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Miscellaneous - 2201 SALEM STREET 4/30/2018 (2)
_ 2201 SALEM STREET 210/090.6-0045-0000.0 - J B/ J � r3,: 9 r _ 1 North Andover Board of Assessors Public Access Page 1 of 1 3r°0.= •cryo` ]Board,o&Asse_ssor-s, Property Record Card Return to the Home pace click on loco Parcel ID:210/090.B-0045-0000.0 Community:North Andover SKETCH PHOTO New Search Click on Sketch to Enlarge Click on Photo to Enlarge Sales .> Summary Residence F Detached Structure Condo Commercial Comparable Sales .i 2201 SALEM STREET Location: 2201 SALEM STREET Owner Name: BARTON,GREGORY H NORMA REBECCA BARTON Owner Address: 2201 SALEM STREET City:NORTH ANDOVER State:MA ZIP:01845 Neighborhood:5-5 Land Area: 1.02 acres Use Code: 101-SNGL-FAM-RES Total Finished Area:2464 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 528,800 552,000 Building Value: 331,300 344,100 Land Value: 197,500 207,900 Market Land Value: 197,500 Chapter Land Value: LATEST SALE Sale Price:257,500 Sale Date:06/29/1995 Arms Length Sale Code:Y-YES-VALID Grantor:JOHNSON,ANDREW Cert Doc: Book:04286 Page:0003 http://csc-ma.us/NandoverPubAcc/jsp/Home.jsp?Page=3&Linkld=1179024 3/11/2008 ,& FILE# And) 0 '7 / 6 m TITLE.V INSPECTION _ z a Dean G. Luscomb B & Sons .: P.O. Box 135 Middleton, MA 01949 3 �». 978=774-4065 a b - Licensed Plumber # 20285 E SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM " g - m PROPERTY OWNERS NAME Pe r I a.- h a m 6 v PROPERTY ADDRESS a a O 1 G�12 Yin A ;;dOve f l��t m DATE OF INSPECTION U C`}"O L ' r NAME OF INSPECTOR E)e- L U S C O►ten _ --r- QUALITY IS NUMBER ONE TO US h C*AgL* Commonwealth of Massachusetts �� . Title 5 Official Inspection Form REEVED Subsurface Sewage Disposal System Form - Not for Voluntary Assessments OCT 19 2015 72 L7)I5 4M 2201 Salem Street TOWN OF NORTH ANDOVER Property Address Owner Periathamby �/ 14PA Owners Name information is required for North Andover MA 01845 October 7, 2015 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: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Dean G. Luscomb II cursor-do not use the return Name of Inspector key. Dean G. Luscomb II & Sons Company Name P.O. Box 135 Company Address Middleton MA 01949 re°�r City/Town State Zip Code 978-774-4065 S1848 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 ystem:Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority October 7, 2015 Insp ctors 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.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2201 Salem Street Property Address Periathamby Owner Owner's Name information is required for North Andover MA 01845 October 7, 2015 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Checl )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: 6) 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. bThe septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 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 2201 Salem Street Property Address Periathamby Owner Owner's Name information is required for North Andover MA 01845 October 7, 2015 every page. Citylrown 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. bB) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or.due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The © system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. V 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form: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 2201 Salem Street Property Address Periathamby Owner Owners Name information is required for North Andover MA 01845 October 7, 2015 every page. City/Town 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: D ❑ The system has a septic tank and soil absorption stem SAS and the SAS i p Y � s 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 q nitrogen is equal 9 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. O3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: (, Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °�,M ,•''r 2201 Salem Street Property Address Periathamby Owner Owner's Name information is North Andover required for MA 01845 October 7, 2015 every page. Cltyrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a de ' n flow of 10,000 gpd to 15,000 gpd. For large s ms, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Se n D. Yes No V' ❑ ❑ the syste is within 400 feet of a su drinking water supply ❑ ❑ the system is withi 00 fe f a tributary to a surface drinking water supply ❑ ❑ the system is locat Ina ' rogen sensitive area (Interim Wellhead Protection Area—IWPA a mapped Zo II of a public water supply well If you have answered"yes' - any question in Section E the stem is considered a significant threat, or answered "yes" in ion D above the large system has fail e The owner or operator of any large system consider a significant threat under Section E or failed and ection D shall upgrade the system in rdance with 310 CMR 15.304. The system owner should y tact the aPp appropriate riate region. ffice of the Department. t5ins•3l13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 2201 Salem Street Property Address Periathamby Owner Owner's Name information is Noah Andover MA 01845 October 7 2015 required for , every page. City/Town 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 playas 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? P 9 ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd t5ins•3113 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 � 2201 Salem Street Property Address Periathamby Owner Owner's Name information is North Andover MA 01845 October 7 2015 required for every page. Citylrown State Zip Code Date of Inspection D. System Information Description: owner and town Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: "Peril l✓ak-,- tA-" LCa!od on sI t-e p lcr'i Sump pump? ❑ Yes ® No Last date of occupancy: current Date mercial/Industrial Flow Conditions: Type of Esta " ment: Design flow(based on 3 R 15.203): Gallons per da Basis of design flow(seats/persons/s etc.): Grease trap present? ❑ Yes ❑ No Industrial waste hold nk present? ❑ Yes ❑ No Non-s . ry waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2201 Salem Street Property Address Periathamby Owner Owner's Name information is North Andover required for MA 01845 October 7, 2015 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupa Date Other(describe below): General Information Pumping Records: Source of information: Pumped every year Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: Zero gallons How was quantity pumped determined? Reason for pumping: No need at this time 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts u: Title 5 Official Inspection- Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M "r 2201 Salem Street Property Address Periathamby Owner Owner's Name information is required for North Andover MA 01845 October 7, 2015 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: SAS is from 1986. Tank and D-box from 2008 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 22"feet Material of construction: ® cast iron ❑40 PVCCast iron to PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Main line and joints are in very good condition. Septic Tank locate on site plan): r Depth below grade: 12" GJ �' ,rhle� k4olt to `7 feet � H B d. . Ale 4 / Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) Precast rectangular concrete- 1500 gallons If tank is mea, I Is a med by a Certificate of Compliance? (attach a cop�years rtificate) o Dimensions: 5'x 5'x 10'- 1500 gallons Sludge depth: 1" t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts N - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 2201 Salem Street Property Address Periathamby Owner Owners Name information is North Andover required for MA 01845 October 7, 2015 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) 34" Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? by measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic tank and baffle is in very good shape. The solids are light and do not require pumping at this time. The liquid is running at it's correct working hei th. ease Trap (locate on site plan): Depth be grade: NV feet Material of constru n: ❑ concrete ❑ me El fiberglass ❑ pa th lene y ❑ other(explain).- Dimensions: explain):Dimensions: Scum thickness Distance from top of sc to top of outlet tee or baffle Distance from ttom of scum to bottom of outlet tee or baffle Date of'last pumping: Date t5ins•3/13 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 2201 Salem Street Property Address Periathamby Owner Owner's Name information is required for North Andover MA 01845 October 7, 2015 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Co nts (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid leve related to outlet invert, evidence of leakage, etc.): Tig t or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth %of grade: Materinstruction: ❑ concrete \ ❑ metal ❑ fiberglass ❑ polyethylene ❑ oth53, (explain): Dimensions: Capacity: gallons Design Flow: g ns per day Alarm present: "� ❑ Yes ❑ No 4 Alarm level: '4� Alarm in working order: ❑ Yes ❑ No Date of last pumping;all ��ate Comments(conditiond float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 2201 Salem Street Property Address Periathamby Owner Owner's Name information is North Andover MA 01845 October 7, 2015 required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Zero / 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.): The d-box is 16"x 16"and is 36" below grade with cover built to 6" below grade. The d-box is in very good shape with no signs of any problems. The d-box has speed levels. I P mp Chamber(locate on site plan): Pumps in ng order: ❑ Yes ❑ No" AY Alarms in working order: es ❑ No' Comments(note condition of pump ch r, conditio mps and appurtenances, etc.): * 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): l� If SAS not located, explain why: SAS was located by asbuilt drawings and previous title v. t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2201 Salem Street Property Address Periathamby Owner Owner's Name information is North Andover required for MA 01845 October 7, 2015 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: / ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2 -50' x3'W kd-d- ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology.- Comments echnology:Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The SAS is in good condition. There are no signs ofponding or breakout Ce ools (cesspool must be pumped as part of inspection) (locate on site plan): h Number and c ' uration v Depth—top of liquid to inlet in Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of con'%rr ction Indication"of groundwater inflow ❑ YesEl _.., . t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M °p 2201 Salem Street Property Address Periathamby Owner Owner's Name information is required for North Andover MA 01845 October 7, 2015 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Co ents(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): --,------, P I _ v (locate on site plan): t a y( p ) Materials o struction: Dimensions Depth of solids Comments(note condition of soil, signs of hydra failure, level of ponding, condition of vegetation, etc.): r.. I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2201 Salem Street Property Address Periathamby Owner Owner's Name information is required for North Andover MA 01845 October 7, 2015 every page. Cityfrown State Zip Code Date of Inspection D. System Intormation 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 at ached separately c azvt sale,, 54% a � /v.Aoms B r Se.p>�rc 5ku� p�f�'" Tank 1 X r D I "SO X ry A Por: 39, 13 IVT- 3 p�xay� 6 A aIx = a3'G" U10 b - 53t Qh) D 36r W6D = q4 ` t5ins•3/13LL J, p� Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2201 Salem Street Property Address Periathamby Owner Owner's Name information is required for North Andover MA 01845 October 7, 2015 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope 6 ca-1Ue-1 ® Surface water GJ �G+�� 4 `LSA �' a Aa.�•� ® Check cellar b enj 06 SU" P"P ® Shallow wells JQ0 n+e- Estimated depth to high ground water: T +/ 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 85 Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Proposed, asbuilt and previous title v on file. ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: The basement is 7' below grade with no sump pump. 5/13/85 -no water found at 9'and at 10' by: Thomas J. Murphy. Salem Street is 10' + below the grade of the yard. Wetland area is 10'+ below the grade of the yard where is the system is located. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 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 w 2201 Salem Street Property Address Periathamby Owner Owner's Name information is required for North Andover MA 01845 October 7, 2015 every page. Citylrown 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 stlmated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I i t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 , 7f + a f � � -T\1.... a' Oji..OT fi b,. f f i t�t , � t E J I - - (�. , " t`( !�i.: ..,`I."A v i s," ..,-,1 i-'�•,+r I .. 'f+ I _ 3 j Ell S��`"�� ���F> _ .r�`a..-.�,'a. .. Y" nom.-:; E!• `��•�-. L: ! _ ' t r j ' -�' � `j SYS-Foe- -..:U-T- SA;4:-u.m I AIQ T PALAN BUIL - i i Of ISUBSuRFACE DISPOSAL LOWED 1N AS PREPARED FOR , OLD "i fC { DATE : O✓t- PIE- 16, i ��4�� •'>"� ��" ;P� F w _{..�.� { SCALE: f MERRIMACK ENGINEERING SERVICES, INC. l PROFESSIONAL ENGINEERS • LANO SURVEYORS 0 PLANNERS i � 06 PARK STREET + ANDOVER, MASSACHUSETTS 01818 TEL. {617) 473-3365. 37$-5 I j j1 _ 1 . J-440 IU kjo:Af:..W M ASS. . at�1 t.l C J,A 1,b 1t•t .( oZ 01-D H Ili.. com Sr � F L>-� '�},+,.o' �;� .. SOT '��•� E 1 I 1 I '\ 1 4J r,SF DN S-n;cw sit Syr ,moi u��' "Y" wnAN. O AS 9MREO FM 6-j-D MILL CoU�Mak2'1''iOU r r MER-RIMACK NOINEIRRING SRA 'S, 01 Q PNOFESSIONAi ENPINOOS: 0 tIA \ 006 a KANN5 I46 pr.pN sT9E#T MASW,M Nr►e tl 014 . tllr 4071)a73- is. P" 1 Commonwealth of Massachusetts Map-Block-Lot ?�`<<•''° a,¢+o� 090_B-0045- Board of Health Permit No s , • s � � a North Andover BHP-2008_______-0____009____ P.I. FEE CNuSE< F.I. $125.00 ----------------------- Disposal Works Construction Permit Permission is hereby granted Todd-Bate-son to(Construct)an Individual Sewage Disposal System. at No 2201 SALEM STREET as shown on the application for Disposal Works Construction Permit No. BHP-2008-000 Dated February26,2008 --------------------------------------------------------------- Issued On:Feb-26-2008 Board of Health ,►oaa& Ma Block-Lot Commonwealth of Massachusetts p- a 090.B-0045- 3 ` Board of Health ------------------------ O A North Andover ' -,_,°: ° Certificate of Compliance �sS CHU t� THIS IS TO CERTIFY,That the Individual Sewage Disposal System (Construct) by Todd Bateson Installer at No 2201 SALEM 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-20087000 Dated February-26,20-08 ----------------------------------------------------------------- Printed On:Feb-26-2008 Board of Health Application for Septic Disposal System ;Construction Permit - TOVN OF TODAY'S DATE NORTH ANDOVER, MA 01845 $250.00—Full Repair - :•`,5 $125.00 -Component VSs^cHuse� Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer,use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key to move your Nepair or replace an existing system component �'��w K SZ - X cursor-do not use the return A. Facility Information key. Address or Lot# 11 a�, 11 Cityffown d L/X-19- 2.-*TYPE OF SEPTIC SYSTEM*: ❑ Pump ❑ Gravity (choose one) ***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 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 Information I Name �a Address(if different from above) City/Town State Zip Code Telephone Number 3. Installer Information _ aPQame of Com an Name p y Address A-J eq 8!6� City/Town State Zip Code — Telephone Number(Cell Phone#if pssible please) 4. Designer Information Name Name of Company Address CitylTown_ -------- ---- State Zip Code-------..__.. .. Telephone Number(Best#to Reach) Page 1 of 2 Application for Disposal System Construction Permit• f Application for Septic Disposal System -� TODAY'S DATE p onstruction Permit - TONT OF $250.00—Full Repair ORTH ANDOVER, MA 01845 $125.00-Component PAGE 2 OF 2 A. Facility Information continued.... 5. Type of Building: pa<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 issu this Board of Health. Nam Date Applicati Approved B oard of Health Representative) Z--,7_L Ire mDate Application Disapproved for the following reasons: r Office Use Only: 1. Fee Attached? Yes No Z Project Manager Obligation Form Attached? Yes No 3. Pump System? If so.Attach copy ofElectrical Permit Yes No 4. Foundation As-Built?(new construction ronly): Yes /YI No (Same scale as appro wd plan) ^� 5. Floor Plans? new construction only): Yes ( Y) — — -' SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: oao (-address of septic sj,stein) For plans by �Q ^ ngineer) Relative to the application o "v' //✓�i�- ��SG�� (Installer's name) And dated ngma ate Dated 1��4 o ac's ate With revisions dated (Last rexised 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 done. 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 completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a 550.00 fine being levied against me and/or my company. a. Bottom of Bed—Generally,this is the first(15)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 work 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. I further understand that work done by others unlicensed to install sel2tic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover.significant fines to all persons involved are also possible. 5. As the installer,I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached A 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 chamber,retaining wall and other components. 6. As the installer, I understand that I am solely responsible for the installation of the system as per the a� roved plans No instructions by the homeowner,,general contractor or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: oday3s Date) (Name—Print) ee—Signe TOWN OF NORTH ANDOVER aeR7N Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT p 1600 OSGOOD STREET; Building 2-36 NORTH ANDOVER,MASSACHUSETTS 01845 Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 4aol 0�XkAl ? s7: MAP: LOT: INSTALLER: 1�1fiTf�� 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 []Existing septic tank properly abandoned ❑Internal plumbing all to one building sewer ❑Topography not appreciably altered Comments: SEPTIC TANK NNI Bottom of tank hole has 6" stone base Weep hole plugged dA- 1500 gallon tank h itat H-10 loading onolit .ic construc Water tightness of tank has been achieved (Visual or Vacuum Test or Water held for 24hrs) ❑ Inlet tee installed, centered under access port ❑ Outlet tee (gas baffle or effluent filter) installed, centered under access port ❑ 4" inch cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present ❑ Hydraulic cement around inlet & outlet Wastewater System Documentation—Feb 2006 Page 1 of 6 i i - TOWN OF NORTH A1NDv v-n..— _ r Office of COMMUNITY DEVELOPMENT AND SERVICES 32 ' oaG HEALTH. DEPARTMENT A 1600 OSGOOD STREET; Building 2-36 "� x NORTH ANDOVER,MASSACHUSETTS 01845 �'"ss CH„5E<�� Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ Combo Tank installed. Size: ❑ 1000 gallon Pump Chamber installed H-10 loading Monolithic 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 ❑ 24" inch cover to within 6" of final grade installed over pump access port ❑ Water tightness of tank has been achieved Visual testing ❑ Hydraulic cement around inlet & outlet Comments: ADVANCED TREATMENT TECHNOLOGY ❑ Type of treatment device: ❑ Installed per manufacturers requirements ❑ All components working in accordance with manufacturer's requirements Comments: Wastewater System Documentation—Feb 2006 Page 2 of 6 l•L r i TOWN OF NORTH ANDOVER µOR7y Y Office of COMMUNITY DEVELOPMENT AND SERVICES ,r2°6`=� � HEALTH DEPARTMENT - A i * 1600 OSGOOD STREET; Building 2-36 NORTH ANDOVER,MASSACHUSETTS 01845 ��4 S CHUSER�h Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX D-BOX / — ) [� Installed on stable stone base �/ QV, Inlet tee (if pumped or >0.08'/foot) ydraulic cement around inlet &_outlets bserved even distribution [a�Speed levelers provided (not required) Comments: SOIL ABSORPTION SYSTEM ❑ Bottom of SAS excavated down to soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 3/4-1 Y2" double washed stone installed ❑ 1/8-1/2" (peastone) double washed stone installed ❑ Laterals installed and ends connected to header ❑ Laterals vented if impervious material above ❑ Orifices @ 5 & 7 o'clock positions ❑ Gravel-less disposal systems: type, number and location as per plan ❑ Elevations of laterals installed as on approved plan ❑ 40 Mil HDPE barrier installed ❑ Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: Wastewater System Documentation—Feb 2006 Page 3 of 6 Y TOWN OF NORTH ANDOVER µoerk •' Office of COMMUNITY DEVELOPMENT AND SERVICES o HEALTH DEPARTMENT ti A 1600 OSGOOD STREET; Building 2-36 NORTH ANDOVER,MASSACHUSETTS 01845 SSgCHUsk�{h Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health.Director 978.688.8476—FAX PRESSURE DISTRIBUTION ❑ -- inch manifold ❑ laterals installed with end sweeps size: material: ❑ Squirt test ft in height ❑ Equal distribution to all laterals ❑ orifice size inch as per plan Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: ❑ Rated for exterior if placed outside Comments: Wastewater System Documentation—Feb 2006 Page 4 of 6 it TOWN OF NORTH ANDOVER HOR71{ Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 1600 OSGOOD STREET;Building 2-36 NORTH ANDOVER,MASSACHUSETTS 01845 ��SSACHUSE��h Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX 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 10 101 ❑ 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 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02). 3 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 Wastewater System Documentation—Feb 2006 Page 5 of 6 TOWN OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT a p 1600 OSGOOD STREET; Building 2-36 " nq 94Tin NORTH ANDOVER,MASSACHUSETTS 01845 9ssaCHueE{ Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX SYSTEM ELEVATIONS INVERT ON DESIGN PLAN FIELD INVERT ELEV. Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 HIGH Lateral 1 LOW Lateral 2 HIGH Lateral 2 LOW Lateral 3 HIGH Lateral 3 LOW Lateral 4 HIGH Lateral 4 LOW Lateral 5 HIGH Lateral 5 LOW Wastewater System Documentation—Feb 2006 Page 6 of 6 !a)O�/8 3 -S -2p ON RIO �c � FORM U - LOT 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 or requirements. APPLICANT FILLS OUT THIS SECTIO APPLICANT PHONE q78-G83-5-G1 ( LOCATION: Assessors Map Number . PARCEL- SUBDIVISION LOT(S) STREET ST. NUMBERZZ0/ OFFICIAL USE ONL COM D OFT AGENTS: C NSERVATION ADMINISTRATOR DATE APPROVED , DATE REJECTED 1 + COMMENTS]j� O TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-H ` DATE APPROVED JDATE REJECTED SE I INSPECTOR4i TH DATE APPROVED DATE REJECTED COMMENTS S '� PUBLIC WORKS -SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT. BOARD OF HEALTH Town os North Andover ,Mass . Permit Date 19�� „ APPLICATION FOR WELL & PUMP PERMIT Application is hereby made for permit to drill a well ( •_ Application is made to install C ) a pump system-. Location: Address e/� �iP��� .Lot # Owner e f Address / a&Z el . q,3•f-�( �' Well Contractor/�Mc,?/ pg4jl'9d G(��t'/Address �£o� ��i,�/ Te1 .373S-/;7Or Pump Contractor me- Address S,q/0C Tel ✓ S Vme_ ' WELL- CONTRACTOR (To be completed at time of pump test ) •*`....pe. Well used for OolneS T/e- iyo.L Diameter of Well '/ Size of. Casing - Depth o.f Bed Rock p Depth casing into Bed Rock Was Seal Tested? Yes No ( ) Date of Testing Depth ,—f We-=1— — 1 - Well Ended, in W.ha-t-. Material Depth to Water Delivers /a Min. for 4 hours Drawdown feet after pumping c3 _hours- at Jp . .' GPM Zlc4e. 2 3 Date of Completion Signat Well Contractor L LL •�'J(:X.CnJ.J'J.J;J.J.J.J. ,J,J.J.J•J.LI,J,J.,I.J..�t.nniC i�:n i�n"n iC i�i�-X i�;�i�i�i�iC iC iC i�iC-- n��i�iCnn nn.�X iC iC n X�i�:X nen Cnn TJ..J,X X* PUMP INSTALLER (To be'- filled i.n' before installation) Size & Name Pump /y�/�lI/,f �/ ��fj i°Y �1�_.__Pump Type Used177el-91.7JJe. Water Pump Delivers1�9- - -GPM Size of Tank &e? Z-- Pipe Pipe Material Used in Well : Cast Iron (_) G;il.vani.zed (_) Plastic ((�/ Well Pit (_) or Pitless .Adapter (4,�" Was sleeve used .to protect pipe? Yes (_ NO(_) Ty2c or Name Well Seall7joR kif nate fj ��at;U7CC'-;,P ,e�.TD��F� �r�k�41�yM�4ti4�r�t�4tik�lr�a�a�r�a�htia�'r��ti4�lr�r�r�ts4�rs�r�rtilrs��lr�r�hstirti'rs'rtiNi4ti'rs'r�rti'rY: r :;:;c;:;.:::.3.;:::. c;, n Date Water analysis repor-t submitted to Board of ]Tealth Date release given tD owner of record & Bldg. Insp Health Inspector - WELL DATABASE - ADDRESS: AGE OF WELL:�/ A ' WELL DRILLER: ' C WELL PERMIT T: ,O WELL LOCATION: WELL-PERLITT DATE: DEPTH OF WELL: D6 - TYPE OF WELL: a_ DRILLED b. DUG c. OWN — TYPE OF WATER BEARING ROCK: WATER ANALYSIS DATE_ G HIG GANESE:. Y HIGH IRON: �Y N O t CONT ANTS: Y N (603) 868-3212 DVANCE 749-3868 772-5940 PUMP AND FILTER CO., INC. 10 Calef Highway,Route 125,Lee,N.H. 03824 W A T E R T E S T R E P O R T NAME: Jay Alper WELL LOCATION: ADDRESS: 270 Lafayette Road Unit 11-255 ADDRESS: 2201 Salem Street CITY, STATE, ZIP: Seabrook, NH 03874 CITY, STATE, ZIP: North Andover, MA TEL #: 926-2059 TEL #: DATE COLLECTED: 4/25/95 COLLECTED BY: Jay Alper SAMPLE #: 1063 ANALYSIS MAXIMUM YOUR COMMENTS IIANALYSIS MAXIMUM YOUR COMMENTS PERFORMED LEVEL RESULT IIPERFORMED LEVEL RESULT PRIMARY PARAMETERS: SECONDARY PARAMETERS: Total Coliform Bacteria NEG NEG IIpH 6.5 - 8.5 7.15 E-Coli Bacteria NEG NEG IlHardness No Guideline 82.0 S-CONCERN Nitrate7. <10 mg/L 0.16 IlIron <.30 mg/L 0.073 Nitrite <1 mg/L 0.02 IlManganese <.05 mg/L <0.005' Flouride <4 mg/L <0.1 IlChloride <250 mg/L 40.0 Arsenic <.05 mg/L IlSodium <250 mg/L 17.4 Silver <.05 mg/L ,Tannins/Lignins <2 mg/L 0.12 FHA ADDITIONAL PARAMETERS: LEAD & COPPER: IlColor <15 c.u. Lead (flush) * <.015 mg/L <0.01 II0dor None Lead (first draw) * <.015 mg/L IlTurbidity <5 t.u. Copper (flush) * <1.3 mg/L 0.418 OTHER PARAMETERS: Copper (first draw) * <1.3 mg/L IITDS <500 mg/L IlAlkalinity No Guideline IlCalcium Hardness' No Guideline * These are ACTION LEVELS which are set by the EPA, if lead IlLanglier Index >0 and copper exceed the levels, treatment is recommended. IlTemperature No Guideline I) A�The tested parameters meet current standards for drinking water. XXXX The tested parameters meet current primary standards for drinking water, but some secondary parameters exceed maximum levels. The tested parameters fail current standards for drinking Water because the primary standards exceed maximum levels. If any S-Concerns are noted, secondary parameter(s) exceeds maximum levels. KEY TO COMMENTS: P-CONCERN means that a primary parameter exceeds maximum level. Water is not safe. S-CONCERN means that a secondary parameter exceeds maximum levet. Treatment is optional. ACTION means that action should be taken to reduce level. Cathleen Pleadwell, Office Manager Test performed by NH State Certified Lab Certification #102994-D (Water) #102994-C (Wastewater) "AFTER THE SALE, IT'S THE SERVICE THAT COUNTS"