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Miscellaneous - 190 BRIDGES LANE 4/30/2018
190 BRIDGES LANE 210/104.D-0084-0000.0 a • ILED-1- COPY PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 10/28/2013 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Repair of D-Box By:Todd Bateson At: 190 Bridges Lane Map 104D Lot 0084 North Andover, MA 01845 T e Ssuance of this ce ificate shall not be construed as a guarantee that the system will function satisfactorily. Q 0 ich'le Grant Public Health Agent 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com • SES D®646. • .. IL • North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 190 Bridges Lane MAP: 104D LOT: 0084 INSTALLER: Todd Bateson DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS D-Box: 10/28/2103 TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: f° DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANKS` ❑;' 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 wlip Inlet tee installed centered under access ort ❑ p ❑ 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: CONTROLPANEL ❑ 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 []/ Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets [� Observed even distribution Speed levelers provided (not required) Comments:. $4A ani L IL Commonwealth of Massachusetts Map-Block-Lot ` • 104.D0084 --- — -- ------------- �"• BOARD OF HEALTH Permit No North Andover -BHP-2013-09-89---------------- ------ P.I. FEE F.I. $125.00 DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd-Bateson to(Construct)an Individual Sewage Disposal System. b' 60)( at No 190 BRIDGES LANE - ------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP-2013-098 Dated October-22,-2013--- --- ---- - ------- - -- Issued On: Oct-22-2013 > D OF HEALTH / • a Commonwealth of Massachusetts Map-Block-Lot y <; C •. 104.D0084 BOARD OF HEALTH Permit No North Andover - eHP-20130989 FEE $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd Bateson _ _- to(Construct)an Individual Sewage Disposal System. bo)( at No --1-9-0-BRIDGES LANE as shown.on the application for Disposal Works Construction Permit No. BHP-2013-098Dated October 22,2013 --------6�E--- ---Y -------------------------- Issued On: Oct-22-2013 B ARD OF HEALTH r NOPTM W,Y.f{ . • Town of North Andover HEALTH DEPARTMENT ,SSCN�`> AA �4 CHECK#: Q DATE: LOCATION: A6 7��f 1,A60LA H/O NAME: CONTRACTOR NAME S 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: L ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ s ❑ Title 5 Inspector $ ; ❑ Title 5 Report $ ❑ Other. (Indicate) $ f V / Health A#1t Initials." M .White-Applicant Yellow-Health. Pink-Treasurer Application for Septic Disposal System Construction Permit — TOWN lel OF TODAYS DATE NORTH 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 repair or replace an existing system component—What? h�" X cursor-do not use the return A. Facility Information key. /9a B('64 e s 14A." Address or Lot# � � I Cityrrown ISI 2.-*TYPE OF SEPT YSTEW: nor r7 f�n ti ➢ ❑ Pump -2 ravity(choose one) �va � _. **`!f pump syst ach copy of electrical permit to application*** r.� 4 ➢ onventional System (pipe and stone system) ❑ Infiltrator or Biddiffuser(Gravel-Less) (Attach a copy of your certification to-install_Tthisztype of system.) ➢ ❑ Pressure Distribution S.A.S.(No D-Box) ➢ ❑ Pressure Dosed(D-Box Present)S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No if yes, does plan specify make and model of filter? YES =(no further info. needed) NO=(installer must specify brand of filter before DWC issuance) What is the Make? "at is the Model. 2i Owner Information Name Address(if different from above) © d v City/Town State Zip Code Telephone Number 3. Installer Information �'-� ��-7��-sem,✓ Name Name of Company (6 BATESON ENTERPRISES,INC Address ANDOVER AD ,MA 01810 City/Town , ` State Zip Code l?, �"lS—o"t`!v� Telephone Number(Cell Phone#if possible please) 4. Designer Informatio Name Name of Company Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 J. �^ Application for Septic Disposal Svstem /o -ai Construction Permit - TOWN OF TODAY'S DATE NORTH ANDOVER, MA 01845 $250.00-Full Repair $125.00-Component PAGE 2 OF 2 A. Facility Information continued.... 5. Type of Building: residential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover. I understand that until a final Certificate of Compliance has been issued by this Board qf4gialth, the installed system is not approved. /o - �/-� Name Date Application proved y: (Board of Health Representative) Z2 — Date Name / J Applic tion Disapprovd for the following reasons:, ForOffice Use Only..�....,..,..,.... �_.��.....,.�..... ......�.,�.�..._,..�_.-.,......_...�,..m�,_r.�....,,�._�..,4.-m�. ,.�..__.�...�..�v.....�._ .. L Fee Attached. Yes No 2. Pro'ect Mana er Obli ation Form Attached. 1 Y �'' �'' es No I Pump System? If so,Attach copy ofElectrical Permit Yes_ No 4. Reviewed approvalletter, all paperwork received.? Yes No MISSing;' 5. Foundation As-Built. (new construction only): Yes_ No i (Same scale as approved plan) 6. Floor Plans?(new construction only): Yes No Application for Disposal System Construction Permit•Page 2 of 2 SEP'T'IC.SYS'Y'EM.INSTALL BJI�PRGJECT M�?�AGEMENT OBLIGATIONS As fhe North Andover licensed,uistaller for the-edastmction fdz:fihe septic systeYn for.the property at •1gp ����, ��. —-�— �*---'^'— For plans by (Addrest of septic system) n (Engineer) Relative to tht.application ofy-f-e SDs Acid dated (I'n'stallers name) nginal date). Dated With revisions dated o s ac .(Last revised date) I understand the following obligations for management of-this project: 1. As the installer,I am.obligated to obtain all permits and Board offHealth approved plans,priot to :performing any.'work on a site: I must have the'mroved glans and the nermit;on site when any work is b6ing-d 2. As tie installer,.I.mu'st`call for any'ad atfilspe'ctibns: If homeownet,contractor,,project manager, or any other person not associated with my company sc e.aes an inspection and the system is not ready,then item thme•shill be:applicable. .`' As the:irtstahtr,I atn rcgtured to,have.ttie ttecesary work''completed prioi;to the.applicable inspections as indicated below, Ttiftdo-istand thi t requeWngn'" pecti j1„,V1hout cn gletion of the itrmis in accordance "v th Tide 5 artd the$oat i of l eaith ins �y esu7'in a$50:00 a lir g.levied Aem. st:me.AVn r v eo,�v. . a,. Bo't�oYri�Sf'Berl •Generdly,zliis•is the,*s. .(1'�j apeotiom' nless:xhere is a ietaining�vab,'Bich shoula•be'driae< rst: The uistall lh<$t#west the iiispecd6u but dd,6s•not have to be present.- . b. Ftn sons ctj'oii.Ittseetiori—Engtieer btt�s't'frst tla theifi inspection for elevations,•ties,etc. . As-l�iiilt of dctl�k OK'(or e-mail•tio:healtlid t(a to 0 o thaneiover. .from the eri inner must •be stibsiiitied•to':the.Board•ofHealth.,after•:wliieli.installer,ca'ils for vin insp'ectipn time. 'Installer must bepresent for d*.inspection, W-1, i'a pump;system,ail electrical work tnust:be ready and able to cause;putrip.t6 t+ ork grid alazm".to fu 5tion.. c. -Fin 'C� ItistiUl rmustrequest'inspectiontvheii'4•gracing-is-compltte.;.Installer'does not have to 1e•on=site. ' 4. As-the instalier,'I=16tstand that only I perform the.work'(other than xwple weavatim)a-adTui required to complete the installation of the system ideattfied in the.attaphed application'for itistallation understand':that work•done by.otliers cilli-e-"-,s i �taj sen systems.+�North Andover can constitute. reasons for deival of tht syst�rrt andlor; evocati 3�o su lieriston pommy 1ense•to operate in the Town of North Andover eiiri ficant fees o all�,ersona i volved 5.. ,As tlie.insriller, I understand that'.I xnu§t'he'on=.site during t4-pir&=iance-of the following construction steps:: a: Deferrurnatros>f that.the prioperelevadon of the ezcavu on has been reached, - A Inspe,&on ofthe eand:and sfoae'to be used c. Proal inspection by Board of.�Yealth staffor consultant. d. Installation.•oftank,D.&.,,pYpes,stone, vert,pump chamber,rets g walland other components. 6. As the ins&1 t r-uWirstand that T ate+ sblijy=sj2bnsibl for the ins IU of't a y9tem as per the •p ant , No instructions by thehdjQtM=gtneral contM=r.or a y.ot2icr. sonspershy absolve me Qt�l s ooh tion. Undersigned Uceased Septic.Inatallex: oda s Date) —/, ....•..>>.... ✓_':*,��i t i'• <, ... til : Of NORTH,M 6613 3:�." o, . ..•got h y Town of North Andover HEALTH DEPARTMENT S4CHUSE CHECK#: ATE: I� )s l LOCATION: j 9 1 ., U�� �-k H/O NAME: ,3� 10 1('Vi I, CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ Title 5 Report $ ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer f Commonwealth of Massachusetts : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments OCT 15 13 uv TOWN OF NORTk A` DOVER 190 Bridges Lane HEALTH DEP <R'' SENT Property Address -- - - - -- Jodi Delnickas Owner Owner's Name information is required for North Andover MA 01845 10/10/2013 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: When filling out A. General Information forms on the computer,use 1. Inspector: o` only the tab key to move your Neil J. Bateson cursor-do not Name of Inspector us6 the return key. Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover MA 01810 City/Town State Zip Code 978-475-4786 S115 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposals stem at this address and d that the Information reported below is true, accurate and complete as of p 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needp Further Evaluation by the Local Approving Authority 4oe 10/10/2013 ure 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. I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 I Commonwealth of Massachusetts • . Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 190 Bridges Lane Property Address Jodi Delnickas Owner Owner's Name information is required for North Andover MA 01845 10/10/2013 every page. Cityfrown 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: B) System Conditionally Passes: ® One or more system components as described in the Conditional Pass" section need to be replaced or repaired. The system, em u on completion etion of the replacement or repai r, as approved by Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ® N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 190 Bridges Lane Property Address Jodi Delnickas Owner Owner's Name information is required for North Andover MA 01845 10/10/2013 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 ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ® N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioningin a manner which willro p tect 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 UTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 190 Bridges Lane Property Address Jodi Delnickas Owner Owners Name information is required for North Andover MA 01845 10/10/2013 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 y u ctioning 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 aP ublic water supply. The system has a septic Ely pt c 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: Septic tank needs riser&d-box needs to be replaced with riser. 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 j ❑ ® 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•3113 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 , 190 Bridges Lane Property Address Jodi Delnickas Owner Owner's Name information is required for North Andover MA 01845 10/10/2013 every page. Cityrrown 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 El 1:1the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well Ifou have answer " Y ed yes to an question in Section E the es stemisc considered o sidered 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•3113 Title 5 official Inspection Form:Subsurface Disposal Sewage Di g sp System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 190 Bridges Lane Property Address Jodi Delnickas Owner Owner's Name information is required for North Andover MA 01845 10/10/2013 every page. Citylrown 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 190 Bridges Lane Property Address Jodi Delnickas Owner Owner's Name information is required for North Andover MA 01845 10/10/2013 every page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Yes Detail: 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): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 190 Bridges Lane Property Address Jodi Delnickas Owner Owner's Name information is required for North Andover MA 01845 10/10/2013 every page. Cityrrown 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: Pumped 2012, owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Measured tank Reason for pumping: Inspect tank&tees. 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 Forth: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 ,. 190 Bridges Lane Property Address Jodi Delnickas Owner Owner's Name information is required for North Andover MA 01845 10/10/2013 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed (if known)and source of information: Design plan 2/2/1985 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.6 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. Unable ab a to see piping finished cellar. Septic Tank(locate on site plan): Depth below grade: 1.6 I Material of construction: feet ® concrete ❑ metal ❑ fiberglass ❑ polyethylene F-1 other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x 5'x 4' Sludge depth: 2° t5ins-3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 190 Bridges Lane Property Address Jodi Delnickas Owner Owner's Name information is required for North Andover MA 01845 10/10/2013 every page. Cityrrown 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 21" Scum thickness 8„ Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? 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 baffle ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Septic tank 18"deep, needs riser Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle i Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: 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 190 Bridges Lane Property Address Jodi Delnickas Owner Owner's Name information is required for North Andover MA 01845 10/10/2013 every 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 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 190 Bridges Lane Property Address Jodi Delnickas Owner Owner's Name information is required for North Andover MA 01845 10/10/2013 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): 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 cover broken, replaced same. D-box has carryover&sand from broken side of box. Pumped d-box to clean. D-box needs to be replaced. D-box 2'10"deep, needs riser 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 poral System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments < 190 Bridges Lane Property Address Jodi Delnickas Owner Owner's Name information is required for North Andover MA 01845 10/10/2013 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 20'x 63' ❑ 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 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M " 190 Bridges Lane Property Address Jodi Delnickas Owner Owner's Name information is required for North Andover MA 01845 10/10/2013 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts low Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 190 Bridges Lane Property Address Jodi Delnickas Owner Owner's Name information is required for North Andover MA 01845 10/10/2013 every page. 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 �U J A C4 A� 36 ' t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 • -t\, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �t 190 Bridges Lane Property Address Jodi Delnickas Owner Owner's Name information is required for North Andover MA 01845 10/10/2013 every page. CitylTown 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: 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: 2/2/1985 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: As per test pit data on design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Foran-Not for Voluntary Assessments 190 Bridges Lane Property Address Jodi Delnickas Owner Owner's Name information is required for North Andover MA 01845 10/10/2013 every page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed System Information—Estimated depth® y p 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 Foran:Subsurface Sewage Disposal System•Page 17 of 17 aurnmary neoora varo gonerawo on w4or[vw e:,rz:uo rm oy naren nanion Nage 1 Town of North Andover Tax Map # 210-104.D-0084-0000.0 Parcel Id 16751 190 BRIDGES LANE ERIC PAULIK JODY DELNICKAS 190 BRIDGES LANE NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.01 Acres FY 2014 UB Mailing Index Name/Address Type Loan Number Activellnact. From Until ERIC'PAULIK Owner JODY DELNICKAS 190 BRIDGES LANE NORTH ANDOVER,MA 01845 PARNES,ALEXANDER Previous Customer Inactive 6/30/2004 %SALVATORI,PHILLIPS 190 BRIDGES LANE N.ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 17788.0-190 BRIDGES LANE Last Billing Date 7/12/2013 3170452 03 Cycle 03 Active UB Services Maint. Account No.3170452 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 392.35 /1 UB Meter Maintenance Account No.3170452 Serial No Status Location Brand Type Size YTD Cons 36388181 a Active ERT HH b Badger w Water 0.63 0.63 809 Date Reading Code Consumption Posted Date Variance 9/12/2013 899 a Actual 98 27% 6/13/2013 801 a Actual 77 7/24/2013 332% 3/14/2013 724 a Actual 18 4/22/2013 -59% 12/12/2012 706 a Actual 43 1/9/2013 -64% 9/12/2012 663 a Actual 120 10/15/2012 204% 6/12/2012 543 a Actual 39 7/16/2012 79% 3/13/2012 504 a Actual 22 4/14/2012 -17% 12/12/2011 482 a Actual 26 1/17/2012 -79% 9/13/2011 456 a Actual 133 10/13/2011 92% 6/7/2011 323 a Actual 65 7/20/2011 214% 3/7/2011 258 a Actual 20 4/13/2011 1% 12/8/2010 238 a Actual 34 1/12/2011 -4_71 9/9/2010 204 a Actual 162 10/15/2010 324% 5 4/14/2010 6/8/2010 42 a Actual 37 7/15/2010 0 3/10/2010 5 a Actual 163/o-100% 2/6/2010 0 n New Meter 0 4/14/2010 -100% 2/6/2010 4424 r Replacement 13 4/14/2010 -39% 12/11/2009 4411 a Actual 35 1/12/2010 34% 9/8/2009 4376 a Actual 51 10/15/2009 36% 6/9/2009 4325 a Actual 35 7/20/2009 61% 3/16/2009 4290 a Actual 25 4/29/2009 2% 12/8/2008 4265 a Actual 47 1/20/2009 -2_52% 9/11/2008 4218 a Actual 68 10/10/2008 147% Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 S DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/Right front of houseefi�l Righ ear of house Left/right side of house, Left/ Right side of building, Left/Right front of bul rng, Left/Right rear of building, Under deck Address Q Cityrrown State Zip Code 2. System Owner. otj Vh C .� Name Address(if different from location) Citylrown State Zip Code Telephone Number �+ B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? F] Yes Id'No If yes, was it cleaned? ❑ Yes ❑ No. 5. Conditloxi f System: 6. System Pumped By.- Neil y:Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatio ere contents were disposed: L S. Lowell Waste Water BILI, c Sig a Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 iy COMMONWEALTH OF MASSACHUSETTS T EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS M o DEPARTMENT OF ENVIRONMENTAL PROTECTION Y t .y TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 190 Bridges Lane North Andover,MA Owners Name: Alex& Monica Parnes _ �.- ND—OVER/ Owners Address: 190 Bridges Lane ��BOARD OF North Andover,MA ....�-_ Date of Inspection: 04/22/04 a Name of Inspector: Richard A. Briscoe � ---� Company Name: R. A. Briscoe, Inc. " Mailing Address: 61 Garrison St. Groveland, MA 01834 Telephone Number: [9781372-2200 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. I am a DEP approved systems inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: Passes _Conditionally Passes N 6 Further Evaluation By the Local Approving Authority Inspector's Signature: ��/��C Date: 0yz a g The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and, the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and 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. Title 5 Inspection Form 6/15/2000 Page 1 i Page 2 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 190 Bridges Lane North Andover,MA Owner: Alex& Monica Parnes Date of Inspection: 04/22/04 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: A/A One or more system components as described in the"Conditional Pass" section needs 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, or 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 is a Certificate of Compliance indicating that the tank is less than 20 years old is avaliable. ND Explain: _Observation of sewage backup or breakout 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 the 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: 2 Page 3 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 190 Bridges Lane North Andover,MA Owner: Alex& Monica Parnes Date of Inspection: 04/22/04 C. Further Evaluation is Required by the Board of Health: n/A _Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1. System will pass unless the 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 protect the public health and safety and the environment: _The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I 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 coloform 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 was triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION (continued) Property Address: 190 Bridges Lane North Andover,MA Owner: Alex& Monica Parnes Date of Inspection: 04/22/04 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 an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. k Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. �Y Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped �( Any portion of the SAS, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coloform 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.] Q(Yes/No) The system fails. I have determined that one or more of the above failure criteria exists as described in 310 CMR 15.303, there fore 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:/VA 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"yes"or"no"as to each of the following: (The following criteria apply to large systems in addition to the criteria above) The design flow of system is 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone 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. 4 Page 5 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 190 Bridges Lane North Andover,MA Owner: Alex& Monica Parnes Date of Inspection: 04/22/04 Check if the following have been done: You must indicate either"yes" or"no" as to each of the following: Yes No Pumping information was requested of the owner, occupant, and Board of Health. X Were any of the system components pumped out in the previous two weeks ? Has the system received normal flow in the previous two week period ? Have large volumes of water been introduced to the system recently or as part of this inspection ? �i 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 SAS, located on site ? _ Were the septic tank manholes were uncovered, opened, and the interior of the inspected for condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum ? _ Was the facility owner(and occupants if different from the 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 Existing Information. For example, a plan at the Board of Health. /V\ _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] 5 Page 6 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 190 Brides Lane North Andover,MA Owner: Alex& Monica Parnes Date of Inspection: 04/22/04 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): � Number of bedrooms (actual) y DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): A14 Number of current residents: Y Does residence have a garbage grinder(yes or no): 4/0 Is laundry on a separate sewage system) (yes or no):A--Q; [If yes, separate inspection required] Laundry system inspected (yes or no):,P0 Seasonal use (yes or no): AID Water meter readings, if available (last 2 year's usage (gpd)): Sump pump (yes or no): _y Last date of occupancy: o CLv014rlj COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow based on 15.203): and Basis of design flow (seats/persons/sqft, 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: Was system pumped as part of inspection: (yes or no): LI/� If yes, volume pumped gallons - How was the quantity pump determined? Reason for pumping: TYPE OF SYSTEM Septic tank, distribution box, soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative Alternative technology. Attach copy of the current operation and maintenance contract (to be obtained from the system owner) Tight Tank Attach a copy of DEP Approval Other(describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site: (yes or no) �O 6 Page 7 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 190 Bridees Lane North Andover,MA Owner: Alex& Monica Parnes Date of Inspection: 04/22/04 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: cast iron_40 PVC_other(explain): Distance from private water supply well or suction line Comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: V�(locate on site plan) Depth below grade: Material of construction: _concrete_metal_Fiberglass_polyethylene_ other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance (yes/no): (attach a copy of certificate) Dimensions: Sludge depth: 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 dimensions were determined: Comments:(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, evidence of leakage, etc.): GREASE TRAP: y(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.): 7 Page 8 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 190 Bridges Lane North Andover,MA Owner: Alex&Monica Parnes Date of Inspection: 04/22/04 TIGHT OR HOLDING TANK: /4 (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: YS(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 is equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): PUMP CHAMBER: 1(/ 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.): 8 • Page 9 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 190 Bridges Lane North Andover,MA Owner: Alex& Monica Parnes Date of Inspection: 04/22/04 SOIL ABSORPTION SYSTEM (SAS): �&]5 (locate on site plan, excavation not required) If SAS not located, explain why: Type leaching pits, number: leaching chambers, number: leaching galleries, number: leaching trenches, number, length: / leaching fields, number, dimensions: 15_02C ZD 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.) CESSPOOLS: &V (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(yes or no): Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: A10 (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.): 9 Page 10 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 190 Bridtes Lane North Andover, MA Owner: Alex& Monica Parnes Date of Inspection: 04/22/04 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. YQIVe, w�y4 a d C D S"� �-e = 2z•S 5-0 . 0 10 Page I I of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 190 Bridges Lane North Andover,MA Owner: Alex& Monica Parnes Date of Inspection: 04/22/04 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater___y Feet Please indicate all the methods used to determine high groundwater elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked local excavators, installers- (attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: !24 y 11 Page 12 of 12 R. A. BRISCOE, INC. 61 GARRISON ST. GROVELAND, MA 01834 TEL. (978)372-2200 FAX(978) 372-2450 SEPTIC SYSTEMS: DESIGNED, BUILT, REPAIRED AND PUMPED Title V Inspections Title V Inspection Report Property Address: 190 Bridles Lane North Andover,MA Owner: Alex& Monica Parnes Date of Inspection: 04/22/04 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. c TA. Briscoe 12 TO: NORTH ANDOVER, MASS - �� 19 BOARD OF HEALTH FROM: DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at z North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated 1 C, I� COM I ,a Mo�,�y� 71-e ®r Qo � • / cg. n cr/Fe � ni Ian � t L CPL A) s F Phi �,.•�fo _.v.��ti_�,,__��R_��_ -.. /Vu 1��.,( ��v�. /��-�,�-, --• G-._. ...cam? �r a ' z i s A�l _ ��-ams t - � l E ��— • 7 — Q X. C3 C.0 Y' i 7 f D • 77 .p f " 9 4 t i e •� e ; r 1. 1 4 f F I r. T r E E e " 9 � � _ r S 3 Y s f { Board dr Health SEPTIC SISTER North AndoverZMa.ae. r INSTA?S.ATICK CHECK LIST LOT `J_' �P i�VED DATE DISAPPRUTED 'X AVATIC�J OK FAIL V 2Z-25 ea ins t FAIL OK 1. Distance To: a. Wetlands b. Drains Co. Well 2. Water Line Location 3, No PPC Pipe --- - 4. Septic Tank a. .Tees -_Length & To Clean Oat Covers. b. Cement Pipe .to Tank an Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines-Flowl.ng Equal Amounts C. No Back Flow 6. ' Leach Field or Trench a. Dimensions b. Stone Depth c, Capped Inds d. Clean Double Washed Stone 7. Leach Pits a. Dimensions b. Stone Depth c. Splash Pads �- d. Tees e. Cement Pipe to Pit - Both Sides £. Clean Double Washed Stone 8. No Garbage Disposal 9. Final Grading Inspection 10. Barricading Covered System 11. ks Built Submitted a. Lot Location b. Dimensions of System c. Location with Regard-to Perc Test d. Elevations e: Water Table k l health A .....Ai dowr,Mass SUBSURFACE DISPOSAL DESIGN CHECK LIST leu Z LOT 15 APPROM DATE 2 7 js DISAPPROVED DATE Provided: Reasons: Title V FAIL 09 Reg 2.5 The submitted plan must show as a minimcit a) the lot to be served-area,dimensions mot #,abutters b location and log deep observation holes-d&, tance to ties �C location and results percolation tests-distance to ties di design calculations & calculations showing required leaching area (e) location and dimensions of system-including reserve area f) existing and proposed contours (g) location any wet areas within lW1 of sewage disposal system or disclaimer-check wetlands mapping (h) surface and subsurface drains within 1001 of sewage disposal system or disclaimer (i) location any drainage easements within =1 of sewage disposal . system or disclaimer-Planning Board files r (3) known sources of Water supply within 2001 of sewage disposal a system or disclaimer (k) location of any proposed well to serve lot-100' from leaching facility (1) location of water lines on property-101 grom leachtag facility (m) location of benchmark (n) driveways . (o) garbage disposals (p) no PVC to be used in'construction (q) profile of system-elevations of basement. plumb, pipe, septic tank, distribution box inlets and outlets, die- ributionfield piping and Other elevations (r) maximum ground water elevation in art se Wage disposal system (s) plan must be prepared by a Professioi.al. 1 ,gineer or other professional authorized by lax to prepare L. ch plans Reg 6 Septic Tanks (a) capacities-150% of flow, Water table, tees, depth of tees, access, pumping (b) cleanout (c) 10, from cellar wall or inground swimming.pool (d) 251 from subsurface drains Reg 10.2 Distribution Boxes (a) s pe greater UM 0.08 Reg 10.4 b) sump SOIL PROFILE & PERCOLATION TEST DATA orth Andover, Mass. Street No fz% D �t Lot No IS Loc/Subdiv. ' Pland Owner Investigator S�fl-300 Observer �--- SOIL PROFILE DATES 1.Elev 2.Elev 3.Elev 4.Elev Aq 1� 0'. 0 0 0 1 1 1 1 Tiles PsTest 2 � 2 2 2 31 3 3 3 4 4 4 4 5, 5 5 5 ti 6 6 6 6 7 7 7 7 8 OiO 8 8 8 �t 9 9 9 9 10! 10 10 10 Benchmark Location Elevation Datum / PERCO TION TESTS DATES Pit Number 2 ��� 4 Start Saturation '�,�'•`1117 "l,,`,Z, (0 , `� Soak-Minutes Start • •e •` ` tit Drop of 3"-Time 3 Drop of 6"-Time %W Mans.Ist 3" drop G Mins.2nd " Drop3 Percolation 11b o I , �- 1 � P EI.� wrwuwny�+q'mRw.wie.•ne».a.a»iYMm, _ - ---. Lot- ofiSUesue,c b � l N ' F •Po.oc�ED Los �RADi orI w � a 4L N . d No A7EAo%v� . /filAss. ` Tecz. GG4c- c r ¢94183 ` s� 1 4 O `. \ , , QES/c,t! pr4 Tq FLOW �T/Mq d 'IAC/L/7'/cS: N ,q , �4Bsc�pr-�o G-,q 4 OfEfknn" 'v 72r573 �/ G a S•,c- , G( /49,5 S Ez,.i'•4 T o 17 -7 7`c s t /-;,,T` '� c o7,7i o•1/ \ �. r , ` \ `�TU'E'ATiot/ /7/, o /7 X e �saN N QDROP AVAI. G R� M/N. "/,., .IL � � �' ''".� ` °e,,-, � SAT/O �/N. Min• /L�i;t,� /3 .t7iN Aryl// TS ,��/ !/yC rs1.,. /v :+�I, y/,xvrop , SL6s I�� � ",4)0, .- a �oG TABLE ' I ri� 3'Sa ,v oC 5 5lty �J� y ` A/ r'Y'a o �' Ho r a 7-t 4. 1001, p, BD TTpi y ELEt/4T�o /G lfd ' q� (. ► xi / T C�LLlGTEp BY 9,a l7.4L• � an7u/massaarmv,:yr'' '�'',a,pJytic„ ryt - (�.I ' NE SSED .By . N PZ4AI Est R� �, AT YMASYfWAtAW aV�Mea1e'NeiMYWRM.Rn�Mmlw`JYIMiOYN. tYbdeM.MgouM AiIq JNf Y AAidlilViHWt �iH'A")O'.lN.9MU CHS - C� Ecac//VALENT) Ewos ¢..id 10E4FaeA rap P l/C. P/PE • �0�6 EQu/vACENr) cJLA« (Fo,e 5PEC/F1c.4 r1oA1s — SEE SECT/OAJ .4T LOWED .e/GNT) • /QQEA D45rzi8urloAj &x - --• � f h � f / "DD 944. CoA/CQETE .5EP7-1(= 7-4,VX �F' Prc. , s-.pas �BSoePT/DN LES �G.4�/ /T /CIOT TU CSC,4LE c!',64.6-C-T40 - .B�CKF/LL � Z ig � �� �,.,,,,r-� �e' - 1t� .a 4 _ _ •. C.�2US NED STONE ,•��� s . � � � � >sq� a PIPE <::),e ,� ', 'a► ..... - ,,.. .... _ ""' � .-17 G . EOt//vAG ENT _ v 00 s I O D j,¢..To//z wASHEv Q lV y► 4 G CreusNED STavE Q \ C F• /7�.U 1( �'► - ►73 CaoClace w�ts�Eo SPEC,EET 4�, O - rTz S• //• %A/ 1T.2 , O -17/ K.S.., .. " a '�ex11 1_. �BSJ�E'PT/ON BED c.S�ECT/��t/ tA1./ � Fi.v/sti +�dI9�wVwuawulwrn'1��rHmawANreRna�w�muucari.itLmcrNVWsxxcafM9�tnsnww via..�aMs7suawWaAw�.var�lreTliA1evrrar ���� Add ress b ,0Z2jVK-=,&y I-W. Title of File Page of Date File Open: pate file closed:. Doc Document/-Action Title Date of Refer to other Purpose of Document/Action and notes action on document/ Num. Action Department Board of Appeals - Board of Health Planning Board _ Conservafion Commission - BMIlding Departrnen,t -� I i Commonwealth of Massachusetts N. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 190 Bridges Lane Property Address Jodi Delnickas Owner Owner's Name information is required for North Andover MA 01845 10/28/2013 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your Neil J. Bateson cursor-do not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address _ Andover r'-RECEIVPn_ MA 01810 Citylrown State Zip Code 978-475-4786 S115 Telephone Number i 0 License Number TOWN OF NORTH MDOV1=R HEALTH DEPAR`MPt'a1 B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ NWFuftrtherion by the Local Approving Authority 10/28/2013 Ins a 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•3113 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 190 Bridges Lane Property Address Jodi Delnickas Owner Owner's Name information is required for North Andover MA 01845 10/28/2013 every page. Citylrown 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: ® 1 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 riser cover on septic tank, replace d-box& install riser on box, inspection from B.O.H., septic sstem nA asses Title 5 Ins ection. RECEIVED NOV .19 '2013 EEALTOHEA WN OF NORTH H AiV1��9vkR LTH DEP/4 RTMENT 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 Oficial Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17