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Miscellaneous - 197 VEST WAY 4/30/2018 (2)
!' 0 -r p too 101 1 ` 4 1 c'�0— — t! TT S nn ,, i� N�w . -� ' MAP #____ PARCEL # �^� LOT # � V ___________________ SI-REET.--.---.Vc-!;,- W�q QONS�T�RU��ION[AP.P�O�A�L HAS PLAN REVIEW FEE BEEN PAID? PLAN APPROVAL: DATE APP. BY DESIGNER: PLAN DAT CONDITIONS f-19, Fr !§�6 WATER SUPPLY: TOWN WELL WELL PERMIT DRILLER_________ WELL TESTS: CHEMICAL ~DA^FE 8ACTE APPRUVED ERRIA II---�-----�J����-f���E4JVE�) COMMEMTS,;- ^ � ' FORM U APPROVAL: APPROVAL TO ISSUE NO . DATE ISSUED 1hlY _______________ CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID QSNO WELL CONSTRUCTION APPROVAL Y NO SEPTIC SYSTEM CONSTRUCTION APPROVAL NO OTHER YES NO ANY VARIANCE NEEDED FINAL BOARD OF HEALTH APPROVAL: YES NOG�) DATE:BY� M,24,.�-- \ ` / ^ ` �^� LOT # � V ___________________ SI-REET.--.---.Vc-!;,- W�q QONS�T�RU��ION[AP.P�O�A�L HAS PLAN REVIEW FEE BEEN PAID? PLAN APPROVAL: DATE APP. BY DESIGNER: PLAN DAT CONDITIONS f-19, Fr !§�6 WATER SUPPLY: TOWN WELL WELL PERMIT DRILLER_________ WELL TESTS: CHEMICAL ~DA^FE 8ACTE APPRUVED ERRIA II---�-----�J����-f���E4JVE�) COMMEMTS,;- ^ � ' FORM U APPROVAL: APPROVAL TO ISSUE NO . DATE ISSUED 1hlY _______________ CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID QSNO WELL CONSTRUCTION APPROVAL Y NO SEPTIC SYSTEM CONSTRUCTION APPROVAL NO OTHER YES NO ANY VARIANCE NEEDED FINAL BOARD OF HEALTH APPROVAL: YES NOG�) DATE:BY� M,24,.�-- f SEPTI.Q._S.YSZE :.t IS THE INSTALLER LICENSED? YES TYPE OF CONSTRUCTION: NL`W NO REPAIR FINAL CONSTRUCTION APPROVAL: DATE: %//G%/l/-_ BY NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YEs 1,10 CONDITIONS OF APPROVAL YES NO (FROM FORM U) ISSUANCE.OF'DWC PERMIT YES NO DWC PERMIT N0. � INSTALLER:_ .CLL_1 BEGIN .INSPECTION ES O: EXCAVATION .INSPECTION : NEEDED: 4----� " B Y _—_ _— PASSED — -- --- - ------ CONSTRUCTION INSPECTIONS NEEDEDn_•__._.___.._.__.___...._.__.____........_..._........_._ ._ ._._.... _.__.._.__ AS BUILT PLAN SATISFACTORY: APPROVAL TO BACKFILL: DATE:_BY_--.--- BY G� FINAL GRADING APPROVAL: DATE -----/ FINAL CONSTRUCTION APPROVAL: DATE: %//G%/l/-_ BY ZIL -C:)c 1-7.,> g. qS C - s IG LoT -L6 44,�-, 3 S G 7 VES VAl- --- - T - x- r i j 4-4 —_3 i, j 61, T::'–C:, r' E7 14 U-- T— F.— tj F7—c> s._l Of AG 53972 St I -r I qf- 81171 q I so -G--1 l4q. eo -r-,QQ r t4q. c- 5 Iu P-xY- 14A.44. O,rr e.=YA 144.e7 E -+-+v' -L 14-9. OF, (--; . olp ?, 1".04 r i j 4-4 —_3 i, j 61, T::'–C:, r' E7 14 U-- T— F.— tj F7—c> s._l Of AG 53972 St I -r I qf- 12/6/20_17 Resized952017112495094819.jpg iG'1 �e5k+)W �m-Jess Y- -r F'F .� "'LLL555444 ' e p,. I https://mai I.google.com/mail/u/0/#inbox/i 602c2d6749d3ea6?projector-1 1/1 i https://mai I.google.com/mail/u/0/#inbox/i 602c2d6749d3ea6?projector-1 1/1 j,, t ,Y ► +j ` 1'4jz , Commonwealth of Massachusetts Map -Block -Lot ._ BOARD OF 104.D0094 - -------- HEALTH � Permit No North Andover BHP -2017-1100 ------------------- P.I. FEE °j F.I. $175.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT , Permission is hereby granted Bateson Ent ' to (Construct) an Individual Sewage Disposal System. at No ].97 VEST WAY ---------------------------------------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP -2017-110 ted Nove er 017 ----------------- ---------- ----- ---- Issued On: Nov -16-2017 BOA OF HEALTH Commonwealth of Massachusetts A 104.D0094 BOARD OF HEALTH --------------------- Permit No North Andover BHP -2017-1100 ----------------------- Commonwealth of Massachusetts Map -Block -Lot ._ BOARD OF 104.D0094 - -------- HEALTH � Permit No North Andover BHP -2017-1100 ------------------- P.I. FEE °j F.I. $175.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT , Permission is hereby granted Bateson Ent ' to (Construct) an Individual Sewage Disposal System. at No ].97 VEST WAY ---------------------------------------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP -2017-110 ted Nove er 017 ----------------- ---------- ----- ---- Issued On: Nov -16-2017 BOA OF HEALTH Commonwealth of Massachusetts Map -Block -Lot 104.D0094 BOARD OF HEALTH --------------------- Permit No North Andover BHP -2017-1100 ----------------------- FEE $175.00 DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Bateson Ent to Construct an Individual Sewage Disposal System. ,: at No 197 VEST WAY as shown on the application for Disposal Works Construction Permit No. BU-P-2-01-7-6_ated e er , 2017 --------------- -------- Issued On: Nov -16-2017 OF HEALTH r CANNE � Application for S.e�t c Disposal System /0 -1 3— i 7 Construction Perr>`it —TOWN OF roDars DATE NORTH ANDOVER, MA 0.1845 $ 250.00— Full Repair $'25.001 - Component _Application its hereby made for a permit to: Construct a new on-site sewage disposal system" ❑ Repair. or replace an existing on-site sewage disposal' system" 0,11epair or. replace an existing system component - what? 0 k L --f T_-4-0— _Q b- A. Facility Information. f Address or Lot # of City/rown 0 wt- 2.- L2.- *TYPE OF SEPT SYSTEM*: yp�No�pKtM� ➢ ❑ Pump ravity (choose one) �C N —if pump system attach copy of electrical permit to application'" D ❑ Conventional System (pipe and stone system) ➢ ❑ Infiltrator or Biodiffuser (GraveQess) (Attach a copy of your certification to install this type of system.) ❑ Pressure Distribution S.A.S. (No D' Box) ➢ ❑ Pressure Dosed (D -Box Present) S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No if yes, does plan specify make and model of ffiter? YES = (no further info. needed) 'NO = (installer must specify brand of filter before DWC issuance) What is the Make? What is theModcp 2. Owner Information Name 7 s��,v.Ey Yz� Address (if different froomf above) Citylrown State Zip Code Telephone Number 3. Installer Information L3 ,a -t4--.s O ti` Name % Name ofConQVV-,0N ENTERRR,,ES INC. 1r4. 111 ARC, 11-1 Pn Address_ VER, MA Oi810 Cityrrown, 4. Desi_gner';Infonnation Name Address City/Town State Zip Code q2? YIS-a7l,:S Telephone Number (Cell Phone # i`f possible please) Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit - Page 1 oft t PAGE 2 OF 2 13 - /3- TODAY'S DATE $-250.0 * Pull Repair 0 Co "b. • A. "ad litv-100rMation cp-ntlnuedf,,, S. Type, ofBuilding: Mesid ntial-Dwelling or E30ornmercial B. Agreement The undbrilgned agrees to ensure the construction and maintenance a of th. afo rq.destfibed on-siteseWage qfsposal systam,in accordance with the provisions of TItle.5 of the &VIronhiGnt8l C040, as well as. the Local Subsurface Disposal Regulations for the Town of North Andov ' and hot toplace.1h system operation until a 0 OP n cortift 'to alto Of ComplW has been Issue this oard of Health. • Name rate Application Approved By: (Board of Health Representative) Name Us Apollcation DUMPPr.oved.. for the following reasons: For Office Use OnIv: 1. "Fee Amched?: Yes NO 2.- AnqlcctMkfiage-- 0,bVgjd0n'Fb= Attached? Y.7. M 51: �4M=? Ifsoi Attach cepy QfIF No &=kA emk- 4,1. Foundson As Built? (new const'Wdlol) ron).- Yes No (Same scale as fippmvcdplav). A FloorNwsp'(ne.w colis tr=floh- only).. No_ dn fbr,Dj�pbtal $Y.Sti36j-:C:6j . litmflah �P POMIR Paw 2 cif 2 SEMCMY i -D ? k. `' MM 'OBS `�i�C)M As die.Nglth Amlover&=sedawana fot t#OIWWtxut -f*.•t6;SgdC MtC far L thaP i� Fad (Ad4iw ufsgp k sgtaa)f ff�e p1M b3 Rehfwd to ditappt i ,' of A 16 57.0 Al Aid ditd I)SW • f o —13 —17 : r w9tit rtvidor I aartrrstend the followinrr bffligations fats agement of vsrolect: i. As theiast� I i =.obiiguW iR abu&sopen andBoand afhIe 4provcdp a �pe�Omg aap:aork sia R site.and the ;C&Q&M ft when Milml f6 b�iagdeti�' 3. As $ie fi tt0c;.I }aiiat Ball z any sad i�fl m j£ho4xe a arson o� � O04 p!°j�marn�get, or anp �p �oeftlied with xa �oa sad the spste=n is notnudy, thio ftem ,e mob ,'r ser y, tf is t �f" s p - t:thetc ss ar Ian}, Bch sht d bPw tie ikT=d A* sot ha� scant • . for �crc, o t 6k -(or e•o t.t:xe ' .fes the esfgrtaae n2ust ba itibnmittied toetc hoard ofi%a, for iiipertipa tupae. `I itiust bepreie�t< fair., a gsad able to eaaaeutrxp.tti acid to G e Wet �meP ke ttl d s ca p : I taller docs Uot 4 :lea t2u inamllet -1 uodkiMd that aitly 196MY g nn Biu nSc'(dowrbasr s rff l Atft. fired ica earap?ete the nseallstti tt of t1n^ sgreelg iC #kti edjTph hietilIntiaa: lit Atldhve 5... t`ciaadtllesi.I ader�t I rrtaai<'b�3t pace of tg coavtan . Mpg:,Ap r �CQ,a�rtlrrrt•�p�prrele�adenaft�earrl�•tracbedE • . 1d9�G� GlftflCrlJidll dt+RC�b fisc wtdd. ca Pra:laapeyy.,�o�tnia.�YeRltdte►A+A`'otcoaeu Mar, vetF chamber, r+�ttixrgartl other campttaeall� .. a. Und d ce dSt ptit:.Ii4 , Ao :- /3 —1`7. A, goer V V J / 3r � oc F _ 9 Town of North Andover . HEALTH DEPARTMENT $ACMUSf CHECK #: DATE: LOCATION: -) L rteL/ H/O NAME:2��Ll CONTRACTOR NAME: /5aje_S0/) C.l,�, 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 O� r2.� $ SEPTICS stems: ❑ Septic - Soil Testing L) $ ❑ Septic - Design Approval �Pe, $ ' \ Septic Disposal Works Construction (DWC) $ S " ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other: (Indicate) $ Healt gent Initials White - Applicant Yellow - Health Pink - Treasurer PUBLIC HEALTH DEPARTMENT Town of North Andover Community and Economic Development Division CERTIFICATE OF COMPLIANCE As of: December 6, 2017 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Outlet Tee & D -Box Repair of On -Site Sewage Disposal System By: Todd Bateson — Bateson Enterprises, Inc. At 197 Vest Way Map 1041.D Lot 94 North Andover, MA 01845 this certifis"t be cons t�ued as' a guarantee that the system will function satisfactorily. Miehele E. Grant Public Health Inspector 120 Main St., North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web www.northandoverma.gov ✓/ North Andover Health Department (ommunity and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 197 Vest Way INSTALLER: Bateson DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: November 17, 2017 MAP: 104.D LOT: 0094 INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ 'Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep 'hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by 60 Comments: PUMP CHAMBER Comments: CONTROLPANEL Comments: DISTRIBUTION -BOX Comments: visual testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement ❑ Installed on stable stone base ® H-20 D -Box ® Inlet tee (if pumped or >0.087foot) ® Hydraulic cement around inlet & outlets ❑ Observed even distribution ® Speed levelers provided (not required) ® Schedule 40 PVC Pipe PIFA Sent Pictures — Michele Grant SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, ❑ as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder / concrete / timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel -less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = FINAL GRADE ❑ Loamed ❑ Seeded ❑ Cover per plan Comments: DOCUMENTS NEEDED ❑ Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer ❑ As -Built Plan BM = HR= HI = SYSTEM ELEVATIONS ROD ELEVATION AS -BLT INVERT DESIGN INVERT ELEV ELEV Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 TOP Lateral 1 INVERT Lateral 2 TOP Lateral 2 INVERT Lateral 3 TOP Lateral 3 INVERT Lateral 4 TOP Lateral 4 INVERT Lateral 5 TOP Lateral 5 INVERT Lateral 6 TOP Lateral 6 INVERT Top of Chamber Bottom of Bed/Chamber SKETCH PLAN CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation ;10 10 -- ® Deck, on footings, etc 'S 10 -- ® Waterline 10 10 10' ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 125 50 ® Bordering Vegetated Wetland , Salt Marsh, Inland / Coastal Banka 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) '150 150 ® Trib. to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot. Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 ® Drains (Other) Foundation 10 (5) 20 (10) ® Drywells 20 25 ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Commonwealth of Massachusetts RECEIVED Title 5 Official Inspection Form OCT 30 2017 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 197 Vest Way -TOWN y ER DEPARTMENNORTH T Property Address Kevin Foley Owner's Name North Andover City/Town MA 01845 State Zip Code 10-18-2017 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be alteref in any way. Please see completeness checklist at the end of the form. � Af;;� A. General Information Inspector: Neil J. Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover Cityrrown 978-475-4786 Telephone Number B. Certification MA State SI -15 License Number M13 01810 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority i 10-18-2017 Insi a or Signa t re Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system 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.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 197 Vest Way Property Address Kevin Foley Owner's Name North Andover MA 01845 10-18-2017 City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 EW Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 197 Vest Way Property Address Kevin Foley Owner's Name North Andover MA 01845 10-18-2017 Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below): ❑ Y ® N ❑ ND (Explain below): ❑ Y ® N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 197 Vest Way Property Address Kevin Foley Owner's Name North Andover Cityrrown B. Certification (cont.) MA 01845 State Zip Code 10-18-2017 Date of Inspection 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Outlet tee in septic tank, d -box & riser on d -box needs to be installed D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins.doc • rev. 6116 Tide 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 197 Vest Way Property Address Kevin Foley Owner Owner's Name nformation is required for every North Andover MA 01845 10-18-2017 for 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 ❑ ❑ 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.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 i ❑ ® 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.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts H v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 197 Vest Way Property Address Kevin Foley Owner Owner's Name information is required for every North Andover MA 01845 10-18-2017 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): 660 t5ins.doc • rev. 6116 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 197 Vest Way 01845 10-18-2017 Zip Code Date of Inspection Property Address ❑ Kevin Foley Owner Owner's Name information is required for every North Andover MA page. Cityrrown State ❑ D. System Information ❑ Yes Description: 01845 10-18-2017 Zip Code Date of Inspection 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 ❑ C -1r, Number of current residents: Does residence have a garbage grinder? 5 ❑ 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 ears usage d 9 ( y 9 (gp ))� 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): 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.doc • rev. 6116 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 197 Vest Way Property Address Kevin Foley Owner Owner's Name information is required for every North Andover MA 01845 10-18-2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Pumped 2017. owner gallons ❑ Yes 0 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.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 197 Vest Way Property Address Kevin Foley Owner Owner's Name information is North Andover MA 01845 10-18-2017 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 25 years old, 8-17-1992, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" PVC through wall to septic tank, 3" PVC in house, no leak visible. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 1 feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 10'x 5'x 4' Sludge depth: ❑ Yes ❑ No t5ins.doc - rev. 6/16 k Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 197 Vest Way Property Address Kevin Foley Owner Owner's Name information is required for every North Andover MA 01845 10-18-2017 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 Scum thickness 33" 1" 5" Distance from top of scum to top of outlet tee or baffle — Distance from bottom of scum to bottom of outlet tee or baffle 14"— 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.): Inlet tee ok. Outlet tee badly corroded, needs to be replaced. 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 Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: feet ❑ polyethylene ❑ other (explain): t5ins.doc • rev. 6116 1 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 197 Vest Way Property Address Kevin Foley Owner's Name North Andover MA 01845 10-18-2017 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass Dimensions: Capacity: Design Flow: Alarm present: Alarm level: Date of last pumping: ❑ polyethylene ❑ other (explain): gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 197 Vest Way Property Address Kevin Foley Owner's Name North Andover MA 01845 10-18-2017 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert - 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 leakage, corrosion holes in d -box. D -box needs to be replaced. D -box 3' deep, needs riser installed. Evidence of carryover. 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.doc - rev. 6116 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 197 Vest Way Property Address Kevin Foley Owner Owner's Name information is required for every North Andover MA 01845 10-18-2017 page. Cityrrown 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: ❑ overflow cesspool number: 2 trenches 38' long ❑ 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.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 197 Vest Way Property Address Kevin Foley Owner's Name North Andover MA 01845 10-18-2017 Citylrown 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.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 197 Vest Way Property Address Kevin Foley Owner's Name North Andover MA 01845 10-18-2017 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 NNN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments D. System Information (cont.) Site Exam: ® 197 Vest Way ® Property Address ® Kevin Foley Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells MA 01845 10-18-2017 State Zip Code Date of Inspection 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: 10-9-1991Date ❑ 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.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' 197 Vest Way Property Address Kevin Foley Owner Owner's Name information is North Andover MA 01845 10-18-2017 required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.dop - rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 Summary Record Card generated on 10/12/2017 2:30:14 PM by Karen Hanlon Page 1 Town of North Andover • Tax Map # 210-104.D-0094-0000.0 Parcel Id 16781 197 VEST WAY KEVIN & MELANIE FOLEY 197 VEST WAY NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.3 Acres FY 2018 UB Mailina Index Name/Address Type Loan Number .: Active/lnact. From Until KEVIN & MELANIE FOLEY Owner 197 VEST WAY YTD Cons NORTH ANDOVER, MA 01845 a Active SIMON Previous Customer Inactive 12/17/2004 197 VEST WAY 2316 NO.ANDOVER,MA Reading 01845 Consumption THOMAS MURPHY Previous Customer Inactive 10/19/2005 RICHARD CLARK 2915 197 VEST WAY 114 NORTH ANDOVER, MA 01845 54% UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 17824.0 - 197 VEST WAY Last Billing Date 10/10/2017 3170489 03 Cycle 03 Active UB Services Maint. Account No. 3170489 Service Code Rate Charge Multiplier/Users MISCFEEADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 595.78 /1 UB Meter Maintenance Account No. 3170489 Serial No Status Location Brand Type Size YTD Cons 29955819 a Active ERT HH b Badger w Water 0.63 0.63 2316 Date Reading Code Consumption Posted Date Variance 9/12/2017 2915 a Actual 114 10/18/2017 54% 6/8/2017 2801 a Actual 70 7/25/2017 147% 3/9/2017 2731 a Actual 28 4/12/2017 -56% 12/9/2016 2703 a Actual 66 1/23/2017 -67% 9/7/2016 2637 a Actual 186 10/24/2016 148% 6/13/2016 2451 a Actual 82 8/2/2016 234% 3/11/2016 2369 aActual 24 4/22/2016 -66% 12/10/2015 2345 aActual 70 1/20/2016 -56% 9/9/2015 2275 a Actual 156 10/16/2015 100% 6/10/2015 2119 a Actual 77 7/24/2015 235% 3/12/2015 2042 a Actual 23 4/28/2015 -58% 12/12/2014 2019 aActual 56 1/15/2015 -55% 9/10/2014 1963 a Actual 124 10/15/2014 193% 6/9/2014 1839 a Actual 41 7/16/2014 93% 3/11/2014 1798 aActual 21 4/11/2014 -66% 12/12/2013 1777 aActual 64 1/17/2014 -39% 9/12/2013 1713 a Actual 107 10/15/2013 118% 6/11/2013 1606 aActual 47 7/24/2013 156% 3/14/2013 1559 a Actual 19 4/22/2013 -51% 12/12/2012 1540 aActual 38 1/9/2013 -66% 9/12/2012 1502 a Actual 114 10/15/2012 109% Of NOPTp ,M 8060 F r 9 Town of North Andover HEALTH DEPARTMENT CHU CHECK #: DATE: /O. 30, ZOO LOCATION: 2S " H/ O NAME: 4'a/e' CONTRACTOR NAME: . 6 elSO/7 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 1 $ XTitle 5 Report t o) $50- 0 S0❑ Other: (Indicate) $ Heal' ent Initials White - Applicant Yellow - Health Pink - Treasurer COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: _197 Vest Way _ North Andover_ Owner's Name: _Mark Simon Owner's Address: _197 Vest Way_ _ North Andover, MA 01845_ Date of Inspection: _6/18/2004_ Name of Inspector: Neil J. Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, Ma. 01810_ Telephone Number: ( 978 ) 475-4786_ TOWBONORTH FESLNrtr AOHT 2 5 4 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 ail Inspector's Signature: Date: _6/18/2004_ 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: _197 Vest Way_ _ North Andover— Owner: _Simon_ Date of Inspection: 6/18/2004 _ Inspection Summary: Check LAAD 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: _197 Vest Way_ _ North Andover— Owner: _Simon_ Date of Inspection: _6/18/2004 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 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 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: _197 Vest Way _ _ North Andover— Owner: _Simon_ Date of Inspection: 6/18/2004 D. System Failure Criteria applicable to all systems: You must indicate `fres" 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 V2 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 l l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: _197 Vest Way_ _ North Andover_ Owner: _Simon_ Date of Inspection: _6/18/2004_ 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. _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 I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: _197 Vest Way –North ay__North Andover_ Owner: _Simon_ Date of Inspection: 6/18/2004_ 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): _660_ Number of current residents: _4 Does residence have a garbage grinder (yes or no): No Is laundry on a separate sewage system (yes or no): _ No Laundry system inspected (yes or no): Seasonal use: (yes or no) No_ Water meter readings: Yes_ Sump pump (yes or no): _No_ Last date of occupancy: — Current—COMM ERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd. Basis of design flow (seats/persons/sgft,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 two 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) _T.ight 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, 8/17/1992, 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: _197 Vest Way_ _ North Andover— Owner: _Simon_ Date of Inspection: _6/18/2004 BUILDING SEWER _ X _ (locate on site plan) Depth below grade: _24"_ Materials of construction: _ cast iron _X_40 PVC _other Distance from private water supply well or suction line Comments (on condition of joints, venting, evidence of leakage, etc.): _4" PVC thru wall, 3" PVC in house, no leaks SEPTIC TANK: X _ (locate on site plan) Depth below grade: _l2" 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 —4" _ Distance from top of sludge to bottom of outlet tee or baffle: 2311 _ Scum thickness: _5" Distance from top of scum to top of outlet tee or baffle: _8" Distance from bottom of scum to bottom of outlet tee or baffle: _16" How were dimensions determined: _Difference between tee length & scum & sludge depths _ 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 tank leaking out. _ 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 I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _197 Vest Way_ _ North Andover— Owner: _Simon_ Date of Inspection: 6/18/2004_ 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 -bog level & distribution equal. No evidence of leakage out of d -box. Evidence of carryover, pumped d -box to clean. _ PUMP CHAMBER: _ (locate on site plan) Pump in working order (yes or no): Alarm in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 197 Vest Way_ _ North Andover— Owner: _Simon_ Date of Inspection: _6/18/2604_ SOIL ABSORPTION SYSTEM (SAS): _X If SAS not located explain why: (locate on site plan, excavation not required) Type y leaching pits, number: _ leaching chambers, number: leaching galleries, number: X_ leaching trenches, number, length: 2 trenches 38' 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:bio: is on site plan) Materials of. construction: T' Dimmsions. Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 197 vest Way _ —North Andover— Owner: ndover Owner• _Simon— Date of inspection: 6/18/2004 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 Tank = 31'2" 3 D -Box = 38'10" Tank = 43' D -Box = 5018" Page I 1 of I I OFFICIAL INSPECTION FORM _ NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM /PART C SYSTEM STEM INF OI'M TION (continued) Property Address: _197 Vest Way_ _ North Andover_ Owner: _Simon_ Date of Inspection: 6/18/20414 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 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: _101911991_ 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— M. 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Excavating -Water.& Sewer bines -Septic Systems & Pumping Service I I I Argilia road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 197 Vest Wray, North Andover Owner: Simon Date of Inspection: 6/18/2004 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, mid I hereby disclaim any further operation of your current septic system. Ncil T. Bateson Bateson Enterprises, Inc. T DATE S Sheet 1 of BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEE U PERMIT # _411 DATE RECEIVED 7 Z3q l APPLICANT CSTV�j�}IL� ASSESSOR'S MAP ADDRESS t J 2168640T 5T PARCEL # No Pvt400veQ, , MA -LOT # ENGINEER � STREET wxv ADDRESS D.jox 5((Q PLAN DATE _1,11516e REVISION DATE CONDITIONS OF APPROVAL: APPROVED DISAPPROVED k S\/S`fEM IV- �2�as� To k k FT W "Ta W E T C -.%DO o �cST (,�1� 5��1� T3E Got.�nvCT�c�� L�.T ilk W�sl �p Oar `�� S`! 5 ?�t'i "� iJ '�Rc �y �'�r r L Co•.s t�: r► �� 9 uL� � carp c,►.) tell 3) L�.11 �'� P i ►.� 5 5411 li,�c 40 (`VL �-koT-F- 4�I�,o„l► �, og561..�-rte - �'RE6645 51� .s �t--t C-�-i- : -pal- i 1L 5�0717 C SYs r�M 1,33 LOT- ?fid 1G� PLAN REVIEW CHECKLIST ADDRESS ,Z 9-7 fre$-2� ENGINEER � ha ho 0 GENERAL 3 COPIES PROFILE & PERC INFO STAMP t/ SECTION WATERSHED? !Vi SCH40_'�/ SLOPE SEPTIC TANK LOCUS (i'' SCALE CONTOURS BENCHMARK &,-' ELEVATIONS WETS. DISCLAIMER WELLS & WETLANDS SOIL DRIVEWAY/" WATER LINE DRAINS &Aee.b, we A-3, lige MIN 1500G. L,-' .17 INVERT DROP GARB. GRINDERA/ (+200% EDF) 25' TO CELLAR ✓ MANHOLE TO GRADE ri' ELEV_L4 GW �/ D -BOIL SIZE INLET - OUTLET # LINES FIRST 2' LEVEL STATEMENT (2" OR .17 FT) U �-- LEACHING '��5i i h, RESERVE AREA 4' FROM PRIMARY'>kIl 100' TO WETLANDS 2% SLOPE 100' TO WELLS 325' TO SURFACE H2O SUPP 35' TO FND & INTRCPTR DRAINS 4' TO S.H.GW 4' PERM. SOIL BELOW FACILITY MIN 12" COVER FILL? (25' if above natural elevation; 101if below) 4 /n/i f C) � -.kc c ✓? TRENCHES. MIN 660 gpd ,-' SLOPE (min .005 or 6"/1001) e-. >3' COVER? - VENT SIDEWALL DIST. 2X EFF. W OR D (MIN 61) IS RESERVE BETWEEN TRENCHES? / IN FILL? MUST BE 10' MIN._L/ 4" PEA STONE? BOT I X LDNG 11-1 + SIDE 30 X LDNG�G = TOT 75 7 660 (L x W x #) (;G—/f—t2) (DxLx2x#) 77 e ef A f i�J. �� /��r�� 5x 5. DATE 14L2-1-2-:14 Sheet 1 o f "?— BOARD Z BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEE �� PERMIT # �� 7 DATE RECEIVED APPLICANT fjALX-1 ASSESSOR'S MAP ADDRESS PARCEL # LOT # ENGINEER int 00E9- -S STREET ADDRESS— 0 �jp X1(0 {alp, PLAN DATE REVISION DATE CONDITIONS OF APPROVAL: APPROVED DISAPPROVED X Al. 'TLS Skoc�.) \Jet F–:'F–HvEY--)-T ins 6246HAW `l lk %t wrap ;wGG�►.� i YcC-+.,Clic-S `3� awl S.� i tcovA L,. ,,s V rz-, Tt-.j,zoAj .r� ►�t4 i tp 'Cb -3" D i A 40 J Wer --F qo lE , ou i:�2rLc-cY;- -Ft2Z\)a+90 4�OE C0-ecjL valve OL7c-1 E- j 1240 A.111 d'tAvO 1 C r i_ f 17' rs L (b siOic s 7po'D e I CIOcZ e (` AI�DW Al. 'TLS Skoc�.) \Jet F–:'F–HvEY--)-T ins 6246HAW `l lk %t wrap ;wGG�►.� i YcC-+.,Clic-S `3� awl S.� i tcovA L,. ,,s V rz-, Tt-.j,zoAj .r� ►�t4 i tp 'Cb -3" D i A 40 J Wer --F qo lE , ou i:�2rLc-cY;- -Ft2Z\)a+90 4�OE C0-ecjL valve OL7c-1 E- j 1240 A.111 d'tAvO 1 C r i_ f 17' i REVIEW CONTINUED SHEET �- OF 2,S Fi ' t4o,-�sE O1� WA rT tit IS ,yS' �a-�� PST ip goo 0,0 4rz K l (d /L rV2- p PA �a0 t� f RZO Q-�� tb,z F 'C'a P�?' 101 CioLo I FURM U. TOWN OF NORT11 ANDOVER LOT RELEASE FORt1 SUBDIVISION ASSESSORS MAP SUBDIVISION LOT(S) �r� �# '� �/C�5/ LAa PERMANENT ADDRESS (ASSIGNED BY D.P.W. STREET APPLICANT pI"1C� PHONE �v C� a" 7 DATE OF APPLICATION PLANNING BOARD TOWN PLANNER CONSERVATION COkZIISSION TOWN USE BELUW THIS,LINE DATE APPROVED DATE REJECTED DATE APPROVED CONSERVATION ADMIN. DATE—REJECTED riL�'t1Llt1 JH1VL1t1i�1H1V DEPARTMENT OF PUBLIC WORKS DRIVEWAY PERMIT SEWER/WATER CONNECTIONS FIRE DEPT. RECEIVED BY BUILDING INSPECTION DATE ROVED V11AQ AZJEC1Ls This form shall be signed by the agents of the Planning and Health Boards, the Conservation Commission prior to the issuaiice of any building permits for the subject lot. This form shall not releive the applicant from the compliance of any applicable Town requirement or Bylaw. DATE Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEE PERMIT # 7 2 DATE RECEIVED APPLICANT P ASSESSOR'S MAP ADDRESS PARCEL # LOT # a- � STREET # �s � LCJa Y ENGINEER J �—/4yc ) ADDRESS PLAN DATE CONDITIONS OF APPROVAL: APPROVED DISAPPROVED REVISION DATE /, ga- 1-01,10iN0 729 .6,:!5 s c A/ 40 a, 5/amu) wc-7-Z Vbs bc�i�vc--,g7ia� a,c- r SH-oW 1--1141// or :�X614V-47-/4/li i?90 )rDR F11-2- Y- E-A5&iAiENT S. 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E •v oc � cn a► o oA — Cn JA d o o: r A - � a6. —3 aas .� Z e d m tLU L4.. ria a c F 0 iz CL rl) _ e C Q ° O W C r c0 N .0 h O a L 0. y C .0 M C O a a, y c •V Z CL O C C G V � � •I.r �. ao O z one C Town of North Andover, Massachusetts Form No. 2 NORTa BOARD OF HEALTH 19j f � p K � DESIGN APPROVAL FOR ""SE`s SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM /0/3 Applicant Test No. Site Location /] Reference Plans and Specs. - '-4/ Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. Fee 4 6 0 mv CHAIRMAN, BOARCrCrFtKALTHo Site System Permit No. A-17 F-IURD of, 1rte' �;-J^-j NOIl Tm Au��VGIp, i M 1/V r l-aT 2 % V,, y s C� �X t �zrJl,Pr/ UJEU- 6p�y D 114T'C 55 5CP11 c S1► 5 i E. -t vtrs►C� ,. bppjf�Ovt-v PA -r6- � �. PCAAJ DESt Q--7\ Sl-�g390 0-15-�Y CDn1DlT�4�J ��V� S/dn/oj— r�-lq-�� c; K- IGS DI5APPPoVEp 5 DgiE r D� I sc c vSTE. I�SiAI.LQT►��u )4V4T(o� )AJ S F,41L " �iNAL l.V5(��rlon� P( ISE FROAA t-►oL)5& ry -0 0 t� LI M5 `Q F/-O)L ,� Pf'(�dVEJ� GJ/STC /SPPr�vwG ,� �r+tor�rry AVDITIDNAL. IM5Fb:z.j (oNS X11= may) DtSAPt'j?dvF� DArC Rj�6'50 tvs FI&,QL APPROVAL DA -r67 . e,; , f:; Cyl- ; r 01 Nualau 6 y v °4 ,J o v¢ —4 N :F: Ln cis 4 �1 cA cn N Ln o rl G > 00' 3 ca o .o.. cn b C46 'ro r m-.:4 o ' co rr-i z y -rq h+1 •+-.. iJ O 03 -H %D o N W I y o v -,-� J 0 w -i� A r 01 Nualau Ln 0 x ,J o v¢ —4 N :F: Ln U) -W In �1 cA cn N Ln rl G > 00' 3 ca o .o.. cn b C46 'ro r m-.:4 o ' co rr-i z y -rq h+1 •+-.. iJ t i o i4 r -•I -H %D o N 3 I y 2 v 0 v a 0 a� N 4J 0 a EASEMENT We, Thomas D. Laudani and James J. Philbin, Trustees of Jamat Realty Trust under a Declaration of Trust dated June 27, 1988 and recorded with Essex North District Registry of Deeds in Book 2760, Page 28 of Haverhill, Essex County, Massachusetts for the full consideration of One Dollar _($1.00) -paid grant to John D. Shagoury of 13 6c1C.1j5 h1A) b 8r Weston, Middlesex County, Massachusetts with Quitclaim Covenants A temporary construction easement to allow filling and regrading work as necessary over that portion of Lot 26 abutting Lot 27 shown on a septic design plan for Lot 27 filed with the Board of Health for the Town of North Andover dated October 8, 1991 and approved by said Board of Health. Said construction easement shall be for the purpose of access and egress to those portions of Lot 26 and 27 necessary to regrade the land area to accommodate the designated septic system.' Also, granted hereby is a permanent easement in favor of the grantees and their successors in ,title prohibiting the present and future owners the grantors and their successors in title from excavating in the regraded area. Nothing under this easement shall prohibit regrading of the area involved by filling and contouring to higher elevations, but no work shall be allowed which would reduce the contours below that approved for the septic design system for Lot 27. For grantors title see deed recorded in Essex North District Registry of Deeds in Book 2760, Page 30. Thomas D. Laudani and James J. Philbin state that they are the Trustees and the Jamat Realty Trust is in full force and effect and that they have been authorized by all of the beneficiaries to execute this Easement and that they are still the Trustees of said Trust. Executed as a sealed instrument this day of October, 1991 p JAMAT REALTY TRUST Ths D. Laudani, Trustee *am. ZPhilbin, Trustee COMMONWEALTH OF MASSACHUSETTS Essex, ss. October 1/ , 1991 Then personally appeared the above named Thomas D. Laudani and James J. Philbin, Trustees as aforesaid and acknowledged the foregoing instrument to be them free act and deed, Before me I '-.. �_ �- „ .. . W llis Jr. -Nom y Public y com iss, 'o expires: //6 /7k� r /A CST 2701�41� MASSACHUSETTS MASSACI-KiSET[�' ~ . � FIRE INCIDENT REPORT STATE FIRE M(/RSHAL | ) fdid |incident no.| exp | date | day |alarm tm|arry tm|time in serv| A | 101XXXXX 1 1 12:09 127 i | situatinn found | | action taken | | mutual aid | B| | / fixed property | | ignition factor \ | C | | | correct address i zip code | census | D| | | | occup.name last,first,mi | telephone |ronm or apt| E | l-(978>9!75.-13\9. ............ .__- | | | owner name last,first,mi | address | telephonp | F | | | method of alarm | | district | h i f t | no.alarm� | G | 1| | VITA -service |#tankers |#engines |#aerial app | # other vchicles| H 1 __|_| | hazardous material | substance i special equip used | | ___| | numbers of injuries | number of fatalities | rescues | I| | | mobile property | | vehicle stolen ? | estimated total WATT | J ! ___�___ | | insurance company , |tutal insurance | claim paid | � |year | make \ mon del |color| lic no |vi# | | ' ____| \ |if equip involved|year|make \model | serial no | | | | complex | | area of origin | equip inv in ignition | K | | | form of heat ignition| material ignited |form | type | | L | \ | method of extinguishment | ( level of fire origin | | M | -1_-0_1 I numbers of stories i | construction type | | |D .......... -i-0_} \ extent of flame damage | extent of smoke damage | | N\ | | detector performance I | sprinkler performance | | P | | 1 if smoke spread | material generating|form | |type | | | beyond room } most smoke: | 1001 i 001 Q| | R | weather conditions-7REPORTQ,V,1 I -------------------- | entries contained in this report are intended for | | LIGHT RAIN | The sole use of the state fire marshal. Estimat- | | HIGH 30113 | ions evaluations&d h i t "MOST | ( made herin represent ! \ LIKELY" ,& "MOST PROBABLE" cause & effect. Any | || representation as to the conditions outside the | } | State Fire Marshals Office is neither intended nor| I member making_re plied | | R. FOGARTY F.M.---------- 1 [ ] ves 2 [ ] no | TOINN OF 00 H AND 5 G98 ` __ CHECKLIST FOR CARBON MONOXIDE Location of Incident: I FI' -1 y62 S 7�- Date of incident 7 (QUICK CHECKLIST OF OCCUPANTS Headache yes nom Fatigue yes no Nausea yes no Dizziness yes no Confusion yes no Ll Are any members of the household feeling ill? yes no Do the residents feel better away fi-om the house? yes no Since the detector's alarm went off, what have you done? Shut- off carbon monoxide sources I yes no If yes which sources Let in fresh air? yes no If yes how did you let the air in I low long did you let the air in PPM reading ambient outside the dwelling 6 P) M Highest PPM reading in the dwelling 9 ?PM Carbon monoxide detector present? yes v no If yes list the number of dctetors locations and make, and serial number of each below. I. ce/lar- - 15r WLPret - ,U/co 5Y137. 2. 3. 4. Which detector(s) by number above activated? # I I SOURCE CHECKLIST LOCATION PPM READING Chimney clogged flue, blocked opening Fireplace(s) Natural gas, LPG, Wood(indicate type for each fireplace) Gas Appliance (if Gas Company on Scene they can perform this check) (IF MORE THAN 1 OF THE FOLLOWING APPLIANCES LIST EACH ADDITIONAL ON THE COMMENTS PAGE WITH ITS LOCATION, AND PPM READING) reft-igerator stove vent over stove clothes dryer water heater furnace Oil burner car garage Entranceway from garage to house Name of individual operating the. CO monitor /,T• R G,*A Person completing the Checklist I -T. . FD C.dK.-?-7" J—a17 � Fi ea5 '- F 7-->-- / 3 /�? Town of North Andover,AA Watershed Septic SVstE,!n Servicing Report Date: Homeowner: _ _ :Pumper Street _� �7`r2, Z,'C14-� Address : Phone _ c I 6 Phone 1. Nature of Service: Routine Emergency Observation: Good Condition' y� Full to Cover Baffles in PlacE Leachf ieid Runback Ly�i Excessi VE! Solids Heavy GrE!ase /✓'J Roots y'c> Other (Explain) Description of Work; BOARD OF HEALTH 120 MAIN STREET TEL. 682-6483 NORTH ANDOVER, MASS. 01845 Ext. 32 or 52 May 28, 1991 Mr. Al Shaboo Design Engineering 168 Pleasant Street North Andover, MA 01845 Re: Lot 27 Vest Way North Andover, MA Dear Al: As per your request, I have reviewed the Board of Health files relative to Lot 27 Vest Way. A plan of a Subsurface Sewage Disposal Design was approved by this office on April 14, 1988. The plans, however, are over two (2) years old and the approval has expired. A preliminary review indicates that the plans may not conform to the current regulations. The plans will have to be redesigned to meet the requirements of the current regulations. Revised plans should be accompanied by a new plan review fee. Once submitted, I will review the plans in a timely manner. Should you have additional questions, please do not hesitate to call. Health Agent MJR/ cj p