HomeMy WebLinkAboutMiscellaneous - 1770 SALEM STREET 4/30/2018 (2)N
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PUBLIC HEALTH DEPARTMENT
Town of North Andover
Community Development Division
CERTIFICATE OF
COMPLIANCE
As of: 11/5/15
This is to certify that the individual subsurface disposal system received a
SATISFACTORY INSPECTION of the:
Repair of D -Box
By: James Currier
At:
1770 Salem Street
Map 106.B Lot 0149
CN�or/th Andover, MA 01845
ThT�j�uance of this certificate shall not be construed as a guarantee that the system will function satisfactorily.
Michele Grant
Public Health Agent
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
North Andover Health Department
Community and Economic Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 1770 Salem St. MAP: 106.13 LOT: 0149
INSTALLER: James Currier
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
INSPECTIONS
D -Box INSPECTION: 10/29/15
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
❑ Contractor reports any changes to design plan
❑ Existing septic tank properly abandoned''
❑ Internal plumbing all to one building sewer
❑ Topography not appreciably altered
Comments:
SEPTIC TANK
❑ Building sewer in continuous grade, on compacted
firm base
❑ Cleanouts per plan
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ 1500 gallon tank has been installed
H-10 loading
❑ Monolithic tank construction
❑ Water tightness of tank has been achieved by
visual testing
❑ Inlet tee installed, centered under access port
❑ Outlet tee installed, centered under access port
(gas baffle/effluent filter)
❑ inch cover to within 6" of finish grade
installed over one access port
❑ Hydraulic cement around inlet & outlet
Comments:
PUMP CHAMBER
Comments:
CONTROL PANEL
Comments:
DISTRIBUTION -BOX
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ 1500 gallon Pump Chamber installed
❑ H-10 loading
❑ Monolithic tank construction
❑ Inlet tee installed, centered under access port
❑ Pump(s) installed on stable base
❑ Alarm float working
❑ Pump On/Off floats working
❑ Separate on/off floats
❑ Drain hole in pressure line
❑ cover at final grade installed over pump
access port
❑ Water tightness of tank has been achieved by
testing
❑ Hydraulic cement around inlet & outlet
❑ Alarm & Pump are on separate circuits
❑ Alarm sounds when float is tripped
❑ Location of control panel: basement
❑ Alarm signal located inside: basement
X Installed on stable stone base
X H-20 D -Box
❑ Inlet tee (if pumped or >0.08'/foot)
X Hydraulic cement around inlet & outlets
X Observed even distribution
X Speed levelers provided (not required)
X Schedule 40 PVC Pipe
Comments: 2 outlet pipes are not taken effluent, cannot sign COC yet. Title V inspector
needs to do further inspecting. Spoke to T -V inspector Brian Murphy. He will evaluate.
11/2/15 — spoke to Brian Murphy with B&D and Jim with Currier. The homeowner will
take down the tree. Currier will replace the 2 pipes. Asked them both to call with results.
11/3/14 — tree removed
11/4/15 — Spoke to Jay Currier — 2 outlet pipes were crushed because of the tree on top
of them
11/5/15 — D -box is taking equal distribution
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iN 5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1770 SALEM STREET
RECE D
OCT 19 2015 I
-,WN OF NORTH ANDOVER'
Property Address HEALTH Utr� �%
MARY HANCOCK
Q" ner CUv ner's Name
infortn is
equiredforevery NORTH ANDOVER, MA. 01845 10/12/15
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.
portant:
Immo
A. General Information
filling out forms
out
on the conputer,
use only the tab
1. Inspector
key to move your
cursor -do not
BRIAN S MURPHY
use the return
key.
Name of Inspector
B & D SEPTIC INSPECTIONS
Co rrpany Name
P.O. BOX 47
Company Address
HULL,
MA. 02045
CityrFown
State Zip Code
(781) 290-9942
S13675
Telephone Number
License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
❑ Passes ® Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
10/12/15
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 origi nal 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.
t5ns• 3/13 Title 5 Official InspectionFomc Subsurface Sewage Disposal System -Pagel of 17
Commonwealth of Massachusetts
Title 5 Official Insp
Subsurface Sewage Disposal System Form
1770 SALEM STREET
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E / a/wayscomplete 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.
Comm ents:
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):
t5i ns - 3113 Title 5 Official Inspection Form Subsurface Sevoge Disposal System • Page 2 of 17
ection
Form
- Not for Voluntary Assessments
Property Address
MARY HANCOCK
aNner Ory ner's Name
infortion is
equiredfor every NORTH ANDOVER,
MA.
01845 10/12/15
page. Cityrrown
State
Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E / a/wayscomplete 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.
Comm ents:
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):
t5i ns - 3113 Title 5 Official Inspection Form Subsurface Sevoge Disposal System • Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1770 SALEM STREET
Property Address
MARY HANCOCK
QN ner Ov ner's Name
information is
required for every NORTH ANDOVER, MA. 01845 10/1215
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
® Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if (with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
❑ Y ❑ N ❑ ND (Explain below):
❑ Y ❑ N ❑ ND (Explain below):
® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below):
D -box needs to be replaced due to tree roots on all sides of box
causing box to bow. System will pass title v upon replacement of box.
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if (with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ns • 3/13 Title official Inspection Form Subsurface Sevege Disposal System • Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M , •' 1770 SALEM STREET
Property Address
MARY HANCOCK
Ow ner Ow per's Name
inforrnation is
required for every NORTH ANDOVER, MA. 01845 10/12/15
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this farm.
3. Other.
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes No
❑
®
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑
®
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑
®
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
®
Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
t5uns • 3113 Title 6 Official Ins pection F orm Subsurface Sevege Disposal System. Page 4 of W
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 1770 SALEM STREET
Property Address
MARY HANCOCK
On/ ner O�v ner's Name
inforrnation is
equired for every NORTH ANDOVER, MA. 01845 10/12/15
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.
❑ IR 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 fallowing, 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 11 of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5irs - 3113 Title 5 official inspection Form: Subsurface Savage Disposal System • Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
µM 1770 SALEM STREET
Property Address
MARY HANCOCK
ON ner Cvv ner's Name
information is
required for every NORHT ANDOVER, MA. 01845 10/12/15
page. Cityrrown 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?
IN ❑ 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): 4X150=600
t5ns - 3113 Title 5 Official Ins pectlon F orm Subsiaface Semge Disposal System • Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 5••' 1770 SALEM STREET
Roperty Address
MARY HANCOCK
Ojv ner ON ner's Name
infornnation is
equired for every NORTH ANDOVER, MA. 01845 10/12/15
page. Catylfown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 3
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes W No
Water meter readings, if available (last 2 years usage (gpd)): ABX: 125 wd
Detail:
Sump pump?
Last date of occupancy:
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
Industrial waste holding tank present?
Non -sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
❑ Yes ® No
Gallons per day (gpd)
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
t5ins • 3M 3 Title 5 0ffidat Inspection Form: Subsu face SeHege Disposal System- Page 7 of 17
Commonwealth of (Massachusetts
Title 5 Official Inspection Fo
Subsurface Sewage Disposal System Form - Not for Voluntary
1770 SALEM STREET
Property Address
MARY HANCOCK
Om m
ner O+v ner's Nae
information is
required for every NORTH ANDOVER MA. 018
page. City/Town State Zip Co
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Type of System:
System last pumped 1 year - owner
gallons
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Yes ® No
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Altemative 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 (descri be):
tyre -3X13 Title50fficialIns pectionForm Sut%urfaceSewageDisposal System -Page 8of17
rm
Assessments
45 10/12/15
Code Date of Inspection
Date
Pumping Records:
Source of information:
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Type of System:
System last pumped 1 year - owner
gallons
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Yes ® No
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Altemative 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 (descri be):
tyre -3X13 Title50fficialIns pectionForm Sut%urfaceSewageDisposal System -Page 8of17
Commonwealth of Massachusetts
Title 5 Official Insp
Subsurface Sewage Disposal System Form
1770 SALEM STREET
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
32 years, system installed 12/82 - local BOH records.
Were sewage odors detected when arriving at the site? ❑ Yes FRI No
Building Sewer (locate on site plan):
"
Depth below grade: 20
feet
Material of construction:
® cast iron ❑ 40 PVC ❑ other (explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade: 16"
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:
12'x 6'x 5' 2000 pal.
Sludge depth:
1"
t5ins• 3113 Title5Official Ins pectionForm Subsurface Sewage Disposal System -Page 9of17
ection
Form
- Not for Voluntary Assessments
Property Address
MARY HANCOCK
CW ner Oru ner's Name
information
required f or every NORTH ANDOVER,
MA.
01845 10/12//15
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:
32 years, system installed 12/82 - local BOH records.
Were sewage odors detected when arriving at the site? ❑ Yes FRI No
Building Sewer (locate on site plan):
"
Depth below grade: 20
feet
Material of construction:
® cast iron ❑ 40 PVC ❑ other (explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade: 16"
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:
12'x 6'x 5' 2000 pal.
Sludge depth:
1"
t5ins• 3113 Title5Official Ins pectionForm Subsurface Sewage Disposal System -Page 9of17
Commonwealth of Massachusetts
Title 5 Official Insp
o Subsurface Sewage Disposal System Form
M 1770 SALEM STREET
Property Address
MARY HANCOCKm
ON ner Ow per's Nae
inforrnation is
equired for every NORTH ANDOVER,
page. City/Tow n
D. System Information (cont.)
Septic Tank (cont.)
ection
Form
- Not for Voluntary Assessments
MA.
01845 10/12/15
State
Zip Code Date of Inspection
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
2711 (outlet (@, 5211)
511
22°
Measured in field
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank and cement baffle's in good condition, liquid level with outlet, tank
appears sound no signs of leakage.
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
Dimensions:
Scum thickness
feet
❑ fiberglass ❑ polyethylene ❑ other (explain):
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
t,9ru• 3/13 Title50fficial Ins pectionForm Subsurface Sewage Disposal System -Page 10 of 17
Ory net
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1770 SALEM STREET
Property Address
MARY HANCOCK
ON ner's Name
NORTH ANDOVER MA. 01845 10/12/15
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
gallons
❑ polyethylene ❑ other (explain):
gallons per day
❑ Yes ❑ No
Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
* Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins- 3113 Titie50fficial lnspectionFom[ 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 ••' 1770 SALEM STREET
Property Address
MARY HANCOCK
CW ner Ojv ner's Name
inforrnation is
required for every NORTH ANDOVER, MA. 01845 10/12/15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
a
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 needs to be replaced due to tree roots on all 4 sides of box
causing sides of box to bow.
Recommend relocating box or removing tree.
Pump Chamber (locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order. ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins• W3 Tifle50ffidal Inspection Form Subsurface SeHegeDisposal System- Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspec
Subsurface Sewage Disposal System Form -
1770 SALEM STREET
Property Address
MARY HANCOCK
O'^' ner Cw ner's Name
is
equiredlon forevery NORTH ANDOVER,
page. City/town
D. System Information (cont.)
Type:
❑ leaching pits
E] leaching chambers
11 leaching galleries
El leaching trenches
® leaching fields
El overflow cesspool
Elinnovative/altemative system
tion
Form
Not for Voluntary Assessments
MA.
01845 10/12/15
State
Zip Code Date of Inspection
number:
number:
number:
number, length:
number, dimensions: 1 & 30'x35'
number:
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil conditions appear normal, no signs of hydraulic failure, vegetation
appears normal.
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
t5ns• 3113 Title5Official Impaction Form Subsurface SevsgeDisposal System - Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Insp
_ a Subsurface Sewage Disposal System Form
M s••' 1770 SALEM STREET
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.):
tyre- 3/13 Title 5 Official Ins pectionForm Subsurface Savage Disposal System - Page 14 of 17
ection
Form
- Not for Voluntary Assessments
Property Address
MARY HANCOCK
Ojv ner Ov✓ ner's Name
information is
required for every NORTH ANDOVER,
MA.
01845 10/12/15
page. City/Town
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.):
tyre- 3/13 Title 5 Official Ins pectionForm Subsurface Savage Disposal System - Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 1770 SALEM STREET
Property Address
MARY HANCOCK
Ow ner Ow ner's Name
information is
required for every NORTH ANDOVER, MA. 01845 10/12/15
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below.
❑ hand -sketch in the area below
® drawing attached separately
t5ns - 3113 Tide 5 Official Iris pection F orryc Subsurface Sewage Disposal System • Page 15 d 17
Commonwealth of Massachusetts
Title 5 Official Insp
Subsurface Sewage Disposal System Fo
M 1770 SALEM STREET
ection
Form
rm - Not for Voluntary Assessments
❑
Surface water
Property Address
Check cellar
MARY HANCOCK
Shallow wells
ON ner Cw ner's Name
information is
equiredforevery NORTH ANDOVER, MA.
01845 10/12/15
page. Cityfrown 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.
6'
feet
Please indicate all methods used to determine the high ground water elevation:
it
FN
C
Obtained from system design plans on record
If checked, date of design plan reviewed:
5/1/79
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:
Groundwater determined from design plan on record at local BOH,
water encountered Cad 6' (98.50) on perk test dated 3/31/79
ESHGW (@ 98.50 bottom of system (a- 104.82 per as -built on record.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ms• 3113 Tiitle50fficial InspecticnForm: Subsurface Sewage Disposal System -Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not ibr Voluntary Assessments
M i ' 1770 SALEM STREET
Property Address
MARY HANCOCK
Cw ner Ow ner's Name
inforis
equiredton forevery NORTH ANDOVER, MA. 01845 10/12/15
page. CityfTown State Zip Code ate of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information — Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins- 3113 Title50fficial IrspectionForm Subsurface SeNegeDisposal System - Page 17 of 17
L�
B & D SEPTIC. INSPECTIONS
STATE CERTIFIED TITLE V INSPECTIONS
P.O.BOX 47 HULL. MA. 02045 PHA781) 290-9942
BnDSepticinspect@aol.com Fax (781) 843-3807
N A
1770 Sa1e•� SE" A.), �tno�aver
p -Bax ,4tac= 23.6.E
C&D:
3V
'i:
p
c.X-
Commonwealth of Massachusetts Map -Block -Lot
106.BO149
BOARD OF HEALTH -----------
Permit No ---------
North Andover- BHP -2015-0889 89 -
--------------- --
P.I. FEE
F.I. $125.00
-----------------------
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted James Currier ------------------------------------------------------------------------------------------
--------- ----- -----
to (Repair) an Individual Sewage Disposal System.
at No 1770 SALEM STREET __ — bo x-
- 0 ------------------------------------------------------------------ ----------------------------
as shown on the application for Disposal Works Construction Permit No. BHP -2015-088__ Date er 22, 2015
--------------------- ----------------
--- -----------------------
Issued On: Oct -22-2015 BOARD OF HEALTH
----------------------------------------------------------------------------------
THIS
by J s_
at No --- 777 -- - --------------
has been insta n
cc ccordanc,
application for Disposal Works
Printed On: Oct -22-20U /
- ---------------------------------------
Com nweal of Massachusetts M -Block-Lot
'w -Block-Lot
1 6. 149
BOAR 0 LTH --- ---- -------------
ERT Nort n r P Massachusetts
4�P
...... . . . . . . .
--------------------- ;0 --- -- -- j'�> --- ----------- -----------
State Environmental Code as *be ' the
�����88 Dated October 22, 20115
-----------
-----------------------------------------------------------------
BOARD OF HEALTH
Commonwealth of Massachusetts Map -Block -Lot
106.BO149
BOARD OF HEALTH -----------------------
Permit No
North Andover - BHP -2015-0889 89 ----
-----------------
FEE
$125.00
-----------------------
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted James -Currier ------------------------------------------------------------------------------------------
to (Repair) an Individual Sewage Disposal System.
at No -17 -7 -0 -SALEM -STREET -------- .-t-bu --------------------------------------------------------------------------------
as shown on the application for Disposal Works Construction Permit No.B r -T ��,OVMIX Q)ctober 22, 2015
---------------------------
- - -------------------------------------------------------
Issued On: Oct -22-2015 BOARD OF HEALTH
------------------------ -------------------------------------
• Application for Septic Disposal System
Construction Permit —TOWN OF
NORTH ANDOVER, MA 01845
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
Application is hereby made for a permit to:
❑ Construct a new on-site sewage disposal system*
lo_2z-1�' , )_
TODAY'S DATE
$ 250.00 – Full Repair
$125.00 - Component
❑ Repair or replace an existing on-site sewage disposal system* f
Repair or replace an existing system component —What? l! l / co, k/
A. Facility Information
or Lot #
City/Town
"a-
2.- *TYPE OF SEP C SYSTEM*:
OCT 2A2015
➢ ❑ Pump Gravity (choose one)
***If pump sy9tem, attach copy of electrical permit to application—
OF NORTH ANDOVER
➢ Conventional System (pipe and stone system)
TOWN EPARTMENT
➢ El Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to o is type of system.)
➢ ❑ Pressure Distribution S.A.S. (No D -Box)
➢ ❑ Pressure Dosed (D -Box Present) S.A.S.
➢ ❑ Does the system require an effluent filter? Yes
No
If yes, does plan specify make and model of filter. YES = (no further info. needed)
NO = (installer must specify brand of filter before DWC issuance)
What is the Make?
2. Owner Information
i
Name
Address (if diff rent from above)
City/Town
Email address
What is the Model.
5Y__
State
Telephone Number
3. Installer Information
Namea of Company
l °d/�1_�
City/Town
4. Designer Information
Name
Address
City/Town
Zip Code
t_ l 015;
�f
State Zip Code
q?14/2,-*3 �'Y/:::; I?
TIP one Number (Cell Phone # if possible please)
e4��"
Name of Company
Zip Code
Number (Best # to Reach)
\- \
Application for Disposal System Construction Permit • Page 1 of 2
A• Application for Septic Disposal System
.~^ "�� ,!- TODAY'S DATE
Construction Permit - TOWN OF
MW NORTH ANDOVERpair
, MA 01845 $125.00 - Component
PAGE 2OF2
A. Facility Information continued....
5. Type of Building: Residential 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. I understand that until a final Certificate of Compliance has been issued by
this B and of Health, a installed system is not approved.
N/111e Date
Application Approv o of Health Representative)
N Date
Application Disapproved for the following reasons:
For Office Use Only:
Z Fee Attached? Yesz No
2. Project Manager Obligation Form Attached? Yes No
3. Pump S sy tem? If so, Attach copy ofElectrical Permit Yes No
Applicantreceived copy of
"Electrical Inspection Notes for Septic Systems" Yes No
Handout?
4. Reviewed approvalletter, all paperwork received? Yes No
Missing:
5. Foundation As -Built? (new construction only):
(Same scale as approved plan)
Yes No
6. Floor Plans? (new construction only): Yes No
Application for Disposal System Construction Permit • Page 2 of 2
Summary Record Card genmWd an Sr25r1015 IZ49:52 PM by Karma Hardw Page 1
Town of North Andover
Tax Map # 210-106.B-0149-0000,0
Parcel Id 17553
1770 SALEM STREET
HANCOCK, LAWRENCE & MARY
1770 SALEM STREET
N. ANDOVER, MA
01845
Class 101 Single Family Property Type 1 Residential
Zonin92 1 Residential Zonin93 1 Residential
Size Total 1.01 Acres
FY 2016
UB Mailina Index
Name/Address
HANCOCK, LAWRENCE 8 MARY
1770 SALEM STREET
N. ANDOVER, MA
01845
UB Account Maint.
Account No Cycle
Bldg Id. 17593.0 -1770 SALEM STREET
3170263 03 Cycle 03
UB Services Maint.
Account No. 3170263
Service Code
MISCFEE ADMIN FEE
WTR WATER
UB Meter Maintenance
Type Loan Number ActiveMact. From
Payor
Occupant Name Activelinactive
Last Billing Date 7/14/2015
Active
Rate Charge Multiplier/Users
0.635/8 7.82 1/
01 ALL METER SIZE 49.40 /1
until
Account No. 3170263
Serial No Status
Location
Brand
Type Size
YTD Cons
18736625 a Active
ERT HH
METE METE
w Water 0.63 0.63
553
Date
Reading
Code
Consumption
Posted Date
Variance
6/8/2015
999
a Actual
13
7/24/2015
7%
3/912015
986
a Actual
12
4/28/2015
-140/6
12/9/2014
974
a Actual
14
1/15/2015
-24%
9/10/2014
960
a Actual
19
10/15/2014
16%
6/9/2014
941
a Actual
16
7116/2014
-3%
3/10/2014
925
aActual
17
4/11/2014
40/6
12/6/2013
908
a Actual
15
1/17/2014
-1%
9/11/2013
893
a Actual
16
10/15/2013
-15%
6/12/2013
877
a Actual
19
7/24/2013
4%
3/1212013
858
a Actual
18
4/22/2013
4%
12/11/2012
840
aActual
17
1/9/2013
-14%
9/13/2012
823
a Actual
21
10/15/2012
12%
6/11/2012
802
aActual
18
7/16/2012
7%
3/13/2012
784
aActual
17
4/14/2012
-1%
12/13/2011
767
aActual
17
1/17/2012
-12%
9/14/2011
750
a Actual
21
10/13/2011
-14%
6/8/2011
729
a Actual
23
7/20/2011
6%
3/8/2011
706
a Actual
21
4/1312011
1 %
12/9/2010
685
aActual
21
1/12/2011
-4%
9/10/2010
664
a Actual
23
10/15/2010
-10%
617/2010
641
aActual
24
7/15/2010
16%
3/10/2010
617
a Actual
21
4/14/2010
-3%
12/10/2009
596
a Actual
22
1/12/2010
7%
9/10/2009
574
a Actual
21
10/15/2009
-10%
6/912009
553
a Actual
22
7/20/2009
11%
3/13/2009
531
a Actual
21
4/29/2009
-1%
12/10/2008
510
aActual
21
1/20/2009
00/0
9/9/2008
489
a Actual
22
10/10/2008
-6%
615/2008
467
a Actual
21
7/16/2008
12%
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
1770 Salem Street
(Address of septic system)
Relative to the application of Jap Currier
{Installer's name)
Dated 10/23/15
(ioday's ate
For plans by
(Engineer)
And dated
ngtn ate
With revisions dated
(l..ast 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 pripr to
performing any work on a site. I must have the approved plans and the pemnit on site when any work is
beinge
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 ins ection, without completion of the items in accordance
with Title 5 and the Board of Health Regulations may result in a S50,00 fine being levied against me and/or
xny 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: healthdcptt(a 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. j furthe
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, significant 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. Detetmfnadon that the proper elevation of the excavation has been react. ed
b. Inspection of the sand and stone to be used.
c. Final inspection by Board ofHealth staffor consultant.
d. InstaUadon of tank, D Box, pipes, stone, vent, pump chamber, retaining wal1 and other
components.
G. As the installer. I understand that I am solely responsible for the installation of tbesytern as,ger the
api2roved plans No instructions by. the homeowner, general contractor, or any other persons :hall absolve
me of this obligation.
Undersigned Licensed Septic Installer. James Currier
(Today's Date) 10/23/15
James Currier II Qom, Lam_
oz"f�
ame —Print) a —Signed)
TO: NORT i ANDOVER, MASS. December 9 1982
BOARD OF HEALTH
FROM:
DESIGN ENGINEER Re: Soil Absorption
Sewage Disposal
System
This is to certify that I have inspected the const
said disposal system at Lot J-, Salem Street
Site LoAW
North Andover, Mass.
The grades and construction materials are as spe'
specifications dated February 6 ,1979 and A
Revised May 1, 1979.
materials of
OF
CRICHARD �
F. 7
KAMINSKI Ca
No. 280 '
AL i
m er 9 19 82 .
Reg. Prof.Engineer/Reg. Sanitarian
�C: tc�i �±�'{:%; gl'h��s• ^�%rC�KJv Sit -TIC STSlEX
INSTAUJJIM CH33K Li ST
nIL
W
React
t �
ci Ctn f,s , r--
TAUC- 1W"
f
1. Distance Tot
a. Wetlands
b. Drains
C Well
2. Water bine Location
LOT 0 '_J_ S&LjrV--Y
L•1
rJ FILL
ti
rr" 3. No PPC Pipe
%. Septic Tank
a. _Tees -_Length & To Clean Dut Covers.. -
b. Cement Pipe to Tank on Both Sides of Tank
-. 5. Distribution Box
' a. Covers & Box - No Cracks
-�/ b. All Lines Flowing Equal Amounts
c. No Back Flow
6. Leach Field or Trench
�- a.
Dimensions
b.
Stone Depth
c.
Capped maids
Clean Double Washed Stone
7. Leach Pits
a.
Dingnsionsl
b.
Stone Depth
c.
Splash' Pads
d.
Tis
e.,AC anent Pipe to Pit - Both Sides
f.
Clean Double Washed Stone
8. No Garbage Disposal
9. Yinal Grading Inspection
Po V_
10. Barricading Covered System
As Built Submitted
a. Lot Location
b. Dimensions of System
c. Location with Aegard_to Perc Test
d. Elevations
e; Water Table
taAaj art Uer
I'Ot?TH ANDOVER BOA iD OF HEALTH / U 7-.
_PPROVED mj,P9 PROVIDED
A
Title 5
Reg. 2.5 IT
Reg. 6
i
DK
(
a)
DISAPPROVED DATE T111E REASON
submitted plan must show as a minumum:
the lot to be served (area,dimensions,l.ot #,abutters)
(Planning Board files)
location and log of deep observation holes -distance
to ties
location and results of percolation tests -distance
to ties
s & calculations showing required
design calculation
_leaching area
location and dimensions sf system .(including reserve
area)
existing and proposed contours
location of any wet -areas within 100 of the sewage
disposal- system -ot--disclaimer (check wetlands mappin
surface and subsurface drain's within 100' of sewage
disposal system or disclaimer
location of any drainage easements within 100' of
/sei-;age disposal system or disclaimer (planning board
files)
known sou-r-ces_-of-writer: supply- within=. 200' of sewage
disposal_. -system= o-r--_disclaiiner :
location of any proposed -well to sery-e---the--lot ('100'
from leaching facility)
location of water lines on property (10' from.leachi
facilities)
%ocation of benchmark
driveways
garbage disposers
no PVC is to be used in construction
a profile of the system (elevations of basement, ply
pipe septic tank, distribution box inlets and outlet=
distribution. -field piping and any other elevations)
maximum ground water elevation in area of sewage di..
system
(s) plan must be prepared by a Professional Engineer or
other professional authorized by law to prepare such
plans.
Suit Tanks
%a Capacities - 150%_of flow, water
%' of tees, access,. pumping,
Cleanout
e 10',from cellar wall or inground
(d 25' from subsurface drains
table, tees, depth
swimming pool
ail
t
'stribution Boxes
�(a Slope greater than 9.08
(b� Sump
Leaching Pits
Leaching pits are preferred where the installation is
possible
(a) Calcul ions of leaching area (minimum 500 S.F.)
(b Spa ng
ng
C rface drainage 2%
d Cgver material
E'- 2 iZ'4" SSP1,Sk
n re c a- C-1 bo .a (ql .rc o �ti+.�4, , .. • � �.. �- �� � � •�
Le hing Fields
:Greater than 20 minutes/inch
�b Area ' (minimum_ -.900 S.F.)
Construction of field
Surface. drainage 2%
(e 20' from - cellar wall or inground- swimming pool
Leaching Trenches.
(a) Calculations of leaching area (min. 500 S.F.)
(b) Spacing - (4 ft. min. 6 ft. with reserve between);
(c) Dimensions
(d _ onstructiori- _-A
(e :Stone-
(f Surface .drainage 2%
Downhill Slope
�a)
ra Slop y/x = to be shown
b) y/ X'150 = to be shown
Pum -Pe
(a) . Appr val
. (b Stan' -by power
J
• SOIL PROFILE & PERCOLATIO EST D TA
Town/City pips
No.&Street -1Z Lo4
t No.
Loc. /Subdiv.�.�� Plan Owner,_
/ r
Investigator tlti 1 Observer 2
SOIL PROFILES -DATE
1'
Elev.Elev.3' Elev.______ 4'Elev.�5�
n i — A— 0 0 ----,
1
2
3
4
5
6
7
8
9
10
Benchmark Location
Elevation Datum
Percolation Tests -Date
1
2
3
4
5
G
7
8
9
10
y -
Pit Number 1 2 `3 4 5
Start Saturation
Soak -Mins.
Start Test -Time
D-rop of 3" -Time 10
Drop of 6" -Time`
Mins. s "Dro
Notes & Sketches on Back Frank
y�C.�Gelinas & Associates, North And.
TO .BUILDING INSPEC LOR:
Dec 20, 1982
This Board :issues a condtional final
approval on the septic system installation on Lot J. Salem St.
_)endinG a final reinspection of the tank and connecting pipes
to be done as soon as permitted by spring, 1983 thaw.
I�.ichael Rosati, S.
Health Insuector
I I
0 fQ 5.
FELEN/A 440
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