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Miscellaneous - 186 CANDLESTICK ROAD 4/30/2018 (2)
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DVN..LNOJ :FIWVN O/H :NOIIVDOZ •g Lva TKT:#)fD9HO .LAIaW LHVJ3Q H.L'Id3H 'p5n��,s;, � ox daao u q .L ' • p � ,�o u�o 4 a � y • , ° N1aoN ► t � V a r v , �10RiM d9 G Of pyo y�h0 w7� Town of North Andover ',�••,'' HEALTH DEPARTMENT ,SSACHU'�t CHECK #: _� DATE: LOCATION: H/O NAME: CONTRACTOR NAME• C �) 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: 0 Septi- ' 6920 ` NORTM 1 0�-Z. • 0 • . Town of North Andover ��'•�:, ;o �: HEALTH DEPARTMENT ,sSACHUSf� / CHECK #: _ DATE: LOCATION: H/O NAME: LWC CONTRACTOR NAMEL 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 $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) $ (P) Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer 4 t V Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 186 CANDLESTICK ROAD Property Address ART MARAVELIS Owner Owner's Name information is N. ANDOVER required for every page. City/Town Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. 4:1 IL Ar MA 01845 State Zip Code 12/30/14 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. r7, ii A. General Information 1 Inspector: John J. Soucy Name of Inspector Soucy's Sewer Company Name 78 North Broad Company Address Salem Inc. NH Citylrown State 603-898-9339 13397 Telephone Number License Number B. Certification JAN 12 2015 Y IL -f-9 9..e 03079 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 ❑ Nee .dTf Evaluation by the Local Approving Authority Signature 12/30/14 Date The system inspector shall subf t 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 a Owner information is required for every page. t5ins • 3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 186 CANDLESTICK ROAD Property Address ART MARAVELIS Owner's Name N.ANDOVER City/Town B. Certification (cont.) MA M Rdr% JldW GHJ t uutl 12/30/14 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): Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 186 CANDLESTICK ROAD Property Address ART MARAVELIS Owner Owner's Name information is N. ANDOVER required for every page. Citylrown t5ins • 3/13 B. Certification (cont.) MA 01845 State Zip Code 12/30/14 Date of Inspection ❑ 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 Title 5 Offidal Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 t , Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 186 CANDLESTICK ROAD Property Address ART MARAVELIS Owner's Name N. ANDOVER MA 01845 12/30/14 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 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 1/z 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 186 CANDLESTICK ROAD Property Address ART MARAVELIS Owner Owner's Name information is required for every N. ANDOVER MA 01845 12/30/14 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 N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 186 CANDLESTICK ROAD Property Address ART MARAVELIS Owner Owner's Name information is required for every N. ANDOVER MA 01845 12/30/14 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ 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 • 3/13 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts G W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 186 CANDLESTICK ROAD Property Address ART MARAVELIS Owner Owner's Name information is required for every N. ANDOVER MA 01845 12/30/14 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: See Attached Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): 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 Offidal Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 186 CANDLESTICK ROAD Property Address ART MARAVELIS Owner Owner's Name information is required for every N. ANDOVER MA 01845 12/30/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: CURRENT 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: Soucy's Sewer Service gallons ❑ Yes ® No 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 - 3/13 Title 5 official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Commonwealth of Massachusetts U Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 5 186 CANDLESTICK ROAD Property Address ART MARAVELIS Owner Owner's Name information is required for every N.ANDOVER MA 01845 12/30/14 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: 1988 Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): D' t f t t 1 II t I; El Yes ® No 20" feet n/a is ance rom priva a wa er supp y we or suc Ion me. feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 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: Sludge depth: ❑ Yes ❑ No t5ins • 3/13 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts N v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 186 CANDLESTICK ROAD Property Address ART MARAVELIS Owner Owner's Name information is required for every N. ANDOVER MA 01845 12/30/14 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 38" 0" 5" 14" How were dimensions determined? Tape and sludge tool Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): PUMP TANK ANNUALLY. 1500 GALLON. FLOW LEVEL GOOD, BAFFELS GOOD, STRUCTURALLY SOUND. 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 • 3/13 Date Title 5 Offidal 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 186 CANDLESTICK ROAD Property Address ART MARAVELIS Owner Owner's Name information is required for every N. ANDOVER MA 01845 12/30/14 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: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ No Alarm in working order: 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 ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M a 186 CANDLESTICK ROAD Property Address ART MARAVELIS Owner Owner's Name information is required for every N. ANDOVER MA 01845 12/30/14 page. 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 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): REPLACED "D" BOX PRIOR TO INSPECTION. SEE PERMIT. 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'GSM ,•�''� 186 CANDLESTICK ROAD Property Address ART MARAVELIS Owner Owner's Name information is required for every N. ANDOVER MA 01845 12/30/14 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: (3) 2'X43' ❑ 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.): NO SIGNS OF HYDRAULIC FAILURE 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 w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 186 CANDLESTICK ROAD Property Address ART MARAVELIS Owner Owner's Name information is required for every N. ANDOVER MA 01845 12/30/14 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 Offidal 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 186 CANDLESTICK ROAD Property Address ART MARAVELIS Owner Owner's Name information is required for every N. ANDOVER MA 01845 12/30/14 page. CitylTown 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 1S/a• REA.�/N 7, /Nra�S• ,Qs LN RotaND_Ld��/V -/2-89 00th N o ' � - y�•�a T •'. T.•t ' i' . C�n�n� sticK RoA�_ Rfoc = 3s' l?to't /7' /Soo Gg/' SEPI%[ f/aNK RfoD= #9' MoD �Y' ° ,� fREN[tiES �' X ?3t'i SEWEiz ocg-Y�__! �v S9__ r:..... 7LAA/K out IC.L SG Qoz ini t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 Commonwealth of Massachusetts H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 186 CANDLESTICK ROAD Property Address ART MARAVELIS Owner Owner's Name information is required for every N. ANDOVER MA 01845 12/30/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 61eet 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: 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: DUG HOLE WITH AUGER IN REAR (95' AWAY) DROP OFF, 3' NO WATER. ELEVATION DIFFERENCE TO FRONT S.A.S. 4' HIGHER THAN REAR. 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 H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M a 186 CANDLESTICK ROAD Property Address ART MARAVELIS Owner Owner's Name information is N required for every. ANDOVER MA 01845 page. Cityrrown State Zip Code E. Report Completeness Checklist 12/30/14 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Summary Record Card generated on 121812014 2:19:42 PM by Maureen McAuley Town of North Andover Class 101 Single Family Zoning2 1 Residential Size Total 1.09 Acres FY 2015 ..UB Mailing Index Name/Address MARAVELIS, ARTHUR 186 CANDLESTICK ROAD NORTH ANDOVER, MA 01845 Tax Map # 210-106.A-0195-0000.0 Parcel Id 17339 186 CANDLESTICK ROAD MARAVELIS, ARTHUR 186 CANDLESTICK ROAD NORTH ANDOVER, MA 018.45 Property Type Zoning3 Type Loan Number Activellnact. From Payor UB Account Maint. Active/Inactive Cycle Account No y Occupant Name Last Billing Date 10/3/2014 Bldg Id. 17627.0 - 186 CANDLESTICK Active 3170298 Cycle 03OAD UB Services Maint. Account No. 3170298 Charge Multiplier/Users Service Code Rate 0 7.82 11 /1 MISCFEE ADMIN FEE 011 ALLL METER SIZE 636.17 WTR WATER UB Meter Maintenance Account No. 3170298 SeriaP�%. Status Location Brand b Badger Type. Size w Water 0.63 0.63 3620U!5h a Active ERT HH Consumption p Posted Date Date "''"` —`:.- Reading 771 Code a Actual 121 83 10h512014 7116/2014 9/1112014 6/11/2014 650 a Actual 25 4/11/2014 3/11/2014 567 a Actual 33 1/17/2014 12/10/2013 542 a Actual 54 10/15/2013 9112/2013 509 a Actual 65 7/24/2013 6112/2013 455 a Actual 28 4/22/2013 3/1412013 390 a Actual 30 1/9/2013 12/11/2012 362 aActual 44 10/15/2012 9113/2012 332 a Actual• 25 7/16/2012 6/12/2012 288 a Actual 27 4/14/2012 3/1412012 263 aActual Y4 1/17/2012 12/12/2011 236. a Actual 36 10/13/2011 911212011 212 a Actual 34 7/20/2011 6/7/2011 176 a Actual 21 4/1312011 3/8/2011 142 a Actual. 24 1/12/2011 12/9/2010 121 a Actual 62 , 10/15/2010 9/10/2010 97 a Actual 25 7/15/2010 617/2010 35 a Actual 10 4/14/2010 3/9/2010 10 a Actual 0 4/14/2010 1/2312010 0 n New Meter 11 4/14/2010 112312010 3935 r Replacement 21 1/12/2010 12/8/2009 3924 a Actual 54 10/15/2009 919/2009 3903 a Actual 28 7/2012009 618/2009 3849 a Actuat 19 4/29/2009 3/13/2009 3821 aActual 22 1/20/2009 12/9/2008 3802 a Actual 54 10/10/2008 918/2008 3780 a Actual 46 7/16/2008 616/2008 3726 a Actual 22 4/11/2008 317/2008 3680 aActual Page 1 1 Residential 1 Residential Until YTD Cons 761 Variance 46% 228% -26% -37% -19% 140% -11% -29% 70% -4% 10% -29% -I% 58% -12% -59% 135% 25% •=100% -100% 2% -60% 80% 59% -15% .58% 14% 100% -31% Commonwealth of Massachusetts Map -Block -Lot 106.AO'195 BOARD OF HEALTH Permit No North Andover BHP -2014-1309 - ------ -------- ------ FEE $125.00 DISPOSAL WORKS CONSTRUCTION PERMIT Permission is bereby granted Jahn Soucy ------------------------- --- ------------ ------- -------- ........... ........ -------- to (Repair) an Individual Sewage, Disposal System. atNo' ..1 -8.6. -CANDLESTICK ROAD -------------------------------------- ---------- -- ---------------- -- ---------- 1-1--.1 --------- -- ------------ as shown on the application for Disposal Works Construction Permit No. BBP-2014-130 Dated, December 24, �2014 --------------------- ------------------ Z;W! T -- Issued On:.Dec-24-2014 IL ------ -- ------------ ------ --------------- OARD OF HEALTH Commonwealth of Massachusetts Map -Block -Lot 106.A0195 BOARD OF HEALTH ------------------- Permit No North Andover BHP -2014-1309 -------------------- FEE $125.00 --------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted John-Soucy--------------------------------------------------------------- to (Repair) an Individual Sewage Disposal System. at No 186 CANDLESTICK ROAD as shown on the application for Disposal Works Construction Permit No. BHP -2014-130 Dated December 24, 2014 ----F HEAL----TH e - OARD O Issued On: Dec -24-2014 / ernai�,�iz�Zab� PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 12/30/2014 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Repair of D -Box B y : John Soucy At: 186 Candlestick Rd. Map 106.A Lot 0195 North Andover, MA 01845 The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Michele Grant Public Health Agent 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Blackburn, Lisa From: Isaac Rowe <irowe@millriverconsulting.com> Sent: Tuesday, December 30, 2014 3:33 PM To: Sawyer, Susan Cc: Blackburn, Lisa; Isaac Rowe; Pam Lally Subject: RE: 186 Candlestick Attachments: IMG 1365.JPG Susan/Lisa, Attached is a photo of the newly installed H-20 d -box at the above referenced property. Everything looked good and I left a message at John Soucy's office allowing the backfill to proceed. I have other photos if you would like them. Please let me know if you have any questions. Thanks, Isaac M. Rowe, R.S. Project Manager Mill River Consulting 6 Sargent Street Gloucester, MA 01930-2719 Phone: 978-282-0014 ext.804 Fax: 978-282-1318 irowe@millriverconsultine.com www.miliriverconsulting.com -----Original Message ----- From: Sawyer, Susan [mailto:ssawyer@townofnorthandover.com] Sent: Monday, December 29, 20141:16 PM To: Isaac Rowe <irowe@mill riverconsulting.com> (irowe@millriverconsulting.com) Cc: Blackburn, Lisa Subject: 186 Candlestick Thank you Isaac, The application for the D -box is attached w/ the as -built and John Soucy's # is on the form. Susan -----Original Message ----- From: noreply@townofnorthandover.com [mailto:noreply@townofnorthandover.com] Sent: Monday, December 29, 201412:37 PM To: Sawyer, Susan 1 te 1R� A 4r lv " fR, K°RTh Application for Septic Disposal System 12/19/2014 ��' °�'' ° p°L TODAY'S DATE pConst ructlon Permit - TOWN OF ORTH ANDOVER MA 01845 $ 250.00 — Full Repair $125.00 - Component Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer, use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key to move your ❑Q Repair or replace an existing system component —what? DISTRIBUTION BOX H-20 cursor - do not use the return key. A. Facility Information 186 CANDLESTICK ROAD AIA Address or Lot # N. ANDOVER Cityfrown 2: *TYPE OF SEPTIC SYSTEM*: ❑ Pump ❑W 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 Areen4FQ_�" El Pressure Dosed (D -Box Present) S.A.S. 2. Owner Information DEC 2 4 2014 TOWN OF.. _Ni ii ANDO,JE ART MARAVELISHEALTH,,� Name ' 186 CANDLESTICK ROAD Address (if different from above) N. ANDOVER MA 01845 Cityrrown State Zip Code 978-866-4041 Telephone Number 3. Installer Information JOHN SOUCY Name 78. BROADWAY Address SALEM CityfTown 4. Designer Information N/A Name Address Cityrrown SOUCY SEWER SERVICE INC r Name of Company NH 03079 State Zip Code 603-898-9339 Telephone Number (Cell Phone # ifposslble please) Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit - Page 1 of 2 A A( -C , mn JS- ///= -�1'4 ' l�foe ' 3S' 13 tot /Soa G,g /- Sceptic ��M k Alto 7Rk1VeAZ j 2'x 'fif SEWEiz 044t_ l7o SO- �3ox itii 7Z - END of .1moi[,E P ' ". Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. rat�m Application for Septic Disposal System Construction Permit -TOWN OF 12/19/2014 TODAY'S DATE $ 250.00 — Full Repair $125.00 - Component Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system* ❑ Repair or replace an existing on-site sewage disposal system* ❑■ Repair or replace an existing system component —What? DISTRIBUTION BOX H-20 A. Facility Information 186 CANDLESTICK ROAD Address or Lot # N.ANDOVER Cityrrown 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 ❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance A ❑ Pressure Dosed (D -Box Present) S.A.S. 2. Owner Information ART MARAVELIS Name 186 CANDLESTICK ROAD Address (if different from above) N.ANDOVER Cityrrown 3. Installer Information JOHN SOUCY Name 78. BROADWAY Address SALEM Cityrrown 4. Designer Information N/A Name Address Cityrrown I this type of system. CLEC 2 4 2014 TOWN OF ANDOVER MA 01845 State 978-866-4041 Zip Code Telephone Number SOUCY SEWER SERVICE INC Name of Company NH 03079 State 603-898-9339 Zip Code Telephone Number (Cell Phone # if possible please) Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 Application for Septic Disposal System Construction Permit -TOWN OF ORTH ANDOVER. MA 01845 PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: ❑■ Residential Dwelling or ❑Commercial B. Agreement 12/19/2014 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 Cod as hell as the Local Subsurface Disposal Regulations for the Town of Wo An over, an n tt�olace th system in operation until a Certificate of Compliance has b iss d by this r f Heal, . N me Date Application Approved By: (Board of Health Representative) Name Date Application Disapproved for the following reasons: For Office Use Only: 1. Fee Attached? yes-11No 2. Project Manager Obligation Form Attached.] T \ Yes No 3. Pump S sy tem? Ifso, Attach gpRE ofElectrical Pe� IV Yes No 4. Foundation As Built? (new construction ly). 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 RZ .taG AfAss. D FAJP �� 'i!`'/2-009 /// =.04 ' C/�N.DL�Sf�CK Ra/9�� R tat al /Soa Gg /• ScLPt/c "t9' 45 fo D ,3 fRENII,E,� X SE'WEA 70 SO So x /n/ /c?, 72- EN b 0 F L /A/ --c .Z 7 -- Commonwealth of Massachusetts Map -Block -Lot 106.A0195 BOARD OF HEALTH - ---- PermittNoo--------- North Andover - BHP -2014-1309 - --------------- ------ P.I. FEE F.I. $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted John Soucy ---------------------------------------------------------------------------------- to (Repair) an Individual Sewage Disposal System. at No 1 -86 -CANDLESTICK -ROAD _ -------------------------------------------- ---� _ , ; ;�• r�"' -�� - --------------------- C, as shown on theapplication for Disposal Works Construction Permit No. BHP014130 Dated D mber 24, 2014 ----------------------------------------------------------------- Issued On: Dec -24-2014 BOARD OF HEALTH NORTH 6856 Town of North Andover HEALTH DEPARTMENT ,SSCMU+tt CHECK #: i5L59 DATE: V�)4 LOCATION: IMTInd 1 I'I C H/O NAME: t� CONTRACTOR NAME:kWA S1 } JV't' 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 $ x Septic Disposal Works Construction (DWC) $ 16 _ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5Inspector $ ❑ Title 5 Report $ ❑ Other: (Indicate) $ ie) Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 RECEIVED JUN It' 1014 TOWN OF NW. i h ANDOVER HEALTH DEPARTMENT DEP has provided this form for umby 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 LocatioeIg front of Nous Left/ Right near of house, Left /right side of house, Left/ Right side of bui m(d g, Left / Right front of building, Left / Right rear of building, Under deck g 9, Address City/Town State 2. System Owner. Name Address (d different from location) Cityrrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ 4. Zip Code State7 Telephone Number r Date Cesspool(s) — Z. Quanb Pumped eptic Tank 1. r` Gallons ❑ Tight Tank ❑ Other (describe): Effluent Tee Filter present? ❑ Yep No If yes, was it cleaned? ❑ Yes ❑ No: 5. Condition of I� v System: i A� _ WQ-eQj V\4exAJ, 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Locatiere contents -were disposed: N S. Lowell Waste Water F5821 Vehicle License Number Date t5form4.doc- 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 kly Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. YkA RECEIVED JUN 1 1 200.7 I TOWN OF NORTH ANDOVER I HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health.. The System Pumping Record must be submitted to the local Board of Health or other approving authority. . A. Facility Information 1. System Location: Address City/Town State Zip Code 2. System Owner: k—UA�-6j �-'5 Name Address (if different from location) City/Town State Zip Code Telephone Number B. Pumping Record oate 2. QuantityPumped Cesspool(s) Septic Tank_ I. Date.of Pumping 3. Type of system: El ❑ Other (describe): Gallons ❑ Tight_Tank 4. Effluent Tee Filter present? ❑ Yes Ly'No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: q 6. System,PumpecL By:l�,-�, Name !` Vehicle License Number Company -- / http://www.mass. t5fonn4.doc• 06103 System Pumping Record • Page 1 of 1 Commonwealth.. of Massachusetts City/Town of IFG I System Pumping Record N Form 4 414 DEP has provided this form for use by local Boards of Health.. The Syst�Pu`mping:Record must be submitted to the local Board of Health or other approving authority. . A. Facility Information Important: When filling out 3. System Location: forms on the computer, use only the tab key Address , to move your cursor - do not use the:retum Cityfrown State fZip Code key. 2 System Owner: Name Address (if different from location) City -frown State Zip Code Telephone Number .B. Pumping Record 1. Date. of Pum in p g Date 2. Quantity Pumped - Gallons 3. Type of system: ❑ cesspool(s) eptic Tank- ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes o 5. 6. SysterrLPumpediy' Name Company -- 7. http://www.mass. t5form4.doc• 06103 If yes, was it cleaned? ❑ Yes ❑ No Vehicle license Number System Pumping Record • Page 1 of 1 Important: When filling out forms on the computer, use only the tab key to move your. cursor - do not use the return key. ream Commonwealth of Massachusetts City/Town of 7RECEIVED System Pumping RecordForm 4AY 2 6 2009 Mre7u-sing N OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. Otheg �' E' information must be substantially the same as that provided here. Bthis 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 front, left rear, left side of hour . fight front r' t rear, right si of house. Address /J (—) /'7 / ` �, 'J , _ U _ / / City/Town G7 SSttatee �l./ Zip (Code 2. System Owner: v `/ Name Address (if different from City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: 8 Other (describe): State �. _ Zip Code Telephone Number �-[�)- Date 2• Quantity Pumped Cesspool(s) eptic Tank Gallons Tight Tank 4. Effluent Tee Filter present? 0 Yes No If yes, was it cleaned? L3 Yes [j No 5. Condition of System: �✓ / � �� .,�/ ` � �- ��% r ✓( �l 6. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: Mof Lowell Waste WaterA - - igDate ` t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 TOWS OF SYSTEM DATE: - p SYSTEM OWNER & ADDR—ESS �' 0 " Oclo Ig� C0,414tskk-y G RECORD (example: left front of house) RECEIVED JUN 2 0 7005 TOWNS O NORTH DE H ANDOVER 0� kou's--e- DATE OF PUMPING: - , S Q AiNTITY PUMPED: ya c � GALLONS CESSPOOL.: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE- EMERGENCY t VRIQF.1?,V ATInIVQ- G00% CONDITION HEAVY GREASE FOOTS EXCESSrjrE. SOErnS SOLIDS CARRYOVEER FULL TO COVER BAFFLES lila PLACE LEACI�rir IELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc.. COT -11 -PN e,'N t S: CONTENTS TRANSFERRED TO: G.L,S.D Is `w4m-7;FT6:~ TOWN OF ,. SYSTEM PUMPING RECORD DATE: 3 SYSTEM OWNER & ADDRESS LovvL6 �b COA Jv 411, L SYSTEM LOCATION (example: left front of house) �t o it 11 3 0 2003 f DATE OF PUMPING: �� 30 ^ DS QUANTITY PUMPED: _8� GALLONS CESSPOOL: NO YESSEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE I EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: LS TOWN OFN. 'n,kr SYSTEM PUMPING RECORD DATE: +a SYSTEM OWNER & ADDRESS oc� Cc q t C0-Jf--6b-Ct SYSTEM LOCATION (example: left front of house) lock �'- koust t4t- DATE OF PUMPING: - QUANTITY PUMPED : GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACIUHLD RUNBACK FLOODED OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: -Z�6�b- - TOWN OF NORTH ANDOVER ©g400 l , SYSTEM PUMPING RECORD du✓ DATE: &y��`��' V SYSTEM OWNER & ADDRESS [ ts—cp (example: left front of house) 4-L � ��- �v DATE OF PUMPING. ✓`)V-0LQUANTITY PUMPED �� �`J GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES 4 -'-- NATURE OF SERVICE: ROUTINE `� EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) 1 CONTENTS TRANSFERRED TO: u C C Z fl r I i Z�� O P, O 71 v 0 ' n 0 0 cuCL O_0 D a. I fD 0 a] a O P, r I � � rr J I i� ofHam. i i-� Lor 2, GANta,5Ti- K Z. ' _ w�TE� S� P►'l.7 Q jbUJr�1 ❑ WEC.L.. ,�Ps�ouED C' SS ° SEPTIC 51sT vEs�C� APRWiN6 Aun-tor'?iTy G Tv4 vsGv IZ ���4PPRpV�p IE G4kie r) Yw(5(c.4, C�,' 3 . G'7�G1✓AT�o/� �NSPEGT�D^J FINAL lV5PEGrlonj ScP-r c Sl+5TEM 1 J ST�O I.LQTioAJ 94rc-0-Pi45s ❑ PAIL - Q PPI3d V ED Quc- t(-1 Z4 T�o�AL 1�15t-. 1 (OSS X11= A►-�Y� DtSAPPtZdvt D RCOSO N5 FK4L APPI)VAL DarC APFRDVIAJG Aur+foRtTy NSTOt t C-� 51, I-tl J>I Or 464 o� TE .I NAL SANS N y �I Q icy i V1 a v W �` 4 I 4 XjN�C,�Q. M 4 4. I,� <N 0 _0 re) Nl I� N. .k 4d 411, N • COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS T� DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: _186 Candlestick Road_ _North Andover_ Owner's Name: John Schaefer Owner's Address: 186 Candlestick Road- - North oad__North Andover, Ma. 01845_ Date of Inspection: _6/30/2001_ Name of Inspector: Neil J. Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, Ma. 01810_ Telephone Number: _( 978 ) 475-4786_ Hca , OF_=- T juu — 6 2001 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: _X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority F 'ls Inspector's Signature: t Date: _6/30/2001_ 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _186 Candlestick Road_ _North Andover— Owner: Schaefer Date of Inspection: _6/30/2001 Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: _X 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. Answer yes, no or not determined (Y,N,ND) in the 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. ND explain: 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 ND explain: 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 obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _186 Candlestick Road_ _North Andover— Owner: Schaefer Date of Inspection: _6/30/2001 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 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 and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _186 Candlestick Road_ _North Andover— Owner: Schaefer Date of Inspection: 6/30/2001_ D. System Failure Criteria applicable to all systems: You must indicate "yes" or `no" to each of the following for all inspections: Yes No _ _No_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ _No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _No_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ _No_ Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow _No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ _No_ Any portion of the SAS, cesspool or privy is below high ground water elevation. _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. No Any portion of a cesspool or privy is within a Zone 1 of a public well. _ _No Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ _No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] _No_ (Yes/No) 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. You must indicate either "yes" or `�no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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. Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: _186 Candlestick Road_ _North Andover_ Owner: Schaefer Date of Inspection: _6/30/2001 Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No Yes _ Pumping information was provided by the owner, occupant, or Board of Health No Were any of the system components pumped out in the previous two weeks ? Yes _ Has the system received normal flows in the previous two week period ? No Have large volumes of water been introduced to the system recently or as part of this inspection ? Yes_ _ Were as built plans of the system obtained and examined? (If they were not available note as N/A) Yes _ Was the facility or dwelling inspected for signs of sewage back up ? Yes _ Was the site inspected for signs of break out ? Yes _ Were all system components, excluding the SAS, located on site ? _Yes_ _ 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 ? _Yes_ _ 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: Yes no Yes _ Existing information. For example, a plan at the Board of Health. No Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: _186 Candlestick Road_ _North Andover– Owner: Schaefer Date of Inspection: _6/30/2001_ FLOW CONDITIONS RESIDENTIAL 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_ Number of current residents: _2 Does residence have a garbage grinder (yes or no): Yes_ Is laundry on a separate sewage system (yes or no): No_ [if yes separate inspection required] Laundry system inspected (yes or no): — Seasonal use: (yes or no): No_ Water meter readings: _March 00 to April 01=20,300 Ft' x 7.5=152,250Gals. / 365 Days = 417 Gals./Day Sump pump (yes or no): –No _ * Has Sprinkler System Last date of occupancy: _Current COMMERCIALANDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgf,etc.): 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/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: _Pumped three years ago, owner_ Was system pumped as part of the inspection (yes or no): Yes_ If yes, volume pumped: ,_1500_gallons -- How was quantity pumped determined? Measured tank _ Reason for pumping: _Inspect tank & tees TYPE OF SYSTEM X Septic tank, distribution box, soil absorption system _ Single cesspool _ Overflow cesspool — Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) _ Tight tank _ Attach a copy of the DEP approval Other (describe): Approximate age of all components, date installed (if known) and source of information: _12 years old, 4/12/1989, as built plan_ Were sewage odors detected when arriving at the site (yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _186 Candlestick Road- - North oad__North Andover— Owner: Schaefer Date of Inspection: 6/30/2001_ MELDING SEWER (locate on site plan) X Depth below grade: 22" Materials of construction: _cast iron —X-40 PVC _other (explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): _4" PVC thru wall to septic tank. 3" PVC in house. No leaks. SEPTIC TANK: X locate on site plan) Depth below grade: _10" Material of construction: —X—concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): — (attach a copy of certificate) Dimensions: 10' x 5' x 4' Sludge depth 8" Distance from top of sludge to bottom of outlet tee or baffle: _19" Scum thickness: _3" 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: _18" How were dimensions determined: Subtract scum & sludge depth to tee length. _ 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 ok. Depth of liquid at outlet invert. No evidence of leakage. _ 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 (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _186 Candlestick Road_ North Andover— Owner: Schaefer Date of Inspection: 6/30/2001_ 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/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: _X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: _0_ Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): _D -box level & distribution equal. Evidence of carryover, pumped d -box to clean. No evidence of leakage. _ 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.): Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _186 Candlestick Road- - North oad__North Andover_ Owner: Schaefer Date of Inspection: 6/30/2001 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: --i--leaching trenches, number, length: 3 trenches 43' long_ leaching fields, number, dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): —Soil ok. Vegetation ok. No sign of ponding to surface _ CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth — top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): 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.): Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _186 Candlestick Road _ _North Andover_ Owner: Schaefer Date of Inspection: _6/30/2001_ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A to 1 = 30'8" Ato2=34'8" A to 3 = 38'8" A to D -Boz = 48'7" Bto1=20'2" Bto2=17' Bto3=14'4" B to D -Boz = 2216" Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _186 Candlestick Road- - North oad__North Andover— Owner: Schaefer Date of Inspection: _6/30/2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water _4 feet Please indicate (check) all methods used to determine the high ground water elevation: X Obtained from system design plans on record - If checked, date of design plan reviewed: _12/5/1988_ 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: As per design plan _ Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 186 Candlestick Road, North Andover Owner: Schaefer Date of Inspection: 6/30/3001 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. it J. eson Bateson Enterprises, Inc. TOWN OF J� Qq - SYSTEM PUMPING RECORD LTH A DATE:_ 6 SYSTEM OWNER & ADDRESS J� ch� a Q-(' � t'5 ( � � C0,0 d t-( J\' C- � SYSTEM LOCATION _.•-! (example: left front of house) r 1'0- �ro4 of �ou� DATE OF PUMPING: QUANTITY PUMPED: s Q GALLONS CESSPOOL: NO YES EPTIC TANK: NO YES 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 (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D_V Lowell Waste Commonwealth of Massachusetts h :=IVED City/Town of System Pumping Record FEB 2 7 2008 V �d~ Form 4 TO`J� iv OF NORTH ANDOVER -EALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. er 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 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. 1. System L� Address C tyrrown Sta16 Zip Code 2. System Owner: Address (if different from location) own State Zip Code 6,9- 9 --V w 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? ElLam Yes 0-14o'— If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: "C 'A� 1zu-� 6. Systema Pymp�d By. Name Vehicle License Number Company 7. Location e?e contents were disr MA t5form4.doc• 06/03 System Pumping Record ^ Page 1 of 1 -C-\ Commonwealth of Massachusetts City/Town of a System Pumping Record __. RCEIVED i M S •v`�� Form 4 DEP has provided this form for use by local Boards of Health. Other forms r ay be used, but the information must be substantially the same as that provided here. Before us WWs torrvQ K� r local Board of Health to determine the form they use. The System Pumping ed*d4IMM M&Ldlo the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left side of house, Right side of house, Left front of house, i , Left rear of house, Right rear of house. Left rear of building. Right rear of building. Address City/Town State Zip Code 2. System Owner: Name Address (if different from location) City/Town State (� Co e Telephone Number B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Date 2. Quantity Pumped: Cesspool(s) eptic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes Flo If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: "�r� timet ),,\-4---r� 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: /6.13 „ Lowell Waste Water of F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts EI ED City/Town of ASR .i 1 't011 W° System Pumping Record Form 4 TOWN OF NORTH ANDOVER �1Q H gEPARTMENT 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 Locatio . eft front of ho , right front of house, left side of house, right side of house, Left rear of house, rig rear o Ouse, left side of building, right rear of building, under deck. City/Town 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): State Hr)� Udl 5 Date Cesspool(s) Telephone Number — 2. Quantity Pumped eptic Tank Zip Code vuuc r Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes a No If yes, was it cleaned? ❑ Yes ❑ No 5. Conditioq ofyste�� �� i V\- 6. 6. System Pumped By: Neil J. Bateson Name Bateson Enterprises Inc. Company 7. Lo ion wft re contents were disposed: G.L.S. F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record ° Page 1 of 1