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Miscellaneous - 220 CANDLESTICK ROAD 4/30/2018 (2)
220 CANDLESTICK ROAD iad 210l106.A-0198-0000.0 l y i I I I I I I� I -- L1 Commonwealth of Massachusetts �L'��► Title 5 Official Inspection Form To JU/V '9?o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments N 01P RT ,, -' ��FP ygNOp M 220 Candlestick Road Property Address Peter Schofield Owner Owner's Name information is required for every North Andover MA 01845 6/8/2017 page. City/Town 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. Immo out forms A. General Information filling out forms W � � on the computer, use only the tab 1. Inspector: key to move your cursor-do not Neil James Bateson use the return Name of Inspector key. Bateson Enterprises Inc. Company Name VQ 111 Argilla Road j Company Address Andover MA 01810 Cityrrown State Zip Code 978-475-4786 SI-15 Telephone Number License Number I i B. Certification I certify that I have pr osal system at this address and that the information reported L L as of the time of the inspection. The inspection was performed based L , �'. proper function and maintenance of on site sewage disposal system, n .aspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) I ® Passes ;onditionally Passes ❑ Fails ❑ N eds Further Evaluatl,l by the Local Approving Authority 6/8/2017 Insp ctorsignature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 . 7 � L1 Commonwealth of Massachusetts �'�L'��► Title 5 Official Inspection Form ro �/ y�,o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments k � �Rry 1J 220 Candlestick Road �FpgR �O M Property Address Q � Peter Schofield Owner Owner's Name information is North Andover MA 01845 6/8/2017 required for every page. City/Town 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 A. General Information ',,, filling out formsA on the computer, 5ca�z�o 55 use only the tab 1. Inspector: key to move your cursor-do not Neil James Bateson use the return Name of Inspector key. Bateson Enterprises Inc. �y Company Name 111 Argilla Road Company Address renin Andover MA 01810 City/Town State Zip Code 978-475-4786 SI-15 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 ❑ N eds Further Evaluation by the Local Approving Authority / 6/8/2017 Insp ctor'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 has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 . A Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 220 Candlestick Road Property Address Peter Schofield Owner Owners Name information is North Andover MA 01845 6/8/2017 required for every page. Cityrrown 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: i After permit from B.O.H., install new outlet tee with gas baffle in septic tank, septic system now passes Title 5 inspection. 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): i t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 0-c��•� o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 220 Candlestick Road Property Address 0 Peter Schofield Owner Owner's Name information is required for every North Andover MA 01845 5/23/2017 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any j way. Please see completeness checklist at the end of the form. I Important:When A. General Information filling out forms on the computer, © �+ use only the tab 1. Inspector: �� D key to move your ��- cursor-do not Neil James Bateson use the return key. Name of Inspector Bateson Enterprises Inc. 4:1 Company Name 111 Argllla Road Company Address Andover MA 01810 Cityrrown State Zip Code 978-475-4786 SI-15 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 5/23/2017 Inspector s Signat Date j The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use. at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 . " }•�y�"w �� � � ���_-� r� -�`����i Commonwealth of Massachusetts ' Inspection Form U Tale 5 Official InspSubsurface Sewage Disposal System Form -Not for Voluntary Assessments 220 Candlestick Road Property Address Peter Schofield Owner Owner's Name information is required for every North Andover MA 01845 5/23/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ® N ❑ ND(Explain below): I I I i t5ins.doc•rev.6116 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 220 Candlestick Road Property Address Peter Schofield Owner Owner's Name information is North Andover MA 01845 5/23/2017 required for every page City[Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below): I I ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The I 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: I ❑ 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 l5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pdge 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 220 Candlestick Road Property Address Peter Schofield Owner Owner's Name information is required for every North Andover MA 01845 5/23/2017 page. Cityfrown 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: Outlet Tee in Septic Tank Needs To Be Replaced I 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.doc•rev.6/16 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Uz Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 220 Candlestick Road Property Address Peter Schofield Owner Owner's Name information is North Andover MA 01845 5/23/2017 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) i Yes No El 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 j 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. El ® 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. I i 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 j I ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 • i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 220 Candlestick Road Property Address Peter Schofield Owner Owner's Name information is North Andover MA 01845 5/23/2017 required for 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 23 ❑ 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? ® E] 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): 600 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i 220 Candlestick Road Property Address Peter Schofield Owner Owner's Name information is North Andover MA 01845 5/23/2017 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: I Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No ! Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) El Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No i Water meter readings, if available(last 2 years usage(gpd)): Yes Detail: Sump pump? ❑ Yes ® No Current Last date of occupancy: Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No i Water meter readings, if available: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 k i Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form- Not for Voluntary Assessments j 220 Candlestick Road Property Address Peter Schofield Owner Owner's Name information is North Andover MA 01845 5/23/2017 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) I Last date of occupancy/use: Date Other(describe below): i General Information i Pumping Records: i Source of information: Pumped last year, 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 i ❑ 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 I ❑ Tight tank. Attach a copy of the DEP approval. ® Other(describe): I Septic Tank To Gallery Of Three Leach Pits t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 I . I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,•�''� 220 Candlestick Road Property Address Peter Schofield Owner Owner's Name information is required for every North Andover MA 01845 5/23/2017 page. CitylTown State Zip Code Date of Inspection D. System Information cont. Approximate age of all components, date installed (if known) and source of information: 29 Years old, 10/13/1988, as built plan. Were sewage odors detected when arriving at the site? ❑ Yes ® No I Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" PVC through wall to septic tank. 3" PVc in house, no leaks visible Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) I If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10' x 5'x 4' Sludge depth: 2" t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I it Commonwealth of Massachusetts i G . Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 220 Candlestick Road Property Address I Peter Schofield Owner Owners Name information is North Andover MA 01845 5/23/2017 required for every page. CitylTown 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 N/A 1" Scum thickness Distance from top of scum to top of outlet tee or baffle N/A= Outlet tee corroded off Distance from bottom of scum to bottom of outlet tee or baffle N/A How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet tee ok. Outlet tee corroded off, needs to be replaced. Depth of liquid at outlet invert. No evidence of leakage. Center cover has access to grade. i i Grease Trap(locate on site plan): Depth below grade: feet Material of construction: I ❑ 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: Date I t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Paga 10 of 17 ` Commonwealth of Massachusetts = v, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 220 Candlestick Road M Property Address Peter Schofield Owner Owner's Name information is required for every North Andover MA 01845 5/23/2017 page. 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.): i I 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 I 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 i t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments eco M 220 Candlestick Road Property Address Peter Schofield Owner Owner's Name information is required for every North Andover MA 01845 5/23/2017 page. City/Town State Zip Code Date of Inspection I D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): Pump Chamber(locate on site plan): Pumps in working order: El Yes ❑ No* i Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): i i I *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: l5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 k i Commonwealth of Massachusetts .o2 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 220 Candlestick Road Property Address Peter Schofield Owner Owner's Name information is 1 / 17 required for every North Andover MA 0 84 5 5/23 20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: Gallery of 3 pits ® leaching pits number: on bed of stone ❑ leaching chambers number: ❑ leaching galleries number: 1 ❑ leaching trenches number, length: ❑ 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. Camera inside of pits through outlet in septic tank, no liquid to inverts. i 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 scum aye Depth f m l r p i Dimensions of cesspool 4 Materials of construction i Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 220 Candlestick Road Property Address j Peter Schofield Owner Owner's Name information is North Andover MA 01845 5/23/2017 required for every State 2i Code Date of Ins ection page. City/Town P P D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i i I Privy(locate on site plan): i Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I i M t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pade 14 of 17 �I i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I 220 Candlestick Road Property Address Peter Schofield Owner Owner's Name information is MA 01845 5/23!2017 required for every North Andover page. 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 i O ` mac I Et' i I C) I t t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form • Subsurface Sewage Disposal System Form Not for Voluntary Assessments 220 Candlestick Road Property Address Peter Schofield Owner Owner's Name information is required for every North Andover MA 01845 5/23/2017 j page. City/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 all methods used to determine.the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date 986 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: As per test pit data on design plan f i I Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 220 Candlestick Road Property Address Peter Schofield Owner Owner's Name information is required for every North Andover MA 01845 5/23/2017 page. Cityfrown 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 i t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts Ci fY/Town of . System Pumping-Record Form 4 DEP has provided this form for use-by local Boards of Health. Other forms maybe 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 Locatio igh Olt of ii us 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 I Address D-3-0 City/rown State - Zip Code 2. System Owner. ek Name' Address(f different from location) Citylrown State, Zip Coe -7� �4- - t Telephone Number .B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons y 3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ Na 5. Condition of Syste 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc I Company 7. Locat!Dmwhere contents-were disposed: _ Lowell Waste Water 14 Y&O Sign a lHaulmU Date F t5form4.doo•06/03 System Pumping Record•Page 1 of 1 Summary Record Card generated on 5/16/2017 2:40:08 PM by Tara Hurley Page 1 Town of North Andover ° Tax Map # 210-106.A-0198-0000.0 Parcel Id 17342 j 220 CANDLESTICK ROAD SCHOFIELD, PETER K Since Jan 2003 LANA L BACHMAN 220 CANDLESTICK ROAD NORTH ANDOVER, MA f 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.07 Acres FY 2017 I UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until SCHOFIELD, PETER Payor 220 CANDLESTICK ROAD N.ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 17684.0-220 CANDLESTICK ROAD Last Billing Date 4/6/2017 3170354 03 Cycle 03 Active UB Services Maint. Account No.3170354 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 81.55 /1 UB Meter Maintenance Account No.3170354 Serial No Status Location Brand Type Size YTD Cons 36388100 a Active ERT HH b Badger w Water 0.63 0.63 2738 Date Reading Code Consumption Posted Date Variance 3/8/2017 2722 a Actual 21 4/12/2017 -72% 12/9/2016 2701 a Actual 78 1/23/2017 -73% 9/9/2016 2623 a Actual 280 10/24/2016 251% 6/13/2016 2343 a Actual 87 8/2/2016 353% 3/9/2016 2256 a Actual 18 4/22/2016 -62% 12/10/2015 2238 aActual 48 1/20/2016 -80% 9/9/2015 2190 a Actual 241 10/16/2015 48% 6/10/2015 1949 a Actual 163 7/24/2015 668% 3/11/2015 1786 aActual 21 4/28/2015 -63% 12/11/2014 1765 aActual 57 1/15/2015 -77% 9/11/2014 1708 a Actual 256 10/15/2014 653% 6/11/2014 1452 aActual 34 7/16/2014 98% 3/11/2014 1418 aActual 17 4/11/2014 -71% 12/10/2013 1401 aActual 58 1/17/2014 -78% 9/12/2013 1343 a Actual 275 10/15/2013 444% 6/12/2013 1068 a Actual 50 7/24/2013 153% 3/13/2013 1018 a Actual 20 4/22/2013 -68% 12/11/2012 998 aActual 61 1/9/2013 -77% 9/13/2012 937 a Actual 283 10/15/2012 661% 6/12/2012 654 a Actual 36 7/16/2012 69% 3/14/2012 618 a Actual 22 4/14/2012 -31% 12/12/2011 596 a Actual 31 1/17/2012 -81% 9/12/2011 565 a Actual 171 10/13/2011 597% 6/7/2011 394 a Actual 23 7/20/2011 7% 3/8/2011 371 a Actual 21 4/13/2011 -71% 12/9/2010 350 a Actual 73 1/12/2011 -61% 9/10/2010 277 a Actual 200 10/15/2010 153% 6/7/2010 77 a Actual 75 7/15/2010 358% • 789 j Of MORT1r 1M Town of North Andover ��'••:;;o::. �' HEALTH DEPARTMENT i cNuset CHECK#: /3 7o DATE: 6 G LOCATION: O n 5-4,C4 H/O NAME: S�o l2,! CONTRACTOR NAME: .Z.`Q�.Son Type of Permit or License: (Check box) l O Animal $ ❑ Body Art Establishment $ ' ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ k ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ i ❑ Recreational Camp $ " ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ E ❑ Well Construction: $ SEPTIC Systems:_ ❑ Septic-Soil Testing $ f ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI $ ❑ Title 5 Inspector V1 IV $ Title 5 Report lJ" $ S� P&55 ❑ Other. (Indicate) $ He gent Initials White-Applicant Yellow-Health Pink-Treasurer i ®v t , s PUBLIC HEALTH DEPARTMENT Town of North Andover Community and Economic Development Division CERTIFICATE OF COMPLIANCE As of: June 8, 2017 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Repair of an installed outlet T - On-Site Sewage Disposal System By: Todd Bateson Bateson Enterprises, Inc. At: 220 Candlestick Road Map 106.A Lot 0198 North Andover, MA 01845 The Is ce of cea/tificate shall not be construed as a guarantee that the system will function satisfactorily. Brian J.L/aGraL C IS' Director of Public Health i i 120 Main St.,North Andover,Massachusetts 01845 Phone 918.688.9540 Fax 918.688.9542 Web www.northandoverma.gov II I i „ le North Andover Health Department Community and Economic Development Division f ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 220 Candlestick Road MAP: 106.A LOT: 0198 INSTALLER: Bateson DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ! ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port i i ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: June 8, 2017 installed outlet T PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑, Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX ❑ Installed on stable stone base ❑ H-20 D-Box ❑ Inlet tee (if pumped or >0.08'/foot) ❑ Hydraulic cement around inlet & outlets ❑ Observed even distribution ❑ Speed levelers provided (not required) ❑ Schedule 40 PVC Pipe Comments: I SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel-less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = E FINAL GRADE ❑ Loamed ❑ Seeded ❑ Cover per plan Comments: DOCUMENTS NEEDED ❑ Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer ❑ As-Built Plan i BM = HR = HI = SYSTEM ELEVATIONS ROD AS-BLT INVERT DESIGN INVERT ELEVATION ELEV ELEV Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 TOP Lateral 1 INVERT Lateral 2 TOP Lateral 2 INVERT Lateral 3 TOP Lateral 3 INVERT Lateral 4 TOP Lateral 4 INVERT Lateral 5 TOP Lateral 5 INVERT Lateral 6 TOP VERT Lateral INVERT Top of Chamber Bottom of Bed/Chamber SKETCH PLAN A I s CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- ® Waterline 10 10 10' ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh, Inland/Coastal Banka 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib. to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot. Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 ® Drains (Other)Foundation 10(5) 20(10) ® Drywells 20 25 ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02). s As defined in 310 CMR 10.55, 10.32, 10.54,and 10.30,respectively,pursuant to 15.211(3),also by NA wetland bylaws I I i 1 6/9/2017 Resized 2.jpg f r � � f E � https:Hm ai l.googl e.com/mai l/u/0/#inbox/15c8ccl9d32b749a?projector=1 1/1 ' Y • • Application for Septic Disposal System TODAY'S DATE Construction Permit — TOWN OF $2501.00-Full Repair NORTH ANDOVER, MA 01845 $425.00-Component Application is hereby made for a permit to: Q Construct a new on-site sewage disposal system* ❑Repair or replace an existing.on-site sewage disposal system* ['Repair or.replace an existing system component—What? A. Facility Information Address or Lot# RE-CE AVa- Ak9 JUN Q 1 1017 Cityfrown $I,+ - 2.-*TYPE OF SEPTIC SYSTEM*: TOWN OF NORTH ANDOVER ➢ ❑Pump ravity(choose one) HEALTH DEPARTMENT " if pump system,attach copy of electrical permit to application"* ➢ ❑Conventional System (pipe and stone system) ➢ ❑Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certihcaffon to install this type of system.) ➢ ❑Pressure Distribution S.A.S.(No D-Box) ➢ ❑Pressure Dosed(D-Box Present)S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No ff yes, does plan specify make and model of filter? YES=(no further info. needed) NO=(installer must specify brand of filter before DWC issuance) i Whatis the Make? [What is die Modae 2. Owner Information Name o�-c�-v C�,••��s�`C Z1C �. it Address(if different from above) Cityrrown State Zip Code X 17 — `/ Telephone Number 3. Installer Information BATESON F(�jTr o USES, Name Name of Company 111 ARG ILLA ROAD /4r '4 ANDOVER,MA 01810 Address J Cityrrown State Zip Code 01' 7b' Y/5-9 A703 Telephone Number(Cell Phone#!f possible please) 4. Designer Information Name Name of Company Address Cityrrown State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 I dRrN Awl -oh Septic. Disposal �ys#ern ,J' _i TODAY'S DATE t T Off. ORTH 1�1ND�Y � MA 01845 $.250.61 .0-full Repair 4C s`aoo-Component ...,PAGE 2 OF 2 A. Fad 11ty.:Information continued.... 5. Type,of Suiidfn : �esldentlal Dwelling or❑Gmmercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system In accordance with the.provlslons of Title 5 of the Environmental Code,as weh as the Local Subsurface Disposal Regulations for the Town of Notth Andover,and not to place the system fn operation until a Certificate of Compliance has been Issued hV this Board of Health. Name S-_O'1Y Date Application Approved By: (Board of Health Representative) Name Date Application Disapproved.for the following reasons:" For Office Use Onlv L -Fee Attached? Yeses No 2. PtojectMatiaget Oblrgadon Form Attached. Yes' 1: &M2Z;: ? Ifsoj Attach aeny OfEle�r�rcal Permit.: 'es ' No^ 4. FOrradI On As Built. (hew consfrucdon-ronly); Yes (Same scale as approvedplan) NO 5. 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CdtEd�f—/ 7 J � Commonwealth of Massachusetts Map-Block-Lot 106.A0198 ----------------------- BOARD OF HEALTH Permit No North Andover BHP-2017-0443 --------------- -- P.I. FEE F.I. $175.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd_Bateson ----------------------------------------------------------------------------------------------------- to(Construct)an Individual Sewage Disposal System. at No 220 CANDLESTICK ROAD as shown on the application for Disposal Works Construction Permit No. BHP- 7-044 _ e 0477 7 --------- � i -------------------------------------------- Issued On: Jun-01-2017 BOARD OF HEALTH ---------------------------------------------------------------------------------- Commonwealth of Massachusetts Map-Block-Lot 106.A0198 BOARD OF HEALTH North Andover CERTIFICATE OF COMPLIANCE THIS IS TO CERTIFY,That the Individual Sewage Disposal System (Constoi by Todd Bateson Installer at No 220 CANDLESTICK ROAD ---------------------------------------------------------------------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. BHP-2017-044 Dated-__June 01,_2017........ ----------------------- ------------------------------------------ Printed On: Jun-01-2017 BOARD OF HEALTH ---------------------------------------------------------------------------------- Commonwealth of Massachusetts Map-Block-Lot 106.A0198 ---- BOARD OF HEALTH -- — Permit No North Andover BHP-2017-0443 ----------------------- 1110 FEE I $175.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd Bateson to(Construct)an Individual Sewage Disposal System. , 0-� at No 220 CANDLESTICK ROAD ______ _______________ � as shown on the application for Disposal Works Construction Permit No. B -2017-044 Dated June O1,2017 -------------- ------------------------------ j Issued On:Jun-01-2017 ------------------------ ------------------------- ------ BOARD OF HEALTH ------------------------- I I '�y W ! X01 NORTp�� 7890 _ O 1 C A ti p fTown of North Andover •� ;. E ��'•�,,,,o.. �' HEALTH DEPARTMENT I ,SSACNOStS CHECK DATE: O/7 LOCATION: O n 6,S>t%G H/O NAME: 5c,�6 rle,. CONTRACTOR NAME: L�?,Sp/� Type of Permit or License: (Check box) ❑ Animal $ ` ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ r ❑ Food Service-Type: $ r ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ r ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ xSeptic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ t ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) $ F i i HeahikAgeent Initials White-Applicant Yellow-Health Pink-Treasurer r �'gi eye • H1ld3M�o 4 � fx►s fin/G x fe 1 � D � U 1 . t { i ; i r s i x