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HomeMy WebLinkAboutMiscellaneous - 209 VEST WAY 4/30/2018 (2)0 .a t7 N 0 � co 0 m w -�� o � 0 i� r MAP # LOT #___..__._ PARCEL # STREET UQ.O_...._.... COIV.STRUCTI.ON APP7-YES HAS PLAN REVIEW FEE BEEN PAID? NO PLAN APPROVAL: DATE 110ole APP. BY.- _ DESIGNER: PLAN DA1-E:__�D�Z6�_ CONDITIONS WATER SUPPLY: TOWN WELL WELL PERMIT _DRILLER,_.„__._.__..._...__._...._.__.._........_. __._._.._........._......__. WELL TESTS: CHEMICAL DALE APPROVED BACTERIA I VA I E (IPPROVED BACTE II DATE APPRUVEll_.___-_.._____.__ COMMENTS: FORM U APPROVAL: APPROVAL I'D ISSUE (; NO DATE ISSUED BY CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID NO NO WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NO ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: ................. .-BY:...- too ZS &v i Z7 I HEREBY CERTIFY THAT I HAVE INSPECTED THE CONSTRUCTION OF THIS DISPOSAL SYSTEM AND THAT THE CONSTRUCTION AND FINAL GRADING HAS BEEN IN ACCORDANCE WITH.THE DESIGNER'S INTENT AND THAT THE MATERIALS USED CONFORM TO THE PLAN SPECIFICATIONS AND 310 CMR 15.00. SLOPE 2e:0U11?6:.1ENT (/50) X /50 — - ........................... DES/GN E'L E!/QT/ON AT.........(TOf' OF ,STONE) EX/57/NCF ELE&T/ON QT ....... 2EQU/�2E0 F/LL a ............................. z!FZiF 4T10W5 DE51(�N 14.5 30/LT INkI PIPE OUT OFI1DU,SE 68,9 168,78 /NV R/RE INTO T4NK 166-44 1681+5 /NV P/PE OUT OF TQNK 168, I q 168, Z 3. /NV PIPE /NTD D. BOX. 167.8-7 167 8 Z" INV P/RE OUT OF D. BOX 6 7, ? 0 16 7, 6 p INV END OF PIPE O 16 7,50 167,47- 67470,SO 0,570 167.SZ NQTE2 EZ EX.4 TION "0Ne- ."r 61,0 ,4VER,46E STONE DEPTH ,47 101eOBE ,45 BU/LT SUB-SU,ZF.4CE D/. SYSTEM /N N01;TH MbO VEA , MA - F02 J. T. MIN6/4t�0, INCL SCALE: 1 �= ZO D4TE: TQLy 11 19�4- N07-E. T1//5 PLAN /5 NOT ,4 G(/,4,eie,,4N7"Y 04R/STIAN5EN SERGl , INC. OF THE SYSTEM BUT ,4 /lER/F/C,47-10N 1&0 SUMMER STREET HAVERHILL , MASS. OF Tf/E LOCATION OF 7110 EX/S7/1V6 STBUCTU2E5. LOT ZG EXIST/NG /70 M I 1 I � n &0 7- ZS G qz ZO i to � ESQ N ,i l 1500 6al,(.oNf SEPTic TANK 00 FWA I HEREBY CERTIFY THAT I HAVE INSPECTED THE CONSTRUCTION OF THIS DISPOSAL SYSTEM AND THAT THE CONSTRUCTION AND FINAL GRADING HAS BEEN IN ACCORDANCE WITH.THE DESIGNER'S INTENT AND THAT THE MATERIALS USED CONFORM TO THE PLAN SPECIFICATIONS AND 310 CMR 15.00. 5LOPE 26:iQU1eEULcNT (/50) X - /50 . _ ........................... DES/GN 6 -1 -FV -d7 -10N AT ......... (TOP OF 57ONE) EX/5T/NCS E'LEI/,4T/ON qT ......... 2E'QU/�E'ED F/LL a ........... . DES/WN 11.5 !3U/LT /NV PIPE OUT OF90U,5E /NY. P/PE INTO T4Nff I C ,�}�j- 16845 /NV. P/PE OUT OF T,4NK 16 8 ,1 q 168, 23 INS/. PIPE INTO 0,30,y 167.87 167.8?, - ZINV INV P/PE OUT OF 0,30X 167,70 167.6(o- 67.6(o/NV INVEND OF P/PE 0 167,50 /67,47- 674716-1,50 /6-1,570 ►67.SZ . W,d TE2 EL EV.4 T/ON "°"'e '4r 61,0 ,4 VE2,44E S7'0NE DEPT/ ,47- P,eOBE NOTE. T///S PLAN /S NOT ,4 WAele4NTY OF T//E SYSTEM BUT ,4 ICE16/F/C,47-101V OF THE LOCATION OF 7WE E.'/ST/NCS ' ST�UCTU2ES. tvi 27 HJ LJU/L/ SUB-SU•2F,4CE D/SPOSAL SYSTEM IN NOKT MDOVEA, MA - F02 S. T. M AN6ANO ) INC, 6C,4EE. I �= ZO DATE. TQLy III 1 qq4- 0I1515TIAIV5EV SERGI ,INC. 1600 SUMMER STREET HAVERHILL , MASS. System Owner RA', :.btSti� 8�uc1:*?ire I>x�°.'•a �lvu Weagtfie;.ct, ;.id, .:u074 317) -b0 -7t -,H0, Type: Em Cesspool: No Date of Pumping: System Pumped By: Contents Transferred to: Contents Disposed at: Date: Commonwealth of Massachusetts Massachusetts System Pumping Record System Location RAI, 09 Ve:;t Way Form 4 -- System Pumpi Record TOWN OF NORTH ANDOVER _HEALTH DLRARTne=a1T N,,r. th Andover, MA, ,) , d r, 5 (978) -687-4259 s Keith Tay"or. Routine Yes Septic Tank: No = Yes Et_ Quantity Pumped: Gallons Wind River Environmental, LLC Permit #: Condition of System/Other Comments Pumper Signature: ® Printed on recycled paper Dep Approved Form - 12/07/95 jadedp IDXOa'uopa7uud Commonwealth of Mass u� E Massachusett System Pumping R cord nrr 15 100 -- ystem Pumping Record b7 BOARD OF HE System Owner System Location TOWN OF NORTH AND VER :: ^tet L I r• !L HEALTH DEPARTMENT Type: Emergen, Cesspool: No Date of Pumping: System Pumped By: Contents Transferred to: Contents Disposed at: I Routine Yes _/ -10-°Y Wind River Environmental, LLC Date: Condition of System/Other Commen- Septic Tank: NovC t Yes Quantity Pumped: - Gallons Permit #: Dep Approved Form - 12/07/95 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. am ISI Commonwealth of Massachuset RECEIVED City/Town of System Pumping Record Form 4 [ZEI DEP has provided this form for use by local Boardse used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left front of h se, Right front of ho , eft rear of house, Right rear of house Address at—s+ �C City/Town 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Zip Code State Zip Code Telephone Number Date 2. Quantity Pumped Cesspool(s) Septic Tank 4. Effluent Tee Filter present? ❑ Yeses 5. Condition of System: A. a f Vim( b�,0,4 6. System Pumped By: Neil Bateson Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No a v� Name Vehicle License Number F5821 Bateson Enterprises Inc Company 7. Location where contents were disposed: Signature of Hauler Lowell Waste Water Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 �-L\ Commonwealth of Massachusetts 21ffin City/Town of � System Pumping Record r do AUG 1 3 2008 ` Form 4 T�` DOVER MEN'T, Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. vQ DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1 Address Cityfroum 2. System Owner: Name Address (if different from location) City/Town Zip Code Stat (Zp Telephone Number B. Pumping Record l 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 No If yes, was it cleaned? ❑ Yes ❑ No 5. Condit* Syy tem: -� .3 7. t5forrn4.doc• 06/03 Name License Number System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of RECEI����, Y System Pumping Record Form 4 AUG - 6 2007 DEP has provided this form for use local Boards of H ittoOt�r f©ritis4 W-6sed, but the p � G� �.. � I information must be substantially the same as that provid �ra'r�e'I�lm#err, ch with your local Board of Health to determine the form they use. The System Pumping 'Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out forms on the computer, use only the tab key to imove your cursor - do not use the return key. qQ INA 1�1 1. System Location: 'V Address ©9 CiR om ate Zip Code 2. System Owner: Name Address (if different from location) cityrrr, State Zip Telephone Number B. 'Pumping Record -07 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 0-1o If yes, was it cleaned? ❑ Yes El No 5. Condition o � s�te "'� V 6. System P m By: Name �\ rji��cle License Number Company 7. Location otents di po ed: ^7 < -,- Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health.. The System Pumping Record must be submitted to the local Board of Health or other approving authority. . A. Facility Information Important: When filling out 1. System Location: forms on the C computer, use only the tab key Address M1� to move your \4`t cursor - do not use the return Cityrrown to Zip Code key. .2. System Owner: c0-f Name Address (if different from location) CityrrownState-.I� Zip Code Telephone umbetJUL -113 Lu-uw- -TOWN OF NCt' :.., 4 ' ;A B. Pumping Record . p� 9 1. Date of Pumping Date 2. Quantity' Pumped: 7-/1S Gallons 3. Type of system: ❑ Cesspool(s) E S—eptic Tank- ❑ Tight.Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes B-00 If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of S,yrstem: V�' 1, 6. System P fnRed 8 Name Vehicle License Number Company 7. Loc ' n where conlefAsw disposed: Date http://www.mass.gov/dept to /approvalsl t5form4.doc• 06103 System. Pumping Record • Page 1 of 1 TOWN OF I' " SYSTE PUMPING R i ED -- DATE: APR 13 2005 SYSTEM OWNER & ADD" TO. -vORTHANDOVER HEAL]H DEPARTMENT SYSTEM LOCATION (example: left front of house) o ©t�C\ - 6 � c�--L--E-v� DATE OF PUMPING: QUANTITY PUMPED: GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES t/ NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste 1 DATE: k-&-t-CSYSTEM PUMPING RECORD I SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: I/Q—VOq QUANTITY PUMPED: I e;, UCS GAL ONS JCESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: coNTENTs TRANsFERRED To: G.L.S.D ✓ Lowell Waste TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: -Q SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) _(( -�—fdKf ')P- 2-0 VCS �a DATE OF PUMPING: 'q --1 -d QUANTITY PUMPED GALLONS CESSPOOL: NO v YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE -2 EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) t COMMENTS: 1�'� AtG 10 9nn, x CONTENTS TRANSFERRED TO: r Ot NORTM ,� 6471 . O F? Town of North Andover ;, HEALTH DEPARTMENT ,SS�CNUSt4 . 4 I Df9l) CHECK #: D�.A1TE: LOCATION: �, n q �/ / 1 10 n 1 H/O NAME: CONTRACTOR NAME Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ XTitle 5 Report $= ❑ Other. (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer 6 (/jj 1 ' NORiM 1 r° •_ Y s Town of North Andover `ti'•.. .... :° ` HEALTH DEPARTMENT cNust� e+r CHECK #: ^ DATE: LOCATION: a 0q V i C�- 1A H/O NAME: nti5Q,A.,- V - CONTRACTOR NAME: LtSM 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 $ ❑ TrashlSolid 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 $_�� xTitle 5 Report $ ❑ Other: (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer I 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. VQ ISI Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 209 Vest Way Property Address Ryan Nelson.. Owner's Name North Andover' Cityrrown MA 01845 State Zip Code Inspection results must be submitted on this form. Inspection forms way. Please see completeness checklist at the end of the form. 4/17/2013 Date of Inspection A. General Information APR 2 2 2013 1. Inspector: TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Neil James Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover MA 01810 City/Town 978-475-4786 Telephone Number B. Certification State S115 License Number Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority -- — - 4/17/2013 In a r' ignatu Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""*This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 11/10 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 209 Vest Way Property Address Ryan Nelson Owner's Name North Andover Cityfrown B. Certification (cont.) MA 01845 4/17/2013 State Zip Code Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 11/10 Title 5 Official Inspection form: Subsurface Sewage Disposal System • Page 2 of 17 1 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 209 Vest Way Property Address Ryan Nelson Owner's Name North Andover MA 01845 4/17/2013 Citylrown B. Certification (cont.) B) System Conditionally Passes (cont.): State Zip Code Date of Inspection ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ ❑ ❑ broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ❑ Y ❑ Y ❑ Y ❑ N ❑ N ❑ N ❑ ❑ ❑ ND (Explain below): ND (Explain below): ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ❑ obstruction is removed ❑ Y ❑ N ❑ or obstructed pipe(s). The ND (Explain below): 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 • 11/10 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 209 Vest Way Property Address Ryan Nelson Owner's Name North Andover MA 01845 4/17/2013 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *" This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 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 % day flow t5ins • 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 ❑ ® 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 209 Vest Way Property Address Ryan Nelson Owner Owner's Name information is required for North Andover MA 01845 4/17/2013 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form - Not for Voluntary Assessments " 209 Vest Way Property Address Ryan Nelson Owner Owner's Name information is required for North Andover MA 01845 4/17/2013 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 t5ins • 11110 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 209 Vest Way Property Address Ryan Nelson Owner Owner's Name information is required for North Andover MA 01845 4/17/2013 every page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes ® No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ® No Yes ❑ Yes ® No Current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 11/10 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 r< 209 Vest Way Owner information is required for every page. Property Address Ryan Nelson Owner's Name North Andover ..A Cityfrown State D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: 01845 4/17/2013 Zip Code Date of Inspection Date General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Pumped two years ago, owner 1500 gallons Measured tank Inspect tank & tees Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 11/10 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 t 209 Vest Way Property Address Ryan Nelson Owner Owner's Name information is required for North Andover MA 01845 4/17/2013 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 19 years old, 7/11/1994, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 1.8 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.): Unable to see piping leaving foundation, finished basement, 3" PVC in house, no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal E 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: 4" ❑ Yes ❑ No t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Owner information is required for every page. t5ins • 11/10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 209 Vest Way Property Address Ryan Nelson Owners Name North Andover MA 01845 4/17/2013 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 23" Scum thickness 4" 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 17" How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 209 Vest Way Property Address Ryan Nelson Owner Owner's Name information is required for North Andover every page. Cityrrown MA 01845 4/17/2013 State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ No Alarm in working order: Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ❑ Yes ❑ No * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins - 11/10 Title 5 official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i" 209 Vest Way Property Address Ryan Nelson Owner Owner's Name information is required for North Andover MA 01845 4/17/2013 every page. 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 cover broken, replaced it. D -box level & distribution equal. No evdence of leakage. evidence of carryover, pumped d -box to clean. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form -W- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,N 209 Vest Way Property Address Ryan Nelson Owner Owner's Name information is required for North Andover MA 01845 4/17/2013 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2 trenches 36' 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 ❑ No t5ins - 11/10 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 209 Vest Way Property Address Ryan Nelson Owner's Name North Andover Cityrrown MA 01845 State Zip Code 4/17/2013 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 - 11110 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 209 Vest Way Property Address Ryan Nelson Owner's Name North Andover Cityrrown MA 01845 4/17/2013 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 A a T�� -Box -.� 3C 7,� a ! W3 V 43 lot( 3C) tgn t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 =4 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 209 Vest Way Property Address Ryan Nelson Owner's Name North Andover MA 01845 4/17/2013 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check, Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 4 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 10/5/1993 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Design plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Test pit data on design plan. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 11/10 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 °( 209 Vest Way E. Report Completeness Checklist 4/17/2013 Date of Inspection ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Property Address Ryan Nelson Owner Owner's Name information is required for North Andover MA 01845 every page. Cityrrown State Zip Code E. Report Completeness Checklist 4/17/2013 Date of Inspection ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 DEP has provided this form for usetby local Boards of Health. Other forms may be, used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. ...A. Facility Information 1. System Location: Le Right front of ho , Left / Right rear of house, Left / right side of house, Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address � ©� city/room state Zip Code 2. System Owner. n )Sc) V Name F v Address (if different from location) Citylrown State Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s). Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No '5. Condition of System: �- C 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locati here contents were disposed: ule Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 ♦ JUIIIII MY McWIU l,elu Yell dMU ul l 411014V IJ I.za.0 l rivl uy muiell namuii Town of North Andover Tax Map # 210-104.D-0093-0000.0 Parcel Id 16780 209 VEST WAY RYAN, & NICOLE NELSON 209 VST WAY NORTH ANDOVER, MA 01845 rage i Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.22 Acres i FY 2013 UB Mailinta Index Name/Address RYAN & NICOLE NELSON 209 VEST WAY NORTH ANDOVER, MA 01845 URRY,CARA 209 VEST WAY NO. ANDOVER, MA 01845 KEITH & DEENA TAYLOR 209 VEST WAY NORTH ANDOVER, MA 01845 GONE TO RELOCATION COMPANY HEARTH N HOME ATTN: BRENTJONES 210 BOSTON ROAD CHELMSFORD, MA 01824 UB Account Maint. Account. No Cycle Bldg Id. 17826.0 - 209 VEST WAY 3170491 03 Cycle 03 UB Services Maint. Account No. 3170491 Service Code MISCFEE ADMIN FEE WTR WATER UB Meter Maintenance Account No. 3170491 Type Loan Number Active/Inact. From Owner Previous Customer Inactive 8/29/2005 Pre ious Customer Inactive 3/22/2010 'I Previous Customer Inactive 2/12/2009 Occupant Name Active/Inactive Last Billing Date 4/10/2013 Active Rate Charge Multiplier/Users 0.635/8 7.82 1/ 01 ALL METER SIZE 86.72 /1 Serial No Status Location 36388109 a Active ERT HH Date Reading Code 3/14/2013 483 a Actual 12/12/2012 461 a Actual 9/12/2012 438 a Actual 6/12/2012 368 a Actual 3/13/2012 327 a Actual 12/12/2011 304 a Actual 9/13/2011 282 a Actual 6/7/2011 222 a Actual 3/7/2011 187 a Actual 12/8/2010 171 a Actual 9/9/2010 130 a Actual 6/8/2010 23 a Actual 4/26/2010 2 f Final Bill 3/10/2010 1 a Actual 2/13/2010 0 n New Meter 2/13/2010 1739 r Replacement Until Brand Type Size YTD Cons b Badger w Water 0.63 0.63 487 Consumption Posted Date Variance 22 4/22/2013 -5% 23 1/9/2013 -67% 70 10/15/2012 69% 41 7/16/2012 80% 23 4/14/2012 2% 22 1/17/2012 -60% 60 10/13/2011 61% 35 7/20/2011 112% 16 4/13/2011 -61% 41 1/12/2011 -60% 107 10/15/2010 136% 21 7/15/2010 2195% 1 4/26/2010 -47% 1 4/14/2010 -100% 0 4/14/2010 -100% 5 4/14/2010 -30% 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 JA LIOWI 12/10/09 p ctor's UAWure Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Cl"C� RECEIVED Commonwealth of Massachusetts . Title 5 Official Inspection For DEC 15 1009 Subsurface Sewage Disposal System Form - Not for Voluntary Asses LTH 209 Vest WayA Property Address Ral Inspection Services Owner Owner's Name information is required for North Andover MA 01845 12/10/09 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: When filling out A. General Information 017- G forms on the computer, use 1. Inspector: only the tab key to move your Paul Jaillet cursor - do not use the return Name of Inspector key. Wind River Environmental Company Name 11 Chocksett Road Company Address Sterling MA _ 0 City/Town State Zipp Code 978-562-4500 S1489 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority JA LIOWI 12/10/09 p ctor's UAWure Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 09108 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 209 Vest Way Property Address Rai Inspection Services Owner's Name North Andover MA 01845 12/10/09 CityrTown 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 • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'y 209 Vest Way Property Address Ral Inspection Services Owner Owner's Name information is required for North Andover MA 01845 12/10/09 every page. CityTTown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with' approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not 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 • 09008 Title 5 01ficial Inspection Forth: Subsurface Sewage Disposal System • Page 3 of 17 Commonwealth of Massachusetts . Title 5 official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 209 Vest Way Property Address Rai Inspection Services Owner Owner's Name information is required for North Andover MA 01845 12/10/09 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: X ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 " Title 5 Official inspection t-orm o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 209 Vest Way Property Address Rai Inspection Services Owner Owner's Name information is North Andover MA 01845 12/10/09 required for State Zip Code Date of Inspection every page. Cityrrown 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 fa. I have determined that one or more of the above failure ils criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system.the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y 209 Vest Way MA State 01845 12/10/09 Zip Code Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ ® ❑ Pumping information was provided by the owner, occupant, or Board of Health Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 t5ins • 09/08 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 6 of 17 Property Address Ral Inspection Services Owner Owner's Name information is North Andover required for every page. City/Town C. Checklist MA State 01845 12/10/09 Zip Code Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ ® ❑ Pumping information was provided by the owner, occupant, or Board of Health Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 t5ins • 09/08 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 6 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 209 Vest Way -- Property Address Yes Ral Inspection Services No Owner's Name North Andover MA 01845 12/10/09 City/Town State Zip Code Date of Inspection D. System Information ❑ Description: ❑ Yes ❑ No Number of current residents: 2 Does residence have a garbage grinder? ®Yes No Is laundry on a separate sewage system? [if yes separate inspection required] Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Copies attached. Sump pump? Last date of occupancy: Commercial/industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/personslsq.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 current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 09108 Title 5 Official Inspection Foran: 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 209 Vest Way Last date of occupancy/use: Other (describe below): 01845 12/10/09 Zip Code Date of Inspection 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: Type of System: Date Owner - last service 8/4109 W11111 gallons as -built check structural integrity ® Yes ❑ No ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Property Address Rai Inspection Services Owner owner's Name information is North Andover MA required for City/Town State every page. D. System Information (cont.) Last date of occupancy/use: Other (describe below): 01845 12/10/09 Zip Code Date of Inspection 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: Type of System: Date Owner - last service 8/4109 W11111 gallons as -built check structural integrity ® Yes ❑ No ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments >Y 209 Vest Way Property Address Ral Inspection. Services Owner Owners Name information is North Andover MA 01845 12/10/09 required for State Zip Code Date of Inspection every page. Citv/Town D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 7-11-1994 per as -built plan. Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): 24" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): town water Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): No evidence of leakage Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal ❑ Yes ® No 12" 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) ❑ Yes ❑ No 101 x 4'6"W x 5'H Dimensions: 2" Sludge depth: t5ins . 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 209 Vest Way Property Address Rai Inspection Services Owners Name North Andover r^i+,rrf%wn D. System Information (cont.) Septic Tank (cont.) MA 01845 12/10/09 State Zip Code Date of Inspection Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 25" 19" 8" 19" 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.): I recommend yearly service. Inlet baffle and outlet tee are intact; structural integrity is good; liquid level to outlet invert is okay; no evidence of leakage Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness ❑ fiberglass Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: feet ❑ polyethylene ❑ other (explain): Date t5ins - 09M Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 209 Vest Way Owner information is required for every page. Property Address Rai Inspection Services Owner's Name North Andover MA 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.): 01845 12/10/09 Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No l5ins • 09108 Title 5 Official Inspection Forth: 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 209 Vest Way Property Address Rai Inspection Services Owner's Name North Andover MA 01845 CityrTown State Zip Code D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 12/10/09 Date of Inspection 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.): Equal distribution; no solids carryover no evidence of leakage. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 t5ins • 09108 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 209 Vest Way Property Address Rai Inspection Services Owner's Name North Andover MA 01845 12/10/09 Citv,Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system 2 A 361 Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No signs of hydraulic failure; no damp soil; normal vegetation. s 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 • 09/08 Title 5 Official Inspection Forth: 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 209 Vest Way Property Address Ral Inspection Services Owner's Name North Andover MA 01845 r.ifv1Tnwn State Zip Code D. System Information (cont.) 12/10/09 Date of Inspection Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 209 Vest Way Property Address Rai Inspection Services Owner Owners Name information is North Andover MA 01845 12/10/09 required for State Zip Code Date of Inspection every page. Cityrrown 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 M Ar�%Alinn nffar Fhpri CPn9ratP1y t5ins - 09/08 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 NN, vC 1 N WE to r zS N 38t A� ISOO bALWN SEPTIC TANK W- N G. O � G9 STEN�'�+W MAA r I HEREBY CERTIFY THAT I HAVE INSPECTED THE CONSTRUCTION OF THIS DISPOSAL SYSTEM AND THAT THE CONSTRUCTION AND FINAL GRADING HAS BEEN IN ACCORDANCE WITH THE DESIGNER'S TNCENT AND THAT THE MATERIALS USED CONFORM TO THE PLAN SPECIFICATIONS AND 310 CMR 15.00. 5LOPF 26Qu1fe&"6c rr (/50) X /50 . ............................ DE6/6N E1EV47'10N 4r ......... (TOP OF STONE) m EX/5T/N6 EL6-XdT/ON 4r......... REQU/.PED F/LL . ............................. D65IGN 41 BU/LT 45 BU/L T INV PIPE OUT OFAlOUSE 168,9 168.78 INV RIPE INTO 754NK 16&,44 168, 45 INV P/PE OUT OF UNK 168. l9 16 6, Z3 INV P/PE INTO D. BOX 10,61 10-82, INV. PIPE OUT OF D. BOX 167,70 167.66 INV. END OF PIPE © 167.50 167,47- 6747OO (D 16'7,$70 16?.5Z DV4TE,P FL 6W TION NONE 61,00 4VE246E STONE DEPT# 47 ?,POBE toi 17 1 SUB-SU�F,4CE D/SPOS�IL SYSTEM /N W,TH MbOVEAI MA FOR S. I MAN6AND, INC. SCAT -E: LO 04TE: 3'ULY III 1 NOTE: 7-1//5 -L.dN /s Nora W.4,P,P41Vrr 049I STIAN,5EN E SERGI , INC, OF TIE SYSTEM BUT .4 IiE,P/F/C4T/ON /&o SUMMER STREET - HAVERHILL . MASS. OF T11E LOG4TION OF TIE EX/STING ST,PUCTU,PES. Owner information is required for every page. Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 209 Vest Way.. Property Address Rai Inspection Services Owner's Name North Andover MA 01845 12/10/09 Citv/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 4 - feet Please indicate ail methods used to determine the high ground water elevation: OR Obtained from system design plans on record If checked, date of design plan reviewed: 10/5/1993 Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: Checked with local excavators, installers - (attach documentation) Accessed USGS database - explain: You must describe how you established the high ground water elevation: n plan on record. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 09M Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 E1 - Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 209 Vest Way Property Address Ral Inspection Services Owner's Name North Andover City/Town MA 01845 State Zip Code E. Report Completeness Checklist 12/10/09 Date of Inspection ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins - 09108 Title 5 Official Inspection Forth: Subsurface Sewage Disposal system • Page 17 of 17 Town of North Andover 120 Main Street North Andover, MA 01845 (978) 688-9550 KEITH & DEENA TAYLOR 209 VEST WAY NORTH ANDOVER, MA 01845 OFFICE HOURS PAYMENT ON BEFORE 12/07/2009 $89.37 Monday to Friday- -- r--- — ACCOUNT 7 BILLING DATE 8:30am to 4:30pm ; 3170491 10/15/2009 Billing Information: SERVICE DATES DUE DATE . . (978) 688-9550 06/09/2009-09/081200_9 12/07/2009 Reading Information: E - SERVICE ADDRESS 777777 (978) 688-9570 209 VEST WAY RETAIN THIS PORTION FOR YOUR RECORDS MOVING? PLEASE CALL (978) 688-9570 IN ADVANCE SERIAL # READINGS USAGE NB OF _ Current _Type Date DAYS 39427381 1,722 Actual 09/08/2009 21 91 i SERIAL # READINGS Previous Type Date 39427381 1,701 Actual 06/09/2009 39427381 1,689 Actual 03/16/2009 CURRENT BILL DETAIL USAGE/UNIT AMOUNT WATER USAGE ADMINISTRATIVE FEE 21 $81.55 $7.82 $0.00 $0.00 $0.00 USAGE NB OF DAYS Sub -Total $89.37 12 85 11 98 TOTAL : • MESSAGES ' NOTE ' PAYMENTS SHOULD BE MADE: TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @ P.O. BOX 184, MEDFORD, MA 02155 WATER RATE: FIRST 20 UNITS @ $3.80 OVER 20 UNITS @ $5.55 SEWER RATE: FIRST 20 UNITS @ $5.83 OVER 20 UNITS @ $8.22 BYPASS METER WATER RATE: ALL UNITS @ $5.55 TRANSACTIONS THIS. PERIOD' AMOUNT7– i PREVIOUS BALANCE $48.50 PAYMENTS THROUGH 10/15/2009 ($48.50) ADJUSTMENTS THROUGH 10/15/2009 $0.00 INTEREST AS OF 12/07/2009 $0.00 BALANCE FORWARD $0.00 CURRENT BILL DETAIL USAGE/UNIT AMOUNT WATER USAGE ADMINISTRATIVE FEE 21 $81.55 $7.82 $0.00 $0.00 $0.00 USAGE NB OF DAYS Sub -Total $89.37 12 85 11 98 TOTAL : • MESSAGES ' NOTE ' PAYMENTS SHOULD BE MADE: TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @ P.O. BOX 184, MEDFORD, MA 02155 WATER RATE: FIRST 20 UNITS @ $3.80 OVER 20 UNITS @ $5.55 SEWER RATE: FIRST 20 UNITS @ $5.83 OVER 20 UNITS @ $8.22 BYPASS METER WATER RATE: ALL UNITS @ $5.55 ' n Town of North Andover 120 Main Street North Andover, MA 01845 (978) 688-9550 KEITH & DEENA TAYLOR 209 VEST WAY NORTH ANDOVER, MA 01845 OFFICE HOURS Monday to Friday 8:30am to 4:30pm Billing Information (978) 688-9550 PAYMENT ON OR BEFORE 08/1912009 $48.50 ACCOUNT i_— BILLING DATE 3170491 07/20/2009 _---...--------T E DAES _ wSERVIC 2mr. inno-nainamn4 nR/1912009 Reading Information: L SERVICE ADDRESS (978) 688.9570 209 VEST WAY RETAIN THIS PORTION FOR YOUR RECORDS MOVING? PLEASE CALL (978) 688-9570 IN ADVANCE SERIAL # READINGS USAGE NB OF i Current Type Date DAYS 39427381 1,701 Actual 06/0912009 12 85 �- TRANSACTIONS THIS PERIOD AMOUNT' PREVIOUS BALANCE $45.11 PAYMENTS THROUGH 07/20/2009 ($45.11) ADJUSTMENTS THROUGH 07/20/2009 $0.00 INTEREST AS OF 08/19/2009 $0.00 BALANCE FORWARD $0.00 CURRENT BILL DETAIL USAGE/UNIT AMOUNT WATER USAGE ADMINISTRATIVE FEE 12 $40.68 $7.82 $0.00 $0.00 $0.00 SERIAL # READINGS USAGE NB OF _ Previous Type Date DAYS _ Sub -Total $48.50 39427381 1,689 Actual 03/16/2009 11 98 39427381 1,678 Actual 12/08/2008 10 91 TOTAL a q(2_,c/-9 4 G -4Z MESSAGES * NOTE ' PAYMENTS SHOULD BE MADE: TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @ P.O. BOX 184, MEDFORD, MA 02155 WATER RATE: FIRST 20 UNITS @ $3.39 OVER 20 UNITS @ $4.96 SEWER RATE: FIRST 20 UNITS @ $4.96 OVER 20 UNITS @ $7.07 BYPASS METER WATER RATE: ALL UNITS @ $4.96 Adismikh. Town of North Andover 120 Main Street North ANdover, MA 01845 (978) 688-9550 KEITH & DEENA TAYLOR 209 VEST WAY NORTH ANDOVER, MA 01845 OFFICE HOURS PAYMENT ON OR BEFORE 05/29/2009 1 $45.11 Monday to Friday 8:30am to 4:30pm F71L_A COUNT1 _—-PILL CG DATE 04/29/2009 Billing Information ISERVICE DATES. DUE DATE, (978) 688-9550 12/08/2008-03/16/200 05129/2009i Reading Information: SERVICE ADDRESS":. -_11:1,.' (978) 688-9570 209 VEST WAY RETAIN THIS PORTION FOR YOUR RECORDS MOVING? PLEASE CALL (978) 688-9570 IN ADVANCE SERIAL # Current 39427381 1,689 READINGS USAGE NU UV Type Date DAYS Actual 03/16/2009 11 98 SERIAL 0 READINGS USAGE NB OF Previous Type Date DAYS 39427381 1,676 Actual 12/08/2008 10 91 39427381 1,668 Actual 09/08/2008 26 94 I MESSAGES TRANSACTIONS THIS .,PERIOD 'Wou PREVIOUS BALANCE $41.72 PAYMENTS THROUGH 04/29/2009 ($41.72) ADJUSTMENTS THROUGH 04/29/2009 $0.00 INTEREST AS OF 05/29/2009 $0.00 BALANCE FORWARD $0.00 CURRENT BILL DETAIL USAGE/UNIT AMOUNT WATER USAGE 11 $37.29 ADMINISTRATIVE FEE $7.82 $0.00 $0.00 $0.00 Sub -Total $45.11 TOTAL NOTE PAYMENTS SHOULD BE MADE: TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @ P.O. BOX 184, MEDFORD, MA 02155 WATER RATE: FIRST 20 UNITS @ $3.39 OVER 20 UNITS @ $4.96 SEWER RATE: FIRST 20 UNITS @ $4.96 OVER 20 UNITS @ $7.07 BYPASS METER WATER RATE: ALL UNITS @ $4.96 %KE P%MENTS TO HORT4 °� •,"� TOWN OF NORTH ANDOVER } ; 120 MAIN STREET NORTH ANDOVER MA 01845 978-688-9550 x'13^CW15�� Billing Information (978)688-9570 Reading Information (978)688-9570 OFFICE HOURS Mon to Fri. 8:30am to 4:30pm RETAIN THIS PORTION FOR YOUR RECORDS MOVING? PLEASE CALL 978-688-9570 IN ADVANCE KEITH & DEENA TAYLOR 209 VEST WAY NORTH ANDOVER, MA 01845 previous., turent Gausuinptioti t3ti(tif:, f Reading R'eadmg ` Days :- WATER USAGE 2/8/08 166-S 1678 10 Actual 91 MESSAGE ON OR BEFORE 02/19/09 00-$41.72 ACCOUNT NO. BILLING DATE 3170491-416731086 1120/2009 SERVICE DATES: DUE DATE 10/1/2008 - 12/31/2008 02/19/09 SERVICE ADDRESS 209 VEST WAY TRANCAc"( ow THIS:PERIOD"- AMOUNT ...,...,..� Y».»..__ Payments Through 01/20/2009 (104.34) Adjustments/ Late Charges - Interest as of: 2/19/2009 - Balance Forward - U4 �'}(oq 6'�( PAYMENTS SHOULD BE MADE: TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @ P.O. BOX 184, MEDFORD, MA 02155 Water rate: First 20 units a $3.39 Over 20 units $4.96 Sewer rate: First 20 units $4.96 Over 20 units a $7.07 Bypass Meter Water rate: all units @ $4.96 IAKt F'AYMtN 15 I U 820 • MO erN TOWN OF NORTH ANDOVER P ; 120 MAIN STREET • • NORTH ANDOVER MA 01845 . �. 978-688-9550 ."SA I Billing Information (978)688-9570 Reading Information (978)688-9570 OFFICE HOURS Mon to Fri. 8:30am to 4:30pm RETAIN THIS PORTION FOR YOUR RECORDS MOVING? PLEASE CALL 978-688-9570 IN ADVANCE KEITH & DEENA TAYLOR 209 VEST WAY NORTH ANDOVER, MA 01845 revtous Current, Consumption Reacitng Reeding Uay5i°. WATER USAGE (::+),ng 1042 9/8/08 1668 26 Actual 94 n� 11,3(01 -14 L-2,1 EF OR 11/10/08 , $104.34 BEFORE ACCOUNT NO. BILLING DATE 3170491-416731086 10/10/2008 SERVICE DATES . ' DUE DATE 7/1/2008 - 9/30/2008 11/10/08 SERVICE ADDRESS: 209 VEST WAY `TRANSACTION. TH1S'PERIQD AMOUNT, revtous Balance 40.13 Payments Through 10/10/2008 (40.13) Adjustments/ Late Charges - Interest as of: 11/10/2008 Balance Forward - `':Usage/Untt � WATER 26 96.52 ADMIN FEE 7.82 Sub -Total 104.34. Total MESSAGE SHOULD BE MADE TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @ P.O. BOX PAYMENTS 184, MEDFORD, MA 02155 Water rate: First 20 units (a� $3.39 Over 20 units @ $4.96 Sewer rate: First 20 units ✓ $4.96 Over 20 units ce $7.07 Bypass Meter Water rate: all units @ $4.96 Y AAKE PAYMENTS TO 776 OY MD ^rh �1' �� '•. 4 TOWN OF NORTH ANDOVER 10 120 MAIN STREET _d- d NORTH ANDOVER MA 01845 978-688-9550 �ss�cvxs4� Billing Information (978)688-9570 Reading Information (978)688-9570 OFFICE HOURS Mon to Fri. 8:30am to 4:30pm RETAIN THIS PORTION FOR YOUR RECORDS MOVING? PLEASE CALL 978-688-9570 IN ADVANCE KEITH & DEENA TAYLOR 209 VEST WAY NORTH ANDOVER, MA 01845 revtous urfent ��Consumpunn Nb o� t Read ngi }" Reading WATER USAGE ),Ij};';z 6/6/08 16 1642 9 Actual 88 ON OR BEFORE 08/15/08 JO -$40.13 ACCOUNT NO. BILLING DATE 3170491-416731086 7/16/2008 SERVICE DATES DUE.DATE . 4/1/2008 - 6/30/2008 08/15/08 SERVICE ADDRESS 209 VEST WAY ...,...,..� �.......__ Payments Through 07/16/2008 (43.72) Adjustments / Late Charges Interest as of: 8/15/2008 - Balance Forward - WATER 9 32.31 ADMIN FEE 7.82 Sub -Total 40.13 Total MESSAGE SHOULD BE MADE: TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @ P.O. BOX PAYMENTS 184, MEDFORD, MA 02155 Water rate: First 20 units @ $3.59 Over 20 units @ $5.53 Sewer rate: First 20 units @ $4.30 Over 20 units @ $6.18 Bypass Meter Water rate: all units @ $5.53 ` ! AKE PAYMENTS TO 1 40RT4 1 TOWN OF NORTH ANDOVER 60 120 MAIN STREET ;; • :, r/ NORTH ANDOVER MA 01845 978-688-9550 ,'f3AfNU��� Billing hil'onnation (978)688-9550 Reading Information (978)688-9570 OFFICE HOFIRS Mon to Fri. 8:30am to 4:30pm RETAIN THIS PORTION FOR YOUR RECORDS MOVING? PLEASE CALL 978-688-9570 IN ADVANCE KEITH & DEENA TAYLOR 209 VEST WAY NORTH ANDOVER. MA 01845 Previous Current Consumption Nb of Reading Reading Days WATER USAGE z'i0/08 1633 10 Actual 89 MESSAGE FT OR 05/11/08 00-$43.72 BGPORE ACCOUNT NO. BILGING DATE 3170491-416731086 4/11/2008 SERVICE, DATES DUE DATE I / I /2008 - 3/3 1 /2008 1 05/11/08 SERVICE ADDRESS 209 VEST WAY TRANSACTION THIS PERIOD AMOUNT -Previous Balance Payments Through 04/11/2008 (72.44) Adjustments / Late Charges - Interest as of: 5/11/2008 - Balance Forward Current Bill Detail WATER ADMIN FEE 6'R �I2a/u8 Usage/Unit 10 Sub -Total Total -It s.q�o Amount 35.90 7.82 43.72 PAYMENTS SHOULD BE MADE: TOWN HALT. W, 120 MAIN STREET OR BY MAIL. TO OUR LOCKBOX 'u? P.O. BOX 184, MEDFORD. Water rate: MA 02155 First 20 units iii, $3.59 Over 20 units 'ii; $5.53 Sewer rate: First 20 units -iU $4.30 Over 20 units iii $6.18 Bypass Meter Water rate: all units 'a $5.53 + -r AKE PAYMENTS TO 702 A6RT4 , °� •�4e TOWN OF NORTH ANDOVER 0 IL 120 MAIN STREET NORTH ANDOVER MA 01845 • s r i 978-688-9550 ysa�cws�t Billing Information (978)688-9550 Reading Information (978)688-9570 OFFICE HOURS Mon to Fri. 8:30am to 4:30pm RETAIN THIS PORTION FOR YOUR RECORDS MOVING? PLEASE CALL 978-688-9570 IN ADVANCE KEITH & DEENA TAYLOR 209 VEST WAY NORTH ANDOVER, MA 01845 revtous -, , , urrent r `rfi Consumption , r A Nb`dl� sRed�111 � � ��Reatltti�'w'x��KK;z x i: t,✓ : I�8'ySi�'� WATER USAGE 0 6:11': 12/12/07 1605 1623 18 Actual 97 7EFREOR 02/22/08 , $72.44 BEFO ACCOUNT NO. BILLING DATE 3170491-416731086 1/22/2018 SERVICE 'DATES' . DUE DATE. 10/1/2007 - 12/31/2007 02/22/08 SERVICE'ADDRESS 209 VEST WAY J Payments Through 01/22/2008 (162.57) Adjustments / Late Charges - Interest as of: 2/22/2008 - Balance Forward - F � �C1>frelit At11 I?eliUb`iJsage/tJnit stir �< Amatmf"a ag."' a .�, s+",� .;kg.,y."�; WATER 18 64.62 ADMIN FEE 7.82 Sub -Total 72.44 Total MESSAGE HOULD BE MADE: TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @ P.O. BOX PAYMENTS S 184, MEDFORD, MA 02155 Water rate: First 20 units �u $3.59 Over 20 units @ $5.53 Sewer rate: First 20 units @ $4.30 Over 20 units @ $6.18 Bypass Meter Water rate: all units (& $5.53 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 ►L INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 209 Vest Way _ _ North Andover— Owner's Owner's Name• _David Urry VED Owner's Address: 209 Vest Way_ _North Andover, MA 01845 13 2005Date of Inspection: 4/4/2005 R Name of Inspector: Neil J. Bateson_ TOW �� �r ��ty;�TH ANDOVER Company Name: Bateson Enterprises Inc._ HEALTH DEPARTMENT 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 blow 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 Inspector's Signature: Date: _4/4/2005_ 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: _209 Vest Way_ _ North Andover — Owner: Urry_ Date of Inspection: _4/4/2005_ 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 M in 310 CR 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: 209 Vest Way_ _ North Andover— Owner: Urry_ Date of Inspection: 4/4/2005 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: _209 Vest Way _ _ North Andover— Owner: Urry_ Date of Inspection: _4/4/2005_ 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 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 1/2 day flow. —No7 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 fat from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either `yes" or "no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: _209 Vest Way _ _ North Andover— Owner: Urry _ Date of Inspection: _4/4/2005_ 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_ T 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: _209 Vest Way _ _ North Andover– Owner: Urry _ Date of Inspection: _4/4/2005_ 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): _440_ 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 readings: Yes,139428Ft3_ 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 last year, 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 & baffles_ 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: _11 years old, 7/11/1994 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: _209 Vest Way- — North Andover— Owner: Urry_ Date of Inspection: _4/4/2005_ 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.): _ Unable to see piping leaving foundation, finished cellar. 3" PVC in house, no leaks visible_ SEPTIC TANKS: X Depth below grade: _12"_ 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 —2" _ Distance from top of sludge to bottom of outlet tee or baffle: 25" _ Scum thickness: _2" _ Distance from top of scum to top of outlet tee or baffle: " _ffi8_ Distance from bottom of scum to bottom of outlet tee or bae: 19" _ How were dimensions determined: _Tape Measure_ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.)_ Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. _ GREASE TRAP: _(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _209 Vest Way- – North Andover– Owner: Urry _ Date of Inspection: _4/4/2005_ 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 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 evidence of 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: 209 Vest Way_ _ North Andover _ Owner: Urry_ Date of Inspection: _4/4/2005_ SOIL ABSORPTION SYSTEM (SAS): _X If SAS not located explain why: (locate on site plan, excavation not required) Type _ leaching pits, number: _ leaching chambers, number: _ leaching galleries, number: _X_ leaching trenches, number, length: —2 trenches 36' long_ leaching fields, number, dimensions: , overflow cesspool, number: innovative/altemative 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: (cesspool must be pumped as part of inspection)(locate on site plan) 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) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _209 Vest Way_ —North Andover— Owner: Urry _ Date of Inspection: _4/4/2005 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 Tank = 39 A to D -Boz = 3 B to Tank = 48 B to D -Boz = 4 Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _209 Vest Way- - North Andover_ Owner: Urry_ Date of Inspection: _4/4/2005_ 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: _10/5/1993_ 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: _ No water found 4' deep, as per design plan deep._ Summary Record Card generated on 4/8/2005 1:31:51 PM by Lisa Warren Page 1 Town of North Andover Tax Map # 210-104.D-0093-0000.0 209 VEST WAY URRY, CARA 209 VEST WAY NO. ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 1.22 Acres FY 2005 UB Mailing Index Name/Address Type Loan Number URRY, CARA Payor 209 VEST WAY NO. ANDOVER, MA 01845 UB Account Maint. Active/Inact. From Account No Cycle Occupant Name Active/inactive Bldg Id. 3100.0 - 209 VEST WA Last Billing Date 4/6/2005 3170491 03 Cycle 03 Active UB Services Maint. Service Code Rate Charge Multiplier/Users MISCFEE'ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 36.40 /1 UB Meter Maintenance Serial No Status Location Brand Type Size 39427381 a Active Y ENC FT (LF) ? w Water 0.63 0.63 Date Reading Code = Consumption Posted Date 3/30/2005 1383 m Manual estimate 13 4/5/2005 12/14/2004 1370 a Actual 13 1/14/2005 9/29/2004 1357 a Actual 19 10/8/2004 6/23/2004 1338 a Actual 16 7/30/2004 4/16/2004 1322 a Actual 22 5/17/2004 Until YTD Cons 0 Variance -28% -12% -18% 29% 0% 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: 209 Vest Way, North Andover Owner: Urry Date of Inspection: 4/4/2005 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. C Neil J. Bateson Bateson Enterprises, Inc. 107 Forest St. Middleton, MA 01949 . (508) 774-2772 ma 0 �GE FILE# fm�iq OF a{ JUN 18 1297 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNER'S NAME: _ I "� -fto -2 (ck PROPERTY ADDRESS: ADDRESS.OF OWNER: �;2VV1 (if different) DATE OF INSPECTION:A�9' NAME OF INSPECTOR: I h01Ylf1S f �'ll��t�, • THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY • r FILE#,.53 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 20q Vest uin N'ANdoVer Address of Owner: Mq t � Saves Q. Date of Inspection: 343 Y 9 1.. � .._ ....... (If different) Name of Inspector: Thorn0.5 T (_4NI6ff5 Company Name, Address and Telephone Number: Currier Septic & Drain Service, Inc. 107 Forest Street, Middleton, MA 01949 (508) 774-2772 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 Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority 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. INSPECTION SUMMARY: Checo. C, or D: A) SYSTEM PASSES: 5 I have not found any information which indicates that the system violates any of the failure criteria as defined in 3� CMR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of dtermination in all instances. If "not determined", explain why not The septic tank is metal, 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 Am' conforming septic tank as approved by. the Board of Health. (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (coNTNud) FILE#�3 9 /q .. B) SYSTEM CONDITIONALLY PASSES (continued) Al 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 th Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced 1V The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass ins ction if (with approval of the Board of Health): /V broken pipe(s) are replaced obstruction is removed C) FURTUHE&L EVALUATION IS REOUIRED 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 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 a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) S SEEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply / or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply . / well. �V The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and 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. D)SYSTEM FAILS: /�1// 1 have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to Zdtermine what will be necessary to correct the failure. '. Backup of sewage into facility or system -component due to an overloaded or clogged SAS or cesspool. IV Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 8/15/95) ME ', I� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ANW PART A CERTIFICATION (continued) FILE#5 9 A D) SYSTEM FAILS (continued) Static liquid level in the distribution box above oulet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is lessthan6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year HQI due to clogged 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: Th�ollowing criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public ^health and safety and the environment because one or more of the following conditions exist: IV 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 -4Z 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/9§)� 3 FILE#�� f( SUBSURFACE -SEWAGE -DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: ✓ pumping information was requested of the owner, occupant, and Board of Health Ane 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. _ZAs built plans have been obtained and examined. Note if they are not available with N/A. ZThe facility or dwelling was inspected for signs of sewage back-up. ZThe system does not receive non -sanitary or industrial waste flow. ✓�fihe site was inspected for signs of breakout. ZAll system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition 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 existing information or approximated by non -intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on thero er p p maintenance of SubSurface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL - Design flo0 allons Number of bedrooms: Number of current residents:. Garbage grinder (yes or no):Mb Laundry connected to system (yes or no): P� Seasonal use (yes or no):_U Water meter readings, if available: Tl�-0h (.c aler- / rm-da Last date of occupancy: rovyoo - Design w:_gallons/day Grease tra resent: (yes or n Industrial Wa Holding Ta present: (yes or no) Non -sanitary wa disch ged to the Title 5 system: (yes or no) Water meter readina if vialble: Last OTHER: (Dq�scribe) Last date 9f occupancy: GENERAL INFORMATION PUMPING RECORDS anasource of information: .Z01 System pumped as paFt of inspection: (yes or no)_[Q If yeses, volume pumped:Ngallons Reason for pumping: NA TY� E �OF SYSTEM r, , Septic tank/distribution box/soil absorption system NO Single cesspool NO Overflow cesspool NO Privy ►JG Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) FILE#`j A PPR X11MATE AGE of all components, date installed (if known) and source of information: Tu- I . 9 InLo Sewage odors detected when arriving at the site: (yes or no)—m-LL (revised 8/15/95) i1 5 . SUBSURFACESEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C TM SYSTEM INFORMATION (continued) SEPTIC TANK:an (locate on site p Depth below grade: Material of construction: concrete _Metal _FRP_other(explain) Sludge depth: 1� `, Distance from top of sludge to bottom of outlet tee or baffle: Scum thic ess: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle:_:/ Comments: (recommendation for pumping, condition of inlet and Structural integrity, evidence of leakage, etc.) Tank h 1---1 i L'„ L, FILE#,f q � Depth Below Outlet Invert: or baffles, depth of liquid level in relation to outlet i 4lEASE TRAP: (o to on site pan) Depth low grade: Material o onstruction: _concrete _metal _FRP —other(explain) Dimensions: Scum thickness: Distance from top Distance !"bot Comments: / (recommenda ion structural intdarity (revised 8/15/95) Depth Below Outlet Invert: pbm to top of outlet tee or baffle: of scum to bottom of outlet tee or baffle: g, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, of leakage, etc.) LL FILE#`S d 9 1,4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM AW,PART C ,.. SYSTEM INFORMATION (continued) - TIG T OR HOLDING TANK: (locat on site plan) Depth be w grade: Material of onstruction: _concrete metal FRP-other(explain) Dimensions: ,i Capacity: allons Design flow: allons/day Alarm level: Comments (condition qf�inlet tee, condition\of alarm and float switches, etc.) DISTRIBUTION BOX:-�0-5 (locate on site. plan) Depth below grade:�� Depth of IW level above outlet invertiuump: Dimensions of D -Box: D° Depth of r Comments: note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) ' a AIO vP N kaG / v� tTtye r' ) -t 7 o - S L k �i n i P�Vtea ER: (lplan Drade:Ping or r:(yes or no)C(nof pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C .SYSTEM INFORMATION (continued) FILE#�`a,,, 9-1-,4 SOIL ABSORPTION SYSTEM (SAS): 1'ou�o4l ' y) op or G rour)� 17� .� 9 (locate on site plan, if possible pir4i kaic n not required ++ but may be approximately by non ---intrusive methods) Depth to o om of SAS: tone r Pit) El evatlon 76P Ito 7.70 If not determined to be present, explain: 81eVcl+i" Type: leaching pits, number: leaching chambers, number: leaching galleries, number: leaching trenches, number, length: -T uwo ?benches = 3S .LX 3 W lung fields; number, dimensions: Comments ( etc. ) CESSPOOLS: Iv (.locate on site p an) D6 th beiowgrade: Num r and configuration: Depth- of liquid to inlet i Depth of s ids layer: Depth of scu layer: Dimensions of c sspool: Materials of constr ti :_ Indication of grown r: inflow (c spool st be pumped as part of inspection) Com ents: (note condition of soil, sign f hydraulic failure, level of ponding, condition of vegetation, etc.) (locatedsite plan) Materials o1 Depth of so Comments: (revised 8/15/95) Dimensions: ofisoil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) 8 r A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two.. permanent references landmarks or benchmarks locate all wells within 100' �ack yard. 209 Vest way DEPTH OF GROUNDWATER Depth to groundwater:2D�feet method of determination or approximation: - �_j i I_ Inn./ 11. 1 srn . , (revised 8/15/95) v septic Tan k Froaj t L .-„�- VVI C) FILE# f2,1 14 N 9 Led er A io Trl -S9"3', f0 j-1 = 34 , 1 AI B i n 9 e NORT#j 1 O ���ao ,aa ti0 O � ♦ �o d' M ,SSACMUs�t Applicant Town of North Andover, Massachusetts BOARD OF HEALTH DISPOSAL WORKS CONSTRUCTION PERMIT RESS Site Location--LO--r 4 Form No. 3 19 rE Permission is hereby granted to Construct k or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. C n Fee - o' AN, BOARD OF HEALTH D.W.C. No. L, b -� Thursday, July 07, 1994 Lot # 26 Vest Way This is a new system for a new house. Bottom of bed inspection 7/1/94 Completed system inspected 7/7/94 This area is very rocky and the excavated material contained a large amount of broken rock. This material will be removed from the site and clean material from the Fox Hill subdivision will be imported to backfill the system. Gayton Osgood " • 'Jv 1 • 'J 51 AI• 'Y • '1„ INSTRUCTIONS: This form is used to verify that all. necessary approvals/permits from Boards and DepaxtZan s having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state lav, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: U N n M qn AIVC - y Phone LOCATION: Assessor's Map Number 1L y Parcel 3 Subdivision f)c i nem Lot(s) Street Vey"T St. Number Use Only********* ****** ******* RE CO MMEIDATIONS qF TOWN AGENTS: Date Approved Cdnservation Administrat Date Rejected • Comments 1 n own Planner Comments Healt agent, Comments Public Works - F -ire DePartr�ent Data Arnrcved Data Rejected Date Approved Data Rejected sewer/ water connections drivewayP e - - '- Received by Building Ins=eam=r Data DATE 7A3 Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER �r SUBSURFACE DISPOSAL DESIGN REVIEW jtj/ZT/-3 FEE , Z PERMIT # ; �2_/ DATE RECEIVED`72Z43 APPLICANT .IQ VAJ ASSESSOR'S MAP ADDRESS ENGINEER ADDRESS ./O1 /v �3 PLAN DATE `- CONDITIONS OF APPROVAL: APPROVED DISAPPROVED PARCEL # LOT # �o STREET REVISION DATE Al A/re� PLAN REVIEW CHECKLIST ADDRESS ENGINEER GENERAL 3 COPIES STAMP L-,-- LOCUS t/ NORTH ARROW L--' SCALE CONTOURS c/ PROFILE L,,-' SECTION/- BENCHMARK SOIL & PERC INFO ELEVATIONS / WETS. DISCLAIMER Z--' WELLS & WETLANDS (,� WATERSHED? -k DRIVEWAY ti/ (Eley) WATER LINE t,� FDN DRAIN L, SCH40 Q,---' TESTS CURRENT? /C11f^J' 9/' /999 SEPTIC TANK MIN 1500G 1/ .17 INVERT DROP GARB. GRINDER(+200% EDF) 25' TO CELLAR MANHOLE TO GRADE -' ELEV / GW__--, D -BOX SIZE # LINES FIRST 2' LEVEL STATEMENT INLET/ 7 8% - OUTLET/( 7 7 _ . /7 ( 2 " OR . 17 FT) TEE REQ' D? LEACHING / / / MIN 660 GPD?t/ RESERVE AREA v 4' FROM PRIMARY?Z/ 2% SLOPE 100' TO WETLANDS LZ' 100' TO WELLS L"'.' 4' TO S.H.GW /--� 35' TO FND & INTRCPTR DRAINS �G� 325' TO SURFACE H2O SUPP 4' PERM. SOIL BELOW FACILITY` MIN 12" COVER b", FILL?-/— (25' if above natural elev; 10'if Belo ) BREAKOUT MET? TRENCHES `% 8DPM6 8c�S MIN 660 gpd 1/ SLOPE (min .005 or 611/1001) ',� >3'COVER?-VENT,4/d SIDEWALL DIST. 2X EFF. W OR (MIN 6') ✓ IS RESERVE BETWEEN TRENCHES?IN FILL?--' MUST BE 10' MIN. / 4" PEA STONE? BOT I "I* X LDNG , + SIDE & ,�6 e X LDNGXd = TOT (5j- (L x W x #) (G/ft2) (DxLx2x#) (G/ft2) =ME DATE &/-3�Z7, Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL_ DESIGN REVIEW FEE PERMIT # APPLICANT Al 51 la ADO ADDRESS ENGINEER /ls0 P/�g54n�S� ADDRESS %� �/G A/ PLAN DATE I'l,3oaf. CONDITIONS OF APPROVAL: APPROVED DISAPPROVED -q- DATE RECEIVED ASSESSOR'S MAP PARCEL # LOT # STREET # es a REVISION DATE 1) -�rouAvDAriorV DRR !/V �«1/Ar�oN M�ssiNG 02) 51fou� �.i.Hr> of �.►-c.4V/3�"roN /=oiP Gi��.. <3) -D eT/�/L t bEP TN OG iA//N6 LcJ/�G G 4) (15F (- DUTG i 0-60-t' PLAN REVIEW CHECKLIST ADDRESS ,�.� ENGINEER �Q GENERAL 3 COPIES L/ STAMP C/ LOCUS t`/ SCALE ti CONTOURS-/----' PROFILE 2i SECTION Li- BENCHMARK `� ELEVATIONSy' SOIL & PERC INFO WETS. DISCLAIMER WELLS & WETLANDS (Je v, / WATERSHED?A10 DRIVEWAY ✓ WATER LINE DRAINS ✓ SCH40 f SLOPE SEPTIC TANK MIN 1500G. t/ 25' TO CELLAR rf D -BOX .17 INVERT DROP t/ MANHOLE TO GRADE_ GARB. GRINDER(+200% EDF) ELEV (-� GW Q,' SIZE Use b8 -S # LINES o2. FIRST 2' LEVEL STATEMENT INLET/6j , S� - OUTLET /� .3 = a2" OR .17 FT) LEACHING RESERVE AREA ✓ 4' FROM PRIMARY? 100' TO WETLANDSL,/"'-2% SLOPE <--' 1001 TO WELLS 325' TO SURFACE H2O SUPP`-"• 35' TO FND & INTRCPTR DRAINS 4' TO S.H.GW L--� 4' PERM. SOIL BELOW FACILITY 1,-� MIN 12" COVER L---- FILL? L-,""(25' if above natural elevation;(10'i below) TRENCHES MIN 660 gpd V SLOPE (min .005 or 6"/1001) t�-' >3' COVER? - VENT SIDEWALL DIST. 2X EFF. W OR D (MIN 61)t.,,� IS RESERVE BETWEEN TRENCHES? ✓ IN FILL?i/ MUST BE1 01 MIN. L---" 411 PEA STONE? BOT 140 4 X LDNG/ + SIDE X LDNG = TOT 61p7Z 7 6,,100 (L x W x #) (G/ft ) (DxLx2x#) 0► ON 0� � :co c3 : -ca � C J ;C O �•+_ CO O OZ 00 Ci2 •.� y , c .�.1 •� WS m o C Ck �O 16. o o. N C a: � cm C3 c Mo - co) 3 : dim o Q► CD CO) N d Of :1..5 • C � S W ` N R E N O .t: CL O: ��ZyL••, O cc mgr c� '� Z a Q i� y m C = m Ow o N �O, N �F- W C R �••, C •N O LO • N AR E O y+ •N'a O � v CD cm COD C• m� O� = R m y •O F- s o - r2 �I N c O •Y'a'm, W O J Q z cm CD U cm C ►'r+ � o o Z CL O D y C CD cm z o o co CD Ftjr COD CD m m W L- H r' o s �B: O i CE) 0 0 Q. lc U w G o w CO2 x C � J .CJ U c oCD CL w O V CO) 0-4 C C_ Q CO) Q CD z _ 0-4 W G a O O A v 7 p O C G cs O G > m= p y G CZ p C = c/) cf) � :co c3 : -ca � C J ;C O �•+_ CO O OZ 00 Ci2 •.� y , c .�.1 •� WS m o C Ck �O 16. o o. N C a: � cm C3 c Mo - co) 3 : dim o Q► CD CO) N d Of :1..5 • C � S W ` N R E N O .t: CL O: ��ZyL••, O cc mgr c� '� Z a Q i� y m C = m Ow o N �O, N �F- W C R �••, C •N O LO • N AR E O y+ •N'a O � v CD cm COD C• m� O� = R m y •O F- s o - r2 �I N c O •Y'a'm, W O J Q z cm CD U cm C ►'r+ � o o Z CL o m cm \ �� c W N CD o pt Z LAN O O' .. • 9: ::o wrn�p• yP.P x ..�•.� CD CD J Q z o E co 0 o o Z CL O D y C CD cm z o co CD COD CD m m W L- H r' o s �B: O i CE) 0 0 Q. O O Q. CL �a CO2 C ccc J .CJ COO Z c oCD CL z V CO) C C_ Q CO) Q CD z z f NORTN F p i SSAC14USEI Town of North Andover, Massachusetts BOARD OF HEALTH DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant 50y A 1%-1 Test No. Site Location A Reference Plans and Specs. klk, t -t ENGINEER Y Form No. 2 -i9 q3 DX Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. $' Pi Fee '. -IA1 CHAIR AN OA FPEALTM- Site System Permit No. Gea/ Town of North Andover, Massachusetts BOARD OF HEALTH APPLICATION FOR SITE TESTING/INSPECTION Form No. 1 19 Test/Inspection Date and Time J'- -4'- 1 "' r' CHAIRMAN, BOARD OF HEALTH Fee Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Applicant _ , t•.�-�` , . NAME ADDRESS TELEPHONE Site Location Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time J'- -4'- 1 "' r' CHAIRMAN, BOARD OF HEALTH Fee Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. � gORTq Q'4�l\O �� 1hrO o � A SSACHUSEt Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 2 DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant. X. Test No. Site Location��'o� Reference Plans and Specs Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. Fee V CHAIRMAN, BOARD OF HEALTH Site System Permit No.SL/ R, nor 2& MG 5 r0 Fly, 5Vs64leAll�r l�V ro GOi 2s f �SL)IA-) G ► Z2M �j w P � zA ZAN f0' (i 4 w