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Home My WebLink AboutMiscellaneous - 210 CANDLESTICK ROAD 4/30/2018Commonwealth of Massachusetts City/Town of =2�Nfl System Pumping Record Form 4 41M SV 6�`'•v DEP has provided this form for use by local Boards of Health. Oth T ii% e information must be substantially the same as that provided here. Ih k 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 hou �ui left side of house, right side of house, Left rear of house, right rear of house, leftt rear of building, under deck. �)- i0 RA �J City/Town 2. System Owner: Name Address (if different from location) City/Town State Zip Code State (`Zip Code Telephone Number \ �cjJ/� 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 No 5. Conditn f System: 6. System Pumped By: If yes, was it cleaned? ❑ Yes ❑ No Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Locati n where contents were disposed: U&I t5form4.doc• 06/03 Date System Pumping Record • Page 1 of 1 C � W r 4855 Of �10RT1� 1N Town of North Andover ` HEALTH DEPARTMENT $3ACMUStS o, CHECK #: .�� DATE: ` LOCATION: H/O NAME: CONTRACTOR NAM TXpe 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 Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑Titl 5Inspector $� itle 5 Report $ ❑ Other. (Indicate) $ `He lth Agent Initials White - Applicant Yellow - Health Pink - Treasurer 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 refum key. VQ F2n�All Commonwealth of Massachusetts Title 5 Official Inspection Fo Subsurface Sewage Disposal System Form - Not for Voluntary) 210 Candlestick Road Property Address Brian Eddy Owner's Name JUL 14 2010 TOWN OF NORTH ANDOVER North Andover MA 01845 7/1/2010 Citylrown 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. A. General Information 1. Inspector: CrV4 Neil J. Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover City/rown 978-475-4786 Telephone Number B. Certification Ma State SI15 License Number 01810 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 7/1/2010 Inspect s ignature 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 210 Candlestick Road Property Address Brian Eddy Owner's Name North Andover MA 01845 7/1/2010 Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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 - 09/08 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 2 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 210 Candlestick Road Property Address Brian Eddy Owner's Name North Andover Cityrrown B. Certification (cont.) B) System Conditionally Passes (cont.): MA 01845 State Zip Code 7/1/2010 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 09106 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 210 Candlestick Road Property Address Brian Eddy Owner's Name North Andover Cityrrown B. Certification (cont.) MA 01845 State Zip Code 7/1/2010 Date of Inspection 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 Y2 day flow t5ins - 09/08 Title 5 official Inspection Form: Subsurface Sewane Disnosal Svstem - Pane d 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 • 09108 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 210 Candlestick Road Property Address Brian Eddy Owner information is Owner's Name required for North Andover MA, 01845 7/1/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. El ® 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 • 09108 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 210 Candlestick Road Property Address Brian Eddy Owner Owner's Name information is required for North Andover MA 01845 7/1/2010 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): t5ins - 09/08 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 M 210 Candlestick Road Owner information is required for every page. Property Address Brian Eddy Owner's Name North Andover City/Town D. System Information Description: Number of current residents: MA 01845 State Zip Code 7/1/2010 Date of Inspection 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) 1 ® Yes ❑ No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ® No Yes ❑ Yes ® No Current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 09/08 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 ' 210 Candlestick Road Owner information is required for every page. Property Address Brian Eddy Owner's Name North Andover City/Town D. System Information (cont.) MA 01845 7/1/2010 State Zip Code Date of Inspection Last date of occupancy/use: Date Other (describe below): General Information Pumping Records: Source of information: Pumped 2009, owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Measured tank Reason for pumping: Inspect tank & tees Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins - 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 210 Candlestick Road Owner information is required for every page. Property Address Brian Eddy Owner's Name North Andover MA 01845 7/1/2010 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 23 years old, 11/20/1987, as built plan Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 3 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" PVC thru wall, 3" PVC in house. no leaks visible. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 2 feet ❑ Yes ® No ❑ 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'x5'x4' Sludge depth: 1" ❑ Yes ❑ No t5ins - 09/08 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 210 Candlestick Road Property Address Brian Eddy Owner Owner's Name information is required for North Andover MA 01845 7/1/2010 every page. City/Town t5ins - 09/08 D. System Information (cont.) Septic Tank (cont.) State Zip Code Date of Inspection Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? 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 Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17 feet ❑ polyethylene ❑ other (explain): Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 210 Candlestick Road Property Address Brian Eddy Owner's Name North Andover MA 01845 7/1/2010 City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes. ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Owner information is required for every page. I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 210 Candlestick Road Property Address Brian Eddy Owner's Name North Andover Cityrrown D. System Information (cont.) MA 01845 7/1/2010 State Zip Code Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D -box level & distibution equal. No evidence 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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 210 Candlestick Road Owner information is required for every page. t5ins • 09/08 Property Address Brian Eddy Owner's Name North Andover Cityrrown D. System Information (cont.) Type: MA 01845 State Zip Cod 7/11/2010 Date of Inspection ® leaching pits 3 number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions.- imensions:❑ El 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. Camera inside of pit gallery thru outlet in d - box. No liquid to invert. 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 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 210 Candlestick Road Property Address Brian Eddy Owner's Name North Andover Cityrrown MA 01845 State Zip Code 7/1/2010 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 • 09/08 title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Owner information is required for every page. t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 210 Candlestick Road Property Address Brian Eddy Owner's Name North Andover MA 01845 7/1/2010 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 t Commonwealth of Massachusetts 1.0 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 210 Candlestick Road Owner information is required for every page. t5ins • 09108 Property Address Brian Eddy Owner's Name North Andover Cityrrown D. System Information (cont.) MA 01845 State Zip Code 7/1/2010 Date of Inspection 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: 4/11/1986 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 Dit data on desin Dlan Before Filing this Inspection Report, please see Report Completeness Checklist on next page. Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17 s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �•''r 210 Candlestick Road Property Address Brian Eddy Owner Owners Name information is required for North Andover MA 01845 7/1/2010 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 Commonwealth of Massachusetts. CitylTown of System Pumping Record Form 4 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 tQ determine the form they use. The System Pumping Record must be submitted to the local Board of Health or-e'r approving authority. A. Facility Information 1. System Location: Left side of house, Right side of house, Left front of house,i ht front of hour Left rear of house, Right rear of house. Left rear of building. Right rear of building. Address Cityrrown State Zip Code 2. System Owner. r--, Name Address (if different from location) Cityrrown State Zip Code B. Pumping Record '1-�—(0 Date 1. Date of Pumping 3. Type of system: ❑ Cesspool(s) ❑ Other (describe): Telephone Number — 2. Quantity Pumped: Gallons eptic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes 0' V>�o If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatio contents were disposed: G.L.S. Jowell Waste Water Date t5form4.doc• 06103 System Pumping Record • Page 1 of 1 4 0 Class Size Total FY Summary Record Card generated on 6/25/2010 1:20:47 PM by Lisa Evans Town of North Andover Tax Map # 210-106.A-0197-0000.0 Parcel Id 17341 210 CANDLESTICK ROAD EDDY, BRIAN 210 CANDLESTICK ROAD N. ANDOVER, MA 01845 101 Single Family 1.02 Acres 2010 UB Mailina Index Property Type Name/Address Type Loan Number Active/Inact, From EDDY, BRIAN Payor 210 CANDLESTICK ROAD N. ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 17634.0 - 210 CANDLESTICK ROAD Last Billing Date 4/2/2010 3170304 1 03 Cycle 03 Active UB Services Maint. Account No. 3170304 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 41.80 /1 UB Meter Maintenance Account No. 3170304 Serial No Status Location Brand Type 35078108 a Active ERT HH b Badger w Water Date Reading Code Consumption Posted Date 6/7/2010 136 a Actual 17 3/9/2010 119 a Actual 11 4/14/2010 12/8/2009 108 a Actual 20 1/12/2010 9/9/2009 88 a Actual 55 10/15/2009 6/8/2009 33 a Actual 10 7/20/2009 3/13/2009 23 a Actual 16 4/29/2009 12/9/2008 7 a Actual 7 1/20/2009 9/22/2008 0 n New Meter 0 10/10/2008 9/22/2008 3013 r Replacement 48 10/10/2008 6/6/2008 2965 m Manual estimate 10 7/16/2008 MSG 3/7/2008 2955 a Actual 9 4/11/2008 12/11/2007 2946 m Manual estimate 20 1/22/2008 MSG 9/6/2007 2926 a Actual 49 10/12/2007 6/18/2007 2877 a Actual 13 7/20/2007 3/15/2007 2864 m Manual estimate 20 4/16/2007 12/8/2006 2844 a Actual 12 1/19/2007 Trouble Code:09 9/12/2006 2832 a Actual 45 10/20/2006 6/14/2006 2787 a Actual 27 7/10/2006 3/8/2006 2760 a Actual 12 4/17/2006 Trouble Code:03 12/21/2005 2748 a Actual 25 1/17/2006 Trouble Code:09 9/21/2005 2723 a Actual 75 10/14/2005 Size 0.63 0.63 Page 1 1 1 Residential Commonwealth of Massachusetts City/Town of System Pumping Record . Form 4 RECEIVED NOV 0 4 2013 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use= by local Boards of Health. Other forms may be Lsed, 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 i^ ht front of hou , 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/Town State Zip Code 2. System Owner. - \ V Name Address (if different from location) CitylTownZi Code Telephone Number f _ l B. Pumping Record 2 1. Date of Pumping Date . 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 gn oSystem: � t 6. System Pumped By: N Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc- Company ncCompany contents were disposed: ttt t--3 t5fomm4.doc• 06/03 System Pumping Record • Page 1 of 1 IL Commonwealth of Massachusetts City/Town of . System Pumping Record Form 4 M DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Leftir�nt-4fbQ , 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 t O C -A Cityrrown State 2. System Owner. OA Name Address (if different from location) City/rown Zip Code RECEIVED AUG 14 2012 TOWN OF NORTH ANDOVER Telephone Number B. Pumping Record �/�✓ a- 1. Date of Pumping Date 2. Quantity Pumped 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Other (describe): //I (S�. Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes [I No If yes, was it cleaned? ❑ Yes ❑ No 5. Conditipn gfoy,ftuLk*: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Loca ' where contents were disposed: �*01 Lowell Waste Water Q1. F5821 Vehicle License Number Date [6) - ['�- t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts 'ity/town of Alx.* &d&vz4 S ste "'u ping Record Fac�fit�7Info- nation: System Location: Address City/Town System Owner: Name: Adress (if different. from location of pump) State City/Town State L ping Rccob d EIWED ZON4 0� NORTH ANDOVER .�I DEPARTMENT ,dip Code Zip Code T elephone Number Tate of bumping '/� Quantity Pumped �� d[� gallons Tyle of System Y Septic Tank Crease Trap other (;what) Systern Pumped by: 0 4 L Company: ROOTER -MAN 46 Portland Street Lawrence, MA 01843 Location where contents were disposed: .ezL,6D Signature of Hauler3 Date Commonwealth of Massachusetts City/Town of NORTH ANDOVER, MASSACHUSETTS o System Pumping in9 Record r` Form 4 4 vv DEP has provided this form for use by local Boards of Health. T e Sy ! PumYi- eco d must li be submitted to the local Board of Health or other approving aut ority. A. Facility Information SEP 0 8 2009 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. � rab 1. System Location: Address nto City/Town 2. System Owner: A n Name Aooress (it different from location) City/Town B. Pumping, Record 1. Date of Pumping TOWN OF NORTH ANDOVER HEALTH DEPARTMENT State State Telephone Number Zip Code Zip Code dffIL30Da2• Quantity Pumped: Gallons 3. Type of system: ❑ ' Cesspool(s) NOOOOSreptic Tank ❑ Tight Tank 1 ❑ 'Other (describe): 4. Effluent Tee Filter present? Vo'rYes ❑ No 5. Condition of System:. If yes, was it cleaned? WYes ❑ No 6. System Pumped By: &C� / U. On) r Vehicle License Number a Company 7. Location where contents were disposed: Signature of Hauler http://www. mass. gov/dep/water/approvals/t5forms, htm#inspect Date. t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 ------------- T, RECEI d Lj O C T 0 7 2005 TOWN OF NORTH ANDOVE1 I OWN U� h'UY 11i ,�h'Lh,.! HEALTH DEPAFT,�iEN UA it 91*6 SY3T N -j P(jMp1NU RFC,OkI... iYSr>rM p NQR DDR.Ess ____�_�_ �l'-- _ t .. ,� . is ti7 C 2 �.._ QLJANTITY PUMpCC rid -- �'t33PCX.�L; N`7._ .... Yt3.. ''�A rVK� G►' 3bRYli_` xUv'rlNc Uti�ti► Af'1UN , flITIUN f v1..:. VU t:O7 LBAC"eLrY, KOM ��C838IY6 501.lps .T.. FLOODEDp KvNaA�'F, $OL iD CARA YO YFR O1"t•fER E X P L ,� I N �'UM&IhNT�. ut�I erN I'� rx.�rr,�r�xrL�u TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM OWNER & ADDRESS A/-�� SYSTEM LOCATION (example: left front of house) 40f)-� (9 h o C - DATE OF PUMPING: 0 QUANTITY PUMPED /`50o GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE 2 EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: Anod Ve - COMMENTS: CONTENTS TRANSFERRED TO: S) • rn c� ,• M� U Q rt CD 71 rb Q Q n O En Q. Z3 6 _, E Z v C rt p J n v 0 n o CL) rt n. o D D p -� N i r� 0 m a 0 rf 3 -9441 3 3 Q rt CD 71 rb Q Q n O En Q. Z3 6 _, E PATRICK J. DONOVAN ASSOCIATES, INC. elaim anal ,Coss Ajustments P. 0. BOX 110 WAKEFIELD, MA 01880 TEL. (781) 245.5540 - FAX (781) 245.7016 January 29, 2001 Building Commissioner City or Town Hall N. Andover, Ma. 01845 Insured Property Address Insurer Policy Number Type of Loss Date of Loss Our File # Brian & Susan Eddy 210 Candlestick R., N. Andover Cambridge Mutual Fire Ins. Co. HP2016627 Water Damage 01/03/01 WAP31774 Claim has been made involving loss, damage or destruction of the above -captioned property, which may either exceed $1,000 or cause Mass: Gen. Laws, Chapter 143, Section 6, to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 313 is appropriate, please direct it to the attention of the writer and include a reference to the captioned Insured, location, policy number, dateof loss and file number. On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. Vern Laws, Adjuster VL/mn ww ASSOCIATION OF INDDPDNDDIT I1SURANCD ADJDSTDR4 of Massuhusexts ., f � �. �f� f a� .� ;.�. s ., t � r . � f .' i 1 i t .. I �' I i i I i (�4R� of H�iF-I Noi�TN /AJPOOe �I Ma. CoNPITlOAJ5 = DI5APPRovED R�4SoNS wAf6i{ SUNFt7 �jpP�� Cq�J I_ ,�Nucz A rb Wnl ❑ wal- 5EPrI G 'SY S TEAA 1OES1 lo/ e APNi OuiNG /ur�lo�iTY D scp��(c SYSTEM I.J S 1A U dTio" L 7�G/�V/JT�cv� )�.�c; �EG ► iotil D/Jr� eD WiC Q E/11SS C] F4IL- FINAL I �1SPFGTIon� APPROVED �/STC i c-w� �6Pi'r�r�v�tiG �4vr�tor��ry �6E �0° 13 FAD RU Z X15° $Ai7 — �4D1�IT�p�A(� I�Sr`�i )ONS X11=-,o►�Y) DISI\ Pt'KovEV )�CA'30 NS FV AL APPNDVAL Dare- O,o��L APPi3al(n)6 I U%IIIIL.' 1111V1111QL1V11. System Location: acv es�� Address City/Town State Zip Code System Owner: Name: i Adress (if different from location of pump) City/Town State ZipCode q�� q ! S--"..;?" `1 �" (P Telephone Number Pumping Record Date of Pumping d�� 10 Quantity Pumped W gallons Type of System—K-Septic Tank Grease Trap Other (what) System Pumped by:_ Q Company: ROOTER -MAN 12 East Dracut Rd., Methuen, MA 01844 Location where contents were disposed: Signature of Hauler Date/J-5 /C