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Home My WebLink AboutMiscellaneous - 2241 TURNPIKE STREET 4/30/2018 (2)FM N_ O N � A O -A C i7 X O Z O WT 9)m o cn o x O m North Andover Board of -Assessors Public Access �"` 4 Page 1 of 1 04 pOR7h �d orth Andover B;oalydd of Asso ssers of s«°o ;°'9ry0 roperty Record Card Parcel ID :210/108.C-0036-0000.0 FY:2012 Community: North Andover Click on Sketch to Enlarge Location: 2241 TURNPIKE STREET Owner Name: ROSTEN, DORIS M Owner Address: 2241 TURNPIKE STREET City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 5 - 5 _ Land Area: 2.03 acres Use Code: '101-SNGL-FAM-RES Total Finished Area: 2510 sgft Total Value: 376,000 — 376,000 J Building Value: 230,000 230,000 Land Value: 146,000 146,000 — - Market Land Value: 146,000 Chapter Land Value: Sale Price: 1 $ Sale 12/23/1993 —.;Date: - - — -- --- __ — -- Arms Length Sale F-NO-CONVNIENT Grantor: ROSTEN, RICHARD Code: Cert Doc: Book: 03941 "Page: 0058 http://csc-ma.us/PROPAPP/display.do?linkld=1896804&town=NandoverPubAcc 12/23/2011 Commonwealth of Massachusetts = City/Town of System Pumping Record NORTH ANDOVE Form 4 OF NORTH ANDOVER I 6. System Pumped By: Name Vehicle License Number Company '^ 7. Location where contents were disposed: of Receiving Facility G.L.S.n.. -- f77r 7 Date Date t5form4.doc• 03106 System Pumping Record • Page 1 of 1 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out forms on the 1. System Location: computer, use only the tab key to move your Address cursor - do not use the return CityfTown State Zip Code key. 2. System Owner: J -Ah Name ---- - - ---- Address (if different from location) CityfTown State Zip Code Telephone Number B. Pumping Record 2. Quantity Pumped: 1. Date of PumpingDate — Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): ---- - — — - -� 4. Effluent Tee Filter present? ❑ Yes8-fVo' - If yes, was it cleaned? ❑ Yes ❑ No 5. ConditionofSyste1 Mr 6. System Pumped By: Name Vehicle License Number Company '^ 7. Location where contents were disposed: of Receiving Facility G.L.S.n.. -- f77r 7 Date Date t5form4.doc• 03106 System Pumping Record • Page 1 of 1 � Town of North Andover HEALTH DEPARTMENT CHECK #: / a;Z DATE: /—,� X— /, — LOCATION• //aC�� 6Y, H/O NAME: CONTRACTOR NAM Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ VT oitle 5 Report_) $ ❑ Other: (Indicate) 0, � Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Coiiinmonwealth of Mamachusette Title 5 Official Inspection FormWE zit j Subsurface Sewage Disposal System Form - Not for Voluntary Assessments um ip ke Street ---- Property Address Doris Rosten Owner owners Name information is North Andover MA 01845 12-23-11 required for Ciry/Town state Zip Code Date of inspection every page. 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. importnt; A. General information When gling out ,_. , forms on the ,. computer, use 1. Inspector: only the tab key _ to move your Benjamin C Osgood, Jr.- cumor - do not Name of inspector 4e use the return — key. none -- ------ fT R s s Company Name hiEALTH DEPARTMENT — "" 16 Hillside Avenue, Unit 3 — — -- -- — �-- Company Address MA 01913 I i Amesbury --- --- ----- Zi Code �--�' Cityrrown State P 978-834-6585 - 870 Tefephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the local Approving Authority �. 12 23-11 — Inspector's nature 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. Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments DTumpike Street _ _— Doris Rosten _ Owners Name North Andover con,rrom B. Certification (cont.) MA 01845 12-23-11 State Zip Code Date of Inspection Inspection Summary: Check A,B,C,D or E i always complete all of Section D A) System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old" or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y 0 N ❑ ND (Explain below): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ?294 umplke Street Property Address Doris Rosten Owner Owner's Name information is required for North Andover MA _ 01845 12-23-11 every page. Ckyfrown StatE Zip Code bats of Inspection B. Celftification (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 ❑ obstruction is removed ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ Y [j N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system Is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system Is not functioning In a manner which will protect public health, safety and the environment: ❑ Cesspool or privy Is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Commonwealth of Massachusetts IVTithe 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ike Street Property Address Doris Rosten Owner Owner's Name Information is required for North Andover MA 01845 12-23-11 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fall unless the 13oard 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 wafter supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "" This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must Indicate "Yes" or "No" to each of the following for AD inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than'/, day flow Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Porn - Not for Voluntary Assessments -228h Turnpike Street Property Address - — Owner Doris Rosten Owner's Name information Is required for North Andover MA 01845 12-23-11 every page. Cityfrown State Zlp 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: ❑ Z 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 &k. 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 ❑ z 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. C.OMMOnWe8ith of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �-Turnpike Scree# Property Address Owner Doris Rosten Owners Name information is -"— required for North Andover MA 01845 12-23-11 every page. city/ town State Zip Code Date of Inspee Mn 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 pians 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): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): commomwreaith of massachusetts Title 5 official Inspection Form Subsurk" $ew890 DlsPosal Syst$m Form - Not for Voluntary Assessments 22ft Tumpike Street Property Address Owner Doris Rosten information is Owners Name - required far North Andover MA 01845 every page. City/Town state Tip Code Date 12-23-11 Impaction — D, System Information Description: Number of current residents: a •., n 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 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/industrial Flow CondiWons: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft, etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) well ® Yes ❑ No current _ Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Commonwealth of massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth - Not for Voluntary Assessments >?Z ,,Tum ike Street Property Address OwnerDoris Rosten information is owner's Name required for North Andover MA 01845 12-23-11 _ every page. city►ITown state Zip Code pate of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Pumped 2003 per owner gallons Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Yes ® No ❑ 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): Septic tank with one leach trench Commonwealth of Massachusetts T'i'tle 5 Official Inspection Form Subsurface Sewage Disposal System Poem - Not for Voluntary Assessments aaW 228+Turn ike Street Property Address Owner Dods Rosten information is Owner's Name required for North Andover MA 01845 12-23-11 every page. CRY/Town 8t to Zip Code Date of inspection D. System Information (Cont,) Approximate age of all components, date installed (if known) and source of information: Constructed in late 60's per owner with possible rework more recent) Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 6' feet Material of construction: (@ cast iron ❑ 40 PVC ❑ other (explain): — --- Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipe looks good in basement Septic Tank (locate on site plan): Depth below grade: 3' feet Material of construction: 0 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: 1000 gallons — z.. Sludge depth: — _ Owner informawn Is required for every page. COMMOnweaith of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Sys„ Form - Not for Voluntary Assessments D-,-)ql 42&rTumpike Street Property Address Owner's Name North Andover City/Town D. Sys#om Ilr!tformation (cont,) MA 01845 12-23-11 state Zip Code bate of Inspection Septic Tank (cont.) 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 Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 30" 5" 14" measure tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc,): Tank in good condition. PVC TEE in good condition Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: filet ❑ polyethylene ❑ other (explain): Date Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurtace Sewage Disposal System Form _ No aaq 1 t for Voluntary Assessments � Turnpike Street Property Address — Owner Doris Rosten Information is owners NamefSqU fired for North Andover MA 01845 12-23-11 every Pte. cl yfrown State Zip Code Data of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow. Alarm present: Alarm level: Date of last pumping: gallons per day 0 Yes ❑ No Alarm in working order: ❑ Yes ❑ No I Comments (condition of alarm and float switches, etc.): 0 x Attach copy of current pumping contract (required). Is copy attached? ❑ Yes 0 No Commonwealth of Mmuchusette Title 5 Official Inspection Form Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments ,;�.jq I ?M Turnpike Street Property Address Owner Doris Roston Information is Owner's Name _ required for North Andover MA 01845 12-23-11 every page. Clty/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 N/A 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.): No Distribution box 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.): Soils Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 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 0 No Commonwealth of Massachusetts Titl-a 5 Official Inspection Foix m Subsurface Sewage Disposal System F - Not for Voluntary ry .Assessments 223'i Tumpike Street Property Address Owner Doris Rosten Information is OWnees Name required for every page. North Andover MA Ctty/rown 01845 1 State D. System Information (cont.) Zip Code Daste of te of 19 inspection Type: ❑ leaching pits number: ❑ leaching chambers number: - ❑ leaching galleries number. ® leaching trenches number, length; 1 78' long trench ❑ leaching fields number, dimensions: -- ❑ overflow cesspool number.- umber:❑ 0innovative/altemative system Type/name of technology; — — Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Area of trench is wooded and looks normal. stone at end of trench clean and dry 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 0 No Commonwealth of Maa®achusetts IOUTitle 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 22ft Turnpike Street Property Address - Owner information is required for every page. uwnnea rjam. North Andover MA 01 Cilylfown — 12-23-11 State ZIP Coda Date of Inspection U. 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.): . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments aa4 *234.Tumpike Street Property Address Owner Doris Rosten infonnaaon is Owners Name required for North Andover MA 01845 12-2319 every page. City/Town Skate 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: I� hand -sketch in the area below ❑ drawing attached separateiv R z, S 12d k 4-- i as Q � Xcccuc:,Zipv. '�51ti u E GLr= OAA �N� J> COMMO wealth Of Massachusetts Title 5 Official Inspection Form $uibsUdace Sewage Dis Daq) ag posai System p'onm -Not far Voluntary Assessments lug 34 -Turnpike Street Property Address _---_ Doris Rosten Owner information is Owner's Name required far North Andover MA 01845 12-23-11 every page. cityrrown State Zlp Code We of Inspection D. 3yatem information (cont.) Site Exam: r Check Slope Surface water Check cellar ® Shallow wells Estimated depth to high ground water: >6 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design pians on record If checked, date of design plan reviewed: bate ® 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: System built on the side of a hili in fill and is 18" below ground at the end of the system. USGS maps indicate water table is > 6 feet below grade Before filing this Inspection Report, please® see Report Completeness Checklist on next page. ' - Commonwealth of Meaasachwi ette WTitle 5 Official Inspection Form subsurface Sewage D1s DNI mesal System Form -Not for Voluntary Assessments -229t Turnpike Street Owner, Doris Rosten information is Owner's Name r"uired for North Andover MA 01645 every page. URY/rown State ti C 12 23-11 E. Report Completeness Checkf fe# -- State -AP Date of inaperlon ® Inspection Summary; A, 8, 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 BUTTERWORTH & O'TOOLE, INC. P.O. BOX 8294 SALEM, MA 01971-8294 ADJUSTERS/APPRAISERS FOR INSURANCE COMPANIES ONLY TELEPHONE (978) 741-5731 FAX (978) 740-9109,,, p�r . January 13, 2004 FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B TO: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectmen City/Town Hall ADDRESSES North Andover, MA 01845 RE: Insured: Doris Rosten Address: Policy No.: Loss of: 2241 Turnpike Street City/Town Hall North Andover, MA 01845 North Andover, MA 01845 F0227284 01/12/04 File or Claim No.: 041-0057 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. If no reply is received from your office within ten days, we will assume you have no liens of any type against this property and we will recommend to the insuring company that this claim is paid. Vicki Gardner. Adjuster BUTTERWORTH & O'TOOLE, INC. P.O. BOX 8294 SALEM, MA 01971-8294 ADJUSTER SIA PPR A I SER S _... _..._ . FOR INSURANCE COMPANIES ONLY TELEPHONE (978) 741-5731 FAX (978) 740-9109 January 13, 2004 FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B TO: Building Commissioner or Inspector of Buildings City/Town Hall ADDRESSES Board of Health or Board of Selectmen City/Town Hall North Andover, MA 01845 North Andover, MA 01845 RE: Insured: Doris Rosten Address: 2241 Turnpike Street North Andover, MA 01845 Policy No.: F0227284 Loss of: 01/12/04 File or Claim No.: 041-0057 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any .notice under Mass. Gen. Laws, Ch. 139, Sec. 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. If no reply is received from your office within ten days, we will assume you have no liens of any type against this property and we will recommend to the insuring company that this claim is paid. Vicki Gardner Adjuster 77 • ` _ _ bv TbwN 0.' NORTH OV�R;.r �4y SYSTEM PUMPING E CORS � --------,---. ; � 203 >> I EM UwN R & ADDRE$Iw SYST W LOCATIOtY (ex�mPle, lc`(froni of hour) a yi rx� U I C OF PVMf'INC, !d 3QUANTITY ('UMPCD �LL(�.�� ,sI,o01`•NC)` YESSEPTIC'TANK; NO YES NATURE.OF SERVICE, ROU'r1NE',,,V EMERCEN'cy tali:>r'fZY�iT10NS;..:; ��•;',.. .. CUOD CUNllJTION, NULL TU CUYEit .13AFFLLS IN PLACh RQOTS a> LEACHFICLD RUNUAC'K..,_ CXCESSIYE SQ:LIDS FLOODED SOL IDS` CARRYOVER p HFR.(EXPLA.1N) r . . a J. 0222027794 j Commonwealth of Massachusetts Massachusetts System Pumping Record Form 4 -- Syste RECEIVED OCT 0 4 2009 TOWN OF NORTH ANDOVER System Owner System Location - Ro:3ten Doris Primary Hamra 2241. Turnpike St 2241 Turnpike St North Andover, MA, 01345 North Andover, MA, 01845 078)-688-1169 x (978)-688-1169 x Ro3ten 00312009 Pumping Record Type: Emergency Routine Cesspool: No YesSeptic Tank: No Yes. Date of Pumping: Quantity Pumped: /013 O Gallons System Pumped By: Wind River Environmental, LLC Permit #: Contents Transferred to: Contents Disposed at: Ipswich Water Treatment Plant Ipswich, ISA 019: Date: ` ' Pumper Signature: ,Condition of System/Other Comments Ipswich Water Treatment Plant Ipswich, MA 01938 ® Printed on recycled paper Dep Approved Form -12/07/95