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Miscellaneous - 205 GRAY STREET 4/30/2018 (2)
I qz April 27, 2007 Ms. Susan Y. Sawyer Public Health Department 1600 Osgood Street North Andover, MA 01845 Dear Susan: Helen M. McKnight 205 Gray Street North Andover, MA 01845 .°ED MAY 0 8 2007 TO`P w c.;; fv lKTH ANDOVER t HEALTH DEPARTMENT My apologies for the delay in responding to your letter dated January 22, 2007 regarding the garbage grinder at 205 Gray Street. I have taken the necessary steps to remove the garbage grinder, so I am now in compliance with the Health Department regulations. If you have any questions, please do not hesitate to call me at 978-208-8038. Sincerely, �/04i� Helen M. McKnight Commonwealth. of Massachusetts RECEIV City/Town of I JUN -.5 2006 System Pumping Record Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. The System Pumping Record must P 9 be submitted to the local Board of Health or other approving authority. . A. Facility Information .Important: When fining out forms ter, u computer, use, 1. System Lo ation, C _ `C 1\ ^-� �C" " \Vv only the tab key to move your Addres .� n / cursor -� do notl use the return : �l Cityrrown State Zip Code key. 2. System Owne Name Address (if different from location) Cdy/Town. State / ►r-, . Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight.Tank ❑ Other (describe): .4. Effluent Tee Filter present? ❑ Yes ❑tPddf If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System,: 6: Systerp Pumped By; Name Vehicle License Number Company - 7. Locati here contents, wedisposed:, Signatur of au r Date hftp://www.niass:go.vldep/water/approvalt,/t5forms.htm#inspect t5fonn4.doc• 06/03 System'Pumping Record • Page 1 of 1 If r O v V C �+ i r a w z d R R � Z c LO w d = ar Cc) o v� a No �p O Z 3 J J 0 ti O v �+ m r a w z d 0 ti 0 a) rn m (L U C N 0 0 0 co m a .0 C 7 A? m m 0 co 0 0 N 0 a) 0 O v �+ O O O R Z Z Z LO w d = ar Cc) o v� a No �p m 42 F- 04 NCD c a� _ O J y p E m y m a a w M d o 0 G o d ,;, U R J CO a w O Z 0 0 Z Z C ami o V m O aS B a1 y m a It Z 0 a) rn m (L U C N 0 0 0 co m a .0 C 7 A? m m 0 co 0 0 N 0 a) 0 O �+ O O O R Z Z Z LO 00 o No �p m F- 04 NCD c a� _ O J y p E m y ayi a O d o 0 G o 0 ,;, U 0 CO a w LL LL 3 ami o O aS B a y m a It io a to c d v cc 0 a) rn m (L U C N 0 0 0 co m a .0 C 7 A? m m 0 co 0 0 N 0 a) 0 v f ,10R711 1 h 9 Town of North Andover �'• °' HEALTH DEPARTMENT �j y ,sS4CMUstt CHECK #: LOCATION: _ s H/O NAME: CONTRACT 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 $ Fi ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ a ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ i ❑ Trash/Solid Waste Hauler $ 1 ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ j ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ �. ❑ Title 5Inspector $ f ; itle 5 Report $ f ❑ Other: (Indicate) $ 1769 Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer a 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 r CERTIFICATION Property Address: _205G�ry Street _ North Andover Owner's Name: John Romanow Owner's Address: _205 Gray Street —North Andover, MA 01845_ Date of Inspection: 8/10/2006_ Name of Inspector: Neil J Bateson_ Company Name: Bateson Enterprises Inca Mailing Address: _111 Argilla Road _Andover, Ma. 01810_ Telephone Number: _( 978 ) 475-0786_ cS V�® AUG 2 4 2006 OWN OF NORTH TM� T TER HEp�TH 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 fimetion 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 Is Inspector's Signature: Date: 8/10/2006_ 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 ' 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 l l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 205 Gray Street_ North Andover Owner: Romanow Date of Inspection: ;8/10/2006 _ Inspection Summary: Check A B C D or E / ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If"not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiitration 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 I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _205 Gray Street _ North Andover— Owner. __Romanow Date of Inspection: 8/1072006 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 widen 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 ether 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 FORD PART A CERTIFICATION (continued) Property Address: _205 Gray Street _ _ North Andover_ Owner' Romanow Date of Inspection: 811012006 _ D. System Failure Criteria applicable to all systems: You must indicate `yes" or "no" to each of the following for all inspections: _ _No Backup of sewage into facility or system component due to overloaded or clogC ed SAS or cesspool No Discharge or ponding of effluent to the surface of the ground or surface e tees due to a*1 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'/2 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. _ _NoAny portion of a cesspool or privy is within a Zone I 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 — suppry well with no acceptable water quality analysis. tThis system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates tbat 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 he attached to this form.] _No_ (YeslNo) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 COIR 15343, therefore the system fails. The system owner should contact the Board of Health to determine ine ,-kat wi11 be necm,emns ton correct the �ihre J ,, E. Large Systems: To 4e considered a large system the systems must serve a facility with a design flow of 10,000 gpd to 15,000 gpd, You must indicate either "}les" or `516" to each of the following: (The following criteria apply to large systems in addition to the criteria abovej yes no — the ystem is vnthin 400 feet of a si-face drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply tine or: 1�r .�1 a1; :n a nit runes s_— i4ive area FTnterinI xyellhead Prv,.ect; t^a ?Vea' — z�sFTD E), or a aaz cx aaa v��s� �,aE.s�uvv ccF..0 1�..:�� <-� of Zone Il 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 t j�°e�i� '- See.»"ttiir.+ - -above the 1—ge cs,�-te.n has faile.l 'me vfi mer s^ir •^pv�i a'as*^r of 'ur_�y Ic'.a �'v �utevi"i'- con"; idvl'eed u. via a uve..� situ sum 5.75ss:` us.� iuu-- sigr iflcant 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 $ of l l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: _205 Gray Street _ _ North Andover _ Owner: _Romanow_ Date of Inspection: _8/10/2006_ 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? 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. _Yes_ _ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 205 Gray Street _ North Andover_ Owner: Romanow Date of Inspection: 8/10/2006_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): _4 Number of bedrooms (actual): _4_ DESIGN flow based on 310 CMR 15.203 600 _ Number of current residents: _4 Does residence have a garbage grinder (yes or no): Yes_ 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 reading: Yes _ Sump pump (yes or no): No Last date of occupancy: — Current-COMMERCIAL/INDUSTRIAL Type; of establishment: Design flow (based on 310 CMR 15.203): ___Md 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 months ago, owner _ Was system pumped as part of the inspection (yes or no): No_ If yes, volume pumped: _ gallons -- How was quantity pumped determined? _ Reason for pumping: _ TYPE OF SYSTEM X Septic tank, distribution box, soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) _Tight tank _ Attach a copy of the DEP approval Other (describe): _ Approximate age of all components, date installed (if known) and source of information: 20 years old, 5/5/1986, as built plan _ Were sewage odors detected when arriving at the site (yes or no): _No_ N Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _205 Gray Street _ North Andover _ Owner: _Romanow_ Date of Inspection: _8/10/2006_ BUILDING SEWER _ X _ (locate on site plan) Depth below grade: _14" Materials of construction: X 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" Cast iron thru wall, 3" PVC in house, no leaks. SEPTIC TANKS: X Depth below grade: _2" 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 0"_ Distance from top of sludge to bottom of outlet tee or baffle: 27" _ Scum thickness: _0" Distance from top of scum to top of outlet tee or baffle: - S" -Distance from bottom of scum to bottom of outlet tee or baffle: 21"_ 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 ok. Depth of liquid at outlet invert. No evidence of septic tank leaking in or 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 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _205 Gray Street North Andover— Owner: _Romanow_ Date of Inspection: _8/10/2006_ 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 BOXS: –X – Depth below grade _ 10" 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. No leakage. 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 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _205 Gray Street _ North Andover— Owner: Romanow Date of Inspection: —8/10/2006 _ SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: leaching chambers, number: leaching galleries, number: —X—. leaching trenches, number, length: 3 trenches 46' long _ _ leaching field, 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 oL Vegetation oL No sign of ponding to surface._ CESSPOOLS: _ Number and configuration: Depth — top of liquid to inlet invert: Depth of sludge layer: _ Depth of scum layer: Dimensions of cesspool: Materials of construction: _ Indication of groundwater inflow (yes or no): — Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (locate on site plan) Mawials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 205 Gray Street _ _ North Andover — Owner: Romanow Date of Inspection: 8/10/2006_ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building A to 1=11'3" Ato2=18'6 A to D -Box = 38'10" BtoI=36'5" Bto2=39'5" B to D -Box = 44'8" Page I 1 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 205 Gray Street _ _ North Andover— Owner: _Romanow_ Date of Inspection: _8/10/206_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water _ 4' _ 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: _8/13/1985_ 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: _ Design plan _ ' Summary Record Card generated on 8111/2006 2:44:42 PM by Elaine Barclay ' Town of -North Andover . Tax Map # 210-107.D-0111-0000.0 0.635/8 205 GRAY STREET 1/1 ROMANOW, JOHN H 01 ALL METER SIZE LEIGH S ROMANOW 1/1 205 GRAY STREET NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type Size Total 1.05 Acres 32939024 a Active FY 2006 b Badger w Water Date Reading US Mailing Index Consumption Name/Address Type Loan Number Active/lnact. ROMANOW, JOHN H Owner LEIGH S ROMANOW 5/2/2006 17 205 GRAY STREET 17 NORTH ANDOVER, MA 1131/2006 0 01845 US Account Maint. Account No Cycle Occupant Name Bldg Id. 18643.0- 205 GRAY STREET Last Billing Date 8/11/2006 1090518 01 Cycle 01 US Services Maint. From Active/Inactive Active Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/1 WTR WATER 01 ALL METER SIZE 59.47 1/1 US Meter Maintenance Serial No Status Location Brand Type 32939024 a Active ERT HH b Badger w Water Date Reading Code Consumption Posted Date 7/28/2006 36 a Actual 19 8/18/2006 5/2/2006 17 a Actual 17 5/16/2006 1131/2006 0 n New Meter 5/16/2006 Size 0.63 0.63 rage i 1 Residential until YTD Cons Variance 17% Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 205 Gray Street, North Andover Owner: Romanow Date of Inspection: 8/10/2006 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. RJBat2esoan Bateson Enterprises, Inc. TO" OF NORTHANDOVER SYSTEM PUMPING RECORD 31&3 7 NIPR 7 20M STEM OWN3F,�5& ADDRESS SYSTEM LOCATION (example: left -front of house) L Ff ov\, a6C6 qov5e,-- U. \T C 0 F P U M P I N C QUANTITY OUMPC- D L L CA'SSPQOL: NO YES SEPTIC TANK: NO y E S ATURE OF SERVICE: ROUTINE --Z EMERCENCY oH.>rRY,:\TIONS: GOOD CONDITION, FULL TO COVER HEAVY CREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK,. EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOYER 10�1-ln (EXPLA.IN) > > , LM PUMPED Bv: , I L11, .1-IL11, y A �','77Z-, � * U.M.'yl E N T S: I A N S F E I Z R ED. TO: COMMONWEALTH OF MASSACHUSETTS UnErum EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAgiS DEPARTMENT OF ENVMONNMAL PRO'I'WnON ONE wIIri a STREET, BOSTON MA 02108 (619) MMM TRUDY CORE ARGEO PAUL CELLUCCI DAVID B. STRUHS Gaveiaar coo' SUBSURFACE SEWAGE DISPOSAL SM13A NSPECTWN FORM PARTA CER1 WAT M Property Address: 205 Gray Street, North Andover Name of Owner Gary Zarse Address of Owner: 205 Gray Street, North Andover, MA. 01845 .Date of Inspection: 3/24/2000 Name of Inspector. Neil J. Bateson I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Bateson Enterprises Inc. Mailing Address: 119 Argilla Road Andover, MA 01810 Telephone Number ( 978 ) 475-4786 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 onsite sewage disposal systems. The system: _X Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fai Inspector's Signature: Date: 3124/2000 The System Inspector .sh I sib it a cop 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: After permit from B. O. H. installing new outlet tee with gas baffle, replace pipe to D -box & new d -box with flow levelers, system now passes Tit! .5 Inspection. B.0.1-1 inspected same. revised 9/2/98 Page I of 11 i I COMMONWEALTH OF MASSACHUSETTS Lj EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTIMM OF ENVIRONMENTAL PR+OTEONON ONE WINMR STREET, BOSTON MA 02108 (617) 292.5500 - TRUDY CO%E Secretary ARGEO PAUL 'CELLUCCI DAVID B. STRUHS Gomwr SUBSURFACE SEWAGE DISPOSAL SYSTEM SIISPEM Ni FOW Commisdonler PART A CER I WATION Property Address: 205 Gray Street, North Andover Name of Owner: Gary Zarse Address of Owner: 205 Gray Street, North Andover Date of Inspection: 3/15/2000 Name of Inspector: Neil J. Bateson I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Bateson Enterprises Inc. Mailing Address: 111 Argilla Road Andover, MA 01810 Telephone Number: ( 978 ) 475-4786 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _X Conditionally Passes Needs Further Evaluation By the Local Approving Authority 4system Inspector's Signature: Date: 3/15/2000 The System Inspector II this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of completing this inspection. If tshared 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: Outlet tee in septic tank & d -box need replaced. revised 9/2/98 Page I of 11 Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 205 Gray Street, North Andover Owner: Zarse Date of Inspection: 3/15/2000 INSPECTION SUMMARY: Check A, B, C, or D.- A. :A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: _X One or move 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. D -box & outlet tee in tank needs replaced. Indicate yes, no, or not determined (Y, N, or NO). Describe basis of determination in all instances. If "not determined", explain why not. _No The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. No Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced _No The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 205 Gray Street, North Andover Owner: Zarse Date of Inspection: 3/15/2000 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 the public health, safety and 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and sal 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 sal absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and sal absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and sal absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free, from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 912/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 205 Gray Street, North Andover Owner. Zarse Date of Inspection: 3/15/2000 r D. SYSTEM FAILS: You must indicate either "Yes" or "No to each of the following: 1 have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged sAs or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or cogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to dogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any'portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS - 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: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area @ IWPA) or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 912198 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B • CHECKLIST Property Address: 205 Gray Street, North Andover Owner. Zarse Date of Inspection: 3/15/2000 Check if the following, have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No _X Pumping information was provided by the owner, occupant, or Board of Health. —X None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _X As built plans have been obtained and examined. Note if they are not available with NIA _,X Thefacility or dwelling was inspected for signs of sewage back-up. _X The system does not receive non -sanitary or industrial waste flow. The site was inspected for signs of breakout. _X All system components, excluding the Soil Absorption System, have been located on the site. _X The'septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for edition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: X Existing information. For example, Plan at B.O.H. X Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [I 5.302(3)(b)] X The;facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 912198 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 205 Gray Street, North Andover Owner: Zarse Date of Inspection: 3/15/2000 FLOW CONDITIONS RESIDENTIAL: Design flow _150 _'.g.p.d./bedroom. Number of bedrooms'(design):_4_ Number of bedrooms (actual-4— Total actual4_Total DESIGN flow 600 Number of current residents: _4 Garbage grinder (yes or no): –No Laundry (separate system) (yes or no):_ No If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):_ No_ Water meter readings. On well water, 100' away from leach system. Sump Pump (yes or no): _ No Last date of occupancy: Current COM M ERCIALII N DUSTRIAL: Type of establishment: Design flow: ;god ( Based on 15.203) Basis of design flow Grease trap present: ;(yes or no) Industrial Waste Holding Tank present: (yes or no) Non -sanitary waste discharged to the Title 5 system: (yes or no) Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Pumped Dec. 1999, owner System pumped as part of inspection: (yes or no)_ No_ If yes, volume pumped: _gallons Reason for pumping: 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed (if known) and source of information: 14 years old, 5/5/1986 installed, as built plan. Sewage odors detected when arriving at the site: (yes or no)_No revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 205 Gray Street, North Andover Owner: Zarse Date of Inspection: 3/15/2000 BUILDING SEWER: X (Locate on site plan) Depth below grade: 14" Material of construction _X cast iron X 40 PVC _ other (explain) Distance from private water supply well or suction line: 100' Diameter: 4" Comments: 4" Cast iron thru wall to septic tank, 3" PVC in house. SEPTIC TANK: X, (locate on site plan) Depth below grade: 2" Material of construction:_X concrete _metal _Fiberglass _Polyethylene other (explain) If tank is metal, list age _Is age confirmed by Certificate of Compliance _ (Yes/No) Dimensions: 10' x'5' x 4' x 7.5 = 1500 gallons. Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: WA Scum thickness: 0 Distance from topof scum to top of outlet tee or baffle: N/A N/A = outlet tee corroded off. Distance from bottom of scum to bottom of outlet tee or baffle: N/A How dimensions were determined: Measure depth of scum & sludge. Comments: Inlet baffle & tee ok. Outlet tee corroded off. Depth of liquid at outlet invert. No evidence of leakage. GREASE TRAP: None (locate on site plan) Depth below grad,:: 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: revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 205 Gray Street, North Andover Owner: Zarse Date of Inspection: 3/15/2000 TIGHT OR HOLDING TANK: _None (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade: Material of construction: concrete _ metal _Fiberglass Polyethylene_other(explain) Dimensions: Capacity:gallons Design flow:_gallons/day Alarm present Alarm level: Alarm in working order. Yes No Date of previous pumping: Comments: DISTRIBUTION BOX.:_x_ (locate on site plan) Depth of liquid level above outlet invert: 0 Comments: D -box level & distribution equal. D -box badly corroded , needs replaced. Evidence of carryover, outlet tee corroded off in septic tank. PUMP CHAMBER: None , gravity system_ (locate on site plan) i Pumps in working order. (Yes or No) Alarms in working order (Yes or No) Comments: Revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued)) Property Address: 205 Gray Street, North Andover Owner: Zaese Date of Inspection: 3/15/2000 SOIL ABSORPTIOWSYSTEM (SAS): X (locate on site plan, K possible; excavation not required, location may be approximated by non -intrusive methods) If not located, explain: Type: leaching pits, number leaching chambers, number: leaching galleries, number: leaching trenches, number, length: 3 Trenches 46' long leaching fields, number, dimensions: overflow cesspool, number: Altemative system: Name of Technology: Comments: Soil ok. Vegetation ok. No sign of ponding to surface. CESSPOOLS: Nonel (locate on site plan) Number and configuration: Depth -top of liquid to inlet invert: Depth of solids layer. Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 205 Gray Street, North Andover Owner: Zarse Date of Inspection: 3/15/2000 SKETCH OF SEWAGE DISPOSALS' include ties to at least two pE locate all wells within 100' ( Ato1=11'3" Ato2= 15' Ato3=18'6" A to D -box = 38'10" B to 1 = 36'5" B to 2 = 37'5" Bto3=39'5" B to D- ox = 44'8" Well ra revised 9/2/98 Page 10 of 11 >100, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 205 Gray Street, North Andover Owner: Zarse Date of Inspection: 3/15/2000 NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 4 Feet Please indicate all the methods used to determine High Groundwater Elevation: X Obtained from Design Plans on record X Observed'Site (Abutting property, observation hole, basement sump etc.) —X—Determined from local conditions X Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Asper design plan. revised 912198 Page 11 of 11 Tel: (978) 475-4786 Fax: (978) 475-5451 B ATE S CSN ENTERPRISES, INC. Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 205 Gray Street, North Andover Owner: Zarse Date of Inspection: 3/15/2000 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. Peil Bateson Enterprises, Inc. TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE: 3/27/00 This is to certify that the individual subsurface disposal system constructed ( ) or repaired (X ) by Todd Bateson at 205 Gray Street has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Board of Health Inspector APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: �l- Cil-RRENT D, 'STALLER'S LICENSE LOCATION: ! "\a1 - LICENSED LNSTALLER: c�4 R�,+ SIGNATURE:' �� `�'�/ TELEPHONEn 77r Y a 7a�3 CHECK ONE: REPAIR. NEW CONSTRUCTION: (e,� IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. X75.00 Fee Attached? Foundation As -Built? Floor Plans? i Administrative Use Only Approval ,� �• vis 31, No No Date: A/C_ C_ C_ -o-I- L/-- INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at 105 C t -4y S�-- relative to the application of- %o- ea dated 3 --"/ -- vG for plans by Al /� and dated with revisions dated P)O K R 0-4 (-� *-� I understand and agree to the following obligations for management of this project: 1. As the installer I am obligated to call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item two shall be applicable . 2. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against my company. a) Bottom of Bed — generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final Inspection — Engineer must first do their inspection for elevations, ties, etc. As -built or verbal OK from engineer must be submitted to BOH, after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade — Installer must request inspection when all grading is complete. Does not have to be on site. 3. As the installer I understand that persons or companies not associated with my company may not perform the work required by my company to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation -or suspension of my license in the Town of North Andover plus significant fines to all persons involved. 4. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff. d) Installation of tank, D -box, pipes, stone, vent, pump chamber, retaining wall and other components. 5. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Under fib d Licensed Septic Installer r �"� Date: —" 1 U Loi hi ���711, y/ GRA Y 9�.3Z u �0/ .3 � R��► 44T?16 5� F l /h , 6�4.4tz'NG f45FMENT M \-� 7 i xp y6�t ST wNF ".� 2$.5 t ----x.__33' 5 SLOPE 1?6:01111eE LCNr (/50) X = /50 - = ........................... DESIGN E'C EV4T/ON 4T ......... (TOP OF STONE) _ .................. . ......... . EX/5T/N6 CIEX47-1ON 4T ......... 2E4?U/k'ED IFLE!/4T/ONS DE51�N 4s BUNT 44 A2U/ INV PIPE 01 -IT OF /-/OUSE NOTE. 90,,7/ 9d. 3 7 INV P/PE INTO T4NK d z 3 o, /3 INV PIPE OUT OF T4NK 89, 9 8 W qct INV PIPE INTO D. BOX I INV PIPE OUT OF D. BOX e773 8q, q INV END OF PIPE 14.sv Y AW TER EL Ev4T/ON 4VE2,4CE 5TONE DEPT,/ ,4T Pe06E 71/I5 PZ -,4N /5 NOT ,4 GV,4,Pe4MTY OF TYIE 5Y57 -EIV B&7-,4 V6-1e1F/C.4T/ON OF T�/E LOC4T/ON OF TWE Ea'/STING 5T'RUCTUfc'E5. LT SUB -SUS dac P -5)PO 4L SYSTEM /N C11,el,57 4NSEN FNCIMEmIN6, INC. //4 AIENOZ.4 <l VES A4VFe11/L L, /Y1,4. 0 Commonwealth of Massachusetts 70qb1OR YtlER/ ,VrLc�I Massachusetts 1996 • OCA 4 r System ng Record Systent Owner Date of Pumping:. lo'. i t — I(,.. Cesspool: No IV Yes U System Location puaiitity Pumped: gallons. Septic Tank: No d Yes 141- System Pumped by: vcti'`adii S#&vq4w License # Contents traiisferrred to: Greater Lawmce Sanitary district Date: Inspector: Commonwealth of Massachusetts /J" �, Massachusetts Systern Pumping Record System Owner *Z alr�sc System Location Date of Pumping: �� Quantity Pumped: l gallons Cesspool: No Yes L:J Septic Tank: No Ll Yes E� i System Pumped by: Sire-doa 510&0�ftm a License # Contents transferrred to: Greater Lawrence sanitary District Date: Inspector: f -c O � Sep -20-99 03:53P North Andover Com. Dev. 508 688 9542 FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards sand Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. APPLICANT FILLS OUT THIS SECTION APPLICANT J h n —2-S \72--C PHONE LOCATION: Assessor's Map Number PARCEL SUBDIVISION LOT (S) STREET C= S� ST. NUMBER6J� ********""OFFICIAL USE ONLY*,�*��******�*"" RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER COMMENTS FOOD INSPECTOR -HEALTH i --tli�I C�[/L� SEPTIC INSPECTOR -HEALTH COMMENTS DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED_ PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised M97 jm P.03 1 dale l {�9 O 19914 AN\ / 6Q'- OL Q.- OrACE T .�.t, MORTGAGE INSPSC MN PLAN This is a mottvp loan iaupsct cn for mmWip purpoaea only MOSTGAG2 SURVEY OONSMZANWaim. SY No. Yate Sbis . Ae&ww, MA 01510 _.. 1,ifl4'.A?iOh AaTH ��NQ!'llEr . .M,4 .' c r_T=--_._SCALM.-..l inchs.4.Q .: City or To" Sate CerdEiatiao is hereby made d '+ri5 •nr, TedoraI Cr)-(,i•erer ,• .a, do the esistia0 unwturer shown on this plan are a umW on the bt designated in compliance with the amJ"hle zoning bylaws of the municiplity when DEED AND PLAN REFERENCE: Regfsary of De Deed Book pw � 98 Plan MA J0- Plan /1H OF Ceni6ation is hereby Mede that the strueatra shown Thio inspection wa prepared in accordance with the this plan IS NOT bated within a SpwW Fbod He mdutial stsudards fisc Mortgage Lawn Inspections as r� JEAN `�,'.� Ares as delineated on the map of adopsed by the Comaanwralth of Mumbusects. .�� NYSTEN �', CoramuDhy `o: 25'J09b-001 Oe Plo. 2G^39 ; 1�,e I :. 1983 Effeaise Date: 4 .-T by �'1p SU-,v� by the U. S. Department of Housing h Urban Deva Land Surreys Ment, Federal Instrtauee Adminiearatiott. f IN ENJOY CAREFREE LEISURE LIVING IN A CUSTOM DESIGNED PATIO ROOM t N f V j Lo M t� jL 1� 'Y r - MOME W!ll R91, I a w k Zi 8.t kA CALL TODAY -OR-CLIP -THIS COUPON AND MAIL ti l I I ' j 1111111111 ►l 9 11 1 :1,11,1110, . "OEFileNo. 242-307 tTo be provided by OEOE) �= Commonwealth city/Townt forth Andover- - Fore of Massachusetts h applicant Rr a1 ty Tr'us't Order of Conditions Massachusetts Wetlands Protection Act , G.L. c.131,.§40 _ - n.nd under the' Town'of North'Andover Bylaw, Chapter 3.5 A'& B" From Nor_t.h. Andover Conservation CrnIm?. ;i C01 7o Forh�> Real..v ir-ii.ql. �^mn (Name of Applicant) (Ns ne of property owner) 401. Andovcr_ 13treeL Address Nj orl:h i%Tirlovor, f�`. ni_R4.5 Address This Order is issued and delivered as follows: ❑ iby hand delivery to applicant or representative on (date) ❑ by certified mail, return receipt requested on 1 o (date) This project is located at Lot 14 Salem Str.eet r The property is recorded at the Registry of Nott:h EG !:z'ex Book 1. R (q? Page . 9% Certificate (if registered) The Notice of Intent for this project was filed on Ju -y 2; 1985 (date) The public hearing was closed on 'July 249 1.985 (date) Findings The NACC has reviewed the above -referenced Notice of Intent and plans and has held a public hearing on the project. Based or..'the information available to the at this time, the T �'� r has determined that the area on which the proposed work is to be done is significant t• the ollowing interests In accordance with the Presumptions of Significance set forth in the regulations for.each b. -a Subject to Protection Under the Act (check as appropriate): w ❑ Public water supply Z Storm damage prevention Q Private water supply JL3• Prevention of pollution ❑ Ground water supply ❑ Land containing shellfish 0 Flood control 0 Fisheries Board of Health North Andpverz?Saas. SEPTIC SISTEM INSTALLATICK CHECK LIST ;LP C►VID DATE DI SAPPRUM 4C FAIL I °K LOT"I AVATI Chi or W 1. Distance Tot a. Wetlands b. Drains ' c.. wen 2. Watsr Line Location r 3. No M Pipe !t. Sep de Tank a. "ess -_Length & To Clean Out Cowers b. 'ement Pipe to Tank On Both Sides of Tank 5. Distribution Box a. Covers k BoSc - No Cracks b. All.Lin©s'Flowing Equal Amounts c. No Back Flow 6.- Leachi eld or Trench a. Dimension b. Stone Depth c: Capped Inds d. Clean Double* Washed Stone 7. U 3ch Pits a. Dimensions b. Stone Depth c.. Sp' .sh Pads d. Tees e. Cement Pipe to Pit - Both Sides f.lean Double Washed Stone 8. No Garbage Disposal 9. -Fir al Grading Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location " b. Dimensions of System c. Location xith Regard -to. Pere Test d. Elevations e. Water Table Nol�TN AuPnVEi'�i MA, SS � F'Pi�ov�D DI 54PPP6V5p R�54NS = wA �'� i� Sv Pr27 p rt' � PPS � Citi I- w/li D U)EU- StI ri c SY s T EAL VESI � APO Ov(N6 Aurh61?ITy 1A-6 CHargfd To We D rP�y(c 5Y ST�it 1 I .� Siip I��t1"j'ti o�J L X/MT(O1J VJS-["tE�6TIoA1 v/JrC ►�,�- - Ii15S [� FAIL - 4 PPRCJvEP/JTC �6P�r�r�v�tiG �4�r+toi��ry AVP(Tlo)--)AL- 1, 1jy "z:1 IONS C1E A► -'Y) DtSl�Pt'�Uv�D RE/jSo NS •, DAiC FkAL APPIR)VAL 0 APP)3ovvJ6 16u iHogi \1&7te BOARD OF HEALTH . No.Anddver, 'v+ass t SUBSURFACE DISPOSAL DESIGN CHECK LIST LOTY APPROVED DATE $5 DISAPPROM DATE Provided. Reasons: ' lt�u.65 J Title V FAIL OK Peg 2.5 The submitted plan must show as a minimum: a) the lot to be served-area,dimensions lot #,abutters b location and log deep observation hoes -distance to ties c location and results percolation tests -distance to ties d 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 1001 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 1001 of setiaage disposal system or disclaimer -Planning Board files (j) knom sources of water supply within 2001 of sewage disposal b system or disclaimer (k) location of any proposed well to serve lot -1001 from leaching facility (1) location of water lines on property -10 I from leaching 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, distribution field piping and other elevations (r) mwd=m ground water elevation in area sewage disposal system (s) plan must be prepared by a Professional Engineer or other professional authorized by lax to prepare such plans Reg 6 Septic Tanks (a) capacit es- 50X of flog, water table, tees, depth of tees, access, pumping (b) cleanout (c) 101 from cellar wall or inground swimming pool (d) 251 from submwface drains Reg 10.2 7Distribution Boxes (a) slope gr-e-a-t—er-ITZ 0.08 Reg 10.1 (b) sump Commonwealth of Massachusetts RECEIVE UCity/Town of SUN 1 6 2008 HEALSystem Pumping Record FOITn 4 TO V TH DEPARTS OT R DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: forms on the computer, use only the tab key Address to move your t /� use the return City/Town rState t Zip Code key. 2. System Owner: Name ISI Address (if different from location) CitylTown Stat e Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) EF -Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No 15. Condition��tem: ULA 6. System Pum By: Name Vehicle License Number Q� Company 7. Location whqFe contents re osed: 66 ZY—A>� (z �;' z Signature of HaLA& Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts = v. City/Town of RECE System Pumping Record OCT 201 4„M SV ey,W Form 4 TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. Other foU591184aus 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 side of house, Right side of Nous eft front of hous Right front of house, Left rear of house, Right rear of house. Left rear of building. Right rear of building. Address Cityrrown State 2. System Owner: Name Zip Code Address (if different from location) CitylTown State EQ'a- r —;s(?— 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? ❑ Yes a No If yes, was it cleaned? ❑ Yes ❑ No 5. Conditijon of System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. L2tiq a contents were disposed: - S.D n „ Lowell Waste Water of F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1