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North Andover Board of Assessors Public Access
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Parcel ID: 210/104.B-0155-0000.0 Community: North Andover
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Location: 165 VEST WAY
Owner Name: CARLSON, WILLIAM H
JOAN G CARLSON
Owner Address: 165 VEST WAY
City: NORTH ANDOVER State: MA ZIP: 01845
Neighborhood: 7 - 7 Land Area: 1.62 acres
Use Code: 101- SNGL-FAM-RES Total Finished Area: 2680 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 598,200 559,100
Building Value: 380,100 357,100
Land Value. 218,100 202,000
Market Land Value: 218,100
Chapter Land Value:
LATEST SALE
Sale Price: 332,000 Sale Date: 11/01/1993
Arms Length Sale Code: Y -YES -VALID Grantor: D'AGOSTINO, JOSEPH J
Cert Doc: Book: 03883 Page: 0047
' Page 1 of 1
http://csc-ma.us/NandoverPubAcc/jsp/flome.jsp?Page=3&LinkId=807903 6/13/2006
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MAPLOT �_____��~~
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PARCEL STREET���_���_aV
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QONS�TRUCTION-APPROVAL
HAS PLAN REVIEW FEE BEEN PAID? YESNU
� PLAN APPROVAL: DATE APP. By
_
DESIGNER: PLAN DA|E______________
`
CONDITIONS' -----------------
'
-__--'-----
,.
�.
'.
' WATER SUPPLY:WELL
.. =TOWN
-
' WELL PERMIT----A1DRILLER.._,.,...
/
WELL TESTS: CHEMICAL DA[E APPROVED.
^' - --- --'
BACTERIA l DAlE A|/PROVED_
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BACTERIA II DA�E APPHOVEU
'.
COMMENTS:
FORM U APPROVAL: APPROVAL lO ISSUE
DATE ISSUED_-lB�_.......
CONDITIONS:
FINAL APPROVAL:
ALL PERMITS PAID
WELL CONSTRUCTION APPROVAL
SEPTIC SYSTEM CONSTRUCTION APjROVAL
OTHER
ANY VARIANCE NEEDED
FINAL- BOARD OF HEALTH APPROVAL:
YES NO
NO
YES
NO
YES
NO
YES
NO
DA7E:
UY �V
NO
BY
-K
SEPT7f_ ..__Y-9JEM
y IS THE INSTALLER LICENSED?
YES NO
TYPE OF CONSTRUCTION :NL --W fZEPA I f+
NEW CONSTRUCTION: CERTIFIED PLOT PLnN REVIEW `YLS IJU
CONDITIONS OF APPROVAL YES NO
(FROM FORM U)
ISSUANCE OF DWC PERMIT YES NO
DWCPERMIT NO. ��� INSTALLER• 5660p
BEGIN .INSPECTION YES q:
: EXCAVATION.INSPECTION: NEEDED:
�v S �✓L. c �/ /� civ
ow
PASSED _ BY _-- -- -- - ---�.
CONSTR CTION INSPE ION: NEEDED:
__Z1267 lrl �/
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AS BUILT PLAN SATISFACTORY:
APPROVAL TO BACKFILL.: DATE: �S_ O BY
FINAL GRADING APPROVAL: DATE BY
FINAL CONSTRUCTION APPROVAL: DATE:__ _DY _ __
OF NO R T/� qtiIT
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��SSA C tiUs���FF71LE COPY
PUBLIC HEALTH DEPARTMENT
Town of North Andover
Community Development Division
CERTIFICATE OF
COMPLIANCE
As of: 9/9/2014
This is to certify that the individual subsurface disposal system received a
SATISFACTORY INSPECTION of the:
Complete Repair of D -Box
By: John Soucy
At:
165 Vest Wav
Map 104B Lot 0155
�orth Andover, MA 01845
r 4 fo/uan,,e of thi c iPjcate sh�ll not be construed as a guarantee that the system will function satisfactorily.
Michele Grant U
Public Health Agent
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com
'e r
-O a
North Andover Health Department
(ommunity Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION.
ADDRESS: 165 Vest Way MAP: 104B
INSTALLER: John Soucy
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
INSPECTIONS 011
D -Box INSPECTION:
DATE OF BED BOTTOM INSPE TION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
Comments:
SEPTIC TANK
LOT: 0155
❑ Contractor reports any changes to design plan
❑ Existing septic tank properly abandoned
❑ Internal plumbing all to one building sewer
❑ Topography not appreciably altered
❑ Building sewer in continuous grade, on
compacted firm base
❑ Cleanouts per plan
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ 1500 gallon tank has been installed
H-10 loading
❑ Monolithic tank construction
❑ Water tightness of tank has been achieved by
visual testing
❑ Inlet tee installed, centered under access port
❑ Outlet tee installed, centered under access port
(gas baffle/effluent filter)
❑ inch cover to within 6" of finish grade
installed over one access port
❑ Hydraulic cement around inlet & outlet
Comments:
PUMP CHAMBER
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ 1500 gallon Pump Chamber installed
❑ H-10 loading
❑ Monolithic tank construction
❑ Inlet tee installed, centered under access port
❑ Pump(s) installed on stable base
❑ Alarm float working
❑ Pump On/Off floats working
❑ Separate on/off floats
❑ Drain hole in pressure line
❑ cover at final grade installed over pump
access port
❑ Water tightness of tank has been 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 control panel: 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)
Hydraulic cement around inlet & outlets
Observed even distribution
Speed levelers provided (not required)
Schedule 40 PVC Pipe
Comments:
V;.,0.. +
ebr,UL I I �
Commonwealth of Massachusetts Map -Block -Lot
104.B0155
BOARD OF HEALTH -----------
Permit No ------------
-
North Andover BHP -2014-0767 -----
-----------------
P.I. FEE
F.I. $125.00
0
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted John Soucy - __-__________________ ______ _ _ - _
--- --------- --------- -----------------
to (Repair) an Individual Sewage Disposal System.
at NoT
----165----VES------------WAY --------------------------------------------------------------------------------------------------------------------------------------
as shown on the application for Disposal Works Construction Permit No. BHP -20147076 wed Se --------
___ 04,201 - 4
Issued On: Sep -04-2014 BOARD OF HEALTH
Commonwealth of Massachusetts Map -Block -Lot
�• 104. B0155
BOARD OF HEALTH Permit No
North Andover BHP -2014-0767
-----------------------
FEE
$125.00
-----------------------
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted JOhn_SOUCy___ ________________
-------------------------------------------------------------
to (Repair) an Individual Sewage Disposal System.
at No 165 VEST WAY
as shown on the application for Disposal Works Construction Permit No. BHP -2014-076 Dated September 04, 2014
-----------------AdOD- -31-Y - --- - ----
Issued On: Sep -04-2014 BOARD OF
s -r
NORTH
F p
• Town of North Andover
`�'• HEALTH DEPARTMENT
CHUStt
qj
r� i
CHECK #: I ( Al DATE. i
LOCATION:
H/O NAME:
CONTRACTOR NAME:
Type of Permit or License: (Check box)
❑ Animal
❑ Body Art Establishment
❑ Body Art Practitioner
❑ Dumpster
❑ Food Service - Type:
❑ Funeral Directors
❑ Massage Establishment
❑ Massage Practice
❑ Offal (Septic) Hauler
❑ Recreational Camp
❑ Sun tanning
❑ Swimming Pool
❑ Tobacco
❑ TrashlSolid Waste Hauler
❑ Well Construction
SEPTIC Systems:
❑ Septic - Soil Testing
❑ Septic -Design Approval
Septic Disposal Works Construction (DWC)
❑ Septic Disposal Works Installers (DWI)
❑ Title 5 Inspector
❑ Title 5 Report
❑ Other. (Indicate) $
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
.. , "'f
K°TApplication for Septic Disposal System
Construction Permit -TOWN OF
%NORTH ANDOVER. MA 01845
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
�
tg&tJr
ADDlication is herebv made for a permit to:
09/04/14
TODAY'S DATE
$ 250.00 — Full Repair
$125.00 - Component
❑ Construct a new on-site sewage disposal system*
❑ Repair or replace an existing on-site sewage disposal system*
■❑ Repair or replace an existing system component — What? DISTRIBUTION BOX H-20
A. Facility Information
165 VEST WAY
Address or Lot #
N. ANDOVER
City/Town
E
2.- *TYPE OF SEPTIC SYSTEM*: SEP `j 3 2014
❑ Pump ❑■ Gravity (choose one)
***If pump system, attach copy of electrical permit to application*** TOWN Uh NUR fhi ANDOVER
HEALTH pEPARTMENT
❑ Conventional System (pipe and stone system)
❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.
❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement)
❑ Pressure Dosed (D -Box Present) S.A.S.
2. Owner Information
KARA LIBERMAN
Name
165 VEST WAY
Address (if different from above)
N.ANDOVER
City/Town
3. Installer Information
JOHN SOUCY
Name
78. BROADWAY
Address
SALEM
City/Town
4. Designer Information
N/A
Name
Address
City/Town
MA
01845
State Zip Code
978-738-0610
Telephone Number
SOUCY SEWER SERVICE INC
Name of Company
NH 03079
State Zip Code
603-898-9339
Telephone Number (Cell Phone # if possible please)
Name of Company
State Zip Code
Telephone Number (Best # to Reach)
Application for Disposal System Construction Permit • Page 1 of 2
H�R� Application for Septic Disposal System
.tt4.fl I��
Construction Permit - TO�KjN OF
ORTH ANDOVER. MA 01
PAGE 2OF2
A. Facility Information continued....
5. Type of Building: ❑■ Residential Dwelling or ❑Commercial
B. Agreement
09/04/14
TODAY'S DATE
$ 250.00 - Full Repair
$125.00 - Component
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
Environme PI Code, as well as the Local Subsurface Disposal Regulations for the Town of
North do r, and not to lace the system in operation until a Certi "cate of Compliance has
bee issue by this Boa f Health.
Q v� L'
Mame Date
Approve I y: (Board of Health Representative)
Date
Disapproved for the following reasons:
For Office Use Only:
1.
Fee Attached.
Yes
No
2.
Project Manager Obligation Form Attached?
Yes
No
I
Pump S sy tem? If so, Attach copy ofElectrical Permit
Yes
No
4.
Foundation As -Built? (new construction ronly).
Yes
No
(Same scale as approved plan)
S.
Floor Plans? (new construction only).
Yes
No
Application for Disposal System Construction Permit • Page 2 of 2
� s
NONTq
6983
Of o o,•y0
Town of North Andover
HEALTH DEPARTMENT
�ss�cwust�
CHECK #: TE-�
LOCATIO Pl ,
H/O NAME:
CONTRACTOR NAME:
Type of Permit or License: (Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service - Type: $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal (Septic) Hauler $
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ TrashlSolid Waste Hauler $
❑ Well Construction $
SEPTIC Sustems:
❑ Septic - Soil Testing $
❑ Septic - Design Approval $
❑ Septic Disposal Works Construction (DWC) $
❑ Septic Disposal Works Installers (DWI) $
❑ Title 5 Inspector $__-6�
Title 5 Report X C $
❑ Other: (Indicate) $
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
Owner
information is
required for
every page.
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
165 Vest Way
Property Address
Carol Liberman
Owner's Name
North Andover
City/Town
MA 01845
State Zip Code
8/18/2014
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.
A. General Information
1. Inspector:
Neil J. Bateson
Name of Inspector
Bateson Enterprises Inc.
Company Name
111 Arailla Road
Company Address
Andover MA
City/Town State
978-475-4786 S115
Telephone Number
B. Certification
License Number
Aur, 2 2 2014
TOWN OF NORTH ANDOVER
HEALTH DEPARTiv ENT
01810
Zip Code
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
❑ Passes ® Conditionally Passes ❑ Fails
Elee Further Evaluation by the Local Approving Authority
8/18/2014
Inspect rs &gnature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins • 3113 - Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17
Owner
information is
required for
every page.
t5ins • 3113
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
165 Vest Way
Property Address
Carol Liberman
Owners Name
North Andover MA 01845 8/18/2014
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
® One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ® N ❑ ND (Explain below):
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
165 Vest Way
Property Address
Carol Liberman
Owner's Name
North Andover MA 01845 8/18/2014
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if (with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
❑ Y ® N ❑ ND (Explain below):
❑ Y ® N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if (with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
165 Vest Way
Property Address
Carol Liberman
Owner's Name
North Andover
Cityrrown
B. Certification (cont.)
MA 01845 8/18/2014
State Zip Code Date of Inspection
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 -Box Replacement
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes
No
❑
®
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑
®
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑
®
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑
®
Liquid depth in cesspool is less than 6" below invert or available volume is less
than'/ day flow
t5ins - 3/13
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
1 0,000g pd.
❑ ® 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
Commonwealth of Massachusetts
Title 5
Official Inspection Form
the system is within 400 feet of a surface drinking water supply
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
❑
165 Vest Way
❑
❑
Property Address
Carol Liberman
Owner
Owner's Name
information is
required for
North Andover
MA 01845 8/18/2014
every page.
Cityrrown
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-
1 0,000g pd.
❑ ® 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 Form: Subsurface Sewage Disposal System • Page 5 of 17
Commonwealth of Massachusetts
ID Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
165 Vest Way
Owner
information is
required for
every page.
Property Address
Carol Liberman
Owner's Name
North Andover MA 01845 8/18/2014
Citylrown 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 - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
Industrial waste holding tank present?
Non -sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
Gallons per day (gpd)
❑
Commonwealth of Massachusetts
❑
No
❑
Title 5 Official Inspection Form
❑
No
o
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
❑
No
165 Vest Way
Property Address
Carol Liberman
Owner
Owner's Name
information is
required for
North Andover MA 01845 8/18/2014
every page.
City/Town 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)):
Yes
Detail:
Sump pump?
❑
Yes ® No
Last date of occupancy:
CurrentDate
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
Industrial waste holding tank present?
Non -sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
Gallons per day (gpd)
❑
Yes
❑
No
❑
Yes
❑
No
❑
Yes
❑
No
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
165 Vest Way
Property Address
Carol Liberman
Owner's Name
North Andover MA
City/Town State
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
01845 8/18/2014
Zip Code Date of Inspection
Date
General Information
Pumping Records:
Source of information:
Pumped 2013, owner
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1500
gallons
How was quantity pumped determined? Measured tank
Reason for pumping: Inspect tank & tees
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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
165 Vest Way
Property Address
Carol Liberman
Owner's Name
North Andover
City,rrown
D. System Information (cont.)
State
01845
Zip Code
8/18/2014
Date of Inspection
Approximate age of all components, date installed (if known) and source of information:
Original, owner
Were sewage odors detected when arriving at the site?
Building Sewer (locate on site plan):
Depth below grade:
Material of construction:
El cast iron ® 40 PVC El other (explain):
Distance from private water supply well or suction line'
❑ Yes ® No
feet
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
4" PVC through wall, 3" PVC in house, no leaks visible.
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
® concrete ❑ metal
feet
❑ fiberglass ❑ polyethylene ❑ other (explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate)
Dimensions:
10' x 5'x 4'
Sludge depth:
3"
❑ Yes ❑ No
t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17
X Commonwealth of Massachusetts
ID
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
165 Vest Way
Property Address
Carol Liberman
Owner
information is
required for
every page.
t5ins • 3/13
Owner's Name
North Andover
Cityfrown
D. System Information (cont.)
MA 01845
State Zip Cod
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
30"
4"
811
1111
8/18/2014
Date of Inspection
How were dimensions determined? Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of
leakage.
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass
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:
feet
❑ polyethylene ❑ other (explain):
Date
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17
Commonwealth of Massachusetts
ID Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
165 Vest Way
Owner
information is
required for
every page.
Property Address
Carol Liberman
Owners Name
North Andover MA 01845 8/18/2014
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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:
Design Flow:
Alarm present:
Alarm level:
gallons
gallons per day
❑ Yes ❑ No
Alarm in working order:
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
❑ Yes ❑ No
Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
165 Vest Way
Property Address
Carol Liberman
Owner's Name
North Andover MA 01845 8/18/2014
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D -box level & distribution equal. Evidence of leakage, has corrosion holes at liquid level.
Evidence of carryover, pumped d -box to clean
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:
l5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17
Owner
information is
required for
every page.
t5ins • 3113
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
165 Vest Way
Property Address
Carol Liberman
Owner's Name
North Andover
Cityrrown
MA
State
01845 8/18/2014
Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑
leaching pits
number:
❑
leaching chambers
number:
❑
leaching galleries
number:
®
leaching trenches
number, length: 3 trenches 60'
long
❑
leaching fields
number, dimensions:
❑
overflow cesspool
number:
❑
innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
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
Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
165 Vest Way
Property Address
Carol Liberman
Owner's Name
North Andover MA 01845 8/18/2014
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.):
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System . Page 14 of 17
11
Owner
information is
required for
every page.
t5ins - 3/13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal. System Form - Not for Voluntary Assessments
165 Vest Way
Property Address
Carol Liberman
Owner's Name
North Andover MA 01845 8/18/2014
Cityrrown 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
A-`\rc
I-
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
165 Vest Way
Property Address
Carol Liberman
Owner's Name
North Andover
Cityrrown
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
MA 01845
State Zip Code
8/18/2014
Date of Inspection
Estimated depth to high ground water: 4feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed. 10/2/2001
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health - explain:
Design plan
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
As per design plan test pit data
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
u
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
165 Vest Way
Property Address
Carol Liberman
Owner
information is
required for
every page.
Owner's Name
North Andover MA 01845 8/18/2014
City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information — Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17
9
�a vur r imunweann oT massacnusens
City/Town of
System Pumping Record
Form 4
DEP has provided this form for userby 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: Leftfront of hou Left / Right rear of house, Left / right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
City/Town
2. System Owner.
b(0
Name
Zip Code
Address (if different from location)
Citylrown Stat 1)
Telephone Number
P i
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons i
3. Type of system: ❑ Cesspool(s),,_�._ ��
. � I�'eptic Tank ❑Tight Tank
4.
❑ Other (describe):
Effluent Tee Filter present? ❑ Yes o if, yes, was it cleaned? ❑ Yes ❑ No
5. Condition f 5�� U�
6: System Pumped By:
Neil. Bateson
Name
Bateson Enterprises Ina
Company
7. 7Locatfil where contents were disposed:
S
Lowell Waste Water
Sis HguWU
t5formCdoic- 06M3
F5821
Vehicle License Number
Data
NUM
System Pumping Record • Page 1 of 1
,
Town of North Andover
Tax Map # 210-1043-0155-0000.0
Parcel Id 16477
165 VEST WAY
MAXIM & KARA LIBERMAN
165 VEST WAY
NORTH ANDOVER, MA 01845
Class 101 Single Family Property Type 1 Residential
Zoning2 1 Residential Zoning3 1 Residential
Size Total 1.62 Acres
FY 2015
UB Mailina Index
Name/Address
MAXIM & KARA LIBERMAN
165 VEST WAY
NORTH ANDOVER, MA 01845
CARLSON, WILLIAM
165 VEST WAY
NORTH ANDOVER, MA
01845
UB Account Maint.
Account No Cycle
Bldg Id. 17822.0 - 165 VEST WAY
3170487 03 Cycle 03
UB Services Maint.
Account No. 3170487
Service Code
MISCFEE ADMIN FEE
WTR WATER
UB Meter Maintenance
Type Loan Number
Owner
Previous Customer
Active/inact. From
Inactive 5/23/2008
Occupant Name Active/Inactive
Last Billing Date 7/8/2014
Active
Rate Charge Multiplier/Users
0.635/8 7.82 1/
01 ALL METER SIZE 41.80 /1
Until
Account No. 3170487
Serial No Status
Location
Brand
Type Size
YTD Cons
35078126 a Active
ERT HH
b Badger
w Water 0.63 0.63
684
Date
Reading
Code
Consumption
Posted Date
Variance
6/9/2014
685
a Actual
11
7/16/2014
21%
3/11/2014
674
aActual
9
4/11/2014
-23%
12/12/2013
665
aActual
12
1/17/2014
-80%
9/12/2013
653
a Actual
62
10/15/2013
493%
6/11/2013
591
aActual
10
7/24/2013
3%
3/14/2013
581
a Actual
10
4/22/2013
-57%
12/12/2012
571
aActual
23
1/9/2013
-77%
9/12/2012
548
a Actual
100
10/15/2012
68%
6/12/2012
448
a Actual
59
7/16/2012
496%
3/13/2012
389
a Actual
10
4/14/2012
-2%
12/12/2011
379
aActual
10
1/17/2012
-86%
9/13/2011
369
a Actual
78
10/13/2011
109%
6/7/2011
291
a Actual
35
7/20/2011
323%
3/7/2011
256
a Actual
8
4/13/2011
-75%
12/8/2010
248
aActual
1 32
1/12/2011
-19%
9/9/2010
216
a Actual
41
10/15/2010
120%
6/8/2010
175
a Actual
18
7/15/2010
123%
3/10/2010
157
a Actual
8
4/14/2010
-50%
12/11/2009
149
aActual
! 17
1/12/2010
-65%
9/8/2009
132
a Actual
47
10/15/2009
131%
6/9/2009
85
a Actual
19
7/20/2009
99%
3/16/2009
66
aActual
11
4/29/2009
-21%
12/8/2008
55
aActual
13
1/20/2009
-67%
9/8/2008
42
a Actual
41
10/10/2008
641%
6/6/2008
1
a Actual
1
7/16/2008
-100%
5/20/2008
0
n New Meter
0
7/16/2008
-100%
T
Town of North Andover
Health Department Date:
Location: /,�
(Indicate Address, if Residential, or Name Busin
Check #:
!/1
Type of Permit or License: (Circle)
➢ Animal $
➢ Dumpster $
➢ Food Service - Type: $
➢ Funeral Directors $
➢ Massage Establishment $
➢ Massage Practice $
➢ Offal (Septic) Hauler $
➢ Recreational Camp $
➢ SEPTIC PERMITS:
❑ Septic - Soil Testing $
❑ Septic - Design Approval $
❑ Septic Disposal Works Construction (DWC) $
❑ Septic Disposal Works Installers (DWI) $
➢ Sun tanning $
➢ Swimming Pool $
➢ Tobacco $
➢ Trash/Solid Waste Hauler $
➢ Well Construction $
➢ OTHER: (Indicate)
Health Agent Initials
159
White - Applicant Yellow - Health Pink - Treasurer
e
NEw IENG� IENG�EMG SERVICFS9 INC.
1600 Osgood Street
Building 20 Suite 2-64
North Andover, MA 01845
TIE1: (978) 686-1768 0 Fax: (978) 327-6138
Benjamin C. Osgood, Jr., P.E.
President
Ms. Susan Sawyer
North Andover Board of Health
400 Osgood Street
North Andover, MA 01845
May 3, 2006
RECE1
MAY 8 2006
TOWN OF NORTH i{ :VER
HEALTH DEPART��'wT
RE: TITLE V REPORT: 165 Vest Way, No. Andover, MA
Dear Ms. Sawyer:
Enclosed is the Title 5 Report for the above referenced property. The system PASSES
the inspection.
If there are any questions please call me at my office, 686-1768.
Sincerely,
9, ��
BenjaInin C. Osgoo , Jr.
Certified Title 5 Inspector
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 165 Vest Way No. Andover, MA 01845
Owner's Name: William Carlson
Owner's Address: 165 Vest Way No. Andover, MA 01845
Date of Inspection: 26 April 2006
Name of Inspector: (please print) Benjamin C. Osgood, Jr. Certified Title 5 Inspector
Company Name: New England Engineering Services Inc.
Mailing Address: 1600 Osgood Street Building 20 Suite 2.64, North Andover, MA 01845
Telephone Number: 978-686-1768
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,
accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the
proper function and maintenance of the on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section
15340 of Title 5 (3 10 CMR 15.000). The system:
wle Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: e- 0 l
The system inspection 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.
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 165 Vest Way No. Andover, MA 01845
Owner's Name: William Carlson
Date of Inspection: 26 April 2006
Inspection Summary: Check A, B, C, D or E/ALWAYS complete all of Section D
A. System Passes:
'E5 - 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:
& System Conditionally Passes:
W 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_
I .
3 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 165 Vest Way No. Andover, MA 01845
Owner's Name: William Carlson
Date of Inspection: 26 April 2006
C. Further Evaluation is Required by the Board of Health:
/� Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect
public health, safety or the environment
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is
not functioning in a manner which will protect public health, safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health ( and Public Water Supplier, if any) determines that the system is
functioning in a manner that protects the public health, safety and environment:
The system has a septic tank and (SAS) Soil Absorption System and the (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 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 organize 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 5ppm, provided that no other failure criteria are
triggered. A copy of the analysis i must be attached to this form.
3. Other:
1
5of11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 165 Vest Way No. Andover, MA 01845
Owner's Name: William Carlson
Date of Inspection: 26 April 2006
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 an 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 sign of break out?
Were all system components, excluding the SAS, located on site?
Were all 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 difference from owner) provided with information on the proper
maintenance of the subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Yes No
Existing information. For example, a plan at the Board of Health.
1✓ 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)]
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 165 Vest Way No. Andover, MA 01845
Owner's Name: William Carlson
Date of Inspection: 26 April 2006
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design) Number of bedrooms (actual):
DESIGN flow based in 310 CMR 15.203 ( for example: 110 gpd x # of bedrooms) &00
Number of current residents:__,__
Does residence have a garbage grinder (yes or no): E 5
Is laundry on a separate sewage system (yes or no):_aj [if yes separate inspection required]
Laundry system inspected ( yes or no): _.
Seasonal use: (yes or no):Veo
Water meter readings, if available (last 2 years usage (gpd): Z03, &,-PIP 6 231 a k TQ
Sump Pump (yes or no): mo
Last date of occupancy G,.% rr -&-T
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR 15.203): gpd
Basis of design flow (seats/persons/sgft, etc
Grease trap present (yes or no):
Industrial waste holding tank present (yes or no):
Non -sanitary waste discharged to the Title 5 system (yes or no)
Water meter readings, if available:
Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: E P 26o.S" PCF - X 9,61-( Ec 0 a DS
Was system pumped as part of the inspection (yes or no): dZo
If yes, volume pumped: gallons - How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
V' 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 Attached a copy of the DEP approval
Other
Approximate age of all components, date installed (if known) and source of information:
t3v,I�- iAr 1%J0 P A %@�ot-t (2CC0 %ZPS
Were sewage odors detected wen arriving at the site (yes or no): 4/0
' of l l
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 165 Vest Way No. Andover, MA 01845
Owner's Name: William Carlson
Date of Inspection: 26 April 2006
BUILDING SEWER (locate on site plan)
Depth below grade: IS��
Materials of construction: cast ironer 40 PVC— other (explain)
Distance from private water supply well or suction line: Al /i
Comments (on condition of joints, venting, evidence of leakage, etc.):
P( f2 `.00 V, f 001 1 ti T`>Q.A.) K
SEPTIC TANK: (locate on site plan)
Depth below grade: -3
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: JS'o 0 (Ti41 cL0 �►+ c
Sludge depth: Gi
Distance from top of sludge to bottom of outlet tee or baffle: jL
Scum thickness: 41
Distance from top of scum to top of outlet tee or baffle: �.
Distance from bottom of scum to bottom of outlet tee or baffle 4. _
How were dimensions determined: ,tl r" s dg d= s nC.14,
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet
invert, evidence of leakage, etc.):
GREASE TRAP: locate on site plan)
Depth below grade:
Materials 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 sludge 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.
8of11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 165 Vest Way No. Andover, MA 01845
Owner's Name: William Carlson
Date of Inspection: 26 April 2006
TIGHT OR HOLDING TANK:�i� (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Materials of construction: concrete metal fiberglass polyethylene other
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present (yes or no):
Alarm level: Alarm in working order (yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Q
Comments ( note if box is level and distribution to outlets equal, any evidnence of solids carryover, any evidence of leakage into or
out of box, etc.):
Fiat j 0IK Wanirow. Ale 9✓/Sc•a.C,2 of 4,6'i4KA66- iti (DA-
pflS Cure.. euLr- ii C,4.0eg,7 ..
PUMP CHAMBER (locate on sire 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.):
of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 165 Vest Way No. Andover, MA 01845
Owner's Name: William Carlson
Date of Inspection: 26 April 2006
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required
If SAS not located explain why
V6114-10
leaching pits number
leaching chambers, number
leaching galleries number
leaching trenches, number in length L o, j a Z` w• c9c Z fl t c i'
leaching fields, number, dimensions:
overflow cesspool, number:
innovative/alternative system Type/name of technology:
Comments ( note condition of soil, signs of hydraulic failure. Level of ponding, damp soil, condition of vegetation, etc)
g.2Ef� DF Lvsrcw.
/06 j&5 no2✓ky.J. No E4,o+c4eega-
CESSPOOLS: A)[,+ (cesspool must be pumped as part of inspection) (locate on site plan)
Number and configuration:
Depth - top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of Construction:
Indication of groundwater inflow (yes or no):
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY:(locate on site plan)
Material of construction:
Dimensions:
Depth of solids:
Comments (note condition of soil signs of hydraulic failure, level of ponding, condition of vegetation, etc.
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 165 Vest Way No. Andover, MA 01845
Owner's Name: William Carlson
Date of Inspection: 26 April 2006
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate
all wells within 100 feet. Locate where public water supply enters the building.
Y �
11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner's Name:
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
165 Vest Way No. Andover, MA 01845
William Carlson
26 April 2006
Estimated depth to ground water feet
Please indicate (check) all methods used to determine the high ground water elevation:
+ Obtained from system design plans on record — If checked, date of design plan reviewed:
_ Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health — explain:
Checked with local excavator, installers — (attach documentation)
Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
tt.. �o ST't .�►'� t� G3 �G nr eX �� t�'k3 a vG «�vr Lit-► ceS cY� �` e2w�� ./kms
P--%/+ry cle bl �� 11 a.w r4-ozz Pg- -nyAo- I )4#4-S a e e, ,t
)� /�CeJG. GV ��-�u..J� CcKc•. G T` Q.Gca lL. c) c - j 4 &D t, ` bGCO�.v
k1264 of 0 j Te .
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for use -by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left ight front of hous Left / Right rear of house, Left /right side of house, Left /
Right side of building, Le ig ron of building, Left / Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner r
lid � -���'►�1
Name
Address (if diff rent froWocaiion)1_ �'
:q
Cityrrown rIov '� �Q13 State Zip Code
61 15was -
TOWN OF NORTH ANDOVER Telephone Number +�
HEALTH DEPARTMENT
B. Pumping Record
1. Date of Pumping
Date
2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No.
5. Conditionpf stem:� � !,
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Lo qfi a,-w4eie contents were disposed:
Lowell Waste
F5821
Vehicle License Number
Date
t5fomi4.doc• 06/03 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
F City/Town of
System Pumping RecordSEP
272011
Form 4 TOWN OF NORTH ANDOVER
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 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 front of I
rear of house, right rear of hou
City/Town State
2. System Owner:
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system:
Date
❑ Cesspool(s)
left side of house, right side of house, Left
t rear of building, under deck.
Zip Code
State l'�'SS •�Zi t:Qde
Telephone Number
— 2. Quantity Pumped
eptic Tank
J-�L-).
Gallons
❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes g No If yes, was it cleaned? ❑ Yes ❑ No
5. Conditiof System:
6. System Pumped By:
Neil J. Bateson
Name
Bateson Enterprises Inc.
Company
7. Locationwhere contents were disposed:
L.S.
Signature
F5821
Vehicle License Number
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
Cf MORTM 1ti 3308
o •�
F p
Town of North Andover
�`o',. HEALTH DEPARTMENT
'SSACHUStt
CHECK #: WE: TE:
LOCATION: 1d� .- , �
H/ O NAME:
CONTRACTOR NAME:
Type
of Permit or License: (Check box)
❑
Animal
$
❑
Body Art Establishment
$
❑
Body Art Practitioner
$
❑
Dumpster
$
❑
Food Service - Type:
$
❑
Fyneral Directors
$
❑
Massage Establishment
$
❑
Massage Practice
$
❑
Offal (Septic) Hauler
$
❑
Recreational Camp
$
❑
Sun tanning
$
❑
Swimming Pool
$
❑
Tobacco
$
❑
Trash/Solid Waste Hauler
$
❑
Well Construction
$
S,s�:
SEPTIC Systems
❑
Septic - Soil Testing
$
❑
Septic - Design Approval
$
❑
Septic Disposal Works Construction (DWC)
$
❑
Septic Disposal Works Installers (DWI)
$
❑
Tit e 5 Inspector
$
COY
Title 5 Report
$ 3
❑ Other: (Indicate) $
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
O` MOFTp 1h
e �
h p
Town of North Andover,
5 HEALTH DEPARTMENT
y',SCMUSt
CHECK #: DATE: p�
LOCATION: �f� /.-j
H/O NAME: ��i, I�I �
CONTRACTOR NAME:X�� U�,yx1
G/
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
01 Title 5 Report
❑ Other: (Indicate) $
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
Owner
information is
required for
every page.
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
165 Vest Way
Property Address
Bill Carlson
Owner's Name
No Andover
City/Town
MA 01845
State Zip Code
4/2/08
Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
A. General Information
1. Inspector:
Benjamin C. Osgood, Jr.
Name of Inspector
New England Engineering Services, Inc.
Company Name
1600 Osgood Street Suite 2-64
Company Address
No. Andover
City/Town
978-686-1768
Telephone Number
B. Certification
MA
State
License Number
MAY 0 6 2-1
HEA'_ I'm tJE: •F.Rfl.itiAT
01845
Zip Code
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
an, G a�
Inspect Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 15
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
165 Vest Way
Property Address
Bill Carlson
Owner's Name
No Andover MA 01845 4/2/08
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:
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
TITLE 5 FORM 2007.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 15
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
165 Vest Way
Property Address
Bill Carlson
Owner's Name
No Andover MA 01845 4/2/08
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if (with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
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.
TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 15
Owner
information is
required for
every page.
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
165 Vest Way
Property Address
Bill Carlson
Owner's Name
No Andover MA 01845
City/Town State Zip Code
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
4/2/08
Date of Inspection
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes
No
❑
2-
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
❑
E"
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑
0"
Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/ day flow
❑
❑-
Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑
a
Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑
Ea,
Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
TITLE 5 FORM 2007.DOC • 08/06
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 15
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM a''p 165 Vest Way
Property Address
Bill Carlson
Owner
information is
required for
every page.
Owner's Name
No. Andover MA 01845 4/2/08
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ Q' Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ED- Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ 0" 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-
1 0,000g pd.
❑ 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
❑ [5"'- the system is within 400 feet of a surface drinking water supply
❑ [D,- 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.
TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 15
Commonwealth of Massachusetts
u W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
GSM
165 Vest Way
SVy
Property Address
Bill Carlson
Owner
information is
required for
every page.
Owner's Name
No Andover MA 01845
City/Town State Zip Code
C. Checklist
4/2/08
Date of Inspection
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes
No
[�
❑
Pumping information was provided by the owner, occupant, or Board of Health
❑
[vr
Were any of the system components pumped out in the previous two weeks?
❑
2"'—
Has the system received normal flows in the previous two week period?
❑
ED,,-
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)
❑
E�r'
Was the facility or dwelling inspected.for signs of sewage back up?
Lg
❑
Was the site inspected for signs of break out?
IK
❑
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?
EK
❑
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:
Lg ❑ Existing information. For example, a plan at the Board of Health.
❑ 2,,- 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)]
TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M
165 Vest Way
Property Address
Bill Carlson
Owner Owner's Name
information is
required for No Andover MA 01845 4/2/08
every page. City[Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): Number of bedrooms (actual): J
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):
Number of current residents:
O
Does residence have a garbage grinder? [''Yes ❑ No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes 2' No
Laundry system inspected? ❑ Yes 2 --No
Seasonal use? ❑ Yes 2" No
Water meter readings, if available last 2 ears usage 200
9 ( Y 9 (gpd)) IZJo(, .Th 12107
Sump pump? ❑ Yes J2 No
Last date of occupancy: „Tg^j 2o0�
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:
Last date of occupancy/use:
Other (describe):
Date
TITLE 5 FORM 2007.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 15
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
165 Vest Way
Property Address
Bill Carlson
Owner's Name
No Andover
City/Town
D. System Information (cont.)
Pumping Records:
Source of information:
MA 01845
State Zip Code
General Information
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
4/2/08
Date of Inspection
?yo" P62 000 /Lazo YtpS
gallons
Type of System:
X Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Yes X No
❑ 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: ,
Were sewage odors detected when arriving at the site? ❑ Yes F No
TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
GSM 165 Vest Way
Owner
information is
required for
every page.
Property Address
Bill Carlson
Owner's Name
No Andover
City/Town
D. System Information (cont.)
State Zip Code
Building Sewer (locate on site plan):
Depth below grade:
Material of construction:
El cast iron N 40 PVC ❑ other (explain):
D'stan f t t 1 II t' I'
4/2/08
Date of Inspection
t�
feet
i ce rom priva a wa er supp y we or Out, U" ine.
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
F.ac 1-00 4.S OK 1 N ?AN1C
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
tZ concrete ❑ metal
.3&
feet
❑ fiberglass ❑ polyethylene ❑ other (explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
--------------------------------------------------------------------------------------------------------------------------
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
�SJy Gfi LLJ N S
�l
G?
/-1
.vL c as ✓ P e- s -n rJ�,
TITLE 5 FORM 2007.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 15
Commonwealth of Massachusetts
W Title 5 Official Insp
o Subsurface Sewage Disposal System Fo
M e'' 165 Vest Way
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.):
'fANl4, tN C-DJi7 Gawi D - Jn 1r�UL 7i%ei / ^ 4 oa —0
N `k Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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):
TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 15
ection
Form
rm - Not for Voluntary Assessments
Property Address
Bill Carlson
Owner
Owner's Name
information is
required for
No Andover
MA
01845 4/2/08
every page.
City/Town
State
Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
'fANl4, tN C-DJi7 Gawi D - Jn 1r�UL 7i%ei / ^ 4 oa —0
N `k Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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):
TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 15
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 165 Vest Way
Owner
information is
required for
every page.
Property Address
Bill Carlson
Owner's Name
No Andover
City/Town
D. System Information (cont.)
(IJ kTight or Holding Tank (cont.)
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
State Zip Code
gallons
4/2/08
Date of Inspection
gallons per day
❑ Yes ❑ No
Alarm in working order:
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
❑ Yes ❑ No
* Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert O
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
J Y ! ✓�
&-Q3
O
&-) ,JSD , ii
J r-' .
N O V 1 A 4^e,
` cis K ft- i�— G
❑
No
�/ J /Ly ✓T
O 2
-s Dc..41s
Gf'<.Ry
yc�GL- t7 rSi rLsBc.
i� X44
MA' Pump Chamber (locate on site plan):
Pumps in working order:
Alarms in working order:
❑
Yes
❑
No
❑
Yes
❑
No
TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 15
Commonwealth of Massachusetts
H v Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°wM 165 Vest Way
Property Address
Bill Carlson
Owner
information is
required for
every page.
Owner's Name
No Andover
City/Town
D. System Information (cont.)
4/2/08
State Zip Code Date of inspection
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
AN -S& OK— T2eh c.W-5 1,0&14.5 lU o (ZA4 4-L iy G E 0 1 p en z-�
U }-jus0Rlr L) E,&.
TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 15
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑
leaching pits
number:
❑
leaching chambers
number:
❑
leaching galleries
number:
leaching trenches
number, length:
Z' X2
❑
leaching fields
number, dimensions:
❑
overflow cesspool
number:
❑
innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
AN -S& OK— T2eh c.W-5 1,0&14.5 lU o (ZA4 4-L iy G E 0 1 p en z-�
U }-jus0Rlr L) E,&.
TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 15
Owner
information is
required for
every page.
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
165 Vest Way
Property Address
Bill Carlson
Owner's Name
No Andover
MA 01845 4/2/08
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
/v I g, Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth — top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N 114 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.):
TITLE 5 FORM 2007.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 15
Commonwealth of Massachusetts
o Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
165 Vest Way
Property Address
Bill Carlson
Owner Owner's Name
information is
required for No Andover MA 01845 4/2/08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 15
12
Owner
information is
required for
every page.
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
165 Vest Way
Property Address
Bill Carlson
Owner's Name
No Andover MA 01845 4/2/08
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
[.J' Check Slope
a Surface water jv o Nt
a Check cellar ,v o 6,v r. r
a Shallow wells iv o,.v C
Estimated depth to ground water:
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health - explain:
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
S �js -re vvi n ea �, ti L%� y ` A- oo je— &-,Qze^jD U- A-�dL
9tisroe m C n%,7-120 6 -M -D ).v Ani &am "1711T" AeogS
g�40-/ ;::�1;12 ',14 Ar- ;e97AR o? -e KyUSC
1 D � f'� E1.J w yy1L �y� b�tS TCVYI
TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 15
L.=, -r- 2R
To S. S.
Env - (48.53
a
GE�T't�tEt= FouUC::)WaTIOu _q,.-,
L.oc.A-t-t.t� 1►,.,1 � 0 2:'r' N A,..) no �/ , ►`�(R
cjGAL✓E,:1'�= 40QAT'E, : S � Io�Qo
til o2r-r-�{ A
S3.6
3g 2
L o`r 30
70, sq¢ s.F-
EXI ST- p o
55.24
SCE-fZT I Fy THAT
THS oFF'SErTS
S EA a w y.1 C.otsl Pt /
\.0 tZ- I { `T' H r-- Zoo►, u�C,
Sy L Aw S v F
1.10. A�DdVFQ..r/(A
1, j"ga.t.1 'a L.) I "T
N
�-= 1So.00
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USE, o TI41=. 8 u t t. n t Z u SPEcTt�R
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[ 48.23
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" 3
t4-(-119
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SCE-fZT I Fy THAT
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4ATFO
9SSACHUSE
BOARD OF HEALTH
120 MAIN STREET TEL: 682-6483
NORTH ANDOVER, MASS. 01845 Ext. 32 or 33
June 12, 1990
Design Engineering, Inc
PO Dox 516
No. Andover, MA 01845
Re: Lots 27-29
Vest Way
No. Andover, MA 01845
Dear Al:
This letter is to inform you and your client that the Board
of Health will allow the installation of a leaching facility as
close as 50 ft to drain lines associated with Vest Way, provided
that it is necessary to do so to maintain a 100 ft setback from
the edge of wetlands and the leaching facility. Please be
advised that the leaching facility should be placed as far from
the drain lines as possible, while still providing for the 100 ft
setback from wetlands.
Should you have any questions regarding this matter, please` /
do not hesitate to call.
Very truly yours,
Zch`ae�' Ros'at
Acting Health Agent
MR/rel
i
r
1/ -?d Q 0
l /: Gcj /114-I
Town of North Andover, Massachusetts Form No. 1
NORTH BOARD OF HEALTH
F ED 6qh
t
°6 0 19
APPLICATION FOR SITE TESTING/INSPECTION
Applicant
NAME ADDRESS TELEPHONE
Site Location
Engineer
NAME ADDRESS TELEPHONE
Test/Inspection Date a dlime
ly
Fee -
CHAIRMAN; BOARD OF HEALTH
Test No.
G6�� p 1Pgv,
S.S. Permit No. 13 D.W.C. No. C.C. Date Plbg. Permit No.
Town of North Andover, Massachusetts
BOARD OF HEALTH
'Co ,
o m
iL
APPLICATION FOR SITE TESTING/INSPECTION
69
Form No. 1
19
Applicant
NAME ADDRESS TELEPHONE
Site Locationye<�rw4y?
Engineer
NAME ADDRESS TELEPHONE
Test/Inspection Date and Time
Fa
CHAIRMAN, BOARD OF HEALTH
Test No
S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No.
FORM U - VERIFICATION FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: _-Vb1+AJA 611L ��;� �L So,U Phone
LOCATION: Assessor's Map Number Parcel
Subdivision Lot(s)
Street LS F LI-) St. Number
************************Official
RECOMMEN ATIO S 0 TOWN GENTS:
Conservation Administ ator
Comments _ v 0&05
-v kcw.
Town Planner
Comments
Use Only************************
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved
Food Inspecto -Health Date Rejected
_ (/%�� Date Approved
Septic Inspector -Health Date Rejected
Comments J
Public works - sewer/water connections
- driveway permit
Fire Department
Received by Building Inspector Date
Y$.rW
4�0/. 67
wt/,g, awe
I'OWNUf Y, TH , N Lh,.)
SYST-em P()MPINQ pp
CC)
S YS T'F h4
72] V E D
OCT 0 7 2005
1TOV,,N )v: CRTH ANDOVER
HEALTH 2CrIARTMENT
4 -
QUA T1 T Y p(jMpC, r.
Y�3
NA rUK6 Op 3eAylea.. Xo UTINr
I
OOOD
RZAYY OV-SA33
KOM
eXCUMS SOLID&—" EbPLOO
"OL rD CA AA YQ . YUK'MER EXPLAIN
�y 14M
k.,umhje
North Andover Realty Corp.
100 Johnnycake Road
North Andover, MA 01845
Tel: (508) 686-7724
April 6, 1990
Board of Health
Town of North Andover
Main Street
North Andover, MA 01845
R9e: Lot 30 Vest Way
Dear Board Members:
As an Officer of the Corporation that is the record owner of the
referenced lot, I hereby request a variance in your Board's regulation that
requires that the distance from.a subsurface disposal system to the wetlands
can not be less than one hundred (100) feet. I am requesting a variance of
twenty feet (20), such that the system for the referenced lot will not be
closer than eight (80). feet from adjacent wetlands. My reasons for the
request are as follows:
1. The corresponding State regulations require that a system can not be
less than -fifty (50) feet from a wetlands. Therefore, at the varied distance,
the system would remain thirty (30) feet in excess of those regulations.
2. Design Approval and Disposal Works permits were obtained in July,
1988, based on a plan by Design Engineering, Inc. dated February 15, 1988,
revised April 20, 1988. As noted on the plan, the wetlands there was flagged
by J. Mallett, Ph.D and located by S. Giles, RIS.
3. Recently, in conjunction with a Notice of Intent for Lots 28 and 29,
Doctor Mallett returned to the site to verify the wetlands location, and
discovered that the line had changed significantly from that originally shown
(see plans by Design Engineering revised April 4, 1990.) The present location
places the system as close as eight (80) feet from the wetlands.
4. Additionally, the owners of Lot 28 propose using Lot 29 for
replication of the wetlands disturbed on lot 28 and in doing so, will create a
wetlands that is approximately eight five (85) feet from the system on Lot
30. (See plans by Design Engineering revised April 4,'1990.)
Board of Health
April 6, 1990
Page 2
5. The system on Lot 30 is -located as remote from the adjacent wetlands
as possible, and the one hundred (100) feet set back regulation, when imposed,
requires filling approximately 1460 square feet of wetlands on Lot 29, 1025 -
square feet of wetlands on Lot 30, and 200 square feet of wetlands on Lot 31A.
Is
6. The filling on Int 29 can not be done because of the work described
in item #4 above. The owners of this lot will not allow that filling.
7. Similarly, the owners of''Lot 31A will not allow filling of their
wetlands.
8. The filling on Int 30 is not required in satisfying disposal system
slope requirements or in lot grading for the dwelling. The sole purpose of
destroying those wetlands is to synthesize the one hundred (100) feet setback
requirement.
9. Since the area of wetlands to be destroyed on Lot 30 in conjunction
with satisfying the setback requirement is in excess of five hundred (500)
square feet, wetlands replication would be required. Replication can only be
accomplished along the rear most property line of Lot 30 and would require
crossing over three hundred (300) feet of wetlands with heavy equipment.
10. All slope requirements for the system can be met without filling the
wetlands and the proposed dwelling would separate the majority of the system
from the wetlands. Breakout of leachate and its related downgradient
contamination of the wetlands is highly improbable. The twenty (20) feet
variance will not jeopardize the wetlands and will enhance its protection by.
eliminating its destruction through filling and the damage caused by heavy
equipment used in replication.
The corporation has owned Lot 30 for six years, but has not developed it
for various economic and logistical reasons. The Lot meets all governing
zoning criteria and has been taxed as a buildable lot for the entire period.
To date, the lot has cost the corporation over Seventy Two Thousand
• ($72,000.00) Dollars. Without the variance requested, the corporation will
Board of Health
April 6, 1990
Page 3
suffer a severe economic hardship that will not be defrayed by the tax rebate
should the lot be deemed unbuildable. Please contact me, or my Engineer, Mr.
Shaboo at (508) 683-3893 should you require additional information or
assistance in rendering a favorable decision regarding my request for a
variance. Thank you for your anticipated cooperation in this matter.
Sincerely,
Charles A. Carroll
President & Treasurer
BOARD OF HEALTH
120 MAIN STREET
NORTH ANDOVER, MASS. 01845
Mr. Charles A. Carroll, President
North Andover Realty Corp.
100 Jonnycake Road
North Andover, MA 01845
Dear Mr. Carroll:
TEL: 682-6483
Ext. 32 or 33
April 30, 1990
This is to inform you that the North Andover Board of Health
voted at its meeting on April 26th to grant a variance for the
construction of a septic system on Lot #30 Vest Way. The septic system
for Lot #30 may be constructed 80 feet from the wetlands as shown on
your plans by Design Engineering dated April 4, 1990.
Sincerely,
l/
Gayton Osgood, Vice Chairman
cc: Conservation Commission
Planning Board
Building Inspector
Board of Health
Town of North Andover
Main Street
North Andover, MA 01845
R9e: Lot 30 Vest Way
Dear Board Members:
North Andover Realty Corp.
100 Johnnycake Road
North Andover, MA 01845
Tel: (508) 686-7724
April 6, 1990
As an Officer of the Corporation that is the record owner of the
referenced lot, I hereby request a variance in your Board's regulation that
requires that the distance from.a subsurface disposal system to the wetlands
can not be less than one hundred (100) feet. I am requesting a variance of
twenty feet (20), such that the system for the referenced lot will not be
closer than eight (80) feet from adjacent wetlands. My reasons -for the
request are as follows:
1. Me corresponding State regulations require that a system can not be
less than -fifty (50) feet from a wetlands. Therefore, at the varied distance,
the system would remain thirty (30) feet in excess of those regulations.
2. Design Approval and Disposal Works.permits were obtained in July,
1988, based on a plan by Design Engineering, Inc. dated February 15, 1988,
revised April 20, 1988. As noted on the plan, the wetlands there was flagged
by J. Mallett, Ph.D and located by S. Giles, RLS.
3. Recently, in conjunction with a Notice of Intent for Lots 28 and 29,
Doctor Mallett returned to the site to verify the wetlands location, and
discovered that the line had changed significantly from that originally shown
(see plans by Design Engineering revised April 4, 1990.) The present location
places the system as close as eight (80) feet from the wetlands.
4. Additionally, the owners of Lot 28 propose using Lot 29 for
replication of the wetlands disturbed on Lot 28 and in doing so, will create a
wetlands that is approximately eight five (85) feet from the system on Lot
30. (See plans by Design Engineering revised April 4, 1990.)
Board of Health
April 6, 1990
Page 2
5. The system on Lot 30 is located as remote from the adjacent wetlands
as possible, and the one hundred (100) feet set back regulation, when imposed,
requires filling.approximately 1460 square feet of wetlands on Lot 29, 1025
square feet of wetlands on Int 30, and 200 square feet of wetlands on Lot 31A.
6. The filling on Lot 29 can not be done because of the work described
in item #4 above. The owners of -this lot will not allow that filling.
7. Similarly, the owners of''Lot 31A will not allow filling of their
wetlands.
8. The filling on Lot 30 is not required in satisfying disposal system
slope requirements or in lot grading for the dwelling. The sole purpose of
destroying those wetlands is to synthesize the one hundred (100) feet setback
requirement.
9. Since the area of wetlands to be destroyed on Lot 30 in conjunction
with satisfying the setback requirement is in excess of five hundred (500)
square feet, wetlands replication would be required. Replication can only be
accouplished along the rear most property line of Lot 30 and would require
crossing over three hundred (300) feet of wetlands with heavy equipment.
10. All slope requirements for the system can be met without filling the
wetlands and the proposed dwelling would separate the majority of the system
from the wetlands. Breakout of leachate and its related downgradient
contamination of the wetlands is highly improbable. The twenty (20) feet
variance will not jeopardize the wetlands and will enhance its protection by
eliminating its destruction through filling and the damage caused by heavy
equipment used in replication.
The corporation has owned Lot 30 for six years, but has not developed .it
for various economic and logistical reasons. The Lot meets all governing
zoning criteria and has been taxed as a buildable lot for the entire period.
To date, the lot has cost the corporation over Seventy Two Thousand
($72,000.00) Dollars. Without the variance requested, the corporation will
Board of Health
April 6, 1990
Page 3
suffer a severe economic hardship that will not be defrayed by the tax rebate
should the lot be deemed unbuildable. Please contact me, or my Engineer, Mr.
Shaboo at (508) 683-3893 should you require additional information or
assistance in rendering a favorable decision regarding my request for a
variance. Mmnk you for your anticipated cooperation in this matter.
Sincerely,
Charles A. Carroll
President & Treasurer
�L\ Commonwealth of Massachusetts
City/Town of SEP 2 9 2010
System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEP RTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, bu t e
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 of -other 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.
2.
Address 5— .. V e64—
City/Town State �( Zip Code
System Owner: L;
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
P ,-2G -I0
2. Quanti .Pumped
Septic Tank
Date
Cesspool(s)
State Zip Code
Telephone Number
Gallons
❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes E2' o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location
S.D
contents were disposed:
A Lowell Waste Water
Date
t5form4.doc- 06/03 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts R�CBi�l�® V
City/Town of �aV 20 2012
System Pumping Record
Form 4 TOWN OF NOfiTti ANDOVER
M HEALTH gcpp RTWENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Le Riah ont ofhour Left / Right rear of house, Left / right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address
City/rown State Zip Code
2. System Owner: ,
Name
Address (if different from location)
City/Town
state Zip Code
iaSSS -�ja55
Telephone Number
B. Pumping Record
1. Date of Pumping "Z 02 uantity Pumped;
Date
3. Type of system: ❑ Cesspool(s) ;Septic Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes
5. Condition of System:
VVI
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Lgga iogavAeere contents were disposed:
C
t5fbrm4.doc• 06/03
1 1970 c�
Gallons
❑ Tight Tank
No If yes, was it cleaned? ❑ Yes ❑ No
Waste Water
F5821
Vehicle License Number
Date
System Pumping Record • Page 1 of 1