. ANDOVER, MA __..______ _ 01845 Class 101 Single Family Size Total 1.01 Acres Property T --- ---- -- ------------------------ Y FY 2007 Pe 1 Residential UB Mailing Index _ Name/Address HOUT,DAVID Type Loan Number Active/Inact. HOLT,JENNIFER Payor From Until 165 MILL ROAD N.ANDOVER,MA 01845 UB Account Maint. oun Acct No Cycle Bldg Id. 14325.0-165 MILL ROAD Occupant Name 210032602 Cycle 02 Last Billing Date 9/5/2007 Active/Inactive UB Services Maint. Active Service Code Rate MISCFEE ADMIN FEE 0.63 5/8 Charge Multiplier/Users WTR WATER 01 ALL METER SIZE 7.82 1/ /1 UB Meter Maintenance 64.62 Serial No Status Location 0023636436 a Active ENC RT Brand Type Size Date Reading Code METE METE w Water YTD Cons 8/3/2007 Consumption Posted Date 0.63 0.63 0 5/4/2007 3146 a Actual Variance 3128 a Actual 18 9/14/2007 2/28/2007 3095 m Manual estimate 33 6/22/2007 -61% 11/3/2006 3079 aActual 16 3/23/2007 271% 8/21/2006 3063 a Actual 16 12/22/2006 -37% 5/25/2006 3047 a Actual 16 9/13/2006 19% 2/8/2006 3023 a Actual 24 6/20/2006 -20% 11/8/2005 3005 a Actual 18 3/13/2006 16% 8/11/2005 2991 a Actual 14 12/14/2005 24% 5/12/2005 2969 a Actual 22 9/12/2005 -35% 2/22/2005 2949 a Actual 20 6/8/2005 -5% 11/19/2004 2929 a Actual 20 3/15/2005 20% 8/17/2004 2906 a Actual 23 12/17/2004 -14% 5/19/2004 2875 a Actual 31 9/20/2004 -29% 2/17/20042822 2822 a Actual 53 6/14/2004 -40% 11/5/2003 2760 n New Meter 62 4/16/2004 -3% 0 11/5/2003 0% 0% Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating-Water& Sewer Lines-Septic Systems&Pumping Service 111 Argilla Road Andover,Mass. 01810 Title 5 Inspection Report Property Address: 165 Mill Road, North Andover Owner: Hout Date of Inspection: 9/14/2007 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Neil J. Bateson Bateson Enterprises, Inc. COMMONWEALTH OF MASSACHUSETTS Z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS r DEPARTMENT OF ENVIRONMENTAL P � i_ HAND VB"/ ._D OF HE._,_. In SV AR �9 I t TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_165 Mill Road_ _North Andover— ___ 7v Owner's Name:_Paul Swartz_ T6 �'�' NORI Owner's Address:_165 Mill Road_ BOARD OF HEAL TI _North Andover,Ma. 01845_ Date of Inspection: 4/4/2001 p Lt3 2001 1 - - � Name of Inspector:_Neil J.Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address:_111 Argilla Road_ _Andover,Ma.01810_ Telephone Number:_(978)475-4786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ails &Z/� Inspector's Signature: Date: _4/4/2001_ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A i CERTIFICATION (continued) Property Address:_165 Mill Road_ _North Andover_ Owner: Swartz Date of Inspection:_4/4/2001_ Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of l l OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_165 Mill Road_ _North Andover— Owner: Swartz Date of Inspection: 4/4/2001 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone l 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: Page 4 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_165 Mill Road_ _North Andover— Owner: Swartz Date of Inspection: 4/4/2001_ D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for all inspections: Yes No _No_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _No_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool No Liquid depth in cesspool is less than 6"below invert or available volume is less than'/i day flow _No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _No_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. No Any portion of a cesspool or privy is within a Zone 1 of a public well. _No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in.310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:_165 Mill Road_ _North Andover_ Owner: Swartz Date of Inspection:_4/4/2001_ Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Yes _ Pumping information was provided by the owner,occupant,or Board of Health No Were any of the system components pumped out in the previous two weeks? Yes _ Has the system received normal flows in the previous two week period? No Have large volumes of water been introduced to the system recently or as part of this inspection? N/A _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _Yes _ Was the facility or dwelling inspected for signs of sewage back up? _Yes _ Was the site inspected for signs of break out? Yes_ _ Were all system components,excluding the SAS,bated on site? _Yes_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _Yes_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? I The size and location of the Soil Absorption System(SAS)on the site has been determined based on: I Yes no Yes _ Existing information.For example,a plan at the Board of Health.Old Title 5 Paperwork. No Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] i i Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_165 Mill Road_ _North Andover_ Owner: Swartz Date of Inspection:_4/4/2001_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_N/A_ Number of bedrooms(actual):_4_ DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):_N/A_ Number of current residents:_4 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no):_No Water meter readings:April 99 to Nov 00=16,200 ft3 x 7.5=121,500Gals./579Days=210Gals./Day Sump pump(yes or no): No Last date of occupancy:_Current COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 3.10 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:_Pumped 7/99,owner_ Was system pumped as part of the inspection(yes or no); Yes_ If yes,volume pumped:_1500_gallons--How was quantity pumped determined?_Measured tank. Reason for pumping: Inspect tank&tees. TYPE OF SYSTEM _X_Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _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: 23 Years old.Nov.21, 1978 ,Owner&Old Title 5 Paperwork. • Page 7 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_165 Mill Road_ _North Andover— Owner: Swartz Date of Inspection: 4/4/2001_ BUIULDING SEWER(locate on site plan)X Depth below grade: 18" Materials of construction:—X cast iron —X-40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.):_4"Cast iron thru wall&to septic tank. 3"PVC in house. SEPTIC TANK:_X locate on site plan) I Depth below grade:_,6"_ Material of construction: X concrete metal._fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:_10'x 5'x 4' Sludge depth: 5" Distance from top of sludge to bottom of outlet tee or baffle: 22" Scum thickness: 8" Distance from top of scum to top of outlet tee or baffle:_8" Distance from bottom of scum to bottom of outlet tee or baffle:_13"_ How were dimensions determined:_Subtract scum&sludge depth to tee length. Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.):_Pumped septic tank.Inlet tee&outlet tee ok.Depth of liquid at outlet invert.No evidence of leakage. GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): i Page 8 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_165 Mill Road_ _North Andover- Owner: Swartz Date of Inspection:_414/2001_ 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: X (if present musk be opened)(locate on site plan) Depth of liquid level above outlet invert:_0_ Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.):_D-Box level&distribution equal.No evidence of leakage.Evidence of solid carryover,pumped d-bog to clean. PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_165 Mill Road_ _North Andover— Owner: Swartz Date of Inspection:_4/4/2001_ SOIL ABSORPTION SYSTEM(SAS):_X (locate on site plan,excavation not required) If SAS not located explain why: Type leachingits number: P leaching chambers,number: leaching galleries,number: leaching trenches,number,length: _X_leaching fields,number,dimensions:—1 Field 20'x 45'_ overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc:Soil oL Vegetation oL No sign of ponding to surface. CESSPOOLS: (cesspool must be pumped as part of inspectionxlocate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): i PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): • Page 10 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_165 Mill Road_ _North Andover– Owner: Swartz Date of Inspection:_4/4/2001 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. Garage House AtoI=10' Ato2=18' A to D-Boz=22'5" A Water Meter BtoI=36'6" Driveway B to 2=40'9" B to D-Boz=45' 1 Septic Tank 2 D- Boz 20' 45' — � • Page 11 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_165 Mill Road_ _North Andover— Owner: Swartz Date of Inspection:_414/2001_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water_4 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: X 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:_Transfer elevation of wetlands in rear yard to field bottom,no water 4'below bed bottom. Tel: (978) 475-4786 Fax: (978)475-5451 BATESON ENTERPRISES, INC. Excavating-Water.& Sewer Lines-Septic Systems&Pumping Service 111 Argilla Road Andover,Mass. 01810 Title 5 Inspection Report Property Address: 165 Mill Road, North Andover pP� Owner: Swartz Date of Inspection: 4/4/2001 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Neil J. Bat on Bateson Enterprises,Inc. Commonwealth of Massachusetts City/Town of System Pumping Record RECEIVED Form 4 - JUN -- 5 .2006 DEP has provided this form for use by local Boards-of Health 1he System Pumping Rec FtTd&H1;A_LTH rdmust be submitted to the local Board of Health or other approving auOF NORTH ANDOVER DEPARTMENT A. Facility Information 1 Important: When ruing out 1. System Location- j forms on the computer,use only the tab key Address c move your cursor-do not use the-return Cityrrown r State Zip Code key. 2. System Owner: V607� Name Address(if different from location) Cdy/Town State Zip Code Telephone Number B. Pumping Record 1. .Date.of Pumpingk" Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) ❑ Septic Tank- El Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes s..KO- If yes, was it cleaned? ❑ Yes'❑ No 5. Condition of System:U� 6. System Pump d By' Nam e Vehicle License Number Company -7. Locat' where contents were disposed:: Sig a,tur of uler pate h.ftp://www.Mass.gov/dep/`water/approvalt,/`t5forms.htm#inspect t5form4.doc•06103 - System Pumping Record•Page 1 of 1 f TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: -9LtiN SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example: left front of house) (ek+ ,9 (A e- DATE OF PUMPING: ^,D3'av�UANTITY PUMPED (.GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: T0�WRTIA AN%v BOAR ALa�t r APR 1 3 2001 COMMENTS: 1; CONTENTS TRANSFERRED TO: F41, TITLE V • .sera C3� • T ALFRED G . • 1 per-_ A 165 MILL • , N . ANDOVER, MA 84 a� r r- r' t. Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection Wllllam F.Weld Governor Trudy Coxe S�crNuy,EDEA David B.Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 165 'Mill Rd. N.Andover,MA Address of Owner: Date of Inspection: November 10 , 19 9 5 (If different) Name of Inspector: Harold F. Garrett Company Name, Address and Telephone Number: Garrett Building Inspection, 4 Ledgewood Rd. , Wilmington,MA 01887 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority., Fails t� Inspector's Sign tur : Date: November 10 , 1995 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: that the system violates an of the failure criteria as defined in 310 CMR 15.303. X I have not found any information which indicates t y Y Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: NA The system, u n com completion of there replacement or repair, or repaired. P more system components need to be replaced paupon P One or y po P passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as 0 approved by the Board of Health. (revised 8/15/95) 1 One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)292-5500 `�Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A e CERTIFICATION (continued) Property Address: `� .•• Owner: Date of Inspection: B]SYSTEM CONDITIONALLY PASSES (continued) NA Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: . NA Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER L WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT ' THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feel to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. — The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. — The syslen- has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D] SYSTEM FAILS: NA I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 165 Mill 1. , N.Andover,MA Owner: Alfred Hambleton Date of Inspection: November 10, 19 9 5 D] SYSTEM FAILS(continued): NA 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is wiihin a Zone I of.a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. O E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: _ The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 •� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 165 Mill Rd. , N.Andover,MA Owner: Alfred G. Hambleton Date of Inspection: November 10 , 1995 Check if the following have been done: X Pumping information was requested of the owner, occupant, and Board of Health. X None of the system components have been pumped for at least two weeks and the system has been receiving normal flow ratei during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X As builtP tans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow S X The site was inspected for signs of breakout. X All system components, excluding the Soil Absorption System, have been located on the site. X The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. X The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. X The facility o•. ncr land occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System.i �r (revised 8/15/95) 4 r' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: '165 Mill Hda . ,N.Andover,MA Owner: Afred G. Hambleton Date of Inspection: November 10, 1995 FLOW CONDITIONS RESIDENTIAL: Design flow: 600 gallons per day Number of bedrooms: 4 Number of current residents:- 1 Garbage grinder (yes or no): no Laundry connected to system (yes or no):,yp—,g Seasonal use (yes or no):ngL (1993-7500 Cu ft. ) (1994 106, 000 cu ft. ) 0995 8900 tuft. ) Water meter readings, if available: Owner says EE–a-F–fFe—usect excessive water tor his t1ower beds Last date of occupancy: Current COMMERCIAUINDUST RIAL: Type of establishment: 14A Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste,Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: ��.ast date of occupancy: OTHER: (Describe) 1,ast date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Personal records 11/13/85 8/15/8.8 9/12/91 System pumped as part of inspection: (yes.or no) No If yes, volume pumped. eallons Reason for pumping: TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) November 21, 1978 APPROXIMATE AGE of all components, date installed (if known)and source of information: .C Sewage odors detected when arriving at the site: (yes or no)No I-revised 8/15/951 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SEPTIC TANK: (locate on site plan) Depth below grade: 12 inches Material of construction: -Xconcrete _metal _FRP other(explain) Dimensions: 110" x 6 4" x 51. 11 Sludge depth: Less than 1" Distance from top of sludge to bottom of outlet tee or baffle: 9 2 � Scum thickness:J-e-%than 1" Distance from top of scum to top of outlet tee or baffle: 9 z Distance from bottom of scum to bottom of outlet tee or baffle: 2 0 " Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) ThenQtreq]llre piimpin Tees in both t e in et and the Outlet are in ooa s ruc. ural on ition, T e tank is structurall sound `"h the invert of the i e GREASE TRAP: NA (locate on site pla_n) Depth belo", grader Material of construction: _concrete_metal _FRP_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom n. sruni 1,, rronom of outlet tee or battle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 8/15/95) 6 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 0 SYSTEM INFORMATION (continued) Property Address: 165 Mill Rd. , N.Andover,MA Owner: Alfred G. Hambleton Date of Inspection: November 10 , 19 9 5 TIGHT OR HOLDING TANK: NA . (locate on site plan) Depth below grade: Material of construction: _concrete _,metal _FRP other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) 0 DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert: 0 Comments: (note if level and distriUuUui i�equal, e\idence of solids carryover, evidence of leakage into or out of box, a c.) The distribution box is level and has a good evern f�ow. roblems . PUMP CHAMBER: NO (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):—X methods) (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive If not determined to be present, explain: Refer to plaAndover Consultants Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length. 4 @ 45 ' (I bacbing Lines) leaching fields,number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) Information obtained by �'ngine rinq nPgian Plan CESSPOOLS: NA (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: _ inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: NA (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.) (revised 8/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 165 Mill Rd. , N.kndover,MA Owner: Alfred G. Hambleton Date of Inspection: November 10, 1995 1 ' SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' /si A: o r LOT 1 AC i • b • v • GwA hl • .Ci.�nw� q *Mo t► AAJosp.Iso Das.say. IOC df' lao7 /L DEPTH TO GROUNDWATER (From the bottom of the rock bed) Depth to groundwater: 5. 55 feet SAS done by Andover Consultants of determination or approximation: method (revised 8115195) 9 Commonwealth of Massachusetts _A Massachusctts System Pumping Record System Owner System Location �-L / j Date of Pumping: Quairiity Pumped: /� gallons / a Cesspool: No �.�''� Yes �._) Septic Tank: No Yes System Pumped by: Fetredert gitreo�fta a License# Contents transferrred to : Greater Lawrence Sanitary District I„ Date: Inspectors TOWN OF NORTN AtlDOVER/ B ARC OF; EALTH Q6JUL 1 2 1999 TOWN OF e-C SYSTEM PUMPING RECORD_. t ' ra ✓• 9 DATE: r -6 NOV 2 6 2003 1 SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example:left front of house) 1 W DATE OF PUMPING: 3 QUANTITY PUMPED : _ (_, 00 GALLONS CESSPOOL: NO YES EPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: coNTENTs TRANSFERRED To: G.L.S.D Lowell Waste TO OF STEM PUMPING RECORD DATE: o:- $""0 i SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example:left front of house) Oo�A JAM DATE OF PUMPING: _ 4; `i QUANTITY PUMPED : l ?J' 0 C7 GALL NS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste Commonwealth of Massachusetts ' I City/Town of RF C E!,V,K- System Pumping Record AUG - 6 2007 s Form 4 TOV� lrG� DEP has provided this form for use by local Boards of Health.Other f 4nayrbe}u�lTbt *4e information must be substantially the same as that provided here. Before using is orm, with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important. When fining out 1. System Location:� forms on the �v computer,use only the tab key Address ,— to move your S cursor-do not , use the return CrtylTorrrr state Zip Code key. 2. System Owner: 1 Name 1C Address(if different from Location) Cityrrown Stat Zip Code �r(,,� Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes. Vo if yes,was it cleaned? ❑ Yes ❑ No 5. Conditi ,n of System: 6. system P�islp��By�C Name l J Vehicle License Number CJS Company 7. Location re contents were osed: 1A V) CL-7 -C3 '7 Signfie of a er Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 and ®ver C O n S U I t�y n 1 S EIGHT TILTON STREET 1 t.1 METHUEN. MASSACHUSETTS 01844 inc. (617) 687-3828 o1''J"',„.o.l (D,sgi,ee-.t 1 ud C- DATE 7�_ n; 110-17 yors 1.0 . NORTH AkDOVESR HEALTH LEPARTMENIT IT.C,..!i. HALL , IwO. ANDOVLaR , Iv,ASS . R : :SUBSURFACE SEYdAGE DISPOSAL SYSTEI, A &'(_ NO. ANDOVER , lViASS . I hereby certify that I have inspected the construction of the disposal system at �4 � , ��/GCS %�%D ,' North Andover, Mass . and that the location and elevations are as shown on the As-Built Drawing dated Oc—• / Ig OF �b9gsr vviu_I;. ANDOVER_ CONSULTANTS INC. ,vl �y r S u, N0 742 4illiam S . IY:acLeod � R�, Registered Sanitarian F SHO� . This ce t ii c _ci0 ) is ;-lot cosi ued as a -ua_rantee of the system. V s A/S T//V 6- IJ1/YER T FLE IIA Tl - 47 fiNOUSE J03•S5 T SEpr/c Ti9,VK QJ'• el , ,L 0 T 1 �o uT� O 3• /8 /. D / ,9l ' i (/,'N) hr ,D/ST .box JD z 98 (our] •. •. /O 2 . -8.3 . P,'PE AT END of SED Joe . 56- 'V � GqR � • f os ri ve V DwEi,c. QS - B L.1/L 7- D, ,�w ///- c; 1 �1 •�e�. �UB�U.2�AC"E cSEve/AGE D/SP0.5AL �SysTE,M r------------- �'' o•• e ExP �S�-�,,r fO DATE o c ro B E/t //, 1978 '9�'EA ,,9'BSORp. .BED �Disr.gpy, 94O �F D Ml/EA>- : 111 C AR FD G. A/A M,8 EL• TOW --- F L OCA T10". / ,11_1 R0 L) /VoRTH 14 11D vER , MAss. /p' yV/DE EA5,6'/NE1V 7 /04 89' . ¢7.0� , andovero u consultants - MACIEOD IW /L l inc. �Fs9No. ,��R�a,��? 8 Tilton Street ; Methuen , Mass. /0 At TN/S PI-4111 w/rhi /,5 1,107- 7-0 BE CO.c%s 7"QUEC� AS .� G'U9,P,q,(/TEE Tf/�T Tf/E .S Y,57-, V! jN/L L FC/,t/C T/0.-/ 14, Commonwealth of Massachusetts City/Town of RECEIVIE System Pumping Record r�G Form 4 JUL Q g 2009 DEP has provided this form for use by local Boards of Health. Other formL 60t� 161,ER information must be substantially the same as that provided here. Before T " NT" our local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: Left front, left rear, left side of hous . Right front, ight rear, right si e of ho se._�) forms on the computer,use only the tab key Address / 1 to move your (� 1 cursor-do not use the return Cityfrown State Zip Code key. _ 2. System Owner: Name Address(if different from location) City/Town Stated t ` Co Telephone Number B. Pumping Record K9 1. Date of Pumping ate r J Z. Quantity Pumped: Gallons 3. Type of system: El Cesspool(s) g—Septic Tank Tight Tank Other(describe): 4. Effluent Tee Filter present? E] Yes 0-?q0If yes,was it cleaned? 0 Yes [ No 5. Condition of System: 6. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: .L.S.D Lowell Waste Water igna ure of H Or Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 .I ,F�w ,. .., i 'i � ! � ; '- •-�' � �`-- �•' � -� t �) � � I I