The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 24 PATTON LANE 4/30/2018 (2)u �. - w ov w a � a n . # . ��. _ ` -. y`r N SY..,—�. .`.nam � r•rr .. _ . _3 - -' . .` - "•' ,*. Gid 1 14 IoA) T1s y efr Y THAV T VFX f7rM . � ALUE SH t4. N A, WARPANTY. �. - r ALAN SH&I'lilac e�u § F_ ._ TION' T LET. _ . ° _DATE 4 - ' .40 n .. .: Commonwealth of Massachusetts( / -RECEIVED p Title 5 Official Inspection Fo m Subsurface Sewage Disposal System Form - Not for Voluntary As essm�2 8 2009 vyl1r M 0'y 24 Patton Lane TH ANDOVER Property Address HEALTH DEPARTM Kevin Patch Owner Owner's Name information is required for North Andover MA 01845 9/3/2009 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be alt9md in any way. Please see completeness checklist at the end of the form. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. A. General Information 1. Inspector: Neil J. Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover Ma 01810 City/Town 978-475-4786 Telephone Number B. Certification State Zip Code SI15 License Number 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 41-A- 9/3/2009 lnspkt# Agnatur(JDate 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 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Patton Lane Property Address Kevin Patch Owner's Name North Andover City/town B. Certification (cont.) MA 01845 State Zip Code 9/3/2009 Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Patton Lane Property Address Kevin Patch Owner's Name North Andover MA 01845 9/3/2009 City/Town 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 ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ 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. 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 • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Patton Lane Property Address Kevin Patch Owner's Name North Andover MA 01845 9/3/2009 Cityrrown 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) 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 Y2 day flow t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17 ❑ ® 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 w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Patton Lane Property Address Kevin Patch Owner information is Owner's Name required for North Andover MA 01845 9/3/2009 every page. Cityfrown 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 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 a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Patton Lane Property Address Kevin Patch Owner information is required for every page. Owner's Name North Andover MA 01845 9/3/2009 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 plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): MX t5ins - 09/08 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 24 Patton Lane Property Address Kevin Patch Owner Owner's Name information is required for North Andover MA 01845 9/3/2009 every page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: 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) 4 ❑ Yes ® No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ® No Yes ❑ Yes ® No Current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 09/08 Title 5 Oficial 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 M 24 Patton Lane Property Address Kevin Patch Owner information is required for every page. Owner's Name North Andover Cityrrown D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: MA 01845 State Zip Code Date General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: 9/3/2009 Date of Inspection Pumped last year,owner 1500 gallons Measured tank Inspect tank & tees 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 • 09108 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Patton Lane Property Address Kevin Patch Owner Owner's Name information is required for North Andover MA 01845 9/3/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 24 years old, 12/27/1985, as built plan Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from rivate water su I well or suction line' ❑ Yes ® No feet F pp y feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" PVC & 3" PVC thru floor & 3" PVC in house, no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 2' feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 10'x 5'x4' Sludge depth: 2 ❑ Yes ❑ No 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 wM 24 Patton Lane Owner information is required for every page. t5ins - 09108 Property Address Kevin Patch Owner's Name North Andover Cityrrown D. System Information (cont.) MA 01845 9/3/2009 State Zip Code Date 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 2611 2 811 1911 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 tee ok. Depth of liquid at outlet invert. Tank under driveway, center cover has riser. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness ❑ fiberglass 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 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 feet ❑ polyethylene ❑ other (explain): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' 24 Patton Lane Property Address Kevin Patch Owner information is required for every page. Owner's Name North Andover City/Town MA 01845 State Zip Code 9/3/2009 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.): 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: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ No Alarm in working order: Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ❑ Yes ❑ No * 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 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Patton Lane Property Address Kevin Patch Owner's Name North Andover MA 01845 9/3/2009 Citylrown 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 evidence of leakage into or out of box, etc.): D -box level & distribution equal. No evidence of leakage. Evidence of light driveway. Pump Chamber (locate on site plan): carryover, any .D -box under 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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Owner information is required for every page. t5ins - 09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Patton Lane Property Address Kevin Patch Owner's Name North Andover MA 01845 9/3/2009 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits ❑ leaching chambers ❑ leaching galleries ® leaching trenches ❑ leaching fields ❑ overflow cesspool ❑ innovative/alternative system number: number: number: number, length: number, dimensions: number: 3 trenches 40' 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 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Patton Lane Property Address Kevin Patch Owner's Name North Andover MA 01845 9/3/2009 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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Patton Lane Property Address Kevin Patch Owner Owner's Name information is required for North Andover MA 01845 9/3/2009 every page. City/Town 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 M A'�o-��`7�W t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 24 Patton Lane Property Address Kevin Patch Owner information is required for every page. Owner's Name North Andover RAA City/Town State D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated de th to hi In round water' 01845 9/3/2009 Zip Code Date of Inspection >4 F g g feet Please indicate all methods used to determine the high ground water elevation: ►/ 1 Obtained from system design plans on record If h kddt fd in Inrv'wd' 4/1/1985 c ec e, a e o es g p a a ie e. 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: As per design plan test pit data no water 4' below trenches Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 09/08 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts H Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Patton Lane Owner information is required for every page. Property Address Kevin Patch Owner's Name North Andover City/Town State Zip Code 9/3/2009 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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 • Summary Record Card generated on 9/3/2009 3:25:36 PM by Karen Hanlon Town of North Andover Tax Map # 210-106.A-0132-0000.0 Parcel Id 17276 24 PATTON LANE PATCH, KEVIN 24 PATTON LANE NORTH ANDOVER, MA 01845 Page 1 Class 101 Single Family Property Type 1 Residential Size Total 1.07 Acres FY 2010 UB Mailing Index Name/Address . Type Loan Number Active/Inact. From Until PATCH, KEVIN Payor 24 PATTON LANE NORTH ANDOVER, MA 01845 UB Account Maint, Account No Cycle Occupant Name Active/Inactive Bldg Id. 17377.0 - 24 PATTON LANE Last Billing Date 7/8/2009 3170047 03 Cycle 03 Active UB Services Maint. Account No. 3170047 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 142.20 /1 UB Meter Maintenance Account No. 3170047 Serial No Status Location Brand Type Size YTD Cons 13242460 a Active ERT HH METE METE w Water 0.63 0.63 161 Date Reading Code Consumption Posted Date Variance 6/4/2009 658 a Actual 35 7/20/2009 30% 3/12/2009 623 a Actual 31 4/29/2009 -39% 12/5/2008 592 a Actual 46 1/20/2009 73% 9/8/2008 546 a Actual 29 10/10/2008 34% 6/4/2008 517 a Actual 20 7/16/2008 32% 3/7/2008 497 a Actual 15 4/11/2008 -34% 12/10/2007 482 a Actual 25 1/22/2008 -43% 9/4/2007 457 a Actual 37 10/12/2007 35% 6/14/2007 420 a Actual 31 7/20/2007 15% 3/13/2007 389 a Actual 28 4/16/2007 12% 12/6/2006 361 a Actual 23 1/19/2007 62% 9/8/2006 338 a Actual 14 10/20/2006 -38% 6/12/2006 324 a Actual 25 7/10/2006 2% 3/6/2006 299 a Actual 20 4/17/2006 11% 12/16/2005 279 a Actual 21 1/17/2006 -65% 9/14/2005 258 a Actual 62 10/14/2005 153% 6/9/2005 196 a Actual 21 7/15/2005 -4% 3/18/2005 175 a Actual 26 4/5/2005 -14% 12/9/2004 149 a Actual 26 1/14/2005 -56% 9/15/2004 123 a Actual 67 10/8/2004 57% 6/10/2004 56 a Actual 26 7/30/2004 89% 4/12/2004 30 a Actual 30 5/17/2004 Ooh, Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left side of house, Right side of house,(Left front of house, Right front of house, Left rear oqf house, Right rear of house. V, v -e_ wit Address City/Town 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): ' State Riz�lt I,— 9— 3 -orl — 2. Quantity Pumped eptic Tank Date Cesspool(s) Zip Code State Zip Code G ��-- 0 Telephone Number Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes 2 -No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location ere contents were disposed: Lowell Waste Water Vehicle License Number F5821 e�r7/— --?--d 9 Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Owner information is required for every page. Important: When filling out forms on the. computer, use only the tab key to move your cursor - do not use the return key. fA Ar Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Patton Lane Property Address Ashley Collins and George Grandmain -- Owner's Name North Andover _ MA 01845 10-12-11 Citylrown 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: A. General Information 1. Inspector: .„ b Benjamin C. Osgood, Jr. Name of Inspector none OCT 1 � 20_tl _. _ --- - - Company Name 16 Hillside_ Avenue, Unit 3 Company Address Amesbury Cityrrown 978-834-65V5 -- Telephone Number B. Certification. TOWN OF NORTH ANDD MA 01913 State Zip Code Ul V License Number l certify that l 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: 0 Passes ❑ Conditionally Passes ❑ Fails ❑ Needs f=urther Evaluation by the Local Approving Authority 0 _ inspectors gnatureIV 10-12-11 Date The systems inspector small submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)uvithin. 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. A -;t ; -tv 1 crit conditions at the time of inspection and under the conditions of use -is isifipection does not address how the system will perform in the future under yr 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 9A Pnftnn I anp Property Address Ashley Collins and George Grandmain Owner's Name North Andover City/Town B. Certification !Cola.) MA 01845 State Zip Code 10-12-11 Date of Inspection 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_ Systern will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health_ * 1 metal Nt"C nL V ll Pass irisPOCtionif i* is structurally sound, not leaking and if a Certificate of inciiicating that the tank is less than 20 years old is available. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Patton Lane Property Address Ashley Collins and George Grandmain Owner owner's Name information is required for North Andover MA 01845 10-12-11 every page. Citylrown 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 it (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ 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. S_ System will pass unless Board of Health determines in accordance with 310 CMR s rstem 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 Tithe 5 Official Inspection Form Subsurface Sewage Disposal System f=orm - Not for Voluntary Assessments 24 Patton Lane Property Address Ashley Collins and George Grandmain Owner Owner's Name information is North Andover MA 01845 10-12-11 required for every page. City(rown 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. C. 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 all Inspections: Yes No ❑ 0 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 Form - Not for Voluntary Assessments 24 Patton Lane Property Address Ashley Collins and George Grandmain Owner Owner's Name information is North Andover MA 01845 10-12-11 required for every page. Cityfrown 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: ❑ N 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 El ® 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 anskvered "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. Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Patton Lane Property Address Ashley Collins and George Grandmain Owner's Name. North Andover MA 01845 10-12-11 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 dimensions, depth of liquid, depth of sludge and depth of scum? ® ® this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not The size and location of the Soil Absorption System (SAS) on the site has available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ® Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined. based. on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Patton Lane Property Address Ashley Collins and George Grandmain owner's. Name.. North Andover MA 01845 10-12-11 City/Town state Zip Code Date of Inspection Owner information is required for every page. D. System Information Description: Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercialllndustrial .Flow Conditions:. 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) ❑ Yes ® No ❑ Yes ® No ❑ Yes ® No ❑ Yes [R No ❑ Yes ® No current Date ❑ Yes ❑ No C] Yes ❑ No ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Patton Lane Property Address Ashley Collins and George Grandmain Owner's. Name North Andover MA 01845 10-12-11 City/Town State Zip Code Date of Inspection Owner information is required for every page. D. System Information (cont.) Last date of occupancy/use: 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: Date 9-30-09 Der BOH records 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): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Patton Lane Property Address Ashley Collins and George Grandmain Owner owner's Name. information is required for North Andover MA 01845 10-12-11 every page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Construction date approx 1986 per assessor's records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 2'feet Material. of. construction: ❑ cast iron ® 40 PVC ❑ other (explain): D' to f t t I II cti 1' ' N/A Is nce roI I IV va a wa er supe y we or su on Ine. feet Comments (on condition of joints, venting, evidence of leakage, etc.): pipe under floor in basement Septic Tank (locate on site plan): Depth below grade: 2.5 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) Dimensions.. 1500 Gallons Sludge depth: 2" ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °f 24 Patton Lane Property Address Ashley Collins and George Grandmain Owner owner's Name. information is required for North Andover MA 01845 10-12-11 every page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cant.) Distance from top of sludge to bottom of outlet tee or baffle 26 1" Scum thickness 9,. Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet -tee. or. baffle... 19" How were dimensions determined? Measure Stick and mirror 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 with riser at grade on center cover in driveway. Recomend installation of risers and covers over inlet and outlet tee to facilitate inspection and maintinance. Grease Trap (locate on site plan): Depth below grade: -twt 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 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Patton Lane Property Address Ashley Collins and George Grandmain OwneCs.Name North Andover MA 01845 10-12-11 Cftyrrown 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.): 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 Dimensions: Capacity: Design Flow: Alarm present: Alarm level: Date of last pumping: gallons ❑ polyethylene ❑ other (explain): gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Owner information is required for every page. Commonwealth of Massachusetts Title 6 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Patton Lane Property Address Ashley Collins and George Grandmain Owner's_ Name. North Andover MA 01845 10-12-11 Cityfrown 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.): Box in good condition. Box located under cut out in driveway. No evidence of solids carryover or leakage. Distribution equal. Pump Chamber (locate on site pian): 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: Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal: System Form - Not for Voluntary Assessments 24 Patton Lane Property Address Ashley Collins and George Grandmain Owners Name North Andover MA 01845 10-12-11 Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system 3 - 401ttrenches Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Area of trenches looks normal. No evidence of damp soil, ponding, or unusual vegetation 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Patton Lane Property Address Ashley Collins and George Grandmain Owner Owner's Name information is required for North Andover MA 01845 10-12-11 every page. City/rown 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.): Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Patton Lane Property Address Ashley Collins and George Grandmain Owner.s_Name. North Andover Cityrrown D. System Information (cont.) MA 01845 state Zip Code 10-12-11 Date of Inspection 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: Q� hand -sketch in the area below ❑ drawing attached separately M Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 24 Patton Lane Property Address Ashley Collins and George Grandmain Owner Owner's_htame information is required for North Andover MA 01845 10-12-11 every page. cityrrown state Zip Code Date of Inspection D. System Information (cont.) Site.Exam:. Estimated depth to high ground water: 0 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) z Accessed USGS database - explain: usgs maps You must describe how you established the high ground water elevation: USGS maps indicate water >6' below grade. System built close to ground surface on the side of a sloping area. Before filing this Inspection Report, please see Report Completeness Checklist on next page. Check Slope ® Surface water Check cellar Shallow wells Estimated depth to high ground water: 0 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) z Accessed USGS database - explain: usgs maps You must describe how you established the high ground water elevation: USGS maps indicate water >6' below grade. System built close to ground surface on the side of a sloping area. Before filing this Inspection Report, please see Report Completeness Checklist on next page. Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Patton Lane Property Address Ashley Collins and George Grandmain Owner Owner's.Name_ information is required for North Andover MA 01845 10-12-11 every page. Cityrrown state Zip Code Date of Inspection.-,-.- E. nspection.___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 COMMONWEALTH OF MASSACHUSETTS 4 ITAL AFFAIRS EXECUTIVE OFFICE OF ENMONMEN DEPARTMENT OF ENVIRONMENTAL PIftoTtCTION, ONE WINTER STREET. BOSTON. NIA 0109 60-293-500 WILLIAM F. WELD :TkIJIYY COXE Govemo- ARGEO PAUL CELLUCCI I)AVID B. STRUMS Lt. Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address: -S Address of Chonen Date of Inspection:'- (if differOnt) Name of Inspector: I am a DEP approved system ins !tor ursuint to Section 15.A40 of title 5 (310 tMR1 Company Name: -P 1 Mailing Address- 1 ( 7_ Qa Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information ooporitd below is #66, Acdira* and complett'as of the time of inspection. the inspection was perfoftn6d based on my training anti Id thd.propet.juin"twoh,and maintenance of on-site �sewageddis al systems. The system: sewage 5 c, asses Conditionally Passes Needsf urther Evaluation By the Local Approving Authority Inspector's Signature: Date.. iAuffi0itio'WiNh thio 00) days 6 1 f-: 161tig" t&t. The System inspector shall vsutmit a CVPY of this Inspection repbrt to the Approving Pe If the system is a shared system or has a design flow of 16,DDO gpd or greAtiri the in'to6doi and thb iy4i% dWh&4hill 90 it:. the report to the appropriate regional office of tke Depattment of Environmental Protection. 'The original should bi Writ to the Sys#ern owner and copies sent to the buyer, if Applicable, and the approvirig authority: INSPECTION SUMMARY: Check A, 0, C, or b: A] SYSTE SSES: I have not found any information which indicates'that the sysf6ffi Violai6i Ahy of thfi hiloi* krit&!� it, dtfinibd i6 310 eMRil 1.00J.. Any failure criteria not evaluated are Indicated Wow. COMMENTS: SYSTEM CONDITIONALLY PASSES:. .. .. . One or more system components as described in the "Conditional Pass 6 section need to W:replaced bri lm -d k. --:The systerirt, upon . completion of the replacement or repair, as approved by the board of Health,. will 099. -haiih-w Indicate yes, no, or not determined (Y' N, or ND). Describe bast's" bi dk6iminatiolt in it in ces'it hot &i*milw"i Wh"tally � The septic tank is metal, unless,the owner or 60Wr O' has OtOVIdod the iyAefi iftoecto with i-a)j* of i A of r ed) Indicating that *ii 06fb th# date of ifit , Oiaion; or Compliance (Attack i the tank *9 IhOIW Within 460*02 : the septic tank, whether or not metal, is cracked, itrudUtAlly iWound, shows substantial ifitilt406h ore , *466 or ikik failure Is imminent, the system Will WS irig0dibtl if the exjgjfjg septic Wk, it. mplkdd With a t0foiMllit j I kojit tank as approved by the Board of Health. (revis*d 04/2$/91) 10 DEP on the World VAde V*b, hftp:/M4W-1ft0giiet:*k0-n*U§1d6P 0 Printed on A*06ed Oa* SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM y PART A ?: CE0h AYION (cofitinued) Property Address: c yL-n Axqx Owner:%tZ�r Date of Inspection: Ll _ I G—,?a a B] SYSTEM CONDITIONALLY PASSES (continued) _ Sewage backup or breakout or high static'water level observed in the distribution box is due to btoken or obstructed ` pipe(s) or due to a broken, settled or uneven distribution box: The system will pais inspection if (with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced . The system required pumping more than four times a yor due to broken or obstructed pipe(s).':The system will pass ; inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed k` C1 FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: x Conditions exist which require further evaluation by, i6e.6oard of Health in order to deteftriiie if the system is failing to protect public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS Nit FUhICT10NiN6 IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 o`r a salt marsh r 2) SYSTEM WILL FAIL UNLESS THE BOARD•OF HEALTH (AND PUBLIC WATER SUPPLItR; 1F A00lkOPRiAfb EfETERWNE5 THA? THE SYSTEM 15 FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTii1 A1415 SAFITY ANO THI ENVIRONMENT: The system has a septic tank and soil absorption systetri (Wand the SAS., within ibo feet to a surfacb:vi+a}er'su ply or; tributary to a surface Water supply. The system has a sepfie tank and soil absorption systtrn and the SAS it Within a Zone 1 of a public water $ripply well The system has a septic tank and soil absorption 9ySttm and the SAS is Within S0 feet of st private water supply,well , _ The system has a septic tank and soil absorption system aria the 51§ it less OW 1010 feet but 50 feet or (tort ffdrrt a private water supply Well, unless a well Water analysis for oolildit bacteria acrd volatile t igahic c ritpdun is indreates that the well is free from pollutlon from that faciliy afid the 0*0fice 61 amfnonia fiiirogen -1fid tiiltWe rl"-tt is equal to oi.` less than 5 ppm. Method used to deteftnine distance (appibxirtrii " "WAW* 3) OTHER y (:wised 04/2S/99) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: C�14 Pb, *x� LV) Owner: � N ti• Date of Inspection: D) SYSTEM FAILS: You must indicate either "Yes" or "No' as to each of the following: I have determined that the system violates one or More of the following failure criteria as defined ifs 310 CMk 15.303 The basis for this determination is identified below. The Board of Health 'should be eontacied td deierrnine what will be hOcessary to porrect , the failure. Yes No - Backup of sewage into facility or system component due to an oveHoaded of clogged SA5 61r. todbL Discharge or ponding of effluent to the surface of the ground or surface,waters due to an overloaded or c16gged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to ars overloaded or clogged SAS or cesspool — — Liquid depth in cesspool is less than 6" below invert or Availibie volume is less than 112 day flow.; Required pumping more than 4 times -in the last yeah NOT due to cloggod or obstructed 000(s). Number of times pumped �. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation Any portion of a ccs"spool or privy is Within 100 feet of a sutface water supply or tributary id a surface watWfatppfy r Any portion of a cesspool or privy is within a Zone I of a public well: ":✓ - - U. _ — Any portion of a cesspool or privy it withih 50 feet of A private water Supply well.. r Any portion of a cesspobl or privy is less than 100 feet but #greater thatt 50 feet f-0 a private watief supplq vireli r�ith no acceptable water quality analysis. if the Well has been analyzed to be acceptable; attach Copy of well wateFia for coliform bacteria, volatile organic cor�npounds; arnnion'A hiiiogkh and nitrate nitrogen.;; 4. E) LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the fdflowin' The following criteria apply to large systems in addition to the criteria abovd: The system serves a facility with a design flow of i0,000 gpd or greater (large System) anti the systim is a significant threat to :. public health and safety and the environment because one or mote of the following cohditit ht 6*isi: 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 wafer supply the system is located )n a nitrogen sensitive area (Interim b1%)lhead Protection Afei • IWPA) or a !A*-*- 'U'of a public water supply well) The owner or operator of any Such sysferrt shall bring the systoh and facility into full t:rb mpliahcp with the groundwater t"ritent 0bgram requirements of 314 CMR 5.00 and 6.00. Please consult the local regidnal offibe sof the C>eparttnet►t for further inforrfiytion, (revised 04/29/97) aiig of ie. r SUBSURFACE SEWAGE DISPOSAL SYStEM INSOCtION FORM PARt 9 . .-} CHECKliSt Property Address: a Pam, UY) Owner: Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "Noy as to each of the following: Yes o� Pumping information was provided by the owner; occupant, or Board of Health. None of the system components have been pumped for at least two weeks and `the system has beers recervini hotmal flow rates during that period: Large vola *9 of waier have hot been introduced into the System recently or as part of this inspection. s built plans have been obtained and examined: Note it they are riot available with N/A. The facility or dwelling was inspected for signs of sewage back-up. hes system does not receive non -sanitary or industrial waste flow. The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the +Septic tank was inspected for conditibm.of . baffles or tees, material of construction, dirbensions, depth of liquid, depth of Sludge, depth bf scum. / The size and location of the Soil Absorption System on the `"site has been determined based on: t/ The facility owner (and occupants, if different from owner) were provided with thfdrmition on the'Eiropef iniainienance of: / Sub -Surface Disposal System. 1/ — Existing information. Ex. Plan at B.O.H. ✓ _ Determined in the field (if any of the failure criteria. telated to Part t` is at issue, apptoxithatlor of distartb6 it unacceptable) (15.3020)(b)J 4 4 bit fo (:.di.•d os/04/2S/0)a4 BUILDING SEINER: (Locate on site plan) Depth below grade:_1 Material of construction: _ cast iron _ort PVCs other Xplai{�► r Distance from private water supply well or suction line Diameter u t Comme ts: (con ition of joints, venting, evidence of leakage; etc.) SEPTIC TANK:.. ✓ (locate on site plan) t � Depth below grade: Material of construction: _ oncrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance (Yes/No) Dimensions: toj1�57� S� — (Sloo e Sludge depth: s r� 1 q Disfance from top of sludge to bottom of outlet tee or baffle: O� Scum thickness: Distance from top of scum to top of outlet tee or baffle: tt Distance from bottom of scum to bottorT< of u' let tee or bafCl A How dimensions were determined: Comments: ka(recommendation for pumping, conditi of inlet and utlet r baffles, depth of 1' id le el i relation t' outlet .M- eg str' ural t integ ity, evide ce of Ie�kag�V 2_�` Q-,� C w, GREASE TRAP: V\QML (locate on site plan) , Depth below grade: Material of construction: _concrete _metal _Fiberglass ._Polyethylene _', other(expiain) f r Dimensions Scum thickness: 3 , 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: `u u t Comments: a " (recommendation lot pumping, condition of inlet and outlet teol or baffles; depth of liquid level tt relatioh to outiet i ivettr Sfrifct(tfal, integrity, evidence of leakage, etc.) (rwiard 04/25/97) Pag4 6 04 ib h SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: L I -c-t- <'tC 'V\ LV\ . Owner: N U _VVI Date of Inspection: ( i _ 16.—C TIGHT OR HOLDING TANO'r)`V- (Tank must be pumped prior to, or 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/dav Alarm level: Alarm in working order — Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: U Comments: (note if lelyel an distr'ttb-tition is eeqqual, evidenCZ,ce of solids cayiry( PUMP CHAMBER:—C::� _ •—`�:Z�.r.��' (locate on site plan) ` V of leakage into or put of bpx, et4.) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (toviead 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: L Owner: 1U C Date of Inspection: Ly SOIL ABSORPTION SYSTEM (SAS): L--'— (locate on site plan, if possible; excavation -not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:, leaching galleries, number: leaching trenches, number,length:� leaching fields, number, dimensions:_ overflow cesspool, number: Alternative system: Name of Technology: Comments: (notf coedition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) o CESSPOOLS: (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:t�� (locate on site plan) Materials of construction: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 Dimensions: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFOkMATION (continued) Property Address: Uvv Owner: j F Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: U Date of Inspection: Depth to Groundwater 6' Feet Please indicate—all—the methods used to determine High Groundwater Elevation: L- Eta ned Jro Design Plans on record '"Observation -ti Site (Abutting property, observation hole, basement sump etc.) L Determine.. it from local conditions U—`Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers l ' Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) LJ (revised 04/25/97) Page 10 of 20 - TEL: (508) 475-1474 t FAX: (508) 475-5451 Ti Of, BATESON ENTERPRISES, INC. Excavating - Water & Sewer Lines - Septic Systems & Pumping Service 1 1 I Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: ----- ----- ---- (-( ( (� CM Date Of Inspection: ---------------- My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. 4"'/jw Neil J. Bateson Bateson Enterprises Inc. Page 11 of 11 BOARD ' OF HEALTH Nr.Andover, Mass. SUBSMFACE DISPOSAL DESIGN CHWK ' SST APPROVED - DATE_7- IX_IS _5. Provided!X6105to V5 7 c% DISAPPROVED Reasonss LOT # T1C�ti� DATE- --- Title ATE- -Title -V FAIL OK -- — -- - - -- - — — ---- Reg 2.5 The submitted plan muss; show as a adnimums a) the lot to be served-areasd'imensions lot #abutters b location and log deep observation hoes -distance to ties c location and resulta percolation tests -distance to ties ddesign calculations & calculations showing required leaching area e location and dimensions of system -including reserve area f� existing and proposed contours (g) location any wet areas within 1001 of seThage disposal system or disclaimer-oheck wetlands mapping (h) surface and subsurface drains within 1)01 of sewage disposal system or disclaimer (i) location any drainage easements within 1001 of savage disposal system or disclaimer -Planning Board fires (j) known sources of water supply within 2.01 of sewage disposal e system or disclaimer (k) location of any,proposed well to serve lot -1001 from leaching facility (1) location of water lines on propert* 3A• from leaching facility (m) location of benchmark (ndriveways (o garbage disposals (p no PVC to be used in construction (q) profile of system -elevations of basements plumbs pipe, septic tank, distribution box inlets and. outlets, distribution field piping and Other elevations (r) maximum ground water elevation in area sewage disposal system (s) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Reg 6 Septic Tanks (a) capacities -150,% of flows water table, tees) depth of tees access* pumping (b) cleanout (c) 3,.01 from cellar wall or i.nground sv&w ng pool (d 251 from subsurface drains Reg 10.2 Distribution Boxes (a) s pe greater 0.06 {b) Reg 10.1 Bump " t TOWN Or NORTi•1 ANDOVCR, MASSACHUS0'T orr+cr, or CONSERVATION COMMISSION __.__ „onur •c',,�4c ur,,•'" ,� ;tieo TCLEP110NC 683• -?101 a 4 •, c•Ss. 1,151, Pursuant to' tile• authority of the, Wetlanus Protection. Act:, I•Iassachusetts General. Laws Chapter 131., Section 40, as amended,. and the Town of North Andover's Wetland Protection By Law, the North Andover. Conservation Commission will hold a. `i'ublic Hearing A ..� on at 8:00 P.M. at the Town Building .er Meeting Room, 1.20 Main Street, North Andover, "t'A on 011 Notice of xnt:entr of Republic Development Corp. t:o alter land at Lots 5, 6 & 7 Sharpner's Pond Road & Libbrty Street ^ for purposes of constructing 3 single LqmilV dwellin s.. Plans arc avai.l.abl.c at the Conservation Cor.Imi.s Sion Office, Town Building, 120 Main Street: North 'Alndover, M11, :'rr=•�--" f By: G. Vicens Cha i•iman, NACC , 1W - - 'run once In the N,, Andover Citizen un Nov 14 1985, .. Copies sent to: Pl.annin Board ° Board o , Health ' Public Works •.... Highway De p t• # , Appl.icnntr I Engineer �...... DEQC • r _ 162.00 L0 ` as \ r t �a fes` �j r A A- 00. r � r .�% L 1 P4r6A) 10 r 1r i� iI b6 1 . /a 1 CERT) l` Y !HAT THE $£ °TIC, P'S- -t_t WAS I N STALLED AS �`• - SHO.'N, THIS PLAN 1S NOT INTE NDED AS A WARRANTY OF THE f 5YSi Emo l - PLJ, N SHOVY ING SUBSURFACE SEWERA6E DISPOSAL SYSTEM AS BUILT LO -C TION T 1 PAT -TON LANE ELEVATIONS f OW*l ER t%l1CHAEL �R WO t `TOP FNV tiCG:5E OUTLET f?4.7 DATE 12-27-85 SCALE 1►I 40! s ST I::, 4ET { 1 S T OUTLET !2',,9t PREPARED BY-; U - b;, X INLET lZ..z3 -8 QX CUTLET p Fnglneers %%��'"�T[• ENCH 1 12.2.73 De-51Gn Assoc. fo Cc,*TENCH 2 i 18.73 Po TRENCH 3 0. Boz 516 ^.� North Andwe IvIGss., D1845, � r��,tt .ice `�"• 7~�`1ZL t�,` znL .' �kms, 3? 'C! .„i f 3975 Ot MORiN"Ah . . o Town of North Andover ••; :: ' %HEALTH DEPARTMENT ,S$ACNUSt1� CHECK #: DATE: / d LOCATION: ,' H/O NAME: CONTRACTOR NAM I Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment ❑ Body Art Practitioner ❑ Dumpster 4 ❑ 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 Systems: ❑ Septic - Soil Testing ❑ Septic - Design Approval ❑ Septic Disposal Works Construction (DWC) ❑ Septic Disposal Works Installers (DWI) ❑ Title 46spector ®�I itle 5 Report ❑ Other: (Indicate) $ 1 Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer DelleChiaie, Pamela From: David Petkewich [David. Petkewich@rjoconnell.com] Sent: Wednesday, August 01, 2012 2:52 PM To: DelleChiaie, Pamela Subject: RE: North Andover Board of Assessors Public Access - 24 Patton Lane, North Andover, MA 01845 Pamela, I appreciate your forwarding the scans of the plan and inspection report. Thanks, DMP David M. Petkewich, PE RJO'CONNELL & ASSOCIATES, INC. CIVIL ENGINEERS & LAND PLANNERS 80 Montvale Ave., Suite 201 Stoneham, MA 02180 Tel: 781-279-0180 ext. 109 Cell: 617-852-6908 Fax: 781-279-0173 david.petkewich@rioconnell.com www.rioconnell.com Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more information please refer to: htto://www.sec.state.ma.us/ore/i)reidx.htm. Please consider the environment before printing this email. North Andover Board of Assessors Public Access Page 1 of 1 ,10RTM Orth Andover Board of Assess®rS Of it��o e,�p roperty Record Card Parcel TD -210/106.A-0132-0000.0 FY -2012 Communitv - North Andover Location: 24 PATTON LANE Owner Name: COLLINS, ASHLEY GRANDMAIN, GINEAU Owner Address: 24 PATTON LANE City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 6 - 6 Land Area: 1.07 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 2620 sqft Value: 473,600 473,600 ing Value: 266,200 266,200 Value: 207,400 207,400 Market Land Value: 207,400 Chapter Land Value: Price: 512,000 Sale Date: 12/03/2009 > Length Sale Code: Y -YES -VALID Grantor: PATCH, KEVIN & GENA Doc: Book: 11862 Page: 301 http://csc-ma.us/PROPAPP/display.do?linkld=1895441 &town=NandoverPubAcc 8/1/2012