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Home My WebLink AboutMiscellaneous - 171 FOREST STREET 4/30/2018 171 FOREST STREET t - 210/106A 0176-D000.0 l sem- . � 1 3 MAP # LOT PARCEL # STREET CO.N.STR.UC.T_I.O.N___AP. ROVA..L. HAS PLAN REVIEW FEE BEEN PAID? NO KLAN APPROVAL: DATE � 1Z APP. BY,..._ ..... DESIGNER: Z14,oV-5-eA- PLAIV CONDITIONS__ WATER SUPPLY: TOWN WELL PERMIT _ DRILLER WELL TESTS: CHEMICAL DAIEfal'PTtUVED.,_..__........__..__......_._. BACTERIA I DA I E f1I'PRUVED 816192 l BACTERIA II DATE APPROVED COMMENTS: '560/am 9eQU1,PEMENTs. jVo CO FC y _ FORM U APPROVAL: APPROVAL TO ISSUE E5 Nf DATE ISSUEDZ_ BY_______ .��._. ..__ _........., CONDITIONS: FINAL APPROVAL: ; ALL PERMITS PAID ES NO r WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NO ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: B) IS THE INSTALLER LICENSED? YCS NO ;._. TYPE. OF CONSTRUCTION: NLW ' REPAIR NEW CONSTRUCTION: CERTIFIED PLOT PLnN REVIE=W Yl_s 110 CONDITIONS OF APPROVAL YES flu (FROM FORM U) ISSUANCE OF 'DWC PERMIT YES NO DWC PERMIT NO. X00 INSTALLER:T_/'')�w/ BEGIN .INSPECTION �NO: — ----- -- ------------ EXCAVATION . INSPECTION: NEEDED: PASSED BY ---— ------ CONSTRUCTION INSPECTION: NEEDED: AS BUILT KLAN SATISFACTORY: YES: APPROVAL TO BACKFILL: DATE: BY -----.- FINAL GRADING APPROVAL: DATE BY FINAL CONSTRUCTION APPROVAL: DATE: DY North Andover Board of Assessors Public Access Page 1 of 1 .n f NORTH North Andover Board of Assessors SS.CHU 21Property Record Card Click Seal To Return Parcel ID:210/106.A-0176-0000.0 FY:2009 Community:North Andover SKETCH PHOTO Click on Sketch to Enlarge Click on Photo to Enlar e Search for Parcels I Search for Sales Summary Residence a �� Detached Structure Condo 171 L-25 FOREST STREET r Commercial Location: 171 FOREST STREET Owner Name: BARRETT,MARIAN P Owner Address: 171 FOREST ST City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood:6-6 Land Area: 3.02 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 2320 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 570,800 588,800 Building Value: 346,800 364,800 Land Value: 224,000 224,000 Market Land Value: 224,000 Chapter Land Value: LATEST SALE Sale Price: 1 Sale 10/19/2006 Date: Arms Length Sale E-NO-GOVERNMNT Grantor: BARRETT, Code: WILLIAM K Cert Doc: 03D1635DV1 Book: 10446 Page: 77 http://csc-ma.us/PROPAPP/display.do?linkld=1465126&town=NandoverPubAcc 4/22/2009 t µ4RTwr Commonwealth of Massachusetts Map-Block-Lot 0 106.A-0176- �; _ Z. Board of Health ----------------------- Permit No • ; BHP-2009-0517 : . North Andover ----------------------- P.I. FEE is3 4cwu$t� F.I. $125.00 ----------------------- Disposal Works Construction Permit Permission is hereby granted Todd B-ateson --------------------------------------------------------------------------------------------------- to(Repair-D-BOX ONLY)an Individual Sewage Disposal System. at No FOREST STREET --171-------------------------------------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP-2009-051 Dated April-13,2009 --- - -!! ----- -------------- Issued On:Apr-22-2009 f Health ,, Application for Septic Disposal System41 • 3r'�`�- -�''� °� ' - Construction Permit - TOWN OF TODAY'S DATE *' • •�' ORTH ANDOVER, MA 01845 $ 250.00-Full Repair $125.00-Component a�C Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer,use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key (� to move your 21fe"pair or replace an existing system component-What? e-,4 Y_ cursor-do not use the return key. A. Facility Information ZZ'7_115PA 3� 1 Address or Lot# Citylrown 2.-*TYPE OF SEPTIC SYSTEM*: ❑ Pump ravity(choose one) ***If pump system, attach copy of electrical permit to application*** B onventional 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) El Pressure Dosed (D-Box Present)S.A.S. 2� Owner Information /1%4 P";4N Name r7/ Td r�s f V, Address(if different from above) —� Ali - S Cityrrown State Zip Code Telephone Number 3. InstallerInformation le� o d-c9---, g /-e Soiv Name Name ._ , //'q f _ 111 PC--:] Address Arl O Z(, Cityrrown State Zip Code Telephone Number(Cell Phone#if possible please) 4. Designer Information Name Name of Company Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 ponsq s `Application for Septic Disposal System ` =Construction Permit — TOWN OF TODAY'S DATE MA 01845 $250.00—Full Repair ORTH ANDOVER ` $125.00-Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: esidential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code,as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation until a Certificate of Compliance has been issued-by this Board of Health. Name Date Applica fsfi Approved (Board of Health Representative) l /C::� Nam Date Application isapproved for the following reasons: For Office Use Only: / L FeeAttaabedP Yes✓ No 2. Project Manager Obligation Form Attached. Yes No I Pump S sv tem? Ifso,Attach copy ofElectrical Permit Yes No 4. Foundation As-Built. (new construction ronly); Yes No (Same scale as approved plan) .5 Floor Plans?(new construction only). Yes No i Application for Disposal System Construction Permit-Page 2 of 2 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: (Address of septic system) For plans by (� (Engine ) �; Relative to the application of `�a�'4 �� Soc✓ (Installer's name) And dated n at d to Dated _ /3 --C3 9 I'oc�ay's ate With revisions dated (Last revised date) I understand the following obligations for management of this project: 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner, contractor,project manager, or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection,without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or MY company. a. Bottom of Bed—Generally, this is the first(1'� inspection unless there is a retaining wall,which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection—Engineer must first do their inspection for elevations,ties,etc. As-built of verbal OK(or e-mail to: healthdeptna townofnorthandover.com) from the engineer must_ be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system,all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade—Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation)and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, siggificant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board of Health staff or consultant. d. Installation of tank D-Box,pipes, stone, vent,pump chamber,retaining wall and other components. 6. As the installer, I understand that I am solely responsible for the installation of the system as per the approved oved plans No instructions by the homeowner,general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: / (Today's Date) fj—u ame— rtnt e—Signed) NORTFr t`ED i6'6�00 6 O � A z � C, ey � O cx.�—.WKw 1 gcHus��y PUBLIC HEALTH DEPARTMENT Community Development Division fYFR IFIC.ArrE OF CO_1VI1-D f-IAjrNrCE As of: April23, 2009 9his is to cert that the individuafsu6surface d4osa(system received a SA`ZISEACr ORT IM(PEC' ON of the: gepfacement of the Oistri6ution Boal By Todd Bateson At: 171 Forest Street Wap - 106.A; ('arref- 1 76 9VorthAndover, 9v1A 01845 The Issuance of this certificate shaCC not 6e construed as a guarantee that the system wilt function satisfactoriCy. us n TSawy CicWealth Director 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com o Al � TOWN OF NORTH ANDOVER t NoerN � Office of COMMUNITY DEVELOPMENT AND SERVICES7. F b r A HEALTH DEPARTMENT 1.600 OSGOOD STREET; Building 2-36 /-, . , 9 '�4i0 � A NORTH ANDOVER,MASSACHUSETTS 01845 'SswCHU Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: I`j ( fbf 1.S MAP: I W A LOT: INSTALLER:Txx DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: r�fS�Z 4�01 DATE OF*BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑Existing septic tank properly abandoned ❑Internal plumbing all to one building sewer ❑Topography not appreciably altered Comments: SEPTIC TANK ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading Monolithic construction ❑ Water tightness of tank has been achieved (Visual or Vacuum Test or Water held for 24hrs) ❑ Inlet tee installed, centered under access port ❑ Outlet tee (gas baffle or effluent filter) installed, centered under access port ❑ 24" inch cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present ❑ Hydraulic cement around inlet & outlet Wastewater System Documentation—Feb 2006 Page I of 6 „ . TOWN OF NORTH ANDOVER E NORT#j Office of COMMUNITY DEVELOPMENT AND SERVICES 3 °•s' � °� HEALTH DEPARTMENT41 1600 OSGOOD STREET; Building 2-36 14 NORTH ANDOVER,MASSACHUSETTS 01845 9SSACMUgt` Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6” stone base ❑ Weep hole plugged ❑ Combo Tank installed. Size: ❑ 1000 gallon Pump Chamber installed H-10 loading Monolithic 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 ❑ 24" inch cover to within 6" of final grade installed over pump access port ❑ Water tightness of tank has been achieved Visual testing ❑ Hydraulic cement around inlet & outlet Comments: ADVANCED TREATMENT TECHNOLOGY ❑ Type of treatment device: ❑ Installed per manufacturers requirements ❑ All components working in accordance with manufacturer's requirements Comments: Wastewater System Documentation—Feb 2006 Page 2 of 6 r TOWN OF NORTH ANDOVER f NORTq Office of COMMUNITY DEVELOPMENT AND SERVICES o:Vty�� °�'•h°off HEALTH DEPARTMENT •i 1600 OSGOOD STREET; Building 2-36 •w-�, .-;��... •. NORTH ANDOVER,MASSACHUSETTS 01845 �ss�cMUSE� Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director s n97, 688.8476—FAX D-Box Installed on stable stone base V V, v�' E] Lnlet tee (if pumped or >0.08'/foot) �� ._.' D,- Hydraulic cement around inlet & outlets (2 �Observed even distribution Comments: Speed levelers provided (not required) � ` SOIL ABSORPTION SYSTEM ❑ Bottom of SAS excavated down to soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 3/4-1 Y2" double washed stone installed ❑ 1/8-1/2" (peastone) double washed stone installed ❑ Laterals installed and ends connected to header ❑ Laterals vented if impervious material above ❑ Orifices @ 5 & 7 o'clock positions ❑ Gravel-less disposal systems: type, number and location as per plan ❑ Elevations of laterals installed as on approved plan ❑ 40 Mil HDPE barrier installed ❑ Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: Wastewater System Documentation—Feb 2006 Page 3 of 6 r` TOWN OF NORTH ANDOVER pCR*N Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 1600 OSGOOD STREET;Building 2-36 NORTH ANDOVER,MASSACHUSETTS 01845 'SSACHU Susan Y.Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX PRESSURE DISTRIBUTION ❑ -- inch manifold ❑ laterals installed with end sweeps size: material: ❑ Squirt test ft in height ❑ Equal distribution to all laterals ❑ orifice size inch as per plan Comments: CONTROLPANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: ❑ Rated for exterior if placed outside Comments: Wastewater System Documentation—Feb 2006 Page 4 of 6 r- TOWN OF NORTH ANDOVER °t N°oTh , Office of COMMUNITY DEVELOPMENT AND SERVICES or�``� HEALTH DEPARTMENT '° 1600 OSGOOD STREET; Building 2-36 NORTH ANDOVER,MASSACHUSETTS 01845 �'S"CHU t� Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback Tank SAS Sewer ❑ Property line 10 10 -- ❑ Cellar wall 10 20 -- ❑ Inground pool 10 20 -- ❑ Slab foundation 10 10 -- ❑ Deck, on footings, etc 5 10 -- ❑ Waterline 10 10 10' ❑ Private drinking well 75 1002 50 ❑ Irrigation well 75 100 ❑ Surface Water 25 50 ❑ Bordering Vegetated Wetland , Salt Marsh, Inland/Coastal Banka 75 100 ❑ Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ❑ Trib. to surface water supply 325 325 ❑ Public well 400 400 ❑ Interim Wellhead Prot. Area ❑ Reservoirs 400 400 ❑ Drains (wat. supply/trib.) 50 100 ❑ Drains (intercept g.w.) 25 50 ❑ Drains (Other)Foundation 10(5) 20(10) ❑ Drywells 20 25 ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02). s As defined in 310 CMR 10.55, 10.32, 10.54,and 10.30,respectively,pursuant to 15.211(3),also by NA wetland bylaws Wastewater System Documentation—Feb 2006 Page 5 of 6 TOWN OF NORTH ANDOVER a N°eTa Office of COMMUNITY DEVELOPMENT AND SERVICES o?°�y�`•° °°� HEALTH DEPARTMENT L4 I 1600 OSGOOD STREET; Building 2-36 50 NORTH ANDOVER,MASSACHUSETTS 01845 �'ss CHU s� Susan Y. Sawyer,.REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX SYSTEM ELEVATIONS INVERT ON DESIGN PLAN FIELD INVERT ELEV. Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 HIGH Lateral 1 LOW Lateral 2 HIGH Lateral 2 LOW Lateral 3 HIGH Lateral 3 LOW Lateral 4 HIGH Lateral 4 LOW Lateral 5 HIGH Lateral 5 LOW Wastewater System Documentation—Feb 2006 Page 6 of 6 Town of North Andover, Massachusetts Form No•,3 f MORTN BOARD OF HEALTH OCIQ j_,� LtA I 19 Z s ; "°�.... DISPOSAL WORKS CONSTRUCTION PERMIT 1SSACHUSE� Applicant STI rn NAME ADDRESS TELEPHONE Site Location Permission is hereby granted to Construct or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN,BOARD OF HEALTH Fee D.W.C. No. . �.+r 1. 1 F 'A.r _ S.. _} i;.4.. +•' .J h- � ..r,., �°{`y{'-k... `r1`�t�' +�4 i ..� •.... .. .. v. ',`..L .y 'w S rA- •S 1: s � a. 9s '��Y."G��*s�r144`�l� Y.��+..�.w...)t ..t, ti.,+,. 'ta �r;,�,3�tG,.� �t R# G�Z. '�•+ r , ..R� �t. a�r;�4';'"` :�� a1� �y +-a�..rJdir��>$. •-! .C R. - r, - ' �+{" "i� %'� ��-a' .� tts.Jy.�+�iN'P t� '+ l . i e� i r 1 � � C I ' I •r ti I i I i i i 1 PLAN REVIEW CHECKLIST ADDRESS DJ��9ENGINEER GENERAL 3 COPIESy STAMP "� LOCUS SCALEy CONTOURS PROFILE SECTION BENCHMARK ELEVATIONS SOIL & PERC INFO L," WETS. DISCLAIMER o-` WELLS & WET,LANDS V-�Grf1�fly WATERSHED DISTRICT DRIVEWAY WATER LINEW DRAINS RESERVE AREA c/ SCH40 C,,-' SLOPE SEPTIC TANK VD- (+200% MIN 1500G. � .17 INVERT DROP LGARB. GRINDER EDF) 251 TO CELLAR/t/ MANHOLE TO GRADE ELEV GW 6� D-BOX q _ _ # OUTLETS / FIRST 2' LEVEL STATEMENT INLET OUTLET6/. _ ,l I-C(2" OR . 17 FT) yam,. LEACHING 100' TO WETLANDS/ 100' TO WELLS 325' TO SURFACE H2O SUPP`-' 35' TO FND & INTRCPTR DRAINS 4' TO S.H.GW L-� 2% SLOPE 4' PERM. SOIL BELOW FACILITY t" MIN 12" COVER FILL? y (25' if above natural elevation; 101if below) TRENCHES MIN 660 SLOPE (min . 005 or 611/1001 ) >3 ' COVER? - VENT SIDEWALL DIST. 2X EFF. W OR D .(MIN 6' ) Q/ IS RESERVE BETWEEN TRENCHES? L/ IN FILL? MUST BE 10' MIN.— . IN. �G� BOT Gj X LDNG �I I2+ SIDE 71, �/ X LDNG 4 = TOT (L x W x #) (G/ft ) (DxLx2x#) D� r DATE Sheet L of BOARD OF HEALTH TOWN OF NORTH ANDOVER //�� SUBSURFACE DISPOSAL DESIGN REVIEW FEE Y"� PERMIT # DATE RECEIVED APPLICANT 54c6---77- ASSESSOR'S MAP ADDRESS PARCEL ## LOT ## ZS 7-- ENGINEER ��S77,#v5rSTREET ADDRESS PLAN DATE REVISION DATE CONDITIONS OF APPROVAL: APPROVED Z -2- DISAPPROVED DISAPPROVED �C too kco �i 11 EQ. C � ��Z O w a r �Ya.c�--r_C.�v 25� l,►:�C.�voc TI rl.�E \I Dr�i-�►3;1cEJl To -�'Lco. S Di PO o i T � o,3 LGS-5 L0 �-t� �a ` r- wt�s LTA( !-tA. ►-L i tom. TO \o o (U b4� 1v- 5 ( -� fi,2-& ,( CcJE� �2 s lti Jt c r�c rz� v F 7NE �l�T r.�CJ �� 'S ��5� t3C ( -,��v�'J +-C�rZ 10 �7T 1 L HNAL F L A N W i N U, EV W A, L H qE RFi ------- tAO RT T own o 6 0 n over f .......... NO-318 ........... _75MWQ47� t ��5Y, PERMIT - er, Mass., a"- Ly "b —1912- C HE W_1': AOR SSA s BOARD OF HEALTH `rra�cT" ��/9/L 0 PERM T z iL Ad..I BUILDING INSPECTOR THIS CERTIFIES THAT... �. nm.AA% FT/w141/c eb jQ 7 s i*Aes-7 gn dings on Rough &0, /0 haspermission to erect buil . ...............................o........... Chimney to be occupied as.... ......~. .vo Final P that the person accepting this permit shall in every respect conform to the terms of the application on rile in IN IPPECTOR Construction of Ro LU this office,and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Cons r Buildings in the Town of North Andover. PERMIT FOR FOUNDATION ONLY REGULATED By PARA. 114.8-S. B.C. Final VIOLATION of the Zoning or Building Regulations Voids this Permit. '/0'* Id% RouE9VICAL INSP TOR _W — g LE PERMIT EXPIRES IN 6 MOW FUPAID4 *'G'/ UNLESS CONSTRUCTION STAR Service rj FOR FRAME/BUILDING . ....A Final PERMIT ............. ............. ........ . ... BUILDING INSPECTOR GAS INSPECTOR DATE: AIA�1_ 'I) '-FEE 0-1 J, 14 A Rough uccupa'ncy 1jermit Required to Occupy Building Final Display in a Conspicuous Place on the Premises FIRE DEPT. Do Not Remove Burner STREET NO -No Lathing to Be Done Until Inspected and Approved by Smoke Det'. I Building Inspector DATEea /Z- C Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER {� SUBSURFACE DISPOSAL DESIGN REVIEW FEE T ��ev�5�d�, PERMIT # � DATE RECEIVED arrLICANT /1D f7L ASSESSOR'S MAP ADDRESS PARCEL # LOT # STREET ENGINEER C` y� ✓/ T7C/G1 S � Q� ADDRESS PLAN DATE 3/ac3"/qa, REVISION DATE CONDITIONS OF APPROVAL: SSC l3�LDw APPROVED DISAPPROVED mus 't (9 ro d I Y, eo s a �h, FORM U - LOT RELEASE 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 or requirements. *****************************APPLICA-NT f+LLS flUT THIS SECTION*********************** APPLICANT i I I i� A r��54_ PHONE LOCATION: Assessor's Map Number �-� PARCELL� SUBDIVISION LOT (S) STREET �`U �S� `� ST. NUMBER 14� **** *** ******* *********** ** *OFFICIAL USE ��l.v'.7 Vl hS,'� .1••' .K✓`moi _. RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSP TOR-HEALTH , DATE APPROVED DATE REJECTED T C PECTOR-HEALTH DATE APPROVED 7 DATE REJECTED COMMENTS PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING 4NSPECTOR DATE Revised 9197 jm FORM U TOWN OF NORTH ANDOVER LOT RELEASE FUM SUBDIVISION ASSESSORS MAP SUBDIVISION LOT(S) PERMANENT ADDRESS (ASSIGNED BY D.P.W. ) STREET F-0x05 S9� APPLICANT ��/ rri j� �SA2/L e PHONE DATE OF APPLICATION ,&d ecZ 30 /ff Z TOWN USE BELOW 111iS L114E PLAN IN BOARD DATE APPROVED z�•��. TOWN—PLANNER DATE REJECTED CONS ON COMMIS ION dTT� DATE APPROVED 4-,'X-� CONSER ATION AD M DATE REJECTED BOARD OF HEALTH ,— 22�— DATE APPRov6/� , HEALTH SANITARIA DATE REJECTED DEPARTMENT OF PUBLIC WORKS DRIVEWAY PERMITLW.CZ4- GG /4/fz SEWER/WATER CONNECTIONS Aic i-v^� Ql (D -4) / Z9h7.� FIRE DEPT. / RECEIVED BY BUILDING INSPECTION DATE This form shall be signed by the agents of the Planning and Ilealtli Hoards, the Conservation Commission prior to the issuance of any building pertl.ts for the subject lot. This form shall not releive the applicant from the compliance of any applicable Town requirement or Bylaw. r i .. • ?` V NUMj',kF.R FEE THE COMMONWEALTH OF MASSACHUSETTS .......TOWN_. of ........................TANDOVER................... •_....... This is to Certify that ......................La.80ZqUe..We-U.S.......................................................... NAME 244A Haven Street, -Reading, MA 01867 .................................................................................................................•---•..._.._.. ADDRESS IS HEREBY GRANTED A LICENSE Well Drilling- Permit — 25A Forest Street For .......:......................•............-...... .• --...--• ................................... ................................. ......................•---•-•--.._........-..................---..._....._.....-......----•-••-------:...................................................................... ..---•---••---•......................•---...._.....-_............._.....-•---.......---------.._......---------...--•-•--......____.-_....................................... ' ......---•-•-•........................................................•-••-....... --._...• -•------•------•-------------------....._•-----. ----......•----•-- t ' This license is granted in conformity"with the Statutes and oNipapces relating thereto, and expires---DeCeMber...31.,-___1.992................ ess sooner s nded d. C - ' •••-••--- ........ ................JULY_--2................,......19.....9 2 ....._...----- ... . .. ... ------ ............ AW ................... ••---••-•- FORM 488 HOBBS & WARREN, INC. "r'7."df �.f•,•(.'�'^fir{'-Y•r+,'f" ''h•� � `f r�. rl�f �. �! 'ti" ... '., �� . a ... �; s f !f1 ,jl�h� ,r! P1 r1 .! �r�'r' x ra xf.4r r \:4. ✓ JI ♦4 T- ' \ r 5 „-r Zr 1J ` It i �4lJ��lr� r1��'`i` rl r, } �•, rj It r ;iY i.„r.�r�+�Fr rf�rl,'I ti��y� F41tyJ ti� ��.- .. . Y ,. f- C�L, �.� �V 1*�~i `.i,. , L�� `1C r r.r�l� i r\i•:I � � �� ti - ., + r r DATE Z Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEE —0 PERMIT # DATE RECEIVED APPLICANT ASSESSOR'S MAP ADDRESS PARCEL # LOT # �?E; ENGINEER c, STREET 9� ADDRESS PLAN DATEfta _ REVISION DATE 2 CONDITIONS OF APPROVAL: APPROVED DISAPPROVED x '15 F1 2.8b, t,. \i� 1JoT �,E CttZA.�,.TC—� 1►.�� & EA c * k lS 2� p, t1D,-�'►�lr, ��1� �P�c �i�.��c�. 1�Z' �1,'C� t v �E �+.�� -- e) BOARD OF III:ALTH Town of ,North Andovcr ,Mass . Permit # 9''19 APPLICATION FOR WELL & PUMP PERMIT Application is hereby made for permit to drill a well (v) . Application is made to install (_) a pump system. Location: Address J7— Lot t Owner Address 1 �� /`c�.2 '3i �% Tel . Well Contractor Address �S�,q,y ®� ��' Tel 5 e eS�TocrJiy Pump Contractor Address Tel . - WELL CONTRACTOR (To be completed at time of purnp test ) Type of Well_ Well used for Diameter of Well Size of. Casing ' Depth of Bed RocIt Depth casing into Bed Rock Was Seal Tested? Yes (_) No (_) Date- of Testing Depth ••o•f W41 — Well Ended in What:. Material r Depth to Water_ Delivers Gals . Per Min . for 4 hour, Drawdown feet after pumping hour. at P� Date of Completion ignature Weil Contractor PUMP INSTALLER (To be'• f•i.1led in- before installation ) r Size & Name Pump Pump Type Used Water Pump Delivers GPM Size of Tank Pipe Material Used in Well : Cast Iron (_) G;n ).vnni.zed (_) Plastic ( j Well Pit (_) or Pitless Adapter ( ) Was sleeve used to protect pipe? Yes (_) NO(_) Type or Name Well Seal nate , �4�4it>4iFe4�1��r�'r�4�4i4�4;1ri4i4�Y�1r;'rNYNY*;YNYNY;'rNY;'r;'r;Y%YVeN'rNle ;'r5'r5'r,',lS,,,P,n Date Water analysis r'epdr-G 'submitted to Hoard of lfcal'tli " Date release given tD owner of record & 1�1,dg . Insp Health Inspector �r f WELL DATABASE ADDRESS: ! 7 :2 AGE OF WELL: WELL DRILLER: V a A 4;; WELL PERMIT#: a 14 t4 WELL LOCATION: � WELL PERIVBT DATE: — DEPTH OF WEI : f7l TYPE OF WELL: a.. DRILLED b. DUG c. UNKNOWN TYPE OF WATER BEARIN ROCK. WATER ANALYSIS DATE. , `�1— HI MANGANESE: Y N HIGH IRON: Y N O CONT ANTS: Y) N r WELL DATABASE/ ADDRESS: AGE OF WELL: WELL D , LER: PERMIT PERT#: WELL L CATION: 1" WELL PERMIT DATE: PTH OF WELL: TYPE OF WELL: a.. DRILL D b. D G c. UNKNOWN TYPE OF WATER BEARING RO WATER ANALYSIS DATE: HIGH MANGANESE: Y N HIGH IRON: Y N OTHER CONTAMINANTS: Y N Bi®marine 16 EAST MAIN STREET, P.O. BOX 1153,GLOUCESTER, MASS.01930 TELEPHONE: (508)281.0222 FAX: (508)283-3374 Certificate of Analysis La Rocque Well Report No.: 28301 244 Haven Street July 28, 1992 Reading, MA 01867 Re: Well Water Analysis Sample Description: Samples of water identified as Barletta, Lot 25,Andover. Sampling: Samples delivered by Steve Murray of Northeast Environmental on July 22, 1992. Findings: Results Guideline Total Coliform Bacterial Count per 100 mL . . . . . . 0 0 pH Value . . . . . . . . . . . . . . . . 1/6.39; Slightly Acidic Hardness(as CaCO3, mg/L) . . . . . . . . . . . 93.2 Moderate Sodium Content (mg/L) . . . . . . . . . . . . . :'29.1..>' 20 Chloride Content (mg/L) . . . . . . . . . . . . . 55.5 250 Iron Content (mg/L) . . . . . . . . . . . . . . . 0.10 0.3 Manganese Content (mg/L) . . . . . . . . . . . . 0.02 0.05 Nitrate Nitrogen Content (mg/L) . . . . . . . . . . 2.5 10 Nitrite Nitrogen Content (mg/L) . . . . . . . . . . <0.02 1.0 Copper Content (mg/L) . . . . . . . . . . . . . . <0.02 1.3 Methods: Standard Methods for the Examination of Water $ Wastewater, 17th Edition, 1989. *Guidelines are based on the recommended maximum levels of the Mass Department of Environmental Protection Agency's 310 CMR 22.00, "Drinking Water Regulations". Remarks: Although the Sodium content detected exceeds the recommended level, 20-50 mg/L is considered tolerable for people who are not on strict salt-restricted diets. Filtration is available to correct this level. B y: John Marletta Lab Director J M/d n Mass. Certified Labs MA026 and MA123 11 pill __ ..... .�� SI1111rA � �� ■iillllll IIiVW�liilllllll�11111�11 11111 1111111111111111®111 1111111 - IIIC�3y�i�11111111 1a1�'�1!111111 Illlrsl�01!!1 IllllfiI milli � �l1lA�11111111lIIE�!�1! 11111. !!lI��1!!1!!�.��1111l�1�■ii��'1 11111111111111l0�1111111111AIE��e� IIIIIIIIIIIIIIIIIIIIIIF ICl�i1�11 111111�1�1111111111I 11111111 111 MINIil��1111111111 �i�'1�i1C�I 111 MINE A1111 11 111111-1E:31l111 111111 fillll 1 �1111l11l16911111 111111111 ME NIIIIII IIIN IIIl 11111111 IIIIIINIIIIM ir�llllI I 1111111 Cel�,1111111111�11111111 1111villiilINS l� 11111111111111 11111111�1111111�1 11111111111111 Iilliil110116l11 1111111111111 11 1111113 1111111 1111111111111 11 1111111111111M11®1111111111111111 IIIIIIA�III�i�IIIIWIIIIIIIIIIIIIII 111111�1j��1��111�1111111111111111 11111111��11�1111�1111111111111111 111111111111111 1111111111111111 M m SENDER: I also wish to receive the H • Complete items 1 and/or 2 for additional services. m • Complete items 3,and 4a&b. following services (for an extra ` • Print your name and address on the reverse of this form so that we can fee): ® return this card to you. e d Attach this form to the front of the mailpiece,or on the back if space 1. El Addressee's Address � does not permit. t • Write"Return Receipt Requested"on the mailpiece below the article number. 2 ❑ Restricted Delivery • The Return Receipt will show to whom the article was delivered and the date I c delivered. Consult postmaster for fee. C -0 3. Article Addressed to: 4a. Article Number i m P 371 890 462 } E Mr. W111?dM Barrett 4b. Service Type C 171 forest Street ❑ Registered El Insured 1 N North Andover, 1.1A 0184 5 Certified [I COD w [I Express Mail ❑ Return Receipt for � Merchandise O 7. Date of Deliv ry z 5. Signature (Addressee) 8. Addressee's Address (Only if requested and fee is paid) H LU 6. Si ature ( ent I HPS Form 3811, December 1991 tru.S.GP0:1893-352-714 DOMESTIC RETURN RECEIPT Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 171 Forest Street Property Address Marian Barrett Owner Owner's Name information is required for North Andover MA 01845 4/24/2009 every page. Cityfrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out RECEIVED forms on the computer,use 1. Inspector: only the tab key MAY 2 6 2009 to move your Neil J. Bateson cursor-do not Name of Inspector use the return TOWN OF NORTH ANDOVER key. Bateson Enterprises Inc. HEALTH DEPARTMENT Company Name 111 Argilla Road Company Address Andover Ma 01810 City/Town State Zip Code 978-475-4786 S115 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs F#ther Evaluation by the Local Approving Authority 4/24/2009 Inspecto 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. t5ms-09108 Title 5 official Inspection Form:Subsurface Sewage Disposal system-Page 1 of 17 Commonwealth of Massachusetts { Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M •''y 171 Forest Street Property Address Marian Barrett Owner Owner's Name information is required for North Andover MA 01845 4/24/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: After permit from Health Dept. install new outlet tee in septic tank, and new d-box , inspection from Health Dept. septic system now passes Title 5 Inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 I r CommobweAth of Masssii�huf:tts p Title 5 Official Inspection Form RECEIVED Subsurface Sewage Disposal System Form-Not for Voluntary Assess nents M 171 Forest Street APR 2 9 2009 Property Address Marian Barrett TOHEALLTH DEPARTMENTER Owner Owner's Name information is required for North Andover MA 01845 4/3/2009 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information c"`� When filling out forms on the computer,use 1. Inspector: only the tab key Pj to move your Neil J. Bateson cursor-do not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name Q 111 Argilla Road Company Address Andover Ma 01810 nen City/Town State Zip Code 978-475-4786 SI15 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Ne sFurther Evaluation by the Local Approving Authority ` 4/3/2009 Insp r s Signa re 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M ,0 171 Forest Street Property Address Marian Barrett Owner Owner's Name information is required for North Andover MA 01845 4/3/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described 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 exMtration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ® N ❑ ND (Explain below): t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 171 Forest Street Property Address Marian Barrett Owner Owner's Name information is required for North Andover MA 01845 4/3/2009 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken i r pipe(s)are replaced Y N ❑ ND(Explain below PPO P ❑ ❑ 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•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ' 171 Forest Street Property Address Marian Barrett Owner Owner's Name information is required for North Andover MA 01845 4/3/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for 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: Outlet tee in septic tank ,inlet pipe to d-box 8r d-box needs replaced 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 '/2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 171 Forest Street Property Address Marian Barrett Owner Owner's Name information is required for North Andover MA 01845 4/3/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts M Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 171 Forest Street Property Address Marian Barrett Owner Owner's Name information is required for North Andover MA 01845 4/3/2009 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 600 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 171 Forest Street Property Address Marian Barrett Owner Owner's Name information is required for North Andover MA 01845 4/3/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d on well water 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 171 Forest Street Property Address Marian Barrett Owner Owner's Name information is required for North Andover MA 01845 4/3/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped 2008,owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 171 Forest Street Property Address Marian Barrett Owner Owner's Name information is required for North Andover MA 01845 4/3/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 17 years old, 12/1/1992, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): 4" PVC thru wall, 3" PVC in house, no leaks visible Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x5'x4' Sludge depth: 2 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 171 Forest Street Property Address Marian Barrett Owner Owner's Name information is required for North Andover MA 01845 4/3/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 25" Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 19" How were dimensions determined? Tape Measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet tee ok. Outlet tee badly corroded, needs to be replaced. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 171 Forest Street Property Address Marian Barrett Owner Owner's Name information is required for North Andover MA 01845 4/3/2009 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): " Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 171 Forest Street Property Address Marian Barrett Owner Owner's Name information is required for North Andover MA 01845 4/3/2009 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box level&distribution not equal. No evidence of leakage. No evidence of carryover. Inlet pipe to d- box pitched away from box. Root infiltration into d-box. D-box has bad corrosion, needs to be replaced &inlet pipe needs to be pitched towards d-box. 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.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 171 Forest Street Property Address Marian Barrett Owner Owner's Name information is required for North Andover MA 01845 4/3/2009 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: three trenches 51' 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 171 Forest Street Property Address Marian Barrett Owner Owner's Name information is required for North Andover MA 01845 4/3/2009 every page. CitylTown 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts • Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 171 Forest Street Property Address Marian Barrett Owner Owner's Name information is required for North Andover MA 01845 4/3/2009 every page. 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 LOW A i �C'AJV4� I i I i -Te - E413 t5ins•09108 Title 5 Offiaal Inspection Porn:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 171 Forest Street Property Address Marian Barrett Owner Owner's Name information is required for North Andover MA 01845 4/3/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: '4 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: 4/16/1992 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: Field notes of engineer showed water Udeep Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts • Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 171 Forest Street Property Address Marian Barrett Owner Owner's Name information is required for North Andover MA 01845 4/3/2009 every page. Cityrrown 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 l5ins-09/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 1 _ J CERTIFIED PLOT PLAN CLIENT: WILLIAM BARRETT THIS CERTIFICATION IS MADE AND LIMITED TO THE ABOVE CLIENT. 3�&a° I CERTIFY THAT THE STRUCTURE SHOWN CONFORMS �e''�• TO THE DIMENSIONAL REQUIREMENTS OF THE °*• ZONING BY—LAWS TOWN OF NORTH ANDOVER LOT 25A WHEN CONSTRUCTED. A=3.02 AC. p ' OFFSETS SHOWN ARE FOR ZONING DETERMINATION ONLY AND ARE NOT TO BE USED TO ESTABLISH 36.7' PROPERTY LINES OR TO DETERMINE LOCATIONS N' OF FUTURE BUILDING ADDITIONS. TO THE BEST OF MY KNOWLEDGE AND BELIEF i THE PRIMARY STRUCTURE SHOWN ON THIS PLAN IS NOT LOCATED WITHIN A FLOOD HAZARD ZONE AS SHOWN ON FEMA FLOOD INSURANCE RATE MAP COMMUNITY NO.: 2500980010B DATE: 6/15/83 ZONE (IF APPLICABLE) OF MICHAEL `ys o J. _ Fs C/ST /17/ MICHAEL J.SERG .L.S. SEE NERD. E K.3100 PG.14 FOR ME EASEMENT s� CH RI STI AN SEN & SERGI INC. 160 SUMMER ST. HAVERHILL,MA. SCALE: 1 '= 60" DATE: 8/92 fi Z LF 1 `a� Y }� p 7— �rcq f 30.5 I ZD S . Qa I _ 41 E � / L t n� SLOPE RCOUIZEUENr yc DES/GN EZ E!/ TION ,4T.. .. ... . .(TOP OF STONE) EX/ST/NCS ELEVd7-10N QT. . . .. . . . . RE U/2ED 41Z Z9. zFLiFI�.4ROW, DE51(�jN .4.5 BUILT 45 BUIL T /NV P/PE OUT OF HOUSE /NV P/PE INTO T,4NK S� .7 3 5��.� J UB —SU/L.!-QC� D�S/ O.S.4L ----- - - - INV P/PE OUT OF TANK /5 b .�{ /-S�. 7 S ST IEM INV INTO D.P/PE s BDX � .5� /�;� 5 B //VV P//0E OUT OF D. BOX /5�}. �!o / 59. �� f<�:e`j /N /NV END OF PIPE 1s4 IV 61? 7 / 53, 15.21 FOR N,aTER EL EV4 T/ON O l L. L 1 AIV r� ' 1 ,4 VE L E SCo e,46E STONE �1 : '-- Q ' ,�TE. DEPTiq ,47 ReOBE NOTE.- Tzl/S 10L,4N /S NOT ,4 w,6?1eQ1vrY CNRISTIQNSEN SERGI , INC. OF THEE SYSTEM BUT ,4 !/ER/F/C,4T/ON 16,0 SUMMER STREET RAVERNILL ,MASS. OF TH67 LOC.4T/ON OF TWE EX/ST/NC' STRUCTU2ES. � 7 `1 i