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Miscellaneous - 220 DALE STREET 4/30/2018
220 DALE STREET j h 2101000.0 t I c' .___�— �— c Z � � � � � �� �� -� . � �� . � v� � �� _.____ � � Q* ^'oTH , Commonwealth of Massachusetts Map-Block-Lot r r* 064.00012 ----------------------- �- BOARD OF HEALTH Permit No ••_°w �. _en` ' BHP-2011-0752North Andover ----------------------- FEE - -- FEE $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd Bateson - - - - - ----------------------------------------------------------------------------------------- to(Repair-DISTRIBUTION BOX)an Individual Sewage Disposal System. at No -22-0-DALE-STREET as shown on the application for Disposal Works Construction Permit No. BHP-2011-075 Dated July 20,2011 ------------------------ ----------------------------- Issued On:Jul-20-2011 ` � S�4'TGEDy . � RATEU_A , North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION ITW ADDRESS: > MAP: LOT: INSTALLER: DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL C TRUCTION INSPECTION: Y DATE OF FINAL GRAD 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 ❑ �eep hole plugged ❑ gallon tank has been installed ding ❑ Monolithic tank nstruction ❑ Watertightness of t has been achieved by testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of final grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ gallon Pump Chamber installed ❑ 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: CONTROLPANEL ❑ 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) Comments: Commonwealth of Massachusetts Map-Block-Lot 064.00012 ----------------------- BOARD OF HEALTH Permit No s a North Andover BHP-2011-0752 4 P.I. FEE F.I. $125.00 DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd Bateson to(Repair-DISTRIBUTION BOX)an Individual Sewage Disposal System. at No 220 DALE STREET as shown on the application for Disposal Works Construction Permit No. r$HP-2011-075 Dated July 20,201.1 --- ------- - -, fir_ --------- ----------------- Issued On:Jul-20-2011 O ALTH 3OR j*oT a a _- Commonwealth of Massachusetts - Ma Blo12Lot - '� BOARD OF HEALTH ---- ---- - • North Andover CERTIFICATE OF COMPLIANCE ACC . THIS IS TO CERTIFY,That the Individual Sewage Disposal System (Repair-DISTRIBUTION BOX) by ---Todd Bateson ------------ -------------------------------------------------------------- Installer at No 220 DALE STREET - ---------------------------------------------------------------------------------------------------------------------------------------------------------- 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-2011-075 Dated___July_20,2011 ----------------------- - ---------- ----------------------------------------------------------------- Printed -Jul-26-2011 BOARD OF HEALTH -- Ot,NORTH;� c 5564 o - w * Town of North Andover � HEALTH DEPARTMENT I , SSACHNStS CHECK#: DATE: LOCATION: HBO NAME: _ �; �-� C 0 N T R A C NA E: Type of Permit or License: (Check box) <5 ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ { ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ s ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ - ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic- hign Approval $ eptic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) $ Health Agent Initials: White-Applicant Yellow-Health . Pink-Treasurer' �J pORTN tion for Septic Disposal S stem Application p p Y 00 -Construction Permit -, TOWN OF T°°ArSPATI: �' •f'' ORTH ANDOVER MA 01845 $z50.00—Full Repair $125.00-Component Important, Application is hereby made for a permit to: formes on t filrine out ElConstruct a new on-site sewage disposal system* computer,use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key �� to move your L7Repair or replace an existing system component—What? �, 30 x cursor-do not use the return key. A. Facility Information Z18f— D40 U)aLOL s�• ILEI Address or Lot# City/rown .a V z_ 2.-*TYPE OF SEPTIC SYSTEM*: ` X11 ❑Pumpra ity(choose one) No ***If pump system,attach copy of electrical permit to appIRNORTH ANDOVER NTH DEPARTMENT Conventional System(pipe and stone system) ❑Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system. ❑Pressure Distribution S.A.S.(No D-Box)(Attach Draft Maintenance Agreement) ❑Pressure Dosed(D-Box Present)S.A.S. 2. Owner Infonnation _ Name dur — jdo Address(if different from above) All City/Town State Zip Code rl i `7 Telephone Number 3. Installer Information Name Name of Co pany �I I ARQI , Address City/Town J State / �•p?.�G�� Zip Code .sVO,IPe 7d� Telephone Number(Cel/Phone#if possible please) 4. Designer Information 4dress Name of Company State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 9 of 2 i as ",°•r 'a Application for Septic Disposal System �- 19 3= •`-' °c TODAYS DATE p Construction Permit - TOWN OF $250.00-Full Repair ORTH ANDOVER, MA 01845 $125.00,-Component ,SSACHU. PAGE 2OF2 A. Facility.lnformation continued.... 5. Type of Building: esidential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation until a Certificate of Compliance has been issued b is Board of Health. Name Date Applicati4Aroved By: (Bo of Health Representative) Name Date Application Disapproved for the following reasons: For Office Use Only: 1 Fee Attached. Yes L// No 2. Project Manager ObEgatlon Form Attached. Yes, No 3.: Pump S sv tem? Ifso;Attach copy ofElectrrcal Permit. Yes-4 No 4. Foundation As Built. (new construction ronly). Yes No (Same scale as approved plan) 5. Floor Plans?(new construction only). Yes_ No Application for Disposal System Construction Permit-Page 2 of 2 '� •� SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: (Address of septic system) For plans by (Enr Relative to theapplication of (installer's name) And dated ate . Dated '6)— — l� o ay s ate With revisions dated ` ast revised date) I understand the following obligations for management of this project: 1. 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 ngam e• 2. As the installer,.I.must call for any and all inspections: If homeowner,contractor,project manager, 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 co=letion of the items in accordance with Title 5 and the Board of Health Regulations tnay:result:in a$50:00 fine being.levied against me and/or Wcompany. a. BottomofBed Generally,this is the first(1 S)inspection unless.there is a retaining wall,which should be done.first. The installer must—request the inspection but does not have to be present. . b. Final Construction.Inspection—Engineer must first.do their inspection for elevations;ties,'etc. As-built of verbal OK(or e-mail to:healthdept(a,,townofnorthandover.com) from the engineer must be submitted to the Board of Health,after:which installer.calls for an inspection time. Installer must be present for this inspection. With a pump system,all electrical work must be ready and able to cause:pump to cork and.alarm.to function.. c. Final Grade—Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer,I understand that only I may perform the work(other than:simple excavation)and I am required to complete the installation of the system identified in.the attached application for installation.: .1 further understand:that work done by others urificense4 to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my licenseto operate in the Town of North Andover, sigiufieant 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. h. Inspection of the sand and stone to be used. c. Final inspection by Board ofHealth staff or consultant. d. Installation of tank,D-Box,pipes, stone, vent,pump chamher,retahlih-wall and other components. 6. As the installer, I understand that I am solely,responsible for the installation of the system as per the app rr oved plans. No instructions by the homeowner general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic.Installer: Ts aQkscai✓ (Today's Date): (Nam e:- suito e FO i! U e LOQ`:':R�LEAS FORA IN.STnUCTiONS: This form is...used:to.verify,.thata11: necessary Gpprovals/permits from Boards and Departments having jurisdiction have been obtained..'This does not relieve the applicant and/or landowner from compliance:wlth any,-applicable e or requirements. *' * *APPLICANT FILLS OUT APPLICANTHaNE LOCATION: Assessor's Map Number 6 PARCEL ` - S H�81�71S7Di� L STREET L S4_ ST. NUMBER ON ****** OFFICIAL ONLY **** �� *** Zec USE POA RECOMMENDATIONS OF TOWN AGENTS: —/00 .lac ORC�. CONSERVATION ADMINISTRATOR DATE-APPROVED DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE.APPROVED DATE REJECTED _&5. 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F 1 f q tc5 2 11 4 fi� _ ''-X \ 4--� v-, Tom, d a ' yPk t tlf � A;t } t t d l i r u , c” , �, sq ,➢n!t�: +' 4 r { 1. t•� � 4i: � �- # � j II�! P w:: dl rt�""rC�1� ,� 6 dp dtl4Y wq >�� -�. t , i r $ski n ti4Rrr t 4tP'� ati 4�Pis a - a Y a n �4 "s +"�`ER•'£�.��kY-rJAc S F t� �:�f' a �t '� w .. r IMI; NnME Nil -R-LT��r�yr¢(. }Iy#IT 1 + �M,� 1 'PsTi iy��( �€3, ^P �'t �Y” g FJ 1 {s X y GtO!e�b4 yr q +'r/ 3SaeR fr r 'S Ks j '^IVI:P",tr: I�� 1 f +rNN� a ✓pINS 4 ''} C, c ' -21e/�?0 i 61,,;,�Z P7o,i •� o�o� 1.0(U - Liv" woo NO JOB ;j >MEa Aiwa maoE�J TOO SMALL EE C,�NS�TRUcCTLUIN CO. � kk 51 DECKS�"+"fiE�51ObELING � AIRS r} X21 HEWITT AVE. KENNETH KEEN NORTH ANDOVER, MA 01845 . President TEL. (508)691-5201 Address Title of File Page of Date f=ile Open: ---- Date file closed: Doc Document/Action Title Date of 6tef'et to other Purpose of�?ocume tin /Action and nates action Document/ doWment/ fWum. -- Action De artment Board of Appeals - Board of Heal h Plannm-q.Board ; onseruatiion Commission — Bu'i6din Department �--- MOPTN 5436,..}� .s ��., �r o o •G it Town of North Andover HEALTH DEPARTMENT ,SSlCHUStt CHECK#: DA r : LOCATION- H/0 OCATION::H/O NAME: r CONTRAC .4 NAME- Type of Permit or License:(Check box) 0 Animal $ ❑ Body Art Establishment $ ;7 ❑ Body Art Practitioner $ . :I ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ D ;r ❑ Massage Establishment $ 0 Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $. ❑ Swimming Pohl $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Tit Inspector $ Title 5 Report $ ✓`�° r { ❑ Other:(Indicate) $ 1 Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer. CommonweaLth pfMassachuseft v Title 5 Official Inspection Form ECEI Subsurface Sewage Disposal System Form-Not for Voluntary Assess ents M 220 Dale Street t iA '18 Z011 Property Address TOWN OF NORTH ANDOVER Jan Baan HEALTH DEPARTMENT Owner Owner's Name information is required for North Andover MA 01845 4/16/2011 / every page. Cityrrown State Zip Code Date of Inspection l Inspection results must be submitted on this form. Inspection forms may not be altered i 4 way. Please see completeness checklist at the end of the form. Important: When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your Neil J. Bateson cursor-do=_not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name 16 111 Argilla Road Company Address Andover Ma 01810 Citylrown State Zip Code 978-475-4786 S115 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Neeq Further Evaluation by the Local Approving Authority 4/16/2011 Inspe or Signature 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•09/08 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 220 Dale Street Property Address Jan Bajan Owner Owner's Name information is North Andover MA 01845 4/16/2011 required for every page. CitylTown 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. i *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 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 GSM 220 Dale Street Property Address Jan Bajan Owner Owners Name information is required for North Andover MA 01845 4/16/2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): I 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 I ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 220 Dale Street Property Address Jan Bajan Owner Owner's Name information is required for North Andover MA 01845 4/16/2011 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ 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-Box needs to be replaced D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No El ® 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 Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 220 Dale Street Property Address Jan Bajan Owner Owner's Name information is required for North Andover MA 01845 4/16/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ED ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified .laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts MOM Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 220 Dale Street Property Address Jan Bajan Owner Owner's Name information is required for North Andover MA 01845 4/16/2011 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): N/A Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#,of bedrooms): N/A t5ins-09108 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 220 Dale Street Property Address Jan Bajan Owner Owner's Name information is wired for required North Andover MA 01845 4/16/2011 every page. Citylrown State Zip Code Date of Inspection D. System Information Description: Two family house, only 1/2 of the house has been used Number of current residents: 2 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Yes 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current 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? e ❑ Yes ❑ No Industrial waste holdingtank resent? Yes N p ❑ ❑ o Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 220 Dale Street Property Address Jan Bajan Owner Owner's Name information is required for North Andover MA 01845 4/16/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped two years ago, owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1200 gallons How was quantity pumped determined? Measured tank Reason for pumping: Inspect tank, baffles&tee 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(ficial Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts j W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 220 Dale Street Property Address Jan Bajan Owner Owner's Name information is required for North Andover MA 01845 4/16/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Original, owner Were sewage odors detected when arriving at the site? ❑ Yes ® No 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' Cast iron thru wall. Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age:, years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 9'x5'x4' Sludge depth: 6" t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 220 Dale Street Property Address Jan Bajan Owner Owner's Name information is required for North Andover MA 01845 4/16/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 21" Scum thickness 6" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" - 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 baffle ok. Outlet baffle corroded off. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap(locate on site plan): Depth below grade: feet 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: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 220 Dale Street Property Address Jan Bajan Owner Owner's Name information is required for North Andover MA 01845 4/16/2011 every 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 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 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .'' 220 Dale Street Property Address Jan Bajan Owner Owner's Name information is required for North Andover MA 01845 4/16/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box level&distribution not equal. Evidence of leakage, has corrosion holes. D-box needs to be replaced. 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 220 Dale Street Property Address Jan Bajan Owner Owner's Name information is required for North Andover MA 01845 4/16/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® - leaching trenches number, length: 4 trenches 50' long ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil Ok. Vegetation ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 220 Dale Street Property Address Jan Bajan Owner Owner's Name information is required for North Andover MA 01845 4/16/2011 every page. City/Town State Zip Code 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 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 220 Dale Street Property Address Jan Bajan Owner Owners Name information is North Andover MA 01845 required for 4/16/2011 every page. CitylTown 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 f� A t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 220 Dale Street Property Address Jan Bajan Owner Owner's Name information is North Andover MA 01845 4/16/2011 required for I+ every page. Cityfrown 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: 3 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 ® 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: Transfer elevation of swamp to trench bottom. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09108 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 M •�''r 220 Dale Street Property Address Jan Bajan Owner Owner's Name information is required for North Andover MA 01845 4/16/2011 every page. City/Town 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Summary Record Card generated on 5/6/2011 2:22:18 PM by Karen Hanlon Page 1 Town of North Andover Tax Map # 210-064.0-0012-0000.0 Parcel Id 12014 220 DALE STREET BAJAN, JAN 220 DALE STREET NORTH ANDOVER, MA 01845 Class 104 Two-family Propertj Type 1 Residential c Size Total 1.5 Acres f FY 2011 I UB Mailing Index Name/Address Type Loan Number Active/lnact. From Until BAJAN,JAN Payor 220 DALE STREET NORTH ANDOVER,MA . 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 18360.0-220 DALE STREET Last Billing bate 4/6/2011 3180441 03 Cycle 03 Active UB Services Maint. Account No.3180441 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 60.80 /2 UB Meter Maintenance Account No. 3180441 Serial No Status Location Brand Type Size YTD Cons 16335724 a Active 00 METE METE w Water 0.63 0.63 125 bate Reading Code Consumption Posted Date Variance 3/16/2011 617 a Actual 16 4/13/2011 23% 12/14/2010 601 a Actual 12 1/12/2011 -29% 9/20/2010 589 a Actual 20 10/15/2010 70% 6/11/2010 569 a Actual 10 7/15/2010 53% 3/17/2010 559 a Actual 7 4/14/2010 15% 12/15/2009 552 a Actual 6 1/12/2010 -22% 9/15/2009 546 a Actual 8 10/15/2009 19% 6/12/2009 538 a Actual 6 7/20/2009 -49% 3/19/2009 532 a Actual 13 4/29/2009 40% 12/15/2008 519 a Actual 9 1/20/2009 -5% 9/15/2008 510 a Actual 10 10/10/2008 16% 6/11/2008 500 a Actual 8 7/16/2008 -2% 3/14/2008 492 a Actual 8 4/11/2008 -55% 12/18/2007 484 a Actual 19 1/22/2008 12% 9/17/2007 465 a Actual 16 10/12/2007 3% 6/22/2007 449 a Actual 17 7/20/2007 12% 3/19/2007 432 a Actual 15 4/16/2007 6% 12/15/2006 417 a Actual 13 1/19;2007 -15% 9/20/2006 404 a Actual 16 10/20/2006 1% 6/22/2006 388 a Actual 16 7/10/2006 16% 3/23/2006 372 a Actual 12 4/17/2006 -6% 1/3/2006 360 a Actual 16 1/17/2006 -18% 9/26/2005 344 a Actual 20 10/14/2005 8% 6/16/2005 324 a Actual 14 7/15/2005 6% 3/31/2005 310 a Actual 17 4/5/2005 3% 12/22/2004 293 a Actual 14 1/14/2005 -13% l VA RIA NCE PLAN OF LAND 'IN' - lII.So' NO. ANDOVER, MA. "OWNED BY' JON BAJA N SCALE.' 11 40' 04TE.' 9/20/94 0 40 80 120 SCOTT L. GILES , R. P. L .S. NO. ANDOVER, MA. 1 CERTIFY THAT I HAVE CON- FORMED WITH THE RULES AND REGULA T IONS OF THE REGISTER OF DEED IN PREPARING THIS PLAN. - 9/20/94 /. DEED BOOK 1999, PAGE 292. 2. PLAN REF. # 2141 NORTH ANDOVER BOARD OF APPEALS N 01 N h 1. 375 ACRES DATE OF FILING.' DA TE OF HEARING .' DA TE OF APPROVA L .* • o y�- i PROPOSED SECOND 9120194 FLOOR CONSTRUCTION OVER EXISTING FOO T PRIN T �2 i 45 ExlS8Y 2' STo gyp, a 122?9 E � RE _� ST r �4� '4 For: Todd Bateson Bateson Enterprises, Andover Fax number: 978.475.5451 From: Pamela DelleChiaie, Departmental Assistant North Andover Health Department Fax number: 978.688.8476 Date: Thursday, April 14, 2011 Regarding: 220 Dale Street, North Andover-Health Department File Number of pages: 10 (including this cover sheet) l Comments: Not too much in file: 1. Assessor's Information Sheets - 2 pages 2. Survey of Existing Septic System - Sept. 8, 1994 3. Mortgage Inspection Plot Plan - Oct. 11, 1990 4. Form U - Lot Release Form - Sept. 9, 1994 5. Septic Pumping Record by Rooterman - Nov. 22, 2004 6. Septic System Inspection Form - Aug. 1986 7. Watershed Residents Questionnaire - No Date 8. Septic Pumping Slip Statement - Bateson - Dec. 20, 1993 TRANSMISSION VERIFICATION REPORT TIME 04/13/2011 10:33 NAME HEALTH DEPARTMENT FAX 9786888476 TEL 9786888476 SER.# 000LON655497 DATE DIME 04113 10:29 FAX NO. /NAME 9784755451 DURATION 00:03:24 PAGE(S) 10 RESULT OK MODE STANDARD ECM North Andover Board of Assessors Public Access Page 1 of 1 NORTH Rorfh Andover Board of Assessors, p amok 9SSACHU UlProperty Record Card Click Seat To Return Parcel ID :210/064.0-0012-0000.0 FY:2011 Community:North Andover SKETCH PHOTO Click on Sketch to e Enlarge Click on Photo to Enlarge g Search for Parcels Search for Sales Summary '® - Residence Detached Structure Condo 220 DALE STREET Commercial Location: 220 DALE STREET Owner Name: BAJAN,JAN STEPHANIE BAJAN Owner Address: 220 DALE STREET City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood:6-6 Land Area: 1.50 acres Use Code: 104-TWO-FAM-RES Total Finished Area: 2304 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 393,900 400,900 Building Value: 183,200 190,200 Land Value: 210,700 210,700 Market and Value: 210,700, Chapter Land Value: LATEST SALE Sale Price: 171,000 Sale Date: 10/28/1990 Arms Length Sale Code: Y-YES-VALID Grantor: DAVIS,SCOTT N Cert Doc: Book: 03180 Page: 0193 http://csc-ma.us/PROPAPP/display.do?linkId=1704393&town=NandoverPubAcc 4/14/2011 Residential Property Record Card PARCEL ID:210/064.0-0012-0000.0 MAP:064.0 BLOCK:0012 LOT:0000.0 PARCEL ADDRESS:220 DALE STREET FY:2011 __ _ _ — ----�_-._-r—�.- -- ----- PARCEL INFORMATION Use-Code: 104—'- Sale Price: 171,000 Book:03180 r Road Type�T--- w Inspect Date: 09/11/2002 Tax-Class: T Sale Date: 10%28/90 Page: 0193 _ ��Rd Condition: P —Me'as Date: 09/11/2002 Owner: Tof Fin Area: 2304 _Sale Type: _P _ Cert/Doc: 'Traffic: M Entrance: 4_D BAJAN,JAN Tot Land Area: 1.50 Sale Valid: Y Water: Collect ld: - RO_ STEPHANIE BAJAN ---- ----------- — -- - —'-- Address: Grantor: DAVIS,SCOTT N Sewer: Inspect Reas: M 220 DALE STREET Exempt-B/L% / Resid-B/L% 100/100 Comm-B/LP/o Indust-B/L% / Open Sp-B/L% / NORTH ANDOVER MA 01845 RESIDENCE INFORMATION LAND INFORMATION Style: DX Tot Rooms: 7 Main Fn Area: 1488 Attic: NBHD CODE: 6 NBHD CLASS: 6 ZONE: R1 T_ y �-- - _ - — `-- - _ - _ —- --- Se T e Code Method S Ft Acres Influ-Y/N Value `-Class Story Height: 2.00 Bedrooms: 4� Up Fn Area: 816 Bsmt Area: -1488— 9 Yp ., , _i Sq-Ft- _ __— _._! --- _ _ T� 1� — P 104 S 43560 1.000 206,910 Roof: _ GFull Batlis: 2 Add Fn Area_:__ _ Fn Bsmt Area: Exf Wall — WS—Half Baths: Unfin Area: — vBsmt-Grade: 2 R 104 A 0 0.500 3,800 Masonry Trim: -Ext Bath Fix _0:Tot Fin Area:—2304:__ --- - 1 VALUATION INFORMATION Foundation: CB Bath Qual T _ RCNLD: 183248 Current Total: 393,900 Bldg: 183,200 Land: 210,700 MktLnd: 210,700 KitCF Qual: T�Eff Yr Built':, 1975 Mkt Adj: _ __ Prior Total: 400,900 Bldg: 190,200 Land: 210,700 MktLnd: 210,700 Heat Type: ER Ext Kitch: Year Built: �1964�JSound Value: - Fuel Type: -E _w Grade:— AG _ Cost Bldg:® 183,200 Fireplace: 0 Bsmt Gar Cap: _ Condition: A Aft Str Val 1: Central AC: N_ 'Bsmt Gay SF:-- Pct Com Tete ---- ,kt-t Str Val2: At Gar SF:— %Good P/F/E/R: /100//79' Porch Tvae Porch Area Porch Grade Factor W 160 SKETCH PHOTO r; 16150 S t f' 28 10 1 34 FM/B FUIFM/B 672 Sq.R 816 Sq.R 24 24 24 28 34 1 • 11 220 DALE STREET Parcel ID:210/064.0-0012-0000.0 as of 4/14/11 Page 1 Of 1 p SEPTIC SYSTEM A T#220> ,ALE STREET NORTH A IVDO V ER, MASS. ' f r SEPTEMBER 8, .199A;.. - TH NOR7-H ANDOVEIR BOARD OF HEALTH, T0141V.HALL €' - .31l mfr 4'TH,Pit DOfV 'j9, MASS. A SURVEY tVAS CONDUCTED AT 7'l IL ABOVJ LOGATIOA'TO DETERMINETHEk5l�E,' _.,•CONDITION AND LO ATTC)N Dl"T1^l E��sT1r�r.sEPTiC SYSTE i!'AND,TH FOLLOWING FACTS 14'ERE DETEPNINE.Q _. ' 71HE SE_ PTIO TANS'MEASL u'6'F Y"10'aY--5 �}��F=11%'EXCESS OI✓-1250 GALLONS. COUR TRENCHES IIWASURUN'0 450'LONG BY 3'WIDE BY '.'DEEB WERE ALSO FOUND. Tw UI'1DEnyv,.G SOIL IS GOARSE SAND HAVING, IN.MY`OPINION,A PERCOLATION 0,TE OF LESS THAN 2 MIN.1INCH: ; USING.A PI+'RCOI_APON RATE OF 6 MIN./INCH TO DI`TEF?MINE THE LEACHING ABILITY OF 7HIr EkSTING'SYSTEV, THE RESULTS ARE IN EXCESS,OF750 GALLONS PER DAY. THIS AIUMBEP IS IN EXCESS OF 7-7-IE 660 GALLONS PER QAYREQUIRED FOR A 4 5 eEbROOM HOMO. f „ ` IT IS MYO'PINION TWAT THE-EXIS"nNG SYS.TENI IS-SATIS, ACTORYFOR THEPROPOSED .WORK TO BE DONE. t , ENCLOSED IS A SKETCH.OF THE S YS TEM AS I T EXI STS. ; + VER,,Y i RULY YOURS • eco'. .. �, _ SCOTTTL. �ILESP,.P,L.S.,i N " rJ - ,< Y �' Yi' � J ak _ii. I � 1 .•.6 Ck ��ti10fih 'S.fi !•S �� S } � '.i' .. '.. ..: :.'a .� �. x; •,f .� rhiy. a..k}k Y a _ k .;.M ORTGAGE INSPECTION PLOT PLAN ` NORTHERN ASSOCIATES, INC &M.a 65 SALEM STREET,LAWRENCE,MA 01843 ijel.508.975-71 i7 b Y440M JA#f 8a+44W V DEED AEFr.'`'!sem/aw PA rXW ots — Rw AA[.B.sTREE T PLAN!>nc:` / ells. NrAW N. AAVOM . 91• SCALE !- s0' '- AM ACT/ !! / s0 !..00/41jk* I• Y - •+i <.' fw• e q t y _ Ir r .i 1:975 ACRES *9 t l Pf" e <t - ISI , 'iz x ; t ,1� r✓��s N©�. r 14 ;0002 J MaQD Sf fi ti I�Q r .. a 0000 Inspection_ was "prepared FURTHER STATE THAT IWW PROFESSIONAL PuMms and Is not b ba nlred —AOPINION Che principlostructurhYsand aoontory -•:k{ Nmpwn Associates Inc. scospis no 1>< "oulbuldnpa,.>. CONFORM1M spansuMhp om said reliance by setback��. Che nquiremenu of Cha local zorirhp J Mtea M amid""09"and its assigns In + with 4"Poesid—19890 financing to said S a ordinances,and Cul two am no whaoad+rneMs of mr>✓or c . Improvements slow way"ss property Irm except as Y 46 :411.Property,is not In a Flood Hazard Ana. , � sees aowrdenee ?r S 1, pv O 2.Property is M a Flood Hazard Aroa. 1lydards ter Mortgage Loan 4 k0 )V ar�� v r O a Information Is InwM*M to determine Food Hazard. eaaa Auoefation Flood Huard defarmlrked Mom latest Federal Food r t Insurance Rate Map panellll Ve a -I/ fj FORM U - IAT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section****************'*a / U `� APPLICANT: �1 b �oj Phone (�0 S ��d LOCATION: Assessor' s Map Number Parcel Subdivision Lot(s) Street er St. Number Z 2e ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Date Approved Conservation Administrator Date Rejected Comments Date Approved Town Planner Date Rejected Comments Date Approved Food Inspector-Health Date Rejected Y �A D Date Approved 9 Septic Inspector-Health Date Rejected Comments Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date Commonwealth of Massachus is [EA '�� �- CitylTown of ,AAAw 0 6 2004 System Pumping Record lug. RTt 1.4 a.OVER Form 4 EPAR;;�,E,�;T DEP has provided this form for use by to I oards of Health. Other forms may be used, but the information must be substantially the Sam s that provided here. Before using this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important. When filling out 1. System LocatiD'0- forms the A— computoter,use only the tab key Address ----� to move your /�- '/� cursor-do not City/Town �v State Zip Code use the return key- 2. System Owner a Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record ' 1. Date of Pumping Da 't`Z 2. Quantity Pumped: Gallons 3. Type of system: E] Cesspool(s) ErSeptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? El Yes If yes,was it cleaned? E] Yes ❑ No 5. Condition of System: 6. S stem Pumped By: Vehicle Ucense Number i Company 7. Location where contents were disposed: to e oauler Date t5form4.doc-06/03 System Pumping Record•Page 1 of 1 1 SEPTIC SYSTEM INSPECTION FORM ADDRESS eZ l DATE INSPECTED PROPERLY FUNCTIONING? Y N WEATHER CONDITIONS COMMENTS U I M6 - - ccs laa ( � e- t v� 14ATER aVAL1TY 7'ES'JEb n jZeS0L:T5' �l DYE TEST PERFORMED? Y N DATE? SKETCH: - Ji L WATERSHED RESIDENTS QUESTIONNAIRE 1. Name !,t 1616 1 'S� ' 5, t-0 yet 2. Street Address o2�o N)e 5--- a3. How many members are in your household? 4. What type of sewage disposal system do you have? ❑ cesspool Xseptic tank and leaching area ❑ connection to municipal sewer ❑ other (describe) ❑ do not know 5. Are the plans (drawings) for your sewage disposal system on file with the Board of Health? ❑ yes ❑ no do not know 6. How old is your sewage disposal system? ❑ 0-5 years ❑ 6-10 years 11-20 years ❑ over 20 years ❑ do not know i 7. Has your, sewage disposal s stem been rebuilt or repaired? ❑ yes ❑ no do not know If yes, approximately how long ago? years. What was done? 8. How frequently is your sewage disposal system pumped out? ❑ annually do '00 ❑ every 2-4 years ❑ every 5-10 years ❑ over 10 years ❑ never�/ K1'IOZv 9. Have you had any problems with your sewage disposal system? ❑ yes Imo, no If yes, what problems? / \ ❑ repeated pump-outs needed ❑ system clogs, backs up, or drains slowly ❑ odors ❑ sewage surfaces through ground 10. How many of each appliance are connected to your sewage disposal system? 2 Washing machine dishwasher garbage disposal dehumidifier drain sump pumptoilet roof/pavement drains shower/bathtub 11. Please state the brand and type (liquid oz.powder) of detergent you use for: dishwasher clotheswasher / 12. Does your property have a lawn? yes ❑ no If yes, approximately what size? ❑ less than 1/4 acre1/4 acre El1/2 acre ❑ 1/4 acre ❑ 1 acre ❑ more than 1 acre (Specify) acres _ 13. How often do you fertilize your lawn? No. of applications per year n e V e - _ OSeason(s) of the year 14. Please state the brand and type (liquid or granular) of lawn fertilizer you use. ❑ Check here if your lawn is maintained by a professional landscape contractor. STATEMENT Tel. (508) 475-4786 Bateson Enterprises Inc. 111 Argilla Road • Andover, Mass. 01810 Dec . 29 19 -93 r hir . Jan Ba 'J an 220 Dale Street North Andover , i,1a. 01845 L J To insure proper credit please return this stub with your remittance. AMOUNT$ Paid DATE DESCRIPTION AMOUNT 12/20/93 220 Dale Street North Andover , LIZ. 01845 At the time of pumping out the septic ank, the septic system was in proper working order . The septic tank is 1200 gallons. } In no way is this certification aranteeing the septic system from ffailure. r y t e 7L J. Bateson Bateson Enterprises, Inc. -Andover, MA 01810 .