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HomeMy WebLinkAboutMiscellaneous - 218 LACY STREET 4/30/2018 (2)i North Andover Board of Assessors Public Access Parcel ID: 210/105.C-0029-0000.0 SKETCH Click on Sketch to Enlarge Community: North Andover PHOTO 0 Pi: c t u rieft Available Location: 218 LACY STREET Owner Name: ROSING, MARK H JANET A ROSING Owner Address: 218 LACY STREET City: NORTH ANDOVER State: MA ZIP: 01845 neighborhood: 6 - 6 Land Area: 1.8 acres :.Tse Code: 101- SNGL-FAM-RES Total Finished Area: 1818 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 406,200 388,500 Building Value: 208,200 199,800 Land Value: 198,000 188,700 (Market Land Value: 198,000 I Chapter Land Value: LATESTSALE Sale Price: 120,000 Sale Date: 12/01/1983 Arms Length Sale Code: Y -YES -VALID Grantor: MARKEY JOHN M Cert Doc: Book: 1753 Page: 172 Page 1 of 1 http://csc-ma.us/NandoverPubAcc/j sp/Home.j sp?Page=3 &Linkld=467164 9/7/2005 o � O N N � o o o a) ((6 41 rR a) m U C C U U am a (1) p w n U.S O O) CO N r r O CD H C r Y O m O R CC UVii-j y N O O H H 0 O 77a CQ G O O r N 3 m E E 0 U —I �I0 0 Z 00 00 c y.0 � O o T C O U .. .. W Ca 3 WR R Of � H QLL O O a0 Z L1i Ln o J IMA co N r- r- N uj m W O 0 z U 8 maU Q }a (7 U i = Op Q Q U M O Uooh Y n � o r w oR Q nQ p a c C i t5form4.doc• 06/03 Commonwealth of Massachusetts City/Town 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 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/ e Righ front of hou eft / Right rear of house, Left / right side of house, Left / Right side of bu�ilf , Left / Right front of building, Left / Right rear of building, Under deck Address ) L/ • a City/Town O`- State Ij 2. System Owner. Name Zip Code Address (if different from location) City/Town Telephone Number f B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s)ptic Tank ❑ Tight Tank 4. ❑ Other (describe): Effluent Tee Filter present? ❑ Yes Leo If. yes, was it cleaned? ❑ Yes ❑ No: 5. Condition of Sys A- 6. System Pumped By. - Nell y: Neil. Bateson Name Bateson Enterprises Inc - Company 7. Location where contents were disposed: RECEIVED F5821 cle License Number MAY TOWN OF NORTH ANDOVER HEALTH DEPARTMENT System Pumping Record • Page 1 of 1 Commonwealth of Massachuse{tts C ity/Town 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 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 Locations Rightont owe, 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 11 CltyirONRI •T 2. System Owner: Yo Name Address (if different from location) Cityrrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ Other (describe) Zip OR i a. H9 TOWN OF NORTH ANDOVER State Telephone Number Zip Code r � i 12. uantity Pumped: Date Gallons ElCesspool(s) Septic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes 5. Condition of System: 6. System Pumped By: Neil Bateson No If yes, was it cleaned? ❑ Yes ❑ No Name Bateson Enterprises Inc Company 7. Location where contents were disposed: qS. Lowell Waste Water O il F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts ��:NORTH City/Town of System Pumping Record MAY2 -2006 Form 4 TOWN OF ANDOVERHEALTP ARTN+ENT DEP has provided this form for use by local Boards of Health.. The ystem 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 1. SySte computer, use only the tab key to move your Address �tatZip cursor - do not�- use the return City/Town Code key. 2. . System Owner: Name Address (if different from location) City/Town . State's,,,,,,Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2- Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank- ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes BIG If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. SystePu/m d B 7:Name Vehicle License Number Company -- .7. Locatio where contents wer lsposed: Sig tire f uler Date http://www.mass.gov/dep/­Water/approvals/t5forins.htm#inspect t5form4.doc• 06103 system Pumping Record • Page t of 1 I.:ETTER OF TRANSMITTAL: North Andover Health Department 400 Osgood Street North Andover, MA 01815 978.688.9540 - Phone 978.688.8476 - Fax healthdentCa).townofnorthandover.com - E-mail www.townofnorthandover.com - Website F NQRT11 '9 0 .V%_a rb 1 0 p h � n s�gOq CNus��,t�s Page � of TO: t DATE: COMPANYi' �✓ i FROM: Pamela Delle hiaie, Health Department Assistant Phone: RE: ll Fax: / ` 5©� (✓� C We are sending you: OCopy of Letter OPlans These are transmitted as checked below: ➢ OasNo L;% ted %Requested Y OAsRequbW OForAppmvid OOther ill in below) ➢ OForRevtewandcotnment ➢ Osubmd OFor Your Use dish ➢ ORevuhn* copiesfor nPPmvid oW eSfor REMARKS: COPY TO: COPY TO: SIGNED: COPY TO: TRANSMISSION VERIFICATION REPORT TIME 1210212005 15:12 NAME HEALTH FAX 9786888476 TEL 9786888476 SER.# 000B4J120960 DATE DIME 12102 15:11 FAX NO./NAME 89784755101 DURATION 00:00:27 PAGE(S) 02 RESULT OK MODE STANDARD ECM Town of North Andover f NORTa Office of the Health Department o f Community Development and Services Division 400 OSGOOD STREET North Andover, Massachusetts 01845 �'s" Et`5 S^CRUS Susan Y. Sawyer, REHS/RS 978.688.9540 - Phone Public Health Director 978.688.8476 - Fax c�9Wq7rCAqff.IEP OE coMPEdANcE As of: September 21, 2005 This is to cert that the individual subsurface disposal system Repaired-1D-oo,-� Only (X) 6y 9l�like 12eiCCy At 218 Lacy Street NorthAndover, 9Y,4 01845 9fas been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Yfealth regulations. 'The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Susan T Sawyer, RUTS, R, � Public 9feafth Director BOARD OL: APpEAI.,S 688-9541 BUIL DING 688-95-15 CONS FRVATION 688-9530 HGALAT1 688-9540 I'I_ANNING 688-9535 jr) " TOWN OF NO SYSTEM PUMPING RECO DATE: I.i 9,-C)q NOV 19 2004 TOL-VN Or NORTH ANDOVER HEALTH DEPARTMENT (example: left front of house) La e DATE OF PUMPING: QUANTITY PUMPED CESSPOOL: NO YES S PTIC TANK: NO NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: CONTENTS TRANSFERRED TO: 6- GALLONS YES FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) TOWN OF KI - Aojo Q SYSTEM PUMPING RECORD DATE:p" SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) 05 c l L0.Ct DATE OF PUMPING: QUANTITY PUMPED : `O IQ GALLONS CESSPOOL: 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: C C, WELL DATABASE ADDRESS: 1P AGE OF WELL.- : W LLL DR1I_LR 0 01WELL PERLtiCT ,T: WELL LCCA-1ON: ' Vi= PE. -ET DATE: DEP7F OF WELL: TYPE: OF WELL. a_ DRb.b. DUC TYPEOFWA=BE.4RING ROCK_ WA=ANAL=DAT BIGgMANGANESE: Y ' N -- -- ffLGPiIPLON: Y N 0TCGNfAN'EiYANIS: 747 T r DAT_A-BASE 4 ADDRESS: "7 L AGE OF WE-i.L:ELL DRILLER: WELL PERMIT T: WILL LOCATION: WELL PERiMITDATE: DEPTH OF WL R i TYPE OF WELL: a . DRILLED b. u'g c! ulm<' OWV TYPE OF WATER BEARl TG ROCK: WATER A`+ALYSIS DATE: HIGH MANGANESE: Y N HIGH IRON: Y N OTHER CONTA:NMNANTS: Y N .� TOWN OF NORTH ANDOVER °t ►ORTh Office of COMMUNITY DEVELOPMENT AND SERVICES ,�: •'`p`��"Oo� HEALTH DEPARTMENT 400 OSGOOD STREET : �•: b` 'r NORTH ANDOVER, MASSACHUSETTS Ol 845ICIM s�c►wet'� Susan Y. Sawyer, REHS/RS 978.688.9540 —Phone Public Health Director 978.688.9542 —FAX SEPTIC SYSTEM CONSTRUCTION NOTES ADDRESS: Xl�ZmAP:_ LOT: INSTALLER: y DESIGNER: PLAN DATE: BOH APPROVAL DAT ON PLAN: DATE OF BED BOTTOM INSPECTION: / vvy DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SELECT SYSTEM TYPE GRAVITY DISTRIBUTION PRESSURE DISTRIBUTION PRESSURE DOSING HOLDING TANK ADVANCED TREATMENT OTHER COMPONENT SUMMARY FROM PLAN GALLON TANK = LOADING OF SEPTIC TANK = GALLON PUMP CHAMBER = LOADING OF PUMP CHAMBER = TYPE OF SAS = DIMENSIONS AND DETAILS OF SAS: SITE CONDITIONS ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Comments: Topography not appreciably altered Page 1 of 4 ,.f TOWN OF NORTH ANDOVER t NORTa Office of COMMUNITY DEVELOPMENT AND SERVICES V''�`� F: HEALTH DEPARTMENT 400 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845 8�awse Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.9542 — FAX SEPTIC TANK ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ gallon tank has been installed (H-10 or H-20) (monolithic or 2 piece) ❑ Water tightness of tank has been achieved (Visual or Vacuum Test or Water held for 24hrs) ❑ Inlet tee installed, under access port ❑ Outlet tee (gas baffle or effluent filter) installed, under access port ❑ inch cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ gallon Pump Chamber installed (H-10 or H-20) (monolithic or 2 piece) ❑ Inlet tee installed, under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off float working ❑ ,Drain hole in pressure line ❑ inch cover to within 6" of final grade installed over one access port ❑ Water tightness of tank has been achieved Visual or Vacuum Test or Water held for 24 hrs ❑ Hydraulic cement around inlet & outlet Comments: Page 2 of 4 .J TOWN OF NORTH ANDOVER of MGRTN q Office of COMMUNITY DEVELOPMENT AND SERVICES 7� HEALTH DEPARTMENT 400 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845 �'1g •'^O �r�' s%CFuse Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.9542 — FAX D -BOX Comments: SOIL ABSORPTION SYSTEM El d Comments: PRESSURE DISTRIBUTION El El Comments: Installed on stable stone base Inlet tee (if pumped or >0.087foot) Hydraulic cement around inlet & outlets Observed even distribution Speed levelers provided (not required) Bottom of SAS excavated down to soil layer, as provided on plan Size of SAS excavated as per plan Title 5 sand installed, if specified on plan 3/4-1 %2" double washed stone installed 1/8-1/2" (peastone) double washed stone installed laterals installed and ends connected to header (and vented if impervious material above) Orifices @ 5 & 7 o'clock positions Gravelless disposal systems: type, number and location as per plan Elevations of laterals installed as on approved plan 40 Mil HDPE barrier installed Retaining wall (boulder / concrete / timber/ block) Final cover as per plan inch manifold laterals installed with end sweeps size: material: Squirt test ft in height Equal distribution to all laterals orifice size inch as per plan Page 3 of 4 TOWN OF NORTH ANDOVER f NORTH Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 400 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 0 184 s�cNuse Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.9542 — FAX CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: 11Rated for exterior if placed outside Comments: SYSTEM ELEVATIONS Benchmark: Rod at Benchmark: Height of Instrument: INVERT ON DESIGN PLAN ELEV @ TOP OF PIPE INVERT ELEVATION Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN D -Box OUT Manifold Lateral 1 HIGH Lateral 1 LOW Lateral 2 HIGH Lateral 2 LOW Lateral 3 HIGH Lateral 3 LOW Lateral 4 HIGH Lateral 4 LOW Lateral 5 HIGH Lateral 5 LOW Page 4 of 4 Town oi NoA ZAnd . /r Health De�artment Date: 19 Location: / ?' / (Indicate Address, if Residential, or Aldine of Business) /0", Check #: 6 Tvve of Permit or License: (Circle) Animal $ Dumpster $- > Food Service - Type. $ );� Funeral Directors $ > Massage Establishment $ > Massage Practice $ > Offal (Septic) Hauler $ > Recreational Camp $- > SEP77C PERMITS: El Septic - Soil Testing L] Septic - Design Approval $ ca", S�tic Disposal Works Construction (DWC)$Td Lj Septic Disposal Works Installers (DWI) $ > Sun tanning $ > Swimming Pool $ > Tobacco $ > TrashlSolid Waste Hauler $- > Well Construction $ > OTHER. (Indicate) C Health Agent Initials 527 White - Applicant Yellow - Health Pink - Treasurer ` TOWN OF NORTH ANDOVER f NORTH Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT p 400 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845&S CH ACHU 978.688.9540 — Phone Susan Y. Sawyer, REHS/RS 978.688.9542 — FAX Public Health Director healthdept@townofnorthandover.com - e-mail www.townofnorthandover.com - website APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: / — 7— 2_ S LOCATION: Z,6 c Sr HOMEOWNER NAME: LICENSED INSTALLER NAME: M r G b PLEASE PRIft SIGNATURE: 4 CHECK ONE: FULL SYSTEM REPAIR: TELEPHONE# q%?— LI -1 5 I Z 3% COMPONENT REPAIR (indicate what parts): d - 4 0 x * NEW CONSTRUCTION: * If NEW CONSTRUCTION, please attach the Foundation As -Built Plan. ($250) ($125) $250.00 or $125 Fee Attached? Yes L No Project Manager Obligation From Attached? Yes ✓ / No Foundation As -Built? Floor Plans? Approval of Health Yes No s No Agent Dat l r J__f INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at -t / g LSC f (/� relative to the application of C'-7 •- 2005 dated for plans by N/141- and dated with revisions dated I understand the following obligations for management of this project: I . As the installer I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer I must call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item three shall be applicable. 3. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Tile 5 and the Board of Health Regulations may result in a $50.00 fine being levied against my company. a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As -built or verbal OK from engineer must be submitted to Board of Health, after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade — Installer must request inspection when all grading is complete. Does not have to be on site. 4. As the installer I understand that only I may perform the work (other than simple excavation) required to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation or suspension of my license to operate in the Town of North Andover; significant fines to all persons involved are also possible. 5. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached. b) Inspection of the sand and stone to be used. .c) Final inspection by Board of Health staff or consultant. d) Installation of tank, D -box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer e�w:' Date: q — 7 Disposal Works Constructi Pe # COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION SEP - 7 2005 `TOWN OF NORTH ANDOVER TITLE 5 i1 HEALTH DEPARTMENT OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSES SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: _218 Lacey Street_ North Andover_ Owner's Name: Mark Rosing_ Owner's Address: 218 Lacey Street _ North Andover, MA 01845_ Date of Inspection: _8/23/2005_ Name of Inspector: Neil J. Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, Ma. 01810_ Telephone Number: ( 978 ) 475-4786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of 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 X Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fai /1 Inspector's Signature: Date: _8/23/2005_ 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: _218 Lacey Street _ North Andover— Owner: Rosine Date of Inspection: 8/23/2005_ 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: X 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. D -Boz needs replaced. N 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: N 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: N 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: 218 Lacey Street_ _ North Andover— Owner: Rosing_ Date of Inspection: _8/23/2005_ 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 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 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: 218 Lacey Street _ _ North Andover_ Owner: Rosing_ Date of Inspection: 8/23/2005_ D. System Failure Criteria applicable to all systems: You mast 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. _ No Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ _No Any portion of the SAS, cesspool or privy is below high ground water elevation. _ _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _ _No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ _No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No(Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either "yes" or `Yno" 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 11 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: 218 Lacey Street _ _ North Andover _ Owner: Rosins Date of Inspection: _8/23/2005_ 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 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 _YesExisting information. _es_ _ _ 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: _218 Lacey Street –North Andover– Owner: Rosing_ Date of Inspection: _8/23/2005_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): _4_ Number of bedrooms (actual): _4_ DESIGN flow based on 310 CMR 15.203 _400_ Number of current residents: _2 Does residence have a garbage grinder (yes or no): No_ Is laundry on a separate sewage system (yes or no): _ No_ Laundry system inspected (yes or no): _ Seasonal use: (yes or no): _No Water meter reading: _On well water, 100 ft from septic system_ Sump pump (yes or no): No_ Last date of occupancy: _Current COMMERCIALANDUSTRIAL Type of establishment: _ _ Design flow (based on 310 CMR 15.203): _gpd Basis of design flow (seats/persons/sgft,etc.): — Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): — Non -sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: _ OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: Pumped last year, owner _ Was system pumped as part of the inspection (yes or no): No_ If yes, volume pumped: , gallons -- How was quantity pumped determined? Reason for pumping: _ TYPE OF SYSTEM X Septic tank, distribution lox, soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ hmovative/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: 27 years old, 7/17/1978, 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: _218 Lacey Street_ _ Andover _ Owner: Rosine Date of Inspection: 8/23/2005_ BUILDING SEWER _ X _ (locate on site plan) Depth below grade: _24" Materials of construction: _X_ cast iron _40 PVC _other Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.) no leaks visible SEPTIC TANKS: X _4" Cast iron thru wall, 3" PVC in house, 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 '_Sludge depth —1" _ Distance from top of sludge to bottom of outlet tee or baffle: 26"_ 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: 20"_ How were dimensions determined: _Tape Measure _ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc. _ Inlet cover under walk. 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: 218 Lacey Street _ North Andover_ Owner: Rosine Date of Inspection: 8/23/2005_ 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 BOXES: 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 -Bog level & distribution equal. D -box cover broken. D -box has corrosion holes. Evidence of carryover. _ 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: _218 Lacey Street_ _ North Andover _ Owner: Rosin Date of Inspection: 8/23/2005_ SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: leaching tranches, number, length: X leaching field, number, dimensions: —1 field 20 x 451 _ overflow cesspool, number: innovativetalternative 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 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: _218 Lacey Street _ North Andover — Owner: Rosing _ Date of Inspection: _8/23/2005_ 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 =18'9" A to D -Box = 28'7" B to Tank = 2115" B to D -Box = 35' Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 218 Lacey Street _ _ North Andover — Owner: Rosma Date of Inspection: 8/23/2005_ SPIE 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: _5/18/1977 Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: _ Checked with local excavators, installers- (attach documentation) Accessed USGS database -explain: _ You must describe how you established the high ground water elevation: As per design plan_ 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: 218 Lacey Street, North Andover Owner: Rosing Date of Inspection: 8/23/2005 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. PJ.Bateson Bateson Enterprises; Inc. aA-& TO: F ROM: NORTH ANDOVER, MASS --7//7 19 '7c --T BOARD OF HEALTH DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at �4 Z /-I C >� _51A— - North Andover, Mass. SITE LOCATION The grades and construction are as specified in my p 19 ications dated 10-3 SaVtarian WJMAW4�1 Im As //V CR6 44 Q ll/ i ZI Z L V4 T!G NS Ct o 2, 7- /Qo NORTH ANDOVER BOARD OF HEALTH INSTALLATION CHECK LIST APP13QVED DATE DISAPPROVED DATE hXCAVATION OK REASO � 7 � � FAIL •M 1. Dist ce To: etlands Drains Well 2.v -'-Water Line Location 3.' No PVC Pipe 4. Septic Tank Tees - Length & To Clean Out Covers Cement Pipe to Tank - On Both Sides of Tank 5. Distribution Box Cover & Box - No Cracks All Lines Flowing Equal Amounts No Back Flow Leach Field or Trench Dimensions 212% wd Stone Depth Capped Ends Clean Double Washed Stone 7. Leach Pits Dimensions Stone Depth Splash Pads Tees Cement Pipe to Pit -.Both Sides Clean Double Washed Stone No Garbage Disposal Final Grading Inspection IO. Barracading Cove_ System 1 guilt Submitted Lo -Location Dimensions of System ocation with Regard to Pere Test Elevations Water Table NORTH ANDOVER SUBSURFACE DISPOSAL SYSTEM CHECK LIST I. General Information Reg. 2.5 The su itted plan must show as a minimum: (a e lot to be served (b) to ation and dimensions of the system (including serve area) (c) sign calculations (d)/calculations showing required leaching area (e)/existing and proposed contours .�j(f)/ to ation and log of deep observation holes - istance to ties A�'( gY location and results of percolation tests - distance to ties h) location of any wet areas within 100' of the sewage disposal system or disclaimer i) surface and subsurface drains within 100' of the sewagee disposal systemstem or disclaimer j) location of any drainage easements within 100' of the sewage disposal system or disclaimer k) known sources of water supply within 200' of tl),__ sewage disposal system or disclaimer ` (1) 1 cation of any proposed well to serve the lot (m) /`location of water lines on the property (n) maximum ground water elevation in the area of t� sewage disposal system (o) r'"a profile of the system P) no PVC is to be used in construction (q ),, - ocation of benchmark (r) *plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans. O�. p.Z7.77 II. Zarbage Disposers ( � III. Septic Tanks - 1 of flo (a )' C -a c i t i e s 5fl� W Reg. 6.1 ` Reg. 6.7 (b),ester table Reg. Re . 6.8 (c)� es Reg 6.9 ( d) / Depth of tees Reg. 6.12 ( e ) -cess / �ryr�"�' o ' � Reg. 6.18 ( f ) Pumping jtra,G) W /Cleanout IV. Pumps VIP - Reg. 9.1 (a) Approval � Q . 9.6 (b) Stand-by power '"` . ,,,,,Reg. L, 2-,51© •. V. Reg. 10.2' Reg. 10.4 VI. Reg. 11.2 Reg. 11.4 Reg. 11.10 Reg. 11.11 Distribution Boxes (a)ope greater than 0.08 (b) f ump Leachina Pits Leaching pits are preferred where the installation is possible. (a) Calculations of leaching area (minimum 500 S.F.) (b) Spacing (c) Surface drainage 2% (d) Cover material VII. Leaching Fields Reg. 15.1 (a) /Greater than 20 minutes/inch Reg. 15.1 (b) e<rea (minimum 900 S.F.) Reg. 15.4 (cL--Construction of field Reg. 15.8) Surface drainage 2% IX. Downhill -Slope (a) Slope y/x = (to be shown) -,' (b) y/x X 150 = (to be shown) y • ti v C 3 q- !, i i i 1 + r _ Y v C 3 q- !, 1 S X7 -40. a L L - �► :1 ; t�► • �C It NN j , a < i i i r _ Y 1 0 1 r 1 S X7 -40. a L L - �► :1 ; t�► • �C It NN j , a < 12" 4"' MSN• �n � (Yin —� all 410- 4 Q Q � n r 44 1� A� 12" 4"' MSN• �n w 1 410- r w r 44 1� r w C\' Commonwealth of Massachusetts City/Town of RECRIVED System Pumping Record Form 4- JUN 1 6 2008 TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. Otht& NT ut the . information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. Syste(Tl LOCA n' /7 ,� `/�1<::� forms on the computer, use only the tab key Address to move your cursor - do not Cityfrown Ste Zip Code use the return key 2 System Owner: Name ISI Address (if different from location) City/Town St--art�r J � �Zip-Code Telephone Number B. Pumping Record / 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s)eptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: Y ` O k2'� 6. System Pumped By: Name Vehicle License Number Company 7. Location Date t5forrn4.doc- 06/03 System Pumping Record a Page 1 of 1