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Miscellaneous - 175 FOREST STREET 4/30/2018 (2)
v Ln m t/1 Nt o � QO N a 00 O O t O 00 � O � 0 0 O C7 a°1 0 d w Con Z (off O a04 o H o � x O b+ o � 0 3AB E a O 0 U � U ' O 'o . N cd O Oi N O A o4o ti ee w .� 4 Q �' Q V 0 u rA m O o O 0 O - a A r 3 a a i � a O O t -- � o 0 0 0 A C7 a°1 0 Z O i � a O � O •r A C7 a°1 i .I FORM U - LOT RELEASE FORM 1,f s+. k INSTRU A, TI NS: This form is used to verify that all necessary approvals/ Boards an Departments having jurisdiction have been obtained. This does notlts relieove the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT LOCATION: Assessor's Map Number Q SUBDIVISION_ q12 STREET E/ gt V// CONSERVATIO COMMENTS TOWN PLANNER PHONE j yj,) 9!5 -C?3J f - PARCEL LOT (S) ST. NUMBER�, ***************************************** OFFICIAL USE ONLY*********************************** TIONS OF TOWN AGENTS: MINISTRATOR DATE APPROVED DATE REJECTED 9%D y INSPECTOR -HEALTH D(tCIIJ SEPTIC INSPECTOR -HEALTH COMME DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE�jREJECTBED— PUBLIC WORKS - SEWER/WATER CONNECTIO DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9\97 im COMMONWEALTH OF MASSACHUSETTS EXECUTIVE; OFFICE OF ENVIRONMENTAL AFFAIF` ' DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: fa ou t�" Owner's Nsune:yu� , !'�.•� ht� Owner's Address: nm - Date of Inspection: 3- % - via Name of Inspector: ease print) Company Name: Mailing Address: cc.rw.n Telephone Numbe.r.i ~ (,NCO sr CERTIFICATION STATEMENT I certify' that I have personally inspected the sewage disposal system at this address and that the information reported below is trine, aocuratc and cotnplcte as of (ime__of the irrspeetion, Mte inq=uon was performed based oft my training and experience in insthe r fitnctiaun and name of on site sewage disposal system, I ass a DEP wroweo system inspector purmaurff Sectios IS. of Title S (310 CMR 13.000). The system: J� Passes tionaily Passes Needs Further Evaluation by the Local Approving Authority 0jInspector's Signiturt: Date.- _ 1- "� o' T The sy stets inspector senua �y of this ittspectio Ato the Approving Authority (Hoard of Health or DF.P) within 30 days of �s inspection If the SUCIn is a shared Kysum or i►ax a design claw of 10,000 gpd or greater. the inspcoor and the system owner small submit the report to the appropriate regional offiot of the DEP, The original Aould be sent to tlx: system owner and copies sent to the tntyer, if applicable, and the approving authority. Notes and Comments ""!'This report only describes conditions at the time of iwpectiaa 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 con"as of ase. TO 36�4d f,,ZlS '1Ii63S AiNn w, -13C 9009-S66-609 6b :0Z tQOvee, r_- Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: X- Poc'c,� ('\, to a.)wy4r Owner- Vu ^ _ pate of Inspeedon: 7 `- 0 �--%! twpection Summary: Cbeck A,B,C,'D or E / &JXAX5 complete all of Section D A. Systeam Pates ./m have not ftlad any information which indicates that arty of the failure criteria described in 310 C, %M 15.303 or in 310 CMR 15.304 exist. Any failure criteria trot (valuated arc indicated below. Comeau: B. System Conditionally Paanes: I;1 ! (� one or system components as described in the "Conditional Pass" see -tion Head to be replaced or repaired. nc 9*m, upon completion of the replacement Of repair, as approved by the Board of Heap will Pass. Answer yes, no ornot uminod (Y,N,ND) in the for the following statements. If ""A deterrrvJte�d" ploam in Cxgla. _ The septic (seek is m® over 20 years old" Of the septic tank (Wh6t1W (metal or not) is strttctorally tursou»d, exhibits sub`tunnel - � on or e�itration or tank failure is imnlinettt. Sy gem tivin pass inspection if the eadsting tank is replaced with a lying septic ta* as approved by the Board of Health. "A metal septic tank will pass ' ..on if it is structurally sound. not leaking and if a Certificate of Compliance lv cating thid the tank is less than 20 y)%ers old is available. ND explain: Observatwn of sewage backup or break t or high static water level in the distribution box due to broken or obstructed, pipe(s) or due to a broken, .44ttled or en distribution box. System will, pass inspection if (with approval of Board of f etth) broken pipe(s) t<'ioed obstruction is rem distribution box is 1 ed or replaced ND explain: The system required paimping more than 4 times a year duebtoicert 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: ZO 39Vd A;dS SIicl3S h.iNnR113C `-'O6S-'-968-609 6b *0Z too."/610;'11-0 Page 3 of 11 OFFICIAL INSIPECTIO14 FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Pr+ttperty Addral3• Owner. ... w.«. Q."` Daae of .Inspectioa: 13-S- 0!:\,— C, Further Evaluation is Rewired by the Board of Health: (\/(4r Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failin to protect public health safety or the environUnM. 1. Syn4qi win pan unless Board of :Health deeerminos in secordasce with 310 CMR 13.303(1)(b) that the ey not functioning in a manner which Will protect public hesith, safety and the environment: CessoW or privy is within So feet of a surface water or privy is within. SO feet of a boadering vegetated wetland or a salt marsh Z. System will fail unless the and of Health (sod 'Public Water Supplier, if any) determines that the system is functioning in a man that proteets the public health, safety and environment: The system has aseptic tari t* soil absorption SySt m (SAS) ar►d the SAS is within 100 fm of a surface water supply or tributary to aWhoc water supply. �..-. The system has a septic tank Md S and the SAS is within a Zone 1 of a public water supply. The system has a septic tante and SAS the SAS is within 50 feet of a private water supply well.. _ The system has a septic tank and SAS and flu AS is less than 100 feet but So feet or more from a ter private wasupply wells* . Method used to distance 4.*T is system passes if the well water analysis, perta at a DEP certified laboratory, for coliform bacteria and volatile orgawo oo.mpounds indicates that the is free from pollution from that facility "Athe presetnoe of ammonia nitrog;cn and nitrate nitrogen is oq to or loss than S ppm, provided that no other failure cnt wu rare to aexed- A copy of the analysis nes=t be to this form. 3. Other: 60 3DVd AAS OU63S niNnw,13C S0CS!-SG 8-509 GV :OZ t 00Z/Eol'c 0 Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Addrew rl S t=o saw Owner. Drat of Inspection' ""C? A System Failure Coria applicable to all systems. You n 10 iUdic;atc "yes" or "coo„ to each of the following for #&inspostions Yes No Back" of sewage into facility or system componemt 4ac to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to as overloafd or / clogged SAS or cesspool J Static liquid k%el in the diftribution box above outlet invert dine to an overloaded or clogged SAS or cesspool fN 10% Liquid depth in cesspool is :less than 6" below invcn or available volume is less than % day flow ]Z Required pumping more ftm 4 times in the last year JQT due to clogged or obsmccted pipe(s). Number of times pumped Any portion of the SAS, cerspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a mufam water supply or tributary to a surface V/ wafer supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. '7 Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portico, of a cesspool or privy is less than 100 flet but greater than 50 feet from a private water supply well with tw Acceptable water quality analysis• [This system pamts if the well water analysis, performed at a DF.P eerdfwd laboratory, for coliform bacteria and volatile organic Compounds indicates that the well is it" from poBmion from that facility and the presence of ammonia nitrogen and nitrate nitre is egpal to or less than 5 ppm, prwvided that no other failure criteria ane triggered. A copy of the analysis crust be attached to this form.) (10 (Ye&oTbe system Lg, l have detercuined that one or snore of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Boats of Health to &Vrnune what will be necessary to =W the failure. a. Large Systems: To bt'C"sidered a WV system the +system must serve a facility with a design now of 10,000 gpd to 15,000 YOU tnum ' to either 'yes" or "no" to each of the following: (The following 'teria apply to large systems in addition to the criteria above) yes no the system is thin 400 feet of a surfaoc drinking water supply the syatena is w ithin 00 feet of a tributary to a surface drin(atug water supply _ the system is located in a 'trogen sensitive area (butrim Wellhead Protection Acta —1WpA) or a tnappad Tone 11 of a public water sW*lly well If you have wwmwod "yes to arry question . E the system is considered a sigaruflM t threat, or ans�+e`red "yes" in Sxtion D above the large syKaem has The owner or operator of arty large system considered a sigaificatrt threat:nudes Section E or £tiled under n D shall upgrade the *V m in accordance with 31(1 GlvOt 15.304. The systettt owner shatuld contact the to regional office of the DepaMnent. t�0 Mlkd AdS licGS AiNNHti13G 9069-968-6:09 6t,:oz t oov80,'co Page 5 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST[' Property Addren: ,c,d,,i (N mf- Owner: <,,^ . Date of Inspection: -S-I - �, LL Chock if the following have been done. You must indicate "yes" or "no" as to each of the following. Y� No Pumping inforination was ptavided by the owner, oocupatat, or Board of Health Were arra+ of the system. components pumped out in the previous two weeks J_ Has the system received normal flows in the previous two week period Have large volumes of water bean muciduced to the system recently or as port of this inspection d Were as bh plans of the sr obtained and examined.^ (If they avers not available note as N/A) _ Was the facility or dwelling inspected for signs of sewage backup Was the site inspected for signs of break out �L Were all system components, excluding the SAS, located on site _ Were the septic tank manholes unwvered, opened. and the interior of the tank inspected for the condition of the baoles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum J- Was the facility owner (and occupants if different from owner) provided with conformation on the proper maintenance of subsurfnoe sewage disposal systems The Wze qnd location of the $oil Absorption System (SAS) on the site bas been determined based on: Y no Eadst+ng information. Por c:ramnpk, a1an at time Board of Healtlm, _ Determined in the field (if any of the faihire criteria related to Part C is at issue approximation of distance ix ta►avxptaisle) (3 to C -NM 15.302(3)(b)j SO 39Vd ,',dS 011163S 1t1NnHV13G Sorg -S62-609 6b. �Z. b et so.,'! �i pap 6 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTI.ON FORM PARI' C SYSTEM INFORMATION Property Addren: O F - Dtste 0� I>tl�CtlOrf� a J �d�"�tC` FLOW CONDITIONS RESIDENTIAL Number of bedrooms (dmgn): nlp Number of bedrooms (acUil): DESIGN flow bused on 310 CMR U203 (for example: 110 bpd x # of bedrooms): 3'30 Number of current residents: '�, Does retade= have a garbage grinder ryes or 40� _ Is laundry on a separate sewage system (yes or o� [s yes separate inspection required] Latttxhy system inspected (yes or no): r1�R seawall use: (No or no): 00 Water meter rt:adnags, if available Gast 2 years usage (gpd)); (Ltcr, Sunup pump (yea or no): r*.o Last date of occupancy: Gstt`t.n . Type lishment: _ Design flow, on 310 CMR 15.203): od Basis of design fl ts/pexsonsl Gmase trap present Industrial waste molding tattle n Non -sanitary waste dischwpd to Water metra resdini, if available: Last date of occupancy/use: OTHER (desenbe): (yes or no): _ 'Zide S system (yes or no) _ GENERAL INFORMATION Pumping Records Source Ofinfotznation: � t` c'A cLL&; ;�ct.�/1�J1 �vr.�t,J1 '3-S -U%A Was system lumped as part of the rection (yes or no): if yes, volume pumped: _W90_01ons –How was quantity pumped demradned?-- Treason for puaPing: nAA%_ TYPE OF SYS'T'EM — Septic tank, disBrfttion box, soil abwrption sYatcm Site cesspool _ Overflow cesgwl Privy Stilted system (yes or no) (if yes, attach ptevims inspection records, if MY) ... _ hmonrative/Altennteve technology. Attach a copy of the cunt operation and maintenance contract (ro be obtained from system owner) — Tight tank _ Attach a 00py of the DEP approval —Other (describe): 'a. �� �� z,c \. � .mac-�r•c�S Approximate age of all componewu, Mete installed (if known) and sauna of information: ��- Were sewage odors decocted when amvmg at ft site (yes of DO): fNz 90 39t'd 1'%dS CiI1c2S t4iHi-HH-13Q 9005-968-x:09 6b 1971 Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oont tined) Property Address•• Owner. Doe of Inspection: "4 -3 -04 NUE.DING SEWER (locate on site plan) Depth below grade: h y ' Materials of eot>smrcuon: cast iron Z40 PVC other (explain): Distance from private water setpply well or suction line' Comments (on condition of joints, vending, evidence of leakage, etc.) o..A_ SEPTIC TANIi: _ (locate on site pLin) Depth below grade: A!. ,Scr , r% � gr -At Material of construction: �ooncrctc __metal fiberglass ,_,,,,polyethylene o0wr(exphin) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) A J►� ��-. Dimenoons: Sludge death, —„tom' Distance from top of sludge to bottom of outlet tee or bugle tsl , Scum thickness:_ Distance from top of scum to tap of outlet We or baffle. l'' - Distance from bottom of scam to bottom of outlet we or baffle: 1 '--- How were dimensions determined` M�sus: e% ,(Na- Commetns (on PmVi ng reommetdaRflns, irdet4nd ouriet tee or baffle condition, structural isitegnty, liquid levels ati related to outlet invert. evidence of leakage, etc.): i (' P, GRRASE TRAP: _0oc,'a1e on Site plan) Depth bolo _ Matenai of co n: _aottarete __,meW __,_fibcrglass __potyetbvlem —othtr (explain): Dinnensiaos: Scum thickness, Distance from top of sewn to top Distance from berttom of stun to outlet tet or bafk: hwn of outlet tee or baffle: Date of last pmwmg: comments (On pcttttping recommendationsNot and outlet tee or baffle coalition, structural inftOty, liquid levels as related to outlet invert, evidence of leakage, C0 3DVd ASIS SIlcM h1NnHVX :9G Pages of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: t1 G.,rst Owner: �g-in kv., Date of inspection: 1:3:Q4 TIG or itOLDING TANK: —(Lank must be pumped at tune of inspection)(locate on site plan) Material of concrete metal fiberglass __polyethylene u___, other(esplain)' Capacity: Moons Design Flow: lons/day Alarm pt+esew (yes or no): Alarm level: Alarm in wo*in (yes or no): — Date of last Fuming: Comments (condition of alarm and float swritches, etc.): DISTRIBUTION BOX: i (if present trust be opened)(locsu on site plan) Depth of liquid level above outlet invert: .2�, %vu,4- Comments (note if box is level and distribution to outlets equal, any evidence of solids caryover, any evidence of lesirnor intn nr out of bnx- etc.): PUMP CBAhWKI : (locate on site plan) Pumps to working (yes or no)' Alanns in w+orWgorder or no): Commem (note oon tion o clkimber, condition of pumps and appurtenances, etc.): 80 3Jtid AAS 0Ilc135 AiNnHVIX SOCS-568-C09 6t :0�1, Page 9 Of 1 i OFFICL4LL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (cottumwd) Property Address: Owner: Date of Iaspectioe: SOIL, ABSORPTION SYSTEM (SAS,)-. _ (locate on site plan, excavation not required) If SAS trot located explain why: Type �•! leaching pits, number: — leaQkng chambers, number: _ leaching galleries, number: _ 77 leaching trenchm number, length: _ �. x \• 'Mep_ leaching fields, number, dimensions: overflow cesspool, number: innovativeialternative system Typehuame of technology. ComsnwU (note condition of soil, sign;: of hydraulic failure, level of ponding damp soil, condition of vegetation. etc.) -1 C- A -h .}yea—. r(\^ ea.n,A'v, ,'A ,t- 1 s—A.A --- CEsspOOL,S: (cesspool must be pumped as part of iaspection)(locate on site plan) Number and n: _ Depth top of liquid et invert: _ Depth of solids layer: Depth of scum laver: _ Dimensions of cesspool.- 'Msterials of ronstructiow _ Indication of gimadwater inflow (Yes or no): , Conuneuts (nye condition of soil, signs of hydraulic fair,re, level of ponding, condition of vegetation, ate.): PRIVY: ue on site plan) Materials of oansun tion: Dimensions: Depth of solids: Cornetts (note condition of soil, signs o draulic failure, level of ponding, condition of vegetation, etc.): 60 39tid AAS 0Iic3S AiNnH113C 9t3�5-�6°-Sa9.. Er v+� too"iee.'Co Page 10 of I 1 OMCIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION ccontiuttad> Property Address: Owner: Date or Inspecdon: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including des to at least mo pemianew reference landmarks or benchmarks, Locate all wells within 100 feet. Locate where public water suppl) enters the building. A' apo 9.6 11VI eo 4 VA 0> 30Vd Ps?JS SIlcl3S J iNnHy-13Q 909'9-959-509 6r :0Z, V007 r 90. 'C O Page It of 11 OFFICIAL ItV`SPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (contmmd) Proporty Addmw. 11s Cw-t4k rA d Owner: Vo--, )S Date o f lespecdom 's -, - o„ j T SITE EXAM Slope \°b Surface water mc.vq, Chwk cellar (No 5 .++►t Shallow wells Minta Ek4uated depth to gamd water3-�- feet Please indicate (check) all methods used m determine the high grout►! water elevation: ('1 Obtained from "em design plans on recmtd - if checked, date of design plan reviewed, Observed site (abutting property/c,bservation hole wiffin 150 feet of SAS) Checked with local Board of Healthexplaua: L Checked with local exomtors, installers- (auach documemation) Acoessed USGS database-e..q)Wn: You must describe how you established the bigb prottad water elevation: Z T 30Vd As E OUd3S.hiNnw,13Q S0� S-S6g-6ly _ — 6b :031 b00u1l6d,'C @ STATEMENT DANIEL A. GIAND Conerai CantrwU ng 130A Appleton Stmt Noi{i AN VER, MA 01845 TE � -,j"- ®% QA '(972) 69F-73 A6S L,Iid3S AiNni-iv-13C, GRES-868-609 T6v:aZ POKI/e0i,E© APPLICATION FOR WATER SERVICE CONNECTION North Andover, Mass. �� V 4 e Appifcation by the undersigned is hereby made to connect with the town water main in_ a�Dr subject to the rules and regulations of the Division of Public Works, Stn*t' 7 The premises are known as No, �`l Street or rWivWon lot no. G �t Owner / '" lid Address ell Contractor Addm5 ti 9 LD U r icant's Sianatt�re �JL fie - ..s i1kY6,14s 5,411 6G`r� filea� dw4-� PERMIT TO CONNECT WITH WATER MAIN The Board of Public Works hereby grants permission to to make a connection with the want main at subject to the rules and regulations of the Division of Public Worcs. inspected by Date 4. 1 39vd See back for rules and dations 4 AAS OIlcM hiNnHv13C1 (01�1,-A r 2� M.4WHAWMAIJ 909-569-£09 bb �0Z t'00�ii30;'4th TO: of. SHAW PLUMBING & HEATING, INC. P.O. pox 766 ANDOVER, MASSACHUSETTS 01810 (978) FAX (972) 52186 33•It344 owop(Q aG,. 1611 TERMS' 4.r — ySl y �----� ll 0 4pURS FATE AMOUNT TOTAL MATERIAL LASOR -�---- i I TCitAL LA80A y/pRN ¢RCERED B� I e.��....as ih.ronv a,¢rtowwd0e I TAX ""M' thank `ice I PAY THIS AMOVNI 1,y I 39Vd r'dS u'Ild3S AiNnHV13Q 5069-963-6.09 6t :oz IMII[cp140MIM TO TOW OF NOW AMER P. 0. B x.IN NO. AMMR, ISA alE95 JOYCE 1041LON COLLECTOR :OF TAXES, WILKINS, LEON & JUDY 175 FOREST ST NORTH ANDOVER MA 01845 TOWN OF NORTH ANDOVER BILL NUMBER 7F:17 2004 WATER/SEWER BILL CYCLE #13 BILL DATE: 10/24/20{3 Retain this voucher for your records Account: 3170638 Meter: 3170538 Service: 175 FOREST ST DETACH Please detach we ana return Lne wt,LUM vw%--ti, _ , ►- 91 3DVd Aw k) '-�YicGS AiNnHVIX SH9-968-C@9 6h 41Z b 3Zl,D0 .:9 TOWN OF NORTH ANDOVER Account DIVISION OF PUBLIC WORKS -WATER R SEWER DEPARTMENT ate a A►pOestlott for AbOAm M of WOW/Sewer ChRr m • Water CurrenL,. 'e' Z 7 Abp-- - --Q NotWater Aftem Abate Net Duo Maintenanm Fee— Abele © Net Due lr =- - ir?� Sewer Current Abate Net Die t Sewer Armand ----- Abate Net Due.010 Total— - `—� Ab a �� Tot. Di — Reason for Abata MnL A! G�..�� �� �s2- Q A -j PjMssii own of Andover. toa�,7 -�-- lLocal No. Andover, MA 01843AuthodW 9I 39Vd A6S 0ll63S AiNnF?.. ix �e��-sFs-E09 �1 TO TOWN OF mom NAM" P,. 0. BOX 124 NO. AMWA*. *A 8IN6 JOYCE VAN*' COLLECTOR 01 TAXES WILKINS, LEON & J60Y 175 FOREST ST NORTH ANDOVER MA 01845 TOWN OF NORTH ANDOVER BILL NUMBER 161'45 2004 WATER/SEWER BILL CYCLE #23 BILL DATE: 01/21/20(4 Account: 3170638 Meter: 3170638 Service: 175 FOREST ST Retain this voucher for your records *16245.041723.2794.5* OET.ALH Pease detach here and return the bottom voucher with your om.Yment vLiAIn ,4.j TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: 0 SYSTEM OWNER & ADDRESS (r) r WA'1K k n ,5- 17,5 f-5 SYSTEM LOCATION (example: left front of house) FEB 2 2001 DATE OF PUMPING: QUANTITY PUMPED / J06 GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES 1� NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: / GOOD CONDITION ✓ FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: COMMENTS: CONTENTS TRANSFERRED TO: al /h 1 PAGE II STEWART'S SEPTIC TANK SERVICE (CONT'D) 04-22-96 A 31 STONE CLEAVE ROAD 1,800 201 BRADFORD STREET 11000 04-23-96 585 BOXFO.RD STREET 1,500 HEAVY A 175 GREAT POND ROAD 2,000 04-24-96 1615 OSGOOD STREET 500 FLOWED A 122 OLYMPIC LANE 1,500 A 1116 SALEM STREET 750 04-25-96 A 75 FORREST STREET 11000 04-26-96 550 BOSTON STREET 2,000 2-1,000 TANKS 04-27-96 A 1015 JOHNSON STREET 11000 175 FOREST STREET 1,000 350 SHARPNER'S POND ROAD 1,500 04-29-96 A 18 STEVENS STREET 1,250 A 100 FOREST STREET 11500 A - 82 PADDOCK DANE 1,500 04-30-96 A 133 SUMMER STREET 11000 A 347 HILLSIDE ROAD 11000 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Owner's Name: Q,,^ Owner's Address: ^K. Date of Inspection: 3' 3 —y�-� VVBOAR DRi�1�fi> CF E,E;,Li� Name of Inspector: (please print) �osea�.. c,��►r\n� r.�"� Company Name: � � �1�..,...,1� ; c. N Mailing Address: a,H�t O� 1, -,\\U' F MAY r 3 Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: V/ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Inspector's Signature: Date: 1-:J-o�t The system inspector shaOS06t a copy of this inspectionport to the Approving Authority (Board of Health or DEP) within 30 days of 04leting 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. .Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: .!/ I have not found any infortnation 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 s} tem, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or nottcrmined (Y,N,ND) in the for the following statements. If "not determined" please explain. \ The septic tank is me and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial tration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a plying septic tank as approved by the Board of Health. *A metal septic tank will pass in on if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 yem old is available. ND explain: Observation of sewage backup or break ut or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled orven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s) ar replaced obstruction is remo d distribution box is lev ed or replaced ND explain: The system required pumping more than 4 times a year duet broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND explain Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: \1, ^ \—,v w.r. e,l Date of Inspection: e3 1-0�` C. Further Evaluation is Required by the Board of Health: 0 / (�- Conditions exist which require further evaluation by the Board) of Health in order to determine if the system is failin to protect public health, safety or the environment. 1. Syst will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system 's not functioning in a manner which will protect public health, safety and the environment: Cess of or privy is within 50 feet of a surface water Ces or privy is within 50 feet of a bordering vegetated wetland or a salt marsh . 2. System will fail unless the oard of Health (and Public Water Supplier, if any) determines that the system is functioning in a mann that protects the public health, safety and environment: The system has a septic tank soil absorption system (SAS) and the SAS is within 100 feet of a su-rface water supply or tributary to a urface water supply. The system has a septic tank and SA and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS an)�,the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the AS is less than 100 feet but 50 feet or more from a private water supply well". Method used to dete ' distance "This system passes if the well water analysis, performkahed EP certified laboratory, for coliform bacteria and volatile organic compounds indicates that thfree from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen isor less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: F\, Owner: Date of Inspection:--U� D. System Failure Criteria applicable to all systems: You must indicate `yes" or "no" to each of the following for aIl 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 tl j R Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ Any portion of a cesspool or privy is within a Zone 1 of a public well. _ Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any, portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (\� (Ye o 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 beconsidered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd, You must in ' ate either "yes" or "no" to each of the following: (The following teria apply to large systems in addition to the criteria above) yes no the system isthin 400 feet of a surface drinking water supply the system is within 00 feet of a tributary to a surface drinking water supply the system is located in a 'trogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a public water ly well If you have answered "yes" to any question ection E the system is considered a significant threat, or answered "yes" in Section D above the large system has fNed. The owner or operator of any large system considered a significant threat under Section E or failed undertion D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropAhte regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: \i� 61�ces�- f� Owner: uv, Date of Inspection: 3-3- v Check if the following have been done. You must indicate `yes" or "no" as to each of the following: Yep No Board Health Pumping information was provided by the owner, occupant, or of _ ✓ Were any of the system components pumped out in the previous two weeks J _ 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 — N/A) J Were as built plans of the system obtained and examined? (If they were not available note as E;\.NL M 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: Ye no Existing information. For example, a plan at the Board of Health. ✓ _ Determined in the field (if any of the failure criteria related to Part Cis at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: \) S Owner: V uf!N Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): t4- Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): 330 Number of current residents: `Dl" Does residence have a garbage grinder (yes or Is laundry on a separate sewage system (yes or [if yes separate inspection required] Laundry system inspected (yes or no): DfN Seasonal use: (yes or no): no Water meter readings, if available (last 2 years usage (gpd)): Q tr rc ..i Sump pump (yes or no): no Last date of occupancy: Cuec tyy -- TRIAL Type of blishment: Design flow ed on 310 CMR 15.203): Bpd Basis of design flo seats/persons/sgft,etc.): Grease trap present (yes no): _ Industrial waste holding tank n Non -sanitary waste discharged to Water meter readings, if available: Last date of occupancy/use: OTHER (describe): (yes or no): _ title 5 system (yes or no): GENERAL INFORMATION , v�G\V�J' /� " Pumping Records Source of information: o,. 4e _ most- ('Lce.y4- c ct tNq Was system pumped as part of the ' spection (yes or no): _ If yes, volume pumped: O20 gallons -- How was quantity pumped determined? Reason for pumping: e.,,rA,,,L- TY)PE OF SYSTEM Septic tank, distribution box, soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) _ Tight tank _ Attach a copy of the DEP approval _ Other (describe): Approximate age of all components, date installed (if known) and source of information: p Were sewage odors detected when arriving at the site (yes or no): n,o Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: x-15 C--Cv_ - Owner: Date of Inspection: -S BUILDING SEWER (locate on site plan) Depth below grade: \u.11 Materials of construction.- _cast iron /40 PVC _other (explain): Distance from private water supply well or suction line: kadr Comments (on condition of joints, venting, evidence of leakage, etc.): Rak�z ss '44"t \. nuv %C*V PIS -t-- \ \' Y V-' TO. V SEPTIC TANK: __._ (locate on site plan) Depth below grade: R. ;Scr NV gy�� t 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: �-1 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: \\i Scum thickness: \ Distance from top of scum to top of outlet tee or baffle: i Distance from bottom of scum to bottom of outlet tee or baffle: \-I y How were dimensions determined: Mt^sjr`: �-acA �\c,Cad' a- sl„�Sc JC C Comments (on pumping recommendations, inlet -And outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): \ �v.M tri..\. -IG(-A., rA^,A 4&,T 6WeS GREASE TRAP: _(locate on site plan) Depth belo rade: _ Material of cons tion: concrete metal (explain): — — Dimensions: Scum thickness: fiberglass polyethylene —other Distance from top of scum to top outlet tee or baffie: Distance from bottom of scum to bo of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, et and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: C1.. f3.n.,1b Owner: \1 Date of Inspection: 3-3--0 TIG T or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth belo ade: Material of cons ction: concrete metal fiberglass _polyethylene other(explain): Dimensions: Capacity: Design Flow: 7ra=lday Alarm present (yes or no): Alarm level: Alarm in working r (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: !aA , ,.ver'' 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.): p \ O'si 6t, "s 4 rze C'avvvv-.c,ZdL PUMP CAMBER: (locate on site plan) Pumps in working o (yes or no).- Alarms o):Alarms in working order or no): Comments (note condition of PWp chamber, condition of pumps and appurtenances, etc.): Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: C' (V. Owner: ft \l u^ �w � Date of Inspection: a —3 - 0 �A 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: '�L, Y, 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.): eA- oi— (N CA C`S TO �n2� �✓1 rsy,.l\ .d.•r�_... �c\A �..- Aa CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and co ation: Depth — top of liquid t et 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: -tec`te on site plan) Materials of construction: Dimensions: Depth of solids: Continents (note condition of soil, signs failure, level of ponding, condition of vegetation, etc.): Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: \1u--\ Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. �tti�i- v Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: V., Date of Inspection: 3-,-&!A SITE EXAM Slope \ ok, Surface water r\c, v e, Check cellar (10 Shallow wells N,.,\L vo v Gr.1 Estimated depth to ground water '2�+ fee-, Please indicate (check) all methods used to determine the high ground water elevation: n 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: f`Gv;w 1 Nti _ Checked with local excavators, installers- (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: . S'p4V'-1 S�CiWS `OVA: ACCPlS .i+v�� _ZJhhL -- SrArJ1 \s...l'1 STATEMENT DANIEL A. GIARD General Contracting 130A Appleton Street 44w,�t NORTH ANDOVER, MA 01845 DATE (978) 686-7653 � .... _.. .--......... ......................... _............. ............. ....... TERMS: 4 " PLEASE DETACH AND RETURN WITH YOUR REMITTANCE $ DATE �. INvOICE NUMBER /. DESCRlP MBEtON CHARD S CtRED}TSN AkAi1C } BALANCE FORWARD ,tom PAY LAST AMOUNT DANIEL A. GIARD 0�"Iy IN THIS COLUMN i fpRMMN" TO TOWN OF NORTH ANDOVER P. 0. BOX 124 NO. ANDOVER, MA 01845 JOYCE HANLON COLLECTOR OF TAXES WILKINS, LEON & JUDY 175 FOREST ST NORTH ANDOVER MA 01845 TOWN OF NORTH ANDOVER BILL NUMBER 16245 2004 WATER/SEWER BILL CYCLE #23 BILL DATE: 01/21/2004 It Account: 3170638 Meter: 3170638 Service: 175 FOREST ST Retain this voucher for your records *16245.041723.2794.5* DETACH Please detach here and return the bottom voucher with your Dayment DETACH Commonwealth of Massachusetts City/Town of NORTH ANDOVER MASSA Id -- Y System Pumping Record Form 4 DOW DEP has provided this form for use by local Boards of Health. T System Pumping Recor must be submitted to the local Board of Health or other approving autirtyliwN OF NORTH ANQOVUR A. Facility Information Important: When filling out 1. System Location: forms on the j��a��� computer, use r7 S only the tab key Address to move your /VD cursor- do not City/Town State Zip Code use the return key. 2. System Owner: Ka Name V= Address (if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Dat /-- / 2. Quantity Pumped: ca/ nt� 3. Type of system: ❑ Cesspool(s) L7 Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 6. Condition of System: o -a 6. Syste�m Pumped By: tecl'lq- cab ✓ l 1�� �7 �o Name Vehicle License Number Company 7. Location where contents were disposed: �dLS-7---) _ A Signature of Hauler http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect j Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1