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HomeMy WebLinkAboutMiscellaneous - 182 OLYMPIC LANE 4/30/2018f North Andover Board of Assessors Public Access # ir Parcel ID: 210/106.11-0127-0000.0 SKETCH Click on Sketch to Enlarge I Community: North Andover PHOTO Location: 182 OLYMPIC LANE Owner Name: KIM, YANGKIL JINHI KIM Owner Address: 182 OLYMPIC LANE City: NORTH ANDOVER State: MA ZIP: 01845 Neighborhood: 7 - 7 Land Area: 1.57 acres Use Code: 101- SNGL-FAM-RES Total Finished Area: 3617 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 643,200 564,800 Building Value: 425,300 363,100 Land Value. 217,900 201,700 Market Land Value: 217,900 Chapter Land Value: LATESTSALE Sale Price: 256,000 Sale Date: 08/23/1989 Arms Length Sale Code: Y -YES -VALID Grantor: SWEENEY JAMES O JR Cert Doc: Book: 02985 Page: 0340 Page 1 of I http://csc-ma.us/NandoverPubAcc/j sp/Home.j sp?Page=3&Linkld=808926 8/16/2006 O H d O C c ai •° a d J_ c m W ~oU�� .± Z mV 3 LO R w x H c V a >; in O CDle N oo S r Uco U) o O -DW ocn W E L) maU Q U 0p 0 Q yJ oo W UJ L) o M W o aQ Ln00 3 0 O a N O O. � U) CL0 f6 G V a C C d0H> `o m O -p -Up O N N N C7 m m O cn cn cn co 0 of O J Lq N CD r � �to HMe� O U R N o N O (D m om�� a m� m o o x c0 D H f- H W O r a Q O Z C; O o � O Q V N o o O o LL co Z W O J Zw WJw � V J O N Q' Y a 0 IL z2 Q Wj iii U o�Z a) C4 QZ CL 0 a T" O r N @ a 00 0 o0 N y -0 N N :.i L 2 2 .•'� > 00 0 c '' r0 t � Z qj z C4 H Q W (C6 N w J J '. wp OLL ONQ Zoo Z Z LLQ M r U. 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Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key VOIlQ reom Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 182 Olympic Lane Property Address Yangkil Kim Owner's Name North Andover City/Town MA 01845 10/2/2015 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. A. General Information 1. Inspector: OCT 07 2015 Jt fl r Neil J. Bateson TOWN CF NORTH ANDOVER Name of Inspector HEAD H DEHAR I witN I Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover Cityrrown 978-475-4786 MA State S115 Telephone Number License Number B. Certification 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 F rther Evaluation by the Local Approving Authority 1 10/2/2015 Inspe Si nature V 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 Forth: Subsurface Sewage Disposal System • Page 1 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 182 Olympic Lane Property Address Yangkil Kim Owners Name North Andover CitylTown B. Certification (cont.) MA 01845 State Zip Code 10/2/2015 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 182 Olympic Lane Property Address Yangkil Kim Owner Owner's Name information is required for North Andover MA 01845 10/2/2015 every 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): ❑ 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 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 182 Olympic Lane Property Address Yangkil Kim Owner Owners Name information is required for North Andover MA 01845 10/2/2015 every 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 form. 3. Other: Outlet tee in septic tank, pipe to d -box & d -box needs to be replaced. Riser on d -box needs to be installed. 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 Y day flow t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts 4 f.-4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 182 Olympic Lane Property Address Yangkil Kim Owner Owner's Name information is required for North Andover MA 01845 10/2/2015 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 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 182 Olympic Lane Property Address Yangkil Kim Owner's Name North Andover MA 01845 10/2/2015 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? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 600 t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M ,•'' 182 Olympic Lane Owner information is required for every page. Property Address Yangkil Kim Owner's Name North Andover City/Town D. System Information Description: Number of current residents: MA 01845 State Zip Code 10/2/2015 Date of Inspection Does residence have a garbage grinder? Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): 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: Gallons per day (gpd) ❑ Yes ® No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ® No Yes ❑ Yes ® No Current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 7 of 17 N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 182 Olympic Lane Property Address Yangkil Kim Owner Owner's Name information is required for North Andover MA 01845 10/2/2015 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Pumped 2010,owner 1500 gallons Measured tank Inspect tank & tees Type of System: ® 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/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M s 182 Olympic Lane Property Address Yangkil Kim Owner Owner's Name information equir for is North Andover required for MA 01845 every page. Cityfrown State Zip Code D. System Information (cont.) 10/2/2015 Date of Inspection Approximate age of all components, date installed (if known) and source of information: 35 years old, 4/23/1980, as built plan Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 4 feet Material of construction: ® cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" Cast Iron through wall. 3" PVC in house, no leaks visible. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal ❑ Yes ® No 3 feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 10'x 5'x 4' Sludge depth: 1" ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 9 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 182 Olympic Lane Property Address Yangkil Kim Owner's Name North Andover City/Town D. System Information (cont.) Septic Tank (cont.) MA 01845 10/2/2015 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? N/A N/A = Outlet tee needs to be replaced. N/A Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumped septic tank. Inlet tee ok. Outlet tee has corrosion holes, needs to be replaced. Liquid level at outlet invert, no evidence of leakage. Outlet pipe to d -box has pulled away from tank, needs to be replaced. Center cover has riser 10" deep. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: feet ❑ polyethylene ❑ other (explain): Date t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments • ,•''t 182 Olympic Lane MA 01845 10/2/2015 State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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 Property Address Yangkil Kim Owner Owner's Name information is required for North Andover every page. City/Town MA 01845 10/2/2015 State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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 s>''p 182 Olympic Lane Owner information is required for every page. Property Address Yangkil Kim Owner's Name North Andover City/Town D. System Information (cont.) State 01845 Zip Code 10/2/2015 Date of Inspection Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields 1 field 25'x 70' number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil Ok. Vegetation ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 182 Olympic Lane Property Address Yangkil Kim Owner's Name North Andover Cityrrown D. System Information (cont.) MA 01845 10/2/2015 State Zip Code Date 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.): t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 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 182 Olympic Lane Property Address Yangkil Kim Owner's Name North Andover MA 01845 10/2/2015 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 t5ins • 3113 Title 5 official Inspection Fonn: 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 182 Olympic Lane Property Address Yangkil Kim 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 10/2/2015 State Zip Code Date of Inspection 4 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 5/18/1977 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Design plan ❑ , Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Test pit data on design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 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 182 Olympic Lane Property Address Yangkil Kim Owner's Name North Andover MA City/Town State E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked 01845 10/2/2015 Zip Code Date of Inspection ® 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 - 3/13 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 17 of 17 Commonwealth of Massachusetts City/Town of . System Pumping. Record y, Form 4 DEP has provided this form for use, by local Boards of Health. Other forms may be'used, but the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility. Information I. System Location: Leff ight front of hous • Left / Right rear of house, Left / right side of house, Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address Citylrown l State Zip Code 2. System Owner. Name C `� •V\t�_- Address (if different from location) Citylrown State • � % �, Zip Code ; " IF Telephone Number B. Pumping 1. Date of Pumping 3. Type -of system. ❑ ❑ Other (describe): Date Cesspool(s) — 2. Quanti Pumped eptic Tank Gallons t ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes LSO If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 4k_Lk� I I/� --��- 6; System Pumped By: 7. Neil. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company contents were disposed: t5form4.doc- 06/03 System Pumping Record • Page 1 of 1 Summary Record Card generated on 9/30/2015 11:06:28 AM by Karen Hanlon Town of North Andover Tax Map # 210-106.6-0127-0000.0 Parcel Id 17531 182 OLYMPIC LANE KIM, YANGKIL 182 OLYMPIC LANE N. ANDOVER, MA 01845 Page 1 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.57 Acres FY 2016 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until KIM, YANGKIL Payor 182 OLYMPIC LANE N. ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 17515.0 - 182 OLYMPIC LANE Last Billing Date 7/14/2015 3170185 03 Cycle 03 Active UB Services Maint. Account No. 3170185 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 231.40 /1 UB Meter Maintenance Account No. 3170185 Serial No Status Location Brand Type Size YTD Cons 36433652 a Active ERT HH b Badger w Water 0.63 0.63 1100 Date Reading Code Consumption Posted Date Variance 9/10/2015 1208 a Actual 112 128% 6/9/2015 1096 a Actual 48 7/24/2015 179% 3/10/2015 1048 a Actual 17 4/28/2015 -42% 12/10/2014 1031 aActual 29 1/15/2015 -68% 9/12/2014 1002 a Actual 95 10/15/2014 210% 6/11/2014 907 aActual 30 7/16/2014 237% 3/12/2014 877 aActual 9 4/11/2014 -86% 12/10/2013 868 aActual 62 1/17/2014 -53% 9/11/2013 806 a Actual 136 10/15/2013 48% 6/11/2013 670 aActual 90 7/24/2013 922% 3/13/2013 580 a Actual 9 4/22/2013 -46% 12/11/2012 571 aActual 16 1/9/2013 -81% 9/13/2012 555 a Actual 91 10/15/2012 781% 6/11/2012 464 a Actual 10 7/16/2012 -1% 3/12/2012 454 a Actual 10 4/14/2012 -47% 12/13/2011 444 aActual 19 1/17/2012 -83% 9/13/2011 425 a Actual 119 10/13/2011 413% 6/8/2011 306 a Actual 22 7/20/2011 93% 3/8/2011 284 a Actual 11 4/13/2011 -77% 12/9/2010 273 aActual 49 1/12/2011 -72% 9/10/2010 224 a Actual 187 10/15/2010 504% 6/7/2010 37 a Actual 29 7/15/2010 120% 3/10/2010 8 a Actual 8 4/14/2010 -100% 1/15/2010 0 n New Meter 0 4/14/2010 -100% 1/15/2010 5402 r Replacement 12 4/14/2010 52% 12/10/2009 5390 m Manual estimate 20 1/12/2010 0% 9/10/2009 5370 a Actual 34 10/15/2009 -1% 6/8/2009 5336 m Manual estimate 30 7/20/2009 103% MSG 9 . PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 12/14/15 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Complete Repair of D -Box, riser and Tee By: Todd Bateson At: 182 Olympic Lane Map 106.B Lot 0127 Nort , ndover, MA 01845 The IVince f this certif1 e sha n t be on rued as a guarantee that the system will function satisfactorily. ,1. Michele Grant Public Health Agent 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 fax 978.688.8476 Web www.townofnorthandover.com Commonwealth of Massachusetts BOARD OF HEALTH North Andover Map -Block -Lot 106.B0127 ----------------------- Permit No BHP -2015-0918 ----------------------- FEE DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd Bateson to (Repair) an Individual Sewage Disposal System. at No -O } _ r 1 1� ------182-----------LYMPIC----------LANE ------------------------ ------------ as shown on the application for Disposal Works Construction Permit N Issued On: Dec -07-2015 $125.00 o. 4J- Jk---------------------------- --------------------- BHP -2015-091 Dated December 07, 2015 ----------------- ------------------ ---- - - - ----- -COPY --------- BOARD C PY--------- BOARD OF HEALTH Important: When filling out forms on the computer, use only;the;tab trey to move your cursor -do not use the return key. C a new on-site'sewage disposal system* ❑ Repair or replace an existing. on-site sewage disposal' system* _ �tepair or replace an existing system component - What? D—Be A. Facility information Address or Lot # X111 Ak - j Cityrrown DEC 0 7 2015 166 2.- *TYPE OF SEPTIC SYSTEM*: TOWN OF NORTH ANDOVER ➢ El Pump cavity (choose one) HEALTH DEPARTMENT * If pump system, attach copy of electrical permit to application*`* ➢ 2�156-nventional 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) ➢ ❑ Pressure Dosed (D -Box Present) SAS. ➢ ❑ Does the system require an effluent filter? Yes Na If yes, does plan specify make and model of filter? YES = (no further info. needed) M = (installer must specify brand of filter before DWC issuance) Mat is the Make? 2. Owner Information / what is dre modatz.. Address (if different from above) /% City/Town State Zip Code Telephone Number 3. Installer Information Name Name of Compan BATE-CON Eh!TF.ODR.ISFS, INC. Address Cityrrown 4. Desi.gnerinformation Name Address Cityrrown State .. . I- t- 1✓ ANDOVER, MA U i at 0 Zip Code 22f Telephone Number (Cell Phone # if possible please) Name of Company Stat Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 J l- CLs - ls' - TODAY'S DATE $:250.00 -ofull Repair $125.00.- Component PAGE 2 OF 2 A. Facility:Information continued.... S. Type -of Building: esidentlai 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. provis/ons of Title 5 of the Environmental Code, as well as the Local Subsun`ace Disposal Regulations for the Town of North Andover, and not to place;the system 16 operation until a Certificate of Compliance has been Issued by this Board of Heath. Nam Date Vic n Appro. By . oard f Health Representative)Id,�1'.5 date Application Disapprove . for the following reasons: For Office Use Only: 1 " Fee Attachcd?: Yes No 2.- ProjectMariager Obligation Form Attached. Yes No :. 3.: BM12 stem? Ifso) Attach C0DEQf9kCdz1Fermit` No 4. Fvunda.donAs Built.? (hew construction •ronly), Yes No (Same scale as approved plan) 5. F1oorPL=s? (hew construction, only). Y.es_ No 40.1 � 6nior•plspotal $'Ati3m.: onstrcicElori permit Page 2 of 2 N I II SEP'�IC S'S�$'r'$M•irT�3'dLL•�Rp,!' .�[�!�►�E'��•�BLiGAiI4l� As 6W.Npith Andover lamed biaaa g f»jr 4ie t�at:~tcptgn f�•the azPtia syete� fc�x.the�p�toj�ty� /201 O! e" 4N 1 (AdcJaw of upik .1rutPun 13) (inY r amu Abd dstod I nadesstaad the following Oft"ttons fat a agemcut oris P jcct: i. 1!a the installer, I aas.obligatod is obmia aIIpmpaa aad'$b�d of �Ie�h appy � � . �paronniag arty Volk oa R sib 2. As dta imll jpb& aIi jwwyand iftqw.&wL IEhcoi= ► gsajectmaanget, or map Qt�ap nets oc #,ed mycampimyinb and the apste is notttack thc$ ` tit at itq pcd 40 �avn eft yar xa the Atd {tom. •bit �ener�Iy,,.�i"p apex is '' sh6ld rib... , spacdo�t isat •nvt b ba ttibaiitticd•m hc.8o d ofi%a ,aft: tem time. Mist hop t+uetfit kspeed6m ttst, �'t be rely stul alalic m C. 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UndepIpM b=W S .RW4= North Andover Health Department (ommunity and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 182 Olympic Lane INSTALLER: Todd Bateson DESIGNER: PLAN'DATE: BOH APPROVAL DATE ON PLAN: MAP: 106.13 LOT: 0127 INSPECTIONS D -Box, riser and T INSPECTION: 12/14/15 DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: SEPTIC TANK ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned; ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION -BOX Installed on stable stone base H-20 D -Box E]/ Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets Observed even distribution Speed levelers provided (not required) chedule 40 PVC Pipe Comments: Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. t� Commonwealth of Massachusetts, Title 5 official Inspection rm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 182 Olympic Ln Property Address Kim Owner's Name N. Andover Cityfrown MA 01845 8/30/2010 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. A. General Information Inspector: Chad Jablonski Name of Inspector Jablonski & Sons Inc. Company Name 167 Willow Ave wttiNdriy rlouress Haverhill city/Town 978-360-9358 Telephone Number t3. certification MA State 4574 License Number 01835 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evatlo by the Local Approving Authority Biu Date The system ins r shall submit a copy of this inspection report to the Approving Authority (Board of Health or D)FXwithin 30 days of completing this inspection. If the system is a shared system or has a design Wow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 182 Olympic Ln Property Address Kim Owner's Name N. Andover MA 01845 8/30/2010 City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SAS and all components in good working order B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Owner information is required for every page. ,Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 182 Olympic Ln Property Address Kim Owner's Name N. Andover City/Town B. Certification (cont.) B) System Conditionally Passes (cont.): MA 01845 State Zip Code 8/30/2010 Date of Inspection ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. t5ins • 09108 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 182 Olympic Ln Property Address Kim Uwner's Name N. Andover MA 01845 8/30/2010 City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 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 1h day flow Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 182 Olympic Ln Property Address Kim Owner Owner's Name formation is information squired for every N. Andover MA 01845 8/30/2010 page. City/"own State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOTdue to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either `yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 L 4filff!_ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 182 Olympic Ln Property Address Kim Owner Owner's Name information is required for every N. Andover page. City/Town 15ins • 09/08 C. Checklist MA 01845 State Zip Code 8/30/2010 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® 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): 900 ` } v Tale 5 Official Inspection Form: Subsurlace Sewage Disposal System • Page 6 of 17 ,Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 182 Olympic Ln Property Address Kim Owner Owner's Name information is required for every N. Andover page. City/Town t5ins • 09/08 D. System Information Description: Number of current residents: MA 01845' State Zip Code 8/30/2010 Date of Inspection Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: CommercialUlndustrial 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? Gallons per day (gpd) E ❑ Yes ® No ® YesNo El Yes (((((® No Attached ❑ Yes ® No Occupied Date ❑ Yes ❑ No ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,.•'' 182 Olympic Ln Property Address Kim Owner Owner's Name information is required for every N. Andover page. Cityrrown D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: MA 01845 8/30/2010 State Zip Code Date of Inspection Date General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: N. Andover BoH na gallons na na Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 . Commonwealth of Massachusetts -^ - Title 5 Official Inspection Form FSubsurface Sewage Disposal System Form - Not for Voluntary Assessments 182 Olympic Ln Property Address Kim Owner Owner's Name information is required for every N. Andover MA 01845 page. City/Town State Zip Code D. System Information (cont.) 8/30/2010 Date of Inspection Approximate age of all components, date installed (if known) and source of information: Plan dated 3/19/2010 Were sewage odors detected when arriving at the site? 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: na feet Comments (on condition of joints, venting, evidence of leakage, etc.): Watertight at foundation Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 0 feet ❑ Yes ® No ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: na years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 8.5 x 5 x 5 Sludge depth: 2" t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Commonwealth of Massachusetts r--- Title 5 Official Inspection Form 4_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments -- 182 Olympic Ln Property Address Kim Owner Owner's Name information is required for every N. Andover page. City/rown D. System Information (cont.) Septic Tank (cont.) MA 01845 State Zip Code 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 8/30/2010 Date of Inspection 36" minimal 7" 14" How were dimensions determined? measuring tape 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 is structurally sound, inlet and outlet baffles in good working order. 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: t5ins - 09108 Date Title 5 Official Inspection Form: SubsuAace Sewage Disposal System - Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 182 Olympic Ln Property Address Kim Owner Owner's Name formation is required for every N. Andover MA 01845 8/30/2010 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: 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 15ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 182 Olympic Ln Property Address Kim Owner's Name N. Andover MA 01845 8/30/2010 City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): Box is level and distributing equally. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 09/08 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 .Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 182 Olympic Ln t5ins • 09/08 D. System Information (cont.) Type: Property Address ❑ Kim Owner Owner's Name information is required for every N. Andover page. City/Town t5ins • 09/08 D. System Information (cont.) Type: ❑ leaching pits ❑ leaching chambers ❑ leaching galleries ❑ leaching trenches ® leaching fields ❑ overflow cesspool ❑ innovative/alternative system MA 01845 State Zip Code 8/30/2010 Date of Inspection number: number: number: number, length: number, dimensions: number: 25'x 70' Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No sign of hydraulic failure or pondinn _ Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer _. Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts w ` Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 182 Olympic Ln MA State 01845 8/30/2010 Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Property Address Kim Owner Owner's Name information is required for every N. Andover page. City/Town MA State 01845 8/30/2010 Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 182 Olympic Ln Property Address Kim Owner's Name N. Andover MA 01845 8/30/2010 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form R 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 182 Olympic Ln D. System Information (cont.) Site Exam: ® Property Address ® Kim Owner Owner's Name information is N. Andover required for every page. City/Town D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells MA 01845 State Zip Code 5 8/30/2010 Date of Inspection Estimated depth to high ground water. feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 3/19/1979 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: Soils test performed by Barbagallo and witnessed by Gelinas. Cellar is dry with no sump pump. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 182 Olympic Ln State E. Report Completeness Checklist 01845 Zip Code 8/30/2010 Date of Inspection ® 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 15ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Property Address Kim Owner Owner's Name information is N. Andover required for every page. City/Town State E. Report Completeness Checklist 01845 Zip Code 8/30/2010 Date of Inspection ® 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 15ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 U-� RE-UMV144W PUM I' Record on eqlth�` f Q assachuse s s `CityCToW.hDOM ..,of NORTH ANDOVE TTS PUM I' Record fortfi 4:.:e .,ng DEP has provided this form for use by local Boards of Health. The System Pumping Record n' be submitted to the local Board of Health or other approving authority. A. Facility Information ling out Location: ,I the 3r,u&e Lab key your do no Ad em . own State Zip Code 2, System Owner Name Address (if different from location) %nown State Tp Code Telephone Number B. Pu.mpjn'g Record Date of Pumping 2Pumped: UW . Quantity Gallons 3., r Type of system: ❑ Cesspool(s)Septic Tank ❑ Tight Tank Other (describe): 4. Effluent Tee Filter present? ❑ Yes 0 No If yei,*was It cleaned? El' Yes' E] No 6. Condition of System: PA- W &I I [g][OT91 jtqp�j - 9 Pon is I 9k, Cgna re of Haul` go ..E /.nlass. MepoOter/approval D03 Vehicle License Number ue— WA A - Da 1,5forms.'htmffinspect System Pumping Record Page 1 of i Commonwealth of Massachusetts North Andover, Massachusetts System Pumping Record System Owner & address: Yangkil Kim 182 Olympic Lane North Andover, MA Location of system: Front Date of Pumping: August 14, 2006 Type of system: Septic tank Gallons Pumped: 1000 Gallons System pumped by: Service Pumping & Drain Co., Inc. License #: BHP -2005-0649 RECEIVED AUG 2 S 2006 TOWN OF NORTH ANDOVER FJEALTH DEPARTMENT Contents transferred to: Greater Lawrence Sanitary District Date: August 14, 2006 - ---' Pumping Technician: CC This is PROPRIETARY and CONFIDENTIAL information that may be used only by the Board of Health for regulatory purposes OF . T6WN OF NORTH -ANDOVER SYSTEM PyJkPING RFGO R-0 - 3 2033 1)ATF: a I 1 s'7'EM OWNER & AUORGSS ,. SYSTEM LOCATION (example: left front of house) . VATE OF PUMPING: QUANTITY PUMPRO ff6o CALL0.7% :: ESSI'OOL: NO YES SEPTIC TANK: NO YES a NATURE OF SERVICE; ROUTINE EMERGENCY 00SERVATION& s GOOD CONOITIOK PULL TO COVE14 iiRAYY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK.., EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER._.=P;HFR (EXPLAIN) i l'STEM PUMPED BY: F.NTS: TRANSRCRREO TO: FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. APPLICANT FILLS OUT THIS SECTION APPLICANT V4A-)klell K I PHONE LOT (S) �•�( STREET ' ST. NUMBER OFFICIAL USE ONLY'"' REC NQATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR COMMENTS DATE APPROVED r DATE- REJECTED TOWN PLANNER DATE gPPROVED r� DATE REJECTED COMMENTS FOOD INSPEC.R-HEALTH __. DATE APPROVED / DATE REJECTED IC/AS#L5CTOR-HEALTH COMMENTS DATE APPROVED 2 DATE REJECTED ,Om--._ coal d , 4� PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPART-/ MENT RECEIVED BY BUILDING INSPECTOR DATE jV `�.. l .-4 5 9..bl© FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. APPLICANT FILLS OUT THIS SECTIO APPLICANT - S j PHONE��jry��,� LOCATION; Assessors Map Number PARCELS (V (06) 3_a(a� SUBDM810/N LOT (S) STREET_ ! � � t�! � ��? /J f-<_ L-/-�y�s ST. NUMBER OFFICIAL USE ONL R 1 F T NT8: \ ; CONSERVATI N ADMINISTRATOR DATE APPROVED S �.._ 1 DATE REJECTED v TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD ECTOR-H DATE APPROVED DATE REJECTED TIC INSPECT R T DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE RwhW MW Jm Board of Health 'North An ver Ma s. pVED DATE PROVED ... BF.PTIC SISTER INSTALLATION CHECK LISP LOT a AVATI OK FAIL OK 1. Distance Tot / . a. Wetlands b. Drains c. Well 2. Water Line Location r 3. No PVC Pipe . %. septic Tank a. _Tees --Length & To Clean Oat 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 a- Capped -Eads Clean Double Washed Stone 7. Leach Pits a. Dimensio b. Stone ePth c. Spl Pads d. T s ' e. Ment Pipe to Pit - Both Sides. f. Clean Double Washed Stone LZ J 8. No Garbage Msposal g. -Final Grading Inspection / lA. Barricading Covered System 11. As Built Submitted. _ _ - a. Lot Location - b. Dimensions of System C. Location -4th Regard -to Perc Test d. Elevations Water Table e; V - OK FAIL r APPROVED �JL11u.J,.:i,.,U14 1Ji:.Jl.V�:iL D4TE PROVIDED Title 5 Reg. 2.5 1 Reg. 6 \1 NORTH A14DOVER BOARD OF HEALTH .yy� DISAPPROVED DATE TIME REASON r _ - y ,. ail OK Tte submitted plan must show as a minumum: In1aloc s (aY the lot to be served (area,dimensions,l.ot //,abutters) (Planning Board files) L. ( location and log of deep observation holes -distance to.ties (c,)- location and results of percolation tests -distance to ties °(d design calculations & calculations showing required leaching area .(e location and dimensions sf system (including reserve area) existing and proposed contours L01�g�location of any wet areas within 100' of the sewage ^disposal system or" disclaimer (check wetlands mapping) (h)" surface and subsurface drains within 100' of sewage disposal system or disclaimer (i) location of any drainage easements within 100' of sei•Yage- disposal system or disclaimer (planning board files) - - knovan_= sources_ of ter supply_ -.within- -200' of sewage-- disposal_ syst-em--or disclaimer - location of any proposed well to serve the lot (100' from leaching facility) .(1:) location of water lines on property (10' from.leachinE facilities) ff1) location of benchmark driveways garbage disposers )` no PVC is to be used in construction �q) a profile of the system (elevations of basement, plural pipe septic tank, distribution box inlets and outle:-s distribution. -field piping and any other elevations) (r --'maximum ground treater elevation in area of sewage disp .system (s) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Septic Tanks (a) Capacities - 150% of flow, water table, tees, depth Of tees, access, pumping, �) Cleanout 10' from cellar wall or inground swimming pool d) 25' from subsurface drains ,eg.'14.1 !,eg.14.3 'eg.14.4 14:5 -_ I`.eg.14.6` =- :eg.14.7 'eg.14.1 '.eg. 9.1 '.eg. 9.6 Distribution B oxe. Slope greater than 0.08 (b) Sump Leaching.Pits Leaching pits are prefe=r-rTd w the installation �,s possible (a) Calciffations of leaching area (minimum 500 S.F.) b,, -Spacing Surface drainage 2% d Cpver material S r2�¢ -lip iso �a SC Fieldsater than 20 minutes/inch a (minimum_.900 S.F.) struction of field facedrainage 2% 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 -.:_Construction _. (e� Storie- (f) Surface drainage 2% Downhill Slope (a) Slope y/x _ (to be shown) b y/x X 150 (to be shown) Pumps (a) Approval . (b Stand-by power Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. I-41 AA ISI Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 182 Olympic Lane Property Address Yang Kil Kim Owner's Name North Andover Cityrrown MA 01845 State Zip Code 12/14/2015 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Neil J. Bateson Name of Inspector Bateson Enterprises Inc. Company Name T rte._.,.. __...... -_.: 111 Argilla Road Company Address Andover MA 01810 Cityrrown State 9784754786 S115 Telephone Number B. Certification License Number 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 ❑ Nees Further Evaluation by the Local Approving Authority [I � / 12/14/2015 lnfeaoeA Signatur 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 182 Olympic Lane Property Address Yang Kil Kim Owner Owner's Name information is required for North Andover MA 01845 every page. Cityrrown State Zip Code B. Certification (cont.) 12/14/2015 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: After permit from B.O.H., install new outlet tee in septic tank, replace broken pipe to d -box, replace..d- box & install riser on d -box., inspection from B.O.H., septic system now passes Title 5 Inspection. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 Qp, I t ItA } a