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Miscellaneous - 18 JOHNNY CAKE STREET 4/30/2018
(D (D fi North Andover Board of Assessors Public Access , Page 1 of 1 t pORr►/ 1 O ttu•o •• Q•G • o �4�4 �,SSACMUgtS Click Seal To Return Search for Parcels Search for Sales Summary Residence Detached Structure Condo Commercial �roperty Record Card Location: 18 JOHNNY CAKE STREET Owner Name: LESSARD, BRIAN R KRISTEN V LESSARD Owner Address: 18 JOHNNY CAKE STREET City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 8 - 8 Land Area: 1.75 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 2544 soft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 588,100 614,000 Building Value: 355,500 369,300 Land Value: 232,600 244,700 Market Land Value: 232,600 Chapter Land Value: http://csc-ma.us/PROPAPP/display.do?linkId=1181891 &town=NandoverPubAcc 9/30/2008 Cf NORT :,y 7147 F P • Town of North Andover :o HEALTH DEPARTMENT ACMUSt� V �./ CHECK #: DA LOCATION:lYtTIAN], �A H/O NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) $ ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type. $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ Title 5 Report $ ❑ Other: (Indicate) $ UU Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Owner information is required for every page. Commonwealth of Massachusetts P J/ Title 5 Official Inspection Form f Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ✓ 0[l 18 Johnny Cake Street Property Address Brian R. Lessard Owner's Name North Andover MA 01845 July 7, 2015 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: When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor - do not Peter Reilly use the return key. Name of Inspector Peter Reilly Company Name 136 Andover Street Company Address Andover City/Town 978-375-3750 Telephone Number B. Certification 0 State S11955 License Number RECEIVED AL I I 1 3 2015 --- TOWN 015 --- TOWN OF NORTH ANDOVER KALTH DEPARTMENT 01810 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Furth aluation by the Local Approving Authority J� 7, 2015 Inspec is Signat 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 • 3/13 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 18 Johnny Cake Street B. Certification (cont.) MA 01845 July 7, 2015 I State Zip Code 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 information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Property Address Brian R. Lessard Owner Owner's Name information is required for every North Andover page. City/Town B. Certification (cont.) MA 01845 July 7, 2015 I State Zip Code 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 information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 3/13 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 18 Johnny Cake Street Property Address Brian R. Lessard _ Owner Owner's Name information is North Andover MA 01845 Jul 7 2015 required for every _ y page. City/Town 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 ❑ 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 pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Johnny Cake Street Property Address Brian R. Lessard Owner's Name North Andover MA CityFrown State B. Certification (cont.) 01845 July 7, 2015 Zip Code Date of Inspection 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) 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 - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Johnny Cake Street _ Property Address Brian R. Lessard Owner Owner's Name information is North Andover MA _ 01845 Jul 7 2015 required for every � � page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Johnny Cake Street Property Address Brian R. Lessard _ Owner Owner's Name information is North Andover MA 01845 Jul 7, 2015 required for every _. y page. CityFrown 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): 440 t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Johnny Cake Street _ Property Address Brian R. Lessard _ Owner-- - — - -- --- -- Owner's Name information is North Andover MA 01845 July 7 2015 required for every _. _ � page. City/Town State Zip Code Date of Inspection D. System Information Description: 1,500 gallon septic tank / d -box / SAS (3-80' trenches). Original system installed in 1992 per "as -built" plan on file at BOH. Number of current residents: Yes 3 No ❑ 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 9 ( Y 9 (gpd)): 200 gpd avg. Detail: Sump pump? ❑ Yes ® No Last date of occupancy: currentDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Johnny Cake Street Property Address Brian R. Lessard Owner Owner's Name information is North Andover MA 01845 Jul 7, 2015 required for every _ � page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: currently occupiedDate Other (describe below): t5ins • 3/13 General Information Pumping Records: Source of information: owner: pumped every year for past 6 years 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): Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 18 Johnny Cake Street _ Property Address Brian R. Lessard Owner Owner's Name information is North Andover MA 01845 July 7 2015 required for every _.... _ _ , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Ordinal system installed in 1985. Design and as -built plans on file at BOH. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 2 +/ feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line. N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Building sewer was watertight an appeared sound at the foundation. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal Tank is about 15" below the surface. 1.5' +/- feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: — - — — years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: rectangular approx. 6' x 12' Sludge depth: 1" - 2.. t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 18 Johnny Cake Street Property Address Brian R. Lessard Owner Owner's Name information is required for every North Andover MA 01845 July 7, 2015 page. City/Town State Zip Code Date of Inspection t5ins • 3/13 D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" - Scum thickness 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 16" How were dimensions determined? estimation/measurement Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was watertight and appeared to be functioningrp operly. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal N/A feet ❑ 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: Data Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Johnny Cake Street _ Property Address Brian R. Lessard Owner Owner's Name information is North Andover MA 01845 Jul 7, 2015 required for every _ _ Y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions Capacity: gallons Design Flow: - -- -- - - gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: date Comments (condition of alarm and float switches, etc.) * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection 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 18 Johnny Cake Street Property Address Brian R. Lessard _ Owner Owner's Name information is North Andover MA 01845 Jul 7, 2015 required for every —. � page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): 0" Depth of liquid level above outlet invert - - — -- 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.): Two lines leading to SAS were accepting effluent evenly. Little carryover was evident. The box was was in good condition. D -box was replaced in 2008. The box cover was about 24" The reader is cautioned that the system is 30 years old and there is no way to know how long it will continue to meet Title V requirements. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 18 Johnny Cake Street Property Address Brian R. Lessard Owner Owner's Name information is North Andover MA_ 01845 Jul 7, 2015 required for every ._ )� page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2 - 80' trenches ❑ 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.): Soils in the area of the SAS appearl normal, no signs of breakout. 2-80' trenches per design plan. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration — Depth - top of liquid to inlet invert — Depth of solids layer Depth of scum layer Dimensions of cesspool ---- Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Johnny Cake Street Property Address Brian R. Lessard _ Owner Owner's Name information is North Andover MA 01845 Jul 7, 2015 required for every _— Y 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.)-. t5ins • 3/13 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 18 Johnny Cake Street_ Property Address Brian R. Lessard Owner Owner's Name information is North Andover MA 01845 July 7, 2015 required for every . _ — page. City[Town 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 APP. WTR. HOUSE A I B AN REAR YARD D- TIES: Box A to Tank: 33.0' B to Tank: 31.0` SAS A to D -Box: 52.5' B to D -Box: 48.0' l5ins - 3113 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Johnny Cake Street Property Address Brian R. Lessard Owner's Name North Andover City/Town D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: MA 01845 July 7, 2015 State Zip Code Date of Inspection >4' below bottom of SAS feet Please indicate all methods used to determine the high ground water elevation: // // e ❑■ R Obtained from system design plans on record If checked, date of design plan reviewed: 1985 Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: Design plan on file at BOH indicated that the SAS was 4' or greater below the high groundwater elevation at that time. Checked with local excavators, installers - (attach documentation) Accessed USGS database - explain: USGS data not specific to site. You must describe how you established the high ground water elevation: Soils, grade changes, and lack of sump pump indicates adequate groundwater separation. Howwever, the precise ground water elevation cannot be determined for certain without a soil evaulation test. NOTE: Soil evaulation is the recognized method for determining or establishing the high groundwater elevation. Since I am not a licensed or certified soil evaulator, I am not qualified to determine or establish the high groundwater elevation beyond the public information available, such as recent design plans of the site or the nearby area. My estimation of the high groundwater elevation is based on a due diligence effort to obtain all available information both on and off the site and my experience as a certified septic system inspector. (see attached Discliamer) Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 18 Johnny Cake Street _ Property Address Brian R. Lessard Owner Owner's Name information is North Andover required for every page. City/Town MA 01845 July 7, 2015 State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 DISCLAIMER This passing septic inspection under Massachusetts Title V is in no way a guaranty or warranty of the inspected septic system. The inspection is a "snapshot in time" and does not constitute a complete assessment of the quality or potential longevity of the septic system. The pass/fail criteria are specific and outlined in detail in this report. Under the limited criteria of a Title V inspection, it is impossible to determine how long any septic system will last. The inspector made a diligent effort to certify the septic system based on the criteria required under Title V. Under Massachusetts Title V, soil evaluation is the accepted method of determining the high groundwater elevation. This inspector is not a certified soil evaluator and is therefore not qualified under Title V to determine or establish the high groundwater elevation. The method used to estimate the high groundwater for this inspection was based on the public records and methods of observation described on the previous page. Groundwater levels can vary greatly from season to season, year to year and soil evaluation is considered the most reliable method of groundwater determination under Title V. Peter F. Reilly Inspector July 7, 2015 Dsc -14- I 4) &Lk IC Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 _ SveyO DEP has provided this form for use by local Boards of Health. Othe RECEIVED NOV 2 5 2008 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT r forms may be used. but 1 information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: Left front, left rear, left side of house. Right fron right rear fight sid of house forms on the computer, use only the tab key Address to move your cursor - do not use the return City/Town State Zip Code key. 2 System Owner: Name Address (if different from location) Cityrrown Stateip Code , 575 Telephone Number B. Pumping Record 1. Date of Pumping Date 2• Quantity Pumped: Gallons 3. Type of system: Cesspool(s) eptic Tank Tight Tank Other (describe): / 4. Effluent Tee Filter present? [I Yes U'te If yes, was it cleaned? [j Yes Q No 5. Condition of S stem: cxu,-� ��&-t \ v�, 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: Lowell Waste Water F 5821 Vehicle License Number ZEN-�-- re of H u r Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 �%/fes ,�,i/ To ;�- '� i'--, � 'd C a G� c � Z �o ° '' 0 bd � � "•. tier°ar 00 ;o 00 o 5' CD n p- c ID O O ca°o C O ° Z pp O y O (D Er =- y o b O :3-� ° =3 o rn N < �_ om (j) 0 3 . CD r\ :. 0 o o � Oo o N CD a w r+ 0 x ITI;WC0 CD '�� 00 IQ b9 j3 ;O N t- 00 O TOWN OF NORANDOVER of NORTH Office of COMMUNITY DEVELOPMENT AND SERVICES o �° HEALTH DEPARTMENT p 1600 OSGOOD STREET; Building 2-36 " r NORTH ANDOVER, MASSACHUSETTS 01845 "SS„CHUstt� Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 97 .688.8476 — FAX 1 7 0 ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: INSTALLER: 0 G DESIGNER: PLAN DATE. BOH APPROVAL DATE ON P INSPECTIONS TANK INSPECTION: MAP: LOT: 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 1 of 6 w 1f ,&ORT4 Commonwealth of Massachusetts Map -Block -Lot o� �,.•, .. �40 107.A- 0202 - s� • 4t ----------------------- Board of Health Permit No s BHP -2008-0209 North Andover ^°, •.» ` P.I. FEE y b�•.,°-`�.. $125.00 ess�cMuy�i F.I. Disposal Works Construction Permit Permission is hereby granted Mike Reilly to (Repair -D -BOX) an Individual Sewage Disposal System. at No 18 JOHNNY CAKE STREET as shown on the application for Disposal Works Construction Permit No. BHP -2008-0209 Dated _-October-0-9,-2-008 ----l=.-=1-- - t- - �-------------------------------------- Issued On: Oct -09-2008 Board of Health ---------------------------------------------------------------------------------- 'joRTM , Commonwealth of Massachusetts Map -Block -Lot <_ �' ° • , �0 107.A- 0202 - oj "4 at Board of Health North Andover Y py - 4• f Certificate of Complian THIS IS TO CERTIFY, That>Individual Sewage ' posal System (Repair-D-BOX) /9 G^�C by Mike Reilly /� -------------------------------------------- w staller at No 18 JOHNNY CAKE STREET esdescribed __0___ ,�7 ------------------------- has been installed in accordance with the provisions of TITLE 5 of the State Environmental Cod in the application for Disposal WorkConstruction Permit No. -BHP-2008-0209 Dated ---October 09, 2008 --- Printed On: Oct -08-2008 Board of Health CONTRACTOR NAME: Type of Permit or License: (Check box) Gf MORTp \ � Animal h 4 +1./ V ttJJ / F f 9 Town of North Andover $ ❑ Body Art Practitioner $ HEALTH DEPARTMENT emustt CHECK #: 1 DATE: ❑ LOCATION: /,0� $ ❑ Funeral Directors $ ❑ H/O NAME: $ ❑ Massage Practice $ ❑ CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑• Septic - Design Approval $ Q Septic Disposal Works Construction (DWC) $� ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other: (Indicate) c4i-OW. Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer RTS Application for Septic Disposal System ole�' pConstruction Permit — TOWN OF TODAYIS DE ORTH ANDOVER, MA 01845 ® e air 4V,eo SLHUS 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 ❑ Re it or replace an existing on-site sewage disposal system* only the tab key to move your Repair or replace an existing system component — What? rD cursor - do not use the return key. A. Facility Information �, w 10 U o A A4 GI Q Address or Lot # Ah no % �4r doy&- ,„ City/Town 2.- *TYPE OF SEPTIC SYSTEM*: ❑ Pump ❑ Gravity (choose one) ***If pump system, attach copy of electrical permit to application*** ❑ Conventional System (pipe and stone system) ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D -Box Present) S.A.S. 2. Owner Information Br -r 4r, L c sS 4rr( Name Address (if different from above) City/Town State Zip Code q7 8- 5- 9d — .75 90 Telephone Number 3. Installer Information ,t^ ��1� 1/4 soAV5 e„ 2r' i� /' t Name Name of Company 2-06 A ra�2 V�-51� A ress a�2 Ver— City/Town State Zip Code 97 375—YIN/ 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 QRTN Appligation for Septic Disposal System O <tNo °Ati -Construction Permit -TOWN OF �' •ORTH ANDOVER. MA 01845 PAGE 2OF2 A. Facility Information continued.... 5. Type of Building:esidential Dwelling or ❑Commercial B. Agreement /a1, off' TODAY'S DATE $ 250.00 - Full Repair $125.00 - Component The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the 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 beesd by this Board of Health. %A/2" Name Date Application roved By: ( and of Health Representative) • • • • Name Date lication Disapproved for'the following reasons: For Office Use Only: Application for Disposal System Construction Permit • Page 2 of 2 1. Fee Attached. Yes // No 2. Project Manager Obligation Form Attached. Yes No 3. Pump S sv tem? If so, Attach copy ofElectrical Permit Yes ^ % lel No 4. FoundationAs-Built? (new construction ronly): Yes No (Same scale as approved plan) 5. Floor Plans? (new construction only): Yes No 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: / F, (Address of septic sys m) Relative to the application of /� 1 (Installer's name) Dated /v r% o ay s ate For plans by (E,dee' eer) And dated Al (ungdnal date) With revisions dated /U/A (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 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 M 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: healthdeptQtownofnorthandover.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 seutic 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. 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 ofHealth 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 annroved plans. No instructions by the homeowner. -aeneral contractor. or anv_other bersons shall absolve me of this obligation. Undersigned Licensed Septic Installer: (Today's Date) ame - rint r-. 71vaAme - t e Page 1 of 1 Attachments can contain viruses that may harm your computer. Attachments may not display correctly. DelleChiaie Pamela From: DelleChiaie, Pamela Sent: Tue 9/30/2008 11:03 AM To: brian.lessard@allstate.com Cc: Subject: 18 Johnnycake Street - Health Dept. File Attachments: 11 SKMBT 60008093010350.pdf(iMB) Hello Brian, Here is a copy of your complete Health Dept. File. It appears that Thomas E. Neve Associates at 447 Old Boston Road, Topsfield, MA was the original engineer back on 4/5/85. The Title 5 report was done on 8/28/98. Your pumping records appear to be up to date. Here is some information on pumping from DEP: How Often Should I Pump Out my Septic Tank? Regular Maintenance is the single most important consideration in making sure your?septicsystem, whether it is a conventional septic system, an innovative/alternative(I/A) system, or a cesspool, works well over time. An amazing number of system owners believe that if they haven't had any problems with their systems, they don't need topump out their tanks. Unfortunately this is a serious and sometimes costly misconception. As your system is used, solid materialssettle to the bottom of the tank, forming a sludge layer. Grease and lightweight materials float to the surface ofthe septic tank as Scum. Normally, properly designed tankshave enough space for up to 3 to 5 years' safe accumulation of sludge. When the sludge level increases beyond this point,sewage has less time to settle properly before leaving the tank. As the sludge level increases, more solid wastes escape intothe soil absorption system (SAS). If the SAS becomes so clogged that it cannot absorb liquid at the rate at which it entersthe tank, the plumbing will "back up" or unsanitary wastewater will bubble to the surface. Remember: Regular pumping helps prevent solids from escaping into thedrainfield and clogging soil pores. While pumping frequency is a functionof use, MassDEP recommends that systems be pumped at least once every 3 years for homes not having a garbage disposal. Ifthe home's system has a garbage disposal, it should be pumped every year. If you are a nonresidential system owner, you should determine how often to pump based on prior accumulation and pumpingrecords. Often you can look at pumping intervals to gauge your pumpingschedule (i.e., previously did you wait too long before having your tank pumped and it was filled to capacity, or could youhave waited a little longer to pump?). When hiring a pumper, be sure the local Board of Health haslicensed them, and always make sure you get a paid receipt from the pumper that spells out the details of the transaction(how many gallons were pumped out of the tank, the date, the charges, and any other pertinent results). Retain this receiptfor your records. The pumper sends a copy of this report to the local Board of Health. Pamela DelleChiaie From: noreply@yourcopier.com [mailto:noreply@yourcopier.com] Sent: Tue 9/30/2008 11:36 AM To: DelleChiaie, Pamela Subject: Message from KMBT 600 http://exchange2003.town.north-andover.ma.uslexchangelpdellechiaie/Sent%2OItems/ 18%... 9/30/2008 W'ILLIAAI F. WELD Govemor ARGEO PAUL CELLUCCI Lt. Governor COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON. NIA 02108 617-293-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: C�) C*tKV_, CJS' 4\ Date of Inspection:r � � Name of Inspector: q 6 M I ptj U)( I am a DEP approved system inspector pursuant to Section Company Name: t-�QrAlp_ko Mailing Address: 19 -t -CI G� -C LI/ktt9 vim, Telephone Number: 600 • 6 (OIL • GFb Cl 1l Vagsgg4► ne� A O lg-,c 5 (If different) 15.340 of Title 5 (310 CMR 15.000) TA EVA) 4460A �, M {A © -Lk g 2— TRUDY COQ Sccrcu DAVID B. STRUI Commission CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: �' Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails -e Inspector's Signature: U Date: .9 125 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. 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, upor completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/23/97) Page 1 of 10 DEP DEP on the World Wide Web: http:tlwww.magnet.slate.me.us/dep 0 Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: I.e) A\A0(: Yf4C' NAA ©l2AL Owner: StEMCVk .k 1--\,,!•klrJ , NU sl Sscn" Date of Inspection: �j - I -LS . 9 Qj 61 SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health), Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed CJ 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 20 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: i.� .Jot{N�rl�' CCK S \ \�Qqz(� ',+� IAV"88 40k ©�8� Owner: STt �aJ (3 1� rl U dJ 5a rQ Date of Inspection: Dj SYSTEM FAILS: You must indicate ew.er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to toner the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. Ej LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Paye 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: t.0 Sat}rQte`( ower-_ & , Vl©q�tC �t`RtDaVc�f'`� l S Owner: S`(PLV t Q {- L_ -J kZ IA 1,k IJ 4' ° Date of Inspection: tib - et e Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No _ Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non -sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions', depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub -Surface Disposal System. _ Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)j (revioad 04/35/97) Pay 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1. 5�) �"3"k"t-L`( Oc�)(-& S�, 1�JR`( t-TN��OV ` �V ► I iv� c,� Owner: `S `vtAk LAN V� A Date of Inspection: Ta FLOW CONDITIONS RESIDENTIAL: Design flow: `114Q g.p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents:- Garbage grinder (yes or no):�� Laundry connected to system (yes or no):�Ot> Seasonal use (yes or no)AAQ !� 3QZ 'j PA s (9 -A Water meter readings, if available (last two (2) year usage (gpd). Sump Pump (yes or no): NO Last date of occupancy: Occ'`3fkvp COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present: (yes or no),_ Industrial Waste Holding Tank present: (yes or no)_ Non -sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) _ Last date of occupancy: PUMPING RECORDS and source of information: L_Asr Nvho .O SUMMW2 OF System pumped as part of inspection: (yes or n If yes, volume pumped: gallons Reason for pumping: GENERAL INFORMATION TYPE,QF 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) N'0 (revised 0{/75/97) Page 5 of 10 l Z — 1'3w" SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 J oKi�N�'l �-��L s k , �kc i 1`:UJOV`2 \ VA6 Q \Q�q �' Owner: \ F L\KQ (Pc \AA)S(3\4 Date of Inspection: Zg 9 9J BUILDING SEWER: (Locate on site plan) Depth below grade: 2 Material of construction: _ cast iron /40 PVC _ other (explain) Distance from private water supply well or suction line "(1i Diameter 4" Comments: (condition of joints, venting, evidence of leakage, etc.) GOOD C01it\-f10kA SEPTIC TANK: I/, - (locate on site plan) kk Depth below grade: I �' � Material of construction: 'concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _ (Yes/No) Dimensions: 10 ' �5 X "+ S x G- 8 Sludge depth: I " �, Distance from top of sludge to bottom of outlet tee or baffle: '�6 Scum thickness: C ; Z" `% Distance from top of scum to top of outlet tee or baffle: r Ll Distance from bottom of scum to bottom of outlet tee or baffle: 30 How dimensions were determined: M6ASVAVL--M W Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) PV C� SPC F FL's llsl F�h� C©MJ�t-C� oto _ AZ o�C tom-'(. Co _ X� GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1<21) (+-"ACV f� , Owner: kku tnsQM Date of Inspection: . 9 i TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in working order _ Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: ✓ (locate on site plan) Depth of liquid level above outlet invert: - O Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) des c2l I&J-n s 6Q'J'At_ ,�Ao_0-v\'O'Eucg- of sa%-4 (A0 Lg' 4 AGV- _ PUMP CHAMBER: (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 0{/25/97) Pays 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) (;? Property Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_, leaching galleries, number: leaching trenches, number,length:__� , leaching fields, number, dimensions: `z3 `5 Y" I 7 - overflow overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) E✓� S �c�t lR A (vim tp� G-tJl CESSPOOLS: _ (locate on site plan) Number and configuration: Depth -top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: _, (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.) (revia6d 04/25/97) Page 0 of 10 C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: l Y� -�& QtA' ct. C V,1z- !S -C cJ o %Q:7C . A V -k {j Q \j cv-�_ Owner:S i �'�% L �N.Y) W �k J t so kA Date of Inspection: , Z� , cte SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) }'4cr(;a �tM@MONS OFF 4'�S -Cc7 ltt'� l.n C19 - (,o -k. t\5 t . %0y" (revised 04/25/97) 1 Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: �T �J f✓`t Q -F L�rt�D N V flSGhC Date of Inspection: , va ,ct� a.! 6>P -- Depth to Groundwater I Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions /Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) PLANA off �2t,t.e J�z &�Ao_0 0 H LTt-i CWprtw- tAp- -N' ca�UUj Qcsz m of spf lgq-� (zevimed 04/25/97) Page 10 at 10 1 255 — o w Al f� D O --� O o o o o Q) w co co J_\ra a� ,�. , 06 o G lY� P n -i© C m . •O NI 1 rD 'S Ia �n ^� N.%. ti 1% I I x o 0 n �O426010c 1 rtH.. V n N N -d O OD 00 'n I .. .. W. W I rt Z 't I rt rt I v � m I •,. rrN N 1 Z- INO.jrN � nrt, aaaaaa� ■• -`)O I J 0 3 ©vvf �vla I UI O c C ro Nwa�oNw 1 ..'S rt \N.14. rD 40 c 40 't V1 C. C. 0.O4-1� I .. A rt I 3 C Ln 1 O. C V1 I O Vn H. O *.. -h Z N I 1n •a V1 1 c oo +0 -a c C. -J C. 00 1 a A rt o aaaaaawN•3c�� V u 0 rt C Z ro vv�vvv i F•ao.... rt o.•oNwO..O 1 � w rD 't N. �a c •0 c O d: 4 W VI VI V1 I Z .. a v A 1n rrtw .A Z rt G1 W .4 V to o N rD -+ rt O N x N rt �1 a -I�NwNwNN 1 O v07vN0. I CSN rt m 1 LnZ0 a aaaaaaN• 1 o m a 1� F•� I It c • • !••� I .. N '9 �O.O.O.O•a �O 1 .. Nwwww�31 0 1 a 1 rt N U1 I O I j V1 I I u J. I I v Nj-��►,�N I I J V7 O. 4r 4r A 1 1 I I a a a a a a l l I I F-9 I F" VJ A-(IRQ, Q s4 -c pi, Lp S -c Z � e4p,5 L�a3C73x �zrDaorD� C7 rD 'S .. d i7 n .. a rt x N 0 v ..► •C I 1 C u u u c C �-+CO reo N• r3'r c 1n r+• LO0 rt rt H.M x o .. 1n rt st m a ..�..Z •• v Z © u © m v 1214 ,` C v ►M u © �, W m O Z n O -i CLx 3 o a rt u r n � 3 �► o�N•c© 101.4 • • rt rD rt -0 W a um + v F+• " rD © N W .s s. rD rD -A v .. Z N O A © �a v v ©o vS i N. uvZ LM r © is n rD 9 .. 0 a3C'D .. Z rD a v crtz rD 1u 1 q2 m 1 © n to N 7 c n rD Ft CL ..., w Commonwealth. of'Massachusetts :,H,�MDOER City/Town ofSystem Pumping Record MAY Form 4 YVoAMENT DEP has provided this form for use by local Boards of Health.. The Syem P ping Record must be submitted to the local Board of Health or other approvin `authority. A. Facility Information Important: When filling out ). System Location: forms onn the "�-- computer, use only the tab key Address to move your � cursor - do not J�� _ use the°retum QrtyfT°wn tate Zip Code key. 2. System Owner: Name aain Address (i(different from .location) Cityfrown State �O S7 e Telephone Number .6. Pumping Record 1 Date. of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank- ❑ Tight Tank ❑ Other(describe' 4. Effluent Tee Filter present? ElYes D-Wo If yes, was it cleaned? El Yet ❑ No 5. Condition of System: rbc �..�C. �-�:� 1= tA- 6: System u ped By :Name Vehicle License Number Jam-'" 1 Ic Compan J. beat* where conte we Isposed:: TON" OF i�kL SYSTEM PIMPING RECORD DATE: 3 SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) f lj� �44 6 �6V�C DATE OF PUMPING: r QUANTI Y PUMPED : �_5� o GALLONS CESSPOOL: NO V YES . EP17IC TANK: NO YES -7 NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER MWLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.17 Lowell Waste TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: % Q SYSTEM OWNER & ADDRESS ze.ss�,�,-6 Calc SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: QUANTITY PUMPED ia2)y GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES `�— NATURE OF SERVICE: ROUTINE OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER '.1'Y STEM P"APED BY: EMERGENCY FULL TO COVER BAFFLES IN PLACE ✓ LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) COMMENTS: V ` e•, -eJ 7—v Ae- iti CONTENTS TRANSFERRED TO: 2Q0\ J i ---s , North Andover Board of Health 120 Main St. North Andover Ma.01845 Haul Lic. #151 -OOH Install Llc. # 128-0 Date Address 11/112000 303 Chester St 11/1/2000 50 Willow Rd 11/1/2000 160 Carelton Ln 11/1/2000 165 Bridal Path 11/4/2000 174 Ingals St 11/4/2000 1062 Salem St 11/6/2000 373 Raligh Tavern Ln 11/6/2000 252 Boxford St 11/6/2000 150 Liberty St 11/6/2000 149 Osgood St 11/7/2000 255 Haymeadow 11/7/2000 850 Winter St 11/8/2000 25 Windsor Ln 11/9/2000 249 Carlton Ln 11/9/2000 767 Johnson St 11/10/2000 56 Academy Rd 11/14/2000 Sugar Cane Ln 11/14/2000 250 Abbott St 11/15/2000 195 Winter St 11/15/2000 187 Winter St 11/16/2000 85 Laconia Cir 11/16/2000 86 Willow Ridge 11/17/2000 2135 Turnpike St 11/20/2000 203 Grandville Ln 11/20/2000 391 Pleasant St 11/20/2000 124 Tucker Farm Rd 11/22/2000 394 Boston Rd 11/22/2000 728 Forest St 11/22/2000 18 Johnney Cake St 11/24/2000 106 Rockey Brook Rd 11/24/2000 258 Rea St 11/28/2000 1815 Great Pond Rd 11/28/2000 1420 Great Pond Rd 11/29/2000 266 Lacy St 11/2912000 155 Laconia Cir Andover Septic 47 Railroad St. Bradford Ma. 01835 Gallons Comments 1000 1000 1500 1500 1000 1250 1000 1000 Leachfield Run Back/ Ex. Solids 1500 1000 1500 1250 1500 1500 1500 1500 1500 1000 Extra Solids 1500 1500 1500 1000 1500 1000 Flooded 1500 1500 1500 1500 1500 1500 1000 1000 1500 1000 1500 EC [=,,O t .� FORM U - LOT RELEASE FORM G3�g-ems`eu 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. X-" *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT rL �1 , PHONE 117 c 9 y e' 0/ C�C� LOCATION: Assessor's Map Number / JT- PARCEL a SUBDIVISION v LOT (S) ST d �l f~� T. NUMBER ° *****************************************OFFICIAL USE RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER COMMENTS FOOD INSPECTOR -HEALTH ,TH COMMENTS DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED rt.�`ttse✓'Z, �4A Y �" + i�'1-.s ta.�i �� ✓'"C. � La v v' � �"-��'7�i G C/�-+-�c2 v- / , �IL ✓ c: cam+¢ %'�`i �' . � t�.+.�s fi: —IT PUBLIC WORKS - SEWERIWATER CONNECTIONS d , DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm Board of Health North An4pyglHa.aa. K(_)V DATII V l Z-1 I SEPTIC SZSTEH Y INSTAILATICK CHECK LISP DI SAPFr�Q'n DAT eaRonst �5 to LOT ` J OMAJ7 X AVATION Og PAIL Vams WOX 1. Distance To: a. Wetlands b. Drains c.. Well 2. Water Line Location 3. No PVC Pipe 4. Septic Tank a. Tees -_Length k To Clean Out Covers b. Cement Pipe to Tank - Both Sides of Tank 5. Distribution Boa 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 Ends d. Clean Double Washed Stone 7. Leach Pits a. Dimensions b. Stone Depth c. dash Pads d. Tees e. Cement Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. No Garbage Disposal 9. F nal Grading Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System c. Location with Regard -to Perc Test d. Elevations e.' Water Table -fowN of NORTH' ANoovar:, M ASsnc1•iuS-`T1' ; orrlcr, or +•l. f� CONSERVATION COMMISSION ' yJ1P� °f.+••"••1ti° TCLCPNONC 683.•7105.ovf1+ yy fi�r+" °/. i:r •t • ; N • � 1/� . K • .mss t.. wNlh7l.t 411.4 t•t 113+1 Pursuant to the authority of the WetlanUs'Protection Act, Massachusetts General Laws Chapter 131, Section 40, as amended, .•r..'r�',+;-s and the Town of, North Andover's Wetland Protection By Lhw, the . - _ North ATS, over Conservation 'Commission will holt a•'I'ublic Hearing '14` ,•.�,�, . . at 8 :00 P.M. at th,c Town Building { ...__ on Mee ting Room, 120 Main Street, North• Andover, MA on the Notice ;; ; •, . _.�..__ ..._ of Intent of A'.J..--Lane•-: Cbi paVy'. o alter land at... Lots-28.--&:.3G--The:.--Pines (Stagecoach Road) for purposes of • ' :• � • <I��. • construct -.:two-singlermi�y'�dweYih'S""'tds'oc sructure •'t'' / arr :'..,";,';.: ' - Plans are available at the Conservation. Commission Office, � Town Building, 120 Main Street North 'Andover, MA, on' Tuesday •'if+ from 12:00 noon to 2:00 p.mr and by'appointment. <+> _.....-- By: G. Vicens.��. . Chairman, NACC r; • N.A. Citizen on Augus�.3.2:, 1:9'8'57' in the • ; run once ,"'"g`'fl Copies sent to • Planning Board" Board of Health Public Works Highway Dept. ' ' Applic/nnt EngineerI DEQE Iwo _Off,. • , a is �•�. ' Health ' SUBSURFACE DISPOSAL DESIGN CHECK LI:' e APPROVED DATE y -Z5- S Provided: (� V5 OV 7- FS 0, r, 7U 1550E DISAPPROVED Reasons: LOT i �� JotiN�GC_�i DATE 1Z� GLV �N jti5- 61-S z tietp$,p vbwc`ve' Title V Reg 2.5 - FAIL The submitted plan must show as a minimum: a) the lot to be served-area,dimensions lot Cabutters location and log deep observation hoes -distance to ties location and results percolation tests -distance to -ties rcddesign calculations & calculations showing required leaching area (e) location and dimensions of system -including reserve area M existing and proposed contours (g) location any vet areas xithin =1 of swage disposal system or disclaimer -check Wetlands mapping (h) surface and subsurface drains within 10CG I of sewage disposal system or disclaimer (i) location any drainage easements within 1101 of sewage disposal system or disclaimer -Planning Board file3 (j) known sources of water supply within 2OU; of sewage disposal e system or disclaimer (k) location of W, proposed well to sere 1..t-1001 from leaebing facility (1) location of water lines on property -..of trom leaching facility (m)' location of benchmark (n) drivewW (o) garbage. disposals (p) no PVC to be used in construction (q) profile of system -elevations of basement, plumb, pipe, septic tank, distribution boa inlets and outlets, distribution field piping and other elevations (r) maximum ground water elevation in area sewage disposal system (s) plan mast be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Reg 6 Septic Tanks (a) capacities -150% of flow, water table, tees, depth of tees, access, pumping (b) cleanout (c) 101 from cellar wall or ingrotnnd suimadr g pool (d) �5, from subsurface drains Reg 10.2 Distribution Boxes (a) pe greater than 0.08 Reg 10.1 b} sung ' ` 2) I� .61 0 vA .61 0 i MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) 1 JdUea, Mass. Date Q oc 19-21Permit # 33 ag Building Location %Zabh Yf Ae_ IC'rY Owner's Name "— Type of Occupancy L(%01A ref,, 4 . T r New ®� Renovation ❑ G Replacement ❑ Plans Submitted: Yes❑ No E&---- 0 ?&r Installing ■ E MEMO EM■ ■■EE■■■M■E■■■EN MOMMEMMIMEM, MMN MEN IMMMMEMEMEMENEEM■■ EM ■■■ MME . 041 - • Installing Company Name_ GAISK10Af PLUMBING. HEATING Address ' GAS FITTING INC. P.O. COX sum SAI_FIUI•_DAA 01871 8869— Business Telephone ,-�;—e�?—%a- yz� 9 Name of Licensed Plumber or Gas Fitter b Check one: Certificate Corporationf-- ❑ Partnership ❑ Firm/Co. INSURANCE COVERAGE: I have a current liab" insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked Yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner[] Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the an r Laws. By T of License: Plumber Agfiature of LjoedWd Plumber or Gas Fitter Title Gasfitter aster License Number City/Town—t7R6I ,1r1 Journeyman APPROVED (OFFICE S _ NL COMMONWEALTH OF MASSACHUSETTS fIUAk11 Ir( I Luwnl:r,s ANU GASFITTERS I'1 I II I II .i II A:. A JUUkNLYMAN PLUMUV TINS I ICFNSF: TO I YI'I_ 111MIA:; k GAGNON {; - . I iA I,() BOX 8860 SALI_t1 MA 01971-8860 691784 18597 05/01/96 691784 � LICENSE NO, EXPIRATION DATE SERIAL NO. COMMONWEALTH OF MASSACHUSETTS BOARD IN PLUMBERS AND GASFITTERS PL REGISTE EDDESTHISLICE MBO INGG CORP TYPE THOMAS R GAGNON -C 1 PO BOX 8860 SALEM MA -01971-8860 674686 1524 05/01/96 674686 IMPORTANTNO11Cr 119IIMIII IFON IfLUMDINU AND if INSTALLATIONS ON STATE OWNI FACILITIES MUST BE FILED At II OFFICE. OF THE STATE DOARD. IMPORTANT NOTICE PERMITS FOR PLUMBING AND G/ INSTALLATIONS ON STATE OWNE FACILITIES MUST BE FILED AT TI' OFFICE OF THE STATE BOARD. IMPORTANT NOTICE PERMITS FOR PLUMBING AND GAS INSTALLATIONS ON STATE OWNED FACILITIES MUST BE FILED AT THE OFFICE OF THE STATE BOARD. 'gyp COMMONWEAL COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF PUBLIC SAFETY BOARD IN PLUMBERS. -..AND GASFITTERS PL LICENSED AS A'MASTER PLUMBER y�Il MASSACHUSETTS ISSUES THIS LICENSE TO TYPE THOMAS R GAGNON -M ;.3(F(j�C$3 LICENSE PO BOX 8860 L-XPIRATION DATI: SALEM Mk`11971-8860 691783 10136 05/01/96 691783 UMNSE NO. EXPIRATION DATE SERIAL NO. COMMONWEALTH OF MASSACHUSETTS BOARD IN PLUMBERS AND GASFITTERS PL REGISTE EDDESTHISLICE MBO INGG CORP TYPE THOMAS R GAGNON -C 1 PO BOX 8860 SALEM MA -01971-8860 674686 1524 05/01/96 674686 IMPORTANTNO11Cr 119IIMIII IFON IfLUMDINU AND if INSTALLATIONS ON STATE OWNI FACILITIES MUST BE FILED At II OFFICE. OF THE STATE DOARD. IMPORTANT NOTICE PERMITS FOR PLUMBING AND G/ INSTALLATIONS ON STATE OWNE FACILITIES MUST BE FILED AT TI' OFFICE OF THE STATE BOARD. IMPORTANT NOTICE PERMITS FOR PLUMBING AND GAS INSTALLATIONS ON STATE OWNED FACILITIES MUST BE FILED AT THE OFFICE OF THE STATE BOARD. 'gyp COMMONWEAL TH DEPARTMENT OF PUBLIC SAFETY OF ONE ASHBORTON PLACE y�Il MASSACHUSETTS BOSTON, MA 02108 ;.3(F(j�C$3 LICENSE CAUTIC L-XPIRATION DATI: SPRINKLER CONTRACTOR 08/31/1995 EFFECTIVE DATE LIC -N0. FOR PROTECTIO THEFT, PUT RIGI RESTFticrIONS NONE 08/31/1993 002265 PRINT INAPPF a BOX ON LIC xTHOMAS R GAGNON 9 ' 4 DRUMLIN RD Q BLASTING OPI SS n 025-48-6K12 0PSWICH MA 01938 = MUSTINCLUD! i:. ; h . L `J nor vKio wrta s�a"Eo o. uct"SEE woo occ,cuuv Sf.V•,VED,0" 1111 -Tell Ot T"l CO1111,1N,En ?;d 1/1957 �` •' •�•: ,5 . .�-:�:" f v f,Ct:fr.�lnl MU51 BE n I f nn,f l•�n t„f. oEn$OnOr �• 5� "E Ot I�CENSEE SiG""SME wtVLE •(IOV[LC••- Dunn, �,t.,.:,,:,•;,..,:.,..� ,�„•,:,.-..,.:,,,.,.:,:,, '� A P OV Ti�"'�/�/� r�iv 4�*-. .w � I,{ A:. 'f�1S�r �a,[ '{• ! G', . fl . .r ��" ( .� of r+,) {� � .� Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 yn 1A, c I ti :'.LjjV -11 r =e� Tip nr_onrTn e�r DEP has provided this form for use, by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left / Right front of house, Left rear , Left / right side of house, Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address y O City/Town V \ State` J Zip Code 2. System Owner. Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Date Cesspool(s) 4. Effluent Tee Filter present? ❑ Yes 2140 State Ip Code Telephone Number — 2. Quantity Pumped: Septic Tank 5. Condition of System: � t-o� 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Locatiyu,�Xh_ere contents were disposed: Lowell Waste Water Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No \ V"'- 4e�'-- F5821 Vehicle License Number Date la -6 ('�'- t5fomi4.doc• 06/03 System Pumping Record • Page 1 of 1