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Miscellaneous - 244 DALE STREET 4/30/2018
North Andover Board of Assessors Public Access Parcel ID: 210/064.0-0027-0000.0 Community: North Andover SKETCH Click on Sketch to Enlarge PHOTO No Picture Available Location: 244 DALE STREET Owner Name: O'TOOLE, RICHARD A Owner Address: 244 DALE STREET City: NORTH ANDOVER State: MA ZIP: 01845 Neighborhood: 6 - 6 Land Area: 0.61 acres Use Code: 101 - SNGL-FAM-RES Total Finished Area: 1404 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 368,200 343,300 Building Value: 173,900 163,500 Land Value: 194,300 179,800- Market 79,800 Market Land Value: 194,300 Chapter Land Value: LATEST SALE Sale Price: 40,000 Sale Date: 02/26/1985 Arms Length Sale Code: H -NO -COURT -ORD Grantor: OTOOLE RICHARD A Cert Doc: Book: 01933 Page: 0102 Page 1 of 1 http://csc-ma.us/NandoverPubAcc/j sp/Home.j sp?Page=3 &Linkld=805403 7/25/2006 H W W H N W J Q D d' N U) v U W '00 oOQ a� Q' J o CL `Q a 'Fuo aO CD Ch O �O J O le to O IL Q Co O O O O ti N O O O m O O N J W U Q a N N ► O o NN CD a) A Ma rr H t6 0— O00_ 0) O rr W ooUWC) O o V 0 ..o 'aa dj cc -j LO p J J 75 a) 0 m yN UM YY V C U am ma ac) O >•- Q- 0 00 CD LU LO) OZ Q �2a w a0 Zrr 0 3 O QZ W JJ 0 0 ai J wN v� VQ Zoo T LL Qo -rn • • m .: Um Z cri cri r!'�► my 3 o -0 (D a) a Z� r� O•• L n a 0 LO _ gU) NN N m W Q Jaa O LU V t =ern j Date..... J..r.-.-. 7 TOWN OF NORTH ANDOVER PERMIT FOR WIRING +4 This certifies that ......... .E.'.......i!................................... has permission to perform .T F7.4".1� .........7.2n.Z-.L. wiring in the building of .... Im7x.5 I �) Lc 5� at ... C. :..:...:.... n ........................................................... . North Andover, Mass. Fee ...f �&....... Lic. No. a f D2 3F ,.0 ry .................. t ELECTR AL INSPECTOR Check # 1 7404 tY A Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank) M APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (M .C), 52 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: � / ,7 City or Town of. NORTH ANDOVER To the Inspector of'Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant G �/ ��5� a, Telephone No. 97& _S3'7S,fjffj Owner's Address _5P. •-We�_ Is this permit in conjunction with a building permit? Yes ❑ No 7-1 (Check Appropriate Box) Purpose of Building Existing Service Amps New Service Amps Number of Feeders and Ampacity Utility Authorization No. Volts Overhead ❑ Volts Overhead ❑ Location and Nature of Proposed Electrical Work: Undgrd ❑ No. of Meters Undgrd ❑ No. of Meters '7,71.;-)A 761_�' Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. rnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump I Number I Tons I KW No. o Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers HeatingAppliances KW pp Security Systems: No. of Devices or Equivalent No. of Water Kir No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: to Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE X BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: �iC. LIC. NO.: Licensee: per- Signature LIC. NO.: tea/ Gb23 (/f app/icab1,! r " zpt" in t/re license number line.)_ - - Bus. Tel. No. Address: Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. Ra"�� 'P-<- F1't', j P/t 97 �?,!> - 'r2 /I I- 9 9 µa In r Ra"�� 'P-<- F1't', j P/t 97 �?,!> - 'r2 /I I- 9 9 µa In The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www. mass.gov/di a Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: �1,��.s� T_ / O .6.5 Phone #: 02-ge 22 y 3;9Si Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] 3.X I am a homeowner doing all work myself. [No workers' comp. insurance required.] t officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.X Electrical repairs or additions 1 ED Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains andpenalties ofperjury that the information provided above is tru and correct Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Date .`....?.. TOWN OF NORT"NDOVER PERMIT FOR PLUMBING This certifies that ....1..... .. ?-.... F....! ................. . has permission to perform .: ....... ................... . plumbing in the buildings of ............... .at.. -4i ll : .'......... , North Andover, Mass. Fee/.`°Lic. No%�L...� r i.3,r}r'! fc� .............. � , / PLU�MBI CONSPECTOR � Check N � — C 7330 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date ,Q -V-07 Building Location 2 O, S Owners Name Rao I��GVJ ry. Permit # 72-3-1 Amount /!r� Type of Occupancy J) dyy / Cy J New M Renovation M Replacement [!] Plans Submitted Yes [] No FIXTURES (Print or type)% Check one: Certificate Installing Company Name 1 l i l Corp. a Address ' , 0 J �� hr, • j L%NJ T P Per. Business Telephone D _ Z :3q, 0 6 $ Firm/CO. .. / Name of Licensed Plumber, i N � ll/1 Insurance Coverage: Indicate the a of insurande coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the M sacbusetts State Plumbing ode and Chapter 142 of the General Laws. BY16 igna o um er Type of Plumbing License Title City/Town icense Numoer Master Journeyman 13/ APPROVED (OFFICE USE ONLY " __:7/ ,-- Date ..C'.... �n .........-........... TOWN OF NORTH ANDOVER PERMIT FOR WIRING - - -, - -'e*% . , , This certifies that .......................................................— --- 'e . .......... has permission to perform ..................... ........................................................ - wiring in the building of ....... ....... 'n .................................................................... at............................................................................... . North Andover, Mass. & 'd Fee�/ .. . .. Lic. No . ............. ..... .................................. ......... ELECTRICAL INSPECTOR Check # J% 7226 0 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. ! L,=) �) G Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: _fie d G� - ,� d i City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) caner or Tenant C I L Owner's Address -7 G R, wi-e,vc Telephone No.� i44cr . Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Ale .a :) (14vvl j,-,rzi S,' -&e -r Utility Authorization No. Existing Service %0 Amps / Volts Overhead L� Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of thefollowing table may be waived by the Inspector of Wires. No. of Recessed LuminairesNo. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs - Generators KVA No. of Luminaires Swimmin Pool Above ❑ In- g rnd. rnd. El IN o Emergency Lighting Battery Units No. of Receptacle Outlets 2 No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Range f-- g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers --- Heat Pump Totals: Number Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers --- Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances g pp Kms' Security Systems:* No. of Devices or E uivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring. No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 3,(1V0 e-0 (When required by municipal policy.) Work to Start: ,i ",9ls - 6'7 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. _ FIRM NAME: j �F 400E ( 6LIC. NO.: %© 7�,: Licensee: i r,, plrltillAl t Signature-- _IeaJ11k LIC. NO.: (If applicable, enter "exempt" in the license numb r line.) Bus. Tel. No.: J -7.f'94- e-, A773 Address: ALC- Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ r// > I Gail T. Nastasia Counselor & Attorney at Law y 76R Allston Street Lawrence, MA 01841 gailnastasia@yahoo.com May .3 2007 Brandolini Electric 8 Golden Street Haverhill, MA 01830 Phone: (978) 557-5840 Toll Free: (877) 557-5840 Facsimile: (978) 557-5843 Re: 244 Dale Street, North Andover, MA—Wiring Permit No. 7226 Dear Mr. Brandolini: Please accept this letter as notice of our intention to hire another electrician to complete work on our property at 244 Dale Street, North Andover, Massachusetts. You're services will no longer be required. We will have our new electrician obtain a permit under his own license. Thank you for the work you have completed. Sincerely, Gail T. Nastasia N .,- Wetlands & Land Management, Inc. August 23, 2006 Gail Nastasia 76 Allston Street Lawrence, MA 01841 RE: Wetland Evaluation at 244 Dale Street, North Andover, MA Dear Mrs. Nastasia: Wetlands & Land Management, Inc. has completed our evaluation of wetland resource areas at the property at 244 Dale Street in North Andover. Wetlands on the site were evaluated using delineation methodology established in the Wetlands Protection Act and the Department of Environmental Protection "Delineating Bordering Vegetated Wetlands Handbook" dated 1995, and the US Army Corps of Engineers Manual (1987). These regulations and methodology incorporate the evaluation of hydric soils, predominance of wetland vegetation and wetland hydrology to evaluate the upper limit of vegetated wetlands. These methods are appropriate to evaluate the limits of wetlands in the Town of North Andover. I noted a purple loosestrife dominated emergent marsh wetland along the rear portion of the property. The near side of bordering vegetated wetlands on the property was identified with sequentially numbered blue surveyors flagging labeled Al to Al 1. Flag Al begins at the left rear corner of the site and the flag line trends along the woods line along the down hill side of the lawn. Flag Al l ends where the wetlands trend away from the site on the opposite side of the'property. A 100 -foot buffer zone extends out from the limit of wetlands. In the field I also place two red flags that denote the approximate limit of the 100 -foot buffer zone as measured from certain critical wetland flags. The buffer zone flagging indicates that the house and the brick patio behind the house are entirely outside of the 100 -foot buffer zone. (The limit of the buffer zone line cuts_ diagonally across the pool that is located adjacent to the brick patio.) 100 Conifer Hill Drive, #516, Danvers, Massachusetts 01923 Tel 978-777-0004 - Fax 978-539-0005 Work in buffer zones to, or in -the bordering vegetated wetland falls under Conservation Commission jurisdiction. Regulations found at 310 -CMR 10.55 apply. The Town of North Andover also has local by-laws that would further regulate activity in buffer zones. Based on our conversation, your intentions were to explore adding a second floor addition over the existing garage. It would appear that if no excavation were to occur and if materials were located to the side or front of the garage, this type of activity would remain outside the jurisdiction of the Conservation Commission. You mentioned that another possibility would be to expand the foundation out into the brick patio. Again, if the excavation could be maintained within the footprint of the patio, it appears that this work would be outside Conservation Commission authority. I trust this information will be useful to you. Be advised, the Conservation Commission is the authority that will make a final determination of the limits of resource areas. Sincerely, Wetlands & Land Management, Inc. William I Manuell Wetland Scientist 2 MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza Boston, Massachusetts 02108-1904 (617) 723-3800 Ma Only (800) 392-6108, FAX (800) 851-8424 Form of Notice of Casualty Loss to Building Under Mass, Gen. Laws, Ch. 139, Sec.313 NORTH ANDOVER HEALTH DEPT. NORTH ANDOVER TOWN HALL NORTH ANDOVER MA 01845 Re: Insured: RONALD A. & GAIL NASTASIA Property Address: 244 DALE STREET, NORTH ANDOVER, MA 01845 Policy Number: 0932701 Type Loss: Windstorm Date of Loss: 04/16/2007 Claim Number: 240336 4/18/2007 FliC - A i IZ APR 2 3 2007 TOWN OF NORTH At 10OVER HEALTH DEPA, i t .EtiT Claim has been made involving loss, damage or destruction of the above captioned propert, which may either exceed $1000.00 or cause Massachusetts General Laws, Chapter 143, section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 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. MPIUA Claims Division CMA00021 Title V Sawyer, Susan From: Golden, Claire (DEP) [Claire.Golden@state.ma.us] Sent: Wednesday, August 23, 2006 6:41 AM To: Sawyer, Susan Subject: RE: Title V Page 1 of 1 The inspector needs to inspect the laundry system on a separate and distinct inspection form. Typically laundry systems are cesspools and therefore subject to the cesspool inspection criteria. In the event that the laundry system is found to be in failure and there is no approved design flow on file for the existing system, then a full upgrade for the entire dwelling is required. I hope this answers your question. Claire From: Sawyer, Susan[mailto:ssawyer@townofnorthandover.com] Sent: Tuesday, August 22, 2006 4:30 PM To: Claire Golden (E-mail) Subject: Title V Claire, I need a point of clarification in regard to this issue below. If you don't mind. An inspector has submitted an inspection answering 'yes " on the question and he does not agree with what I am asking to be submitted. So, I told him I would contact DEP for the answer. I now how I was taught, but I have been known to be wrong. Is the laundry on a separate sewerage system (yes or no) (if yes, separate inspection required) What does the DEP expect... exactly by a "separate inspection required" I won't tell you what I think, so you won't know where I am coming from. Thanks Susan Susan Sawyer, R.S. Public Health Director office 978 688-9540 fax 978 688-8476 8/23/2006 TOWN OF NORTH ANDOVER NORTH Q`tac �6A~�O APPLICATION FOR PLAN EXAMINATION �r o e � Date Received--------- LOCATION eceived Permit NO: Date Issued: IlVLPORTANT: A licant must complete all items on this 1" i `, Identification Please Type or Print Clearly) one OWNER: Name: — LOCATION � Prin PROPERTY OWNER Print u DISTRICT: ZONING t-( PARCEL. —�=---� HISTORIC DISTRICT YES ❑ TYPE AND USE OF BUILDING PROPOSED USE Non- Residential TYPE OF IMPROVEMENT sidential Address: ne family ❑ Industrial _ New Building n Two or more family Addition No. of units: Commercial Altera:ian❑ [IAssessory Bldg b o � Repair. l^ement ARCHITECT/ENGINEER Fj Others: � emiition i5 Other _ F,ou,�dation only DESCRIPTION OF WORK TO B PREFORMED 1" i `, Identification Please Type or Print Clearly) one OWNER: Name: — f 4j 15 6 Address: E2 L CONTRACTOR Name: Phone: r Address: Supervisor's Construction License: Hoene Improvement License: b o � ARCHITECT/ENGINEER Name: Phot 1 �I Address: Reg. No.,_ to d Ise Dj, 014v�- - L>- �- / �Yt� pGSC a �o�oSGc� f a Y V � w m � co L o �S mea ►r e Y � w m � c�oa' U o �S mea ►r m O D d 0 e w 3 ,yam Q ai �W W c m m o a a fi S E m a to w o, J Z Z Z C w Q LL: Ll� o� O y � c m _� C7 co� Z Z Z W � Lno 3 ,o o C, _ LLa y N N d o C o C m In -y 0 a y o E E y Oy 3 3 V d y c 0 U v c o U y a w: O ZL O zO R d o 0 d d 3 io Of Of � G y � a �' G y U D fn C7 I� co C7 Of NORTH , o � 9 • Town of North Andover `;'•�,,,,o .: HEALTH DEPARTME CHECK #: / !� /I 1;//'44 LOCATION: if H/O NAME: CONTRACTOR NAME: 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 Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $- le 5Inspector ❑*Tit* Title e Title 5 Report $ $�r� ❑ Other: (Indicate) $ •j7 6 err—' Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer PETER F. REILLY 136 ANDOVER STREET ANDOVER, MA 01810 (978) 375-3750 TITLE V OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART A - CERTIFICATION Property Address: 244 Dale Street, North Andover, MA 01845 Name of Owner: Richard A. O'Toole Address of Owner: same Name of Inspector: Peter F. Reilly Company Name: same Mailing Address: 136 Andover Street, Andover, MA 01810 Telephone Number: (978) 375-3750 CERTIFICATION STATEMENT 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 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 N/A Conditionally Passes N/A Needs Further Evaluation By the Local Approving Authority N/A Fails Inspector's Signature: Date: August 4, 2006 Peter . eilly The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within thirty (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 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. NOTES AND COMMENTS ****This report only describes conditions a the time of inspection and under 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 (See attached Disclaimer). OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART A - CERTIFICATION (continued) Property Address: 244 Dale Street, North Andover Owner's Name: O'Toole Date of Inspection: 8/4/2006 INSPECTION SUMMARY: A. SYSTEM PASSES: Check A, B, C, D, or E / ALWAYS complete all of Section D ✓ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: The system met the Pass Criteria of Title V. B. SYSTEM CONDITIONALLY PASSES: N/A 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. Answer yes, no, or not determined (Y, N, ND). Describe basis of determination in all instances. If"not determined", explain why not) N The septic tank is metal, and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic 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. ND explain: N Observation of a sewage backup or breakout or high static water level in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health): N/A broken pipe(s) are replaced N/A obstruction is removed N/A distribution box is leveled or replaced ND explain: 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): N/A broken pipe(s) are replaced N/A obstruction is removed OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART A - CERTIFICATION (continued) Property Address: 244 Dale Street, North Andover Owner's Name: O'Toole Date of Inspection: 8/4/2006 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 the public health, safety and 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: N/A Cesspool of privy is within 50 feet of a surface water N/A Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh. 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: N/A The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. N/A The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply well. N/A The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. N/A The system has a septic tank and SAS the SAS is less than 100 feet but 50 feet or more from a private water supply well."*Method used to determine distance N/A This system passes if the water well water analysis, performed at a certified DEP laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. A copy of the analysis must be attached to this form. 3. Other N/A OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART A - CERTIFICATION (continued) Property Address: 244 Dale Street, North Andover Owner's Name: O'Toole Date of Inspection: 8/4/2006 D. System Failure Criteria applicable to all systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. No Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. N/A Liquid depth in cesspool less than 6" below invert or available volume <% day flow. No required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: once No Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. N/A Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. N/A Any portion of a cesspool or privy is within a Zone I of a private water supply well. N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well. N/A 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 laboratory, for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen is less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form). N/A The system fails. I have determined that one or more of the above failure criteria exist as defined in 310 CMR 15.303, therefore the system fails. The property owner should contact the Board of Health should be contacted 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. You Must indicate either "Yes" or "No" to each of the following: (The following criteria apply to a large system in addition to the criteria above) N/A The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No N/A The system is within 400 feet of a surface drinking water supply N/A The system is within 200 feet of a tributary to a surface drinking water supply N/A The system is located in a nitrogen sensitive area (Interim Wellhead 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 such 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. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART B - CHECKLIST Property Address: 244 Dale Street, North Andover Owner's Name: O'Toole Date of Inspection: 8/4/2006 Check if the following have been done. You must indicate either "Yes" or "No" as to each of the following: Yes No N/A Pumping information was provided by the owner, occupant, or Board of Health. No Were any of the system components pumped out in the previous two weeks ? No Has the system received normal flow in the previous two week period ? No Have large volumes of water been introduced to the system recently or as part of this inspection? N/A Were as built plans of the system obtained and examined ? (If they were available note as N/A) Yes Was the facility or dwelling was inspected for signs of sewage backup ? Yes Was the site was inspected for signs of breakout ? Yes Were all system components, excluding the SAS, located on the site ? Yes Were the septic tank manholes uncovered, opened and the interior of the septic tank inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum? N/A Was the facility owner (and occupants of if different from the owner) provided information on the proper maintenance of subsurface sewerage disposal systems ? (house vacant -owner deceased) The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes No N/A Existing information. For example, a plan at the Board of Health. N/A Determined in the field if any of the failure criteria related to Part C is at issue (approximation of distance is unacceptable) [15.302(3)(b)j. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION Property Address: 244 Dale Street, North Andover Owner's Name: O'Toole Date of Inspection: 8/4/2006 FLOW CONDITIONS RESIDENTIAL: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms: Number of Current residents: Does the residence have a garbage grinder (yes or no): Is the laundry on a separate sewerage system (yes or no): Laundry system inspected (yes or no): Seasonal use (yes or no): Water meter readings, if available (last 2 years usage [gpd]) Sump Pump (yes or no): Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of Establishment: Design Flow gpd (based on 15.203): Basis of Design Flow (seats/persons/sq.ft., etc): Grease trap present (yes or no): Industrial waste holding tank present (yes or no): Non -sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER: (Describe) PUMPING RECORDS N/A 3 N/A 3 no yes (if yes, separate inspection required) N/A no about 50 gpd no current N/A N/A N/A N/A N/A N/A N/A N/A N/A GENERAL INFORMATION Source of Information: N/A (owner deceased) Was system pumped as part of inspection (yes or no): no if yes, volume pumped (gallons): N/A How was quantity pumped determined ? N/A Reason for pumping: N/A TYPE OF SYSTEM ✓ Septic tank/distribution box, soil absorption system (plus separate gray water dry well.) Single cesspool Overflow cesspool Privy 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 the system owner) Tight Tank Attach a copy of the DEP Approval Other (describe): Approximate age of all components, date installed (if known) and source of information: original system installed in the 1950s. Install date of gray water system unknown. Were sewerage odors detected when arriving at the site (yes of no): no OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 244 Dale Street, North Andover Owner's Name: O'Toole Date of Inspection: 8/4/2006 BUILDING SEWER: (locate on site plan) Depth below grade: about 36" - 40" Materials of construction: cast iron ✓ 40 PVC other (explain) Distance from private water supply well or suction line N/A Diameter: 4" Comments: Condition of joints, venting, evidence of leakage, etc.) Building sewer was watertight and appeared sound at foundation. SEPTIC TANK: ✓ (locate on site plan) Depth below grade: about 4"-6"" (to top of riser cover) about 45" - 50" to top of tank Material of construction: ✓ concrete metal Fiberglass Polyethylene other (explain) If tank is metal, list age N/A Is age confirmed by Certificate of Compliance N/A (Yes/No) Dimensions: Cylindrical Sludge depth: <1" Distance from top of sludge to bottom of outlet tee or baffle: 28" Scum thickness: <1" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 16" How dimensions were determined: observation Comments: (on pumping recommendations, of inlet and outlet tees or baffle condition, structural integrity, liquid level as related to outlet invert, evidence of leakage, etc.) Tank was watertight and appeared to be functioning properly. PVC outlet tee was installed following the inspection, visible from center cover, which is underneath a riser located 4"-6" below the surface. Last pumping unknown as owner died in November 2006. The size of the tank could not be determined by non -intrusive means, estimated size is 750 to 1,000 gallons. GREASE TRAP: N/A (locate on site plan) Depth below grade: material of construction: concrete metal FRP other (explain) Dimensions: N/A Scum thickness: N/A Distance from top of scum to top of outlet tee or baffle: N/A Distance from bottom of scum to bottom of outlet tee or baffle: N/A Date of Last Pumping: N/A Comments: (on pumping recommendations, of inlet and outlet tees or baffle condition, structural integrity, liquid level as related to outlet invert, evidence of leakage, etc.) N/A OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 244 Dale Street, North Andover Owner's Name: O'Toole Date of Inspection: 8/4/2006 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: N/A material of construction: concrete metal Dimensions: Capacity: Design Flow: Alarm Present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Fiberglass Polyethylene other (explain) N/A N/A gallons N/A gallons per day N/A N/A N/A N/A Comments: (condition of alarm and float switches, etc.) N/A DISTRIBUTION BOX: ✓ (locate on site plan) 0" depth of liquid above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc.) D -box was fairly level. Four lines leading to SAS were accepting effluent unevenly due to settlement. No solids carryover evident. The box cover was originally about 3 feet +/- below the surface. Pre -cast risers were installed to a new cover height of about 12"-14" below the surface. The flow rate appeared to be good, no signs of run back in any lines. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order (yes or no) N/A Alarms in working order (yes or no) N/A Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) not applicable OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 244 Dale Street, North Andover Owner's Name: O'Toole Date of Inspection: 8/4/2006 SOIL ABSORPTION SYSTEM (SAS): ✓ (locate on site plan, if possible; excavation not required) If SAS not located, explain why: Type leaching pits, number leaching chambers and number leaching galleries and number leaching trenches, number, length ✓ leaching fields, number, dimensions overflow cesspool, number alternative system (name of technology) N/A N/A N/A N/A one field, 4 lines, approx 20'x 30'+/ - N/A N/A Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) Soils in area of SAS appeared normal, no signs of breakout. There was a separate dry well for gray water, which was connected to the clothes washer and also the dish washer appeared to be connected. There was no sign of a tank, only pipe leading to a crushed stone dry well. The top of the dry well was excavated and the crushed stone was clean and dry at the top, no sign of hydraulic stress. It's location is shown on the following page. CESSPOOLS: N/A (locate on site plan) Number and configuration N/A Depth -top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow (cesspool must be pumped as part of inspection) N/A Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc.) not applicable PRIVY: N/A (locate on site plan) Materials of construction Dimensions Depth of solids N/A N/A N/A Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc.) not applicable OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 244 Dale Street, North Andover Owner's Name: O'Toole Date of Inspection: 8/4/2006 SKETCH OF SEWAGE DISPOSAL SYSTEM: Provide a sketch of the sewerage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100'. Locate where public water supply enters the building. APP. WATER PORCH ` HOUSE GARAGE A B DECK SEPTIC REAR Ci TANK YARD .` i D -BOX t__......._.. SAS~ �._ ...._. SEPTIC TANK TIES: A to Center (C) 28'10" B to Center 160" D -BOX TIES: A to Box 3918" B to Box 2717" DRY WELL TIES: A to Well 3216" B to Well 1310" NOTE: The system is in the rear yard. The top of the d -box was about 12"-14" deep following the installation of precast concrete risers. Newly installed outlet tee is visible from center cover. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 244 Dale Street, North Andover Owner's Name: O'Toole Date of Inspection: 8/4/2006 SITE EXAM Slope gently sloping in area of system (yard slopes more dramatically downward away from system) Surface water none observed Check cellar dry Shallow wells none observed Estimated Depth to Groundwater >1" (below bottom of SAS - per original design plan) Please indicate (check) all methods used to determine the high ground water elevation: N Obtained from Design Plans on record - if checked, date of design plan reviewed: N/A Y Observed site (abutting property, observation hole within 150 feet of SAS) Y Check with Local Board of Health - explain: information on file Y Check local excavators, installers - (attach documentation) N Accessed USGS Database - explain: website too complicated You must describe how you established the high ground water elevation.* The soils and grade changes in the area indicate no groundwater in the SAS. However, the precise groundwater elevation cannot be determined for certain without a soil evaluation test. *Inspector's Note: Soil Evaluation is the currently recognized method for determining or establishing the high groundwater elevation. Since I am not a licensed or certified soil evaluator, I am not qualified to determine or establish the high groundwater elevation beyond the public information available, such as recent design plans of the site or the nearby area. My estimation of the high groundwater elevation is based on a due diligence effort to obtain all available information both on and off the site and my experience as a certified subsurface disposal system inspector. (see attached Disclaimer) DISCLAIMER This passing septic inspection under Massachusetts Title V is in no way a guaranty or warranty of the inspected septic system. The inspection is a "snapshot in time" and does not constitute a complete assessment of the quality or potential longevity of the septic system. The pass/fail criteria are specific and outlined in detail in this report. Under the limited criteria of a Title V inspection, it is impossible to determine how long any septic system will last. The inspector made a diligent effort to certify the septic system based on the criteria required under Title V. Under Massachusetts Title V, soil evaluation is the accepted method of determining the high groundwater elevation. This inspector is not a certified soil evaluator and is therefore not qualified under Title V to determine or establish the high groundwater elevation. The method used to estimate the high groundwaterfor this inspection was based on the public records and methods of observation described on the previous page. Groundwater levels can vary greatly from season to season, year to year and soil evaluation is considered the most reliable method of groundwater determination under Title V. sF 1 Peter . Reilly Inspector August 4, 2006 r. O ct t v c ti i ti w w y d = G O m m 'Q w of V E a aCi a c__;, s= Pc, s v c ti w w d m m a `�° ami aCi c__;, s= Pc, s v ti d 3 w a W uCi o ayi I► c � m d o c i a a exp � D y 42 d a w y O J Z Z Z w D � LL LL N E N i `(D m C� Q� M LO R 3 Z Z Z Ln W - LO a) N ,0 O a F N _ LL C a to a = N ch 2 d y m o E o o E m y ayi � a O v o v o cq a O O 3 v = o U 0 o U 0 w CL �L O i0 O w' G1 01 lO y O V V O 20 O zm tq C7 12 y C9 c__;, s= Pc, s VONT" • � _ • s Town of North Andover �+�'•�,,,,•:.,� HEALTH DEPARTMENT ,S8 CHUSE� CHECK #: LOCATION:IV� H/O NAME: CONTRACTOR NAME: NAME:G�' 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 Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Tit Inspector $ Title 5 Report $-SMO-e ❑ Other. (Indicate) $ 1762 Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer PETER F. REILLY 136 ANDOVER STREET ANDOVER, MA 01810 (978) 375-3750 REPORT #2: GRAY WATER SYSTEM ONLY TITLE V OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART A - CERTIFICATION Property Address: 244 Dale Street, North Andover, MA 01845 Name of Owner: Richard A. O'Toole Address of Owner: same Name of Inspector: Peter F. Reilly Company Name: same Mailing Address: 136 Andover Street, Andover, MA 01810 Telephone Number: (978) 375-3750 CERTIFICATION STATEMENT 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 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 N/A Conditionally Passes N/A Needs Further Evaluation By the Local Approving Authority N/A Fails Inspector's Signature: Date: August 4, 2006 Pe er F. Reilly The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within thirty (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 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. NOTES AND COMMENTS ""This report only describes conditions a the time of inspection and under 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 (See attached Disclaimer). OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART A - CERTIFICATION (continued) Property Address: 244 Dale Street, North Andover Owner's Name: O'Toole Date of Inspection: 8/4/2006 INSPECTION SUMMARY: A. SYSTEM PASSES: Check A, B, C, D, or E / ALWAYS complete all of Section D ✓ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: The system met the Pass Criteria of Title V. B. SYSTEM CONDITIONALLY PASSES: N/A 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. Answer yes, no, or not determined (Y, N, ND). Describe basis of determination in all instances. If "not determined", explain why not) N/A The septic tank is metal, and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic 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. ND explain: N/A Observation of a sewage backup or breakout or high static water level in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health): N/A broken pipe(s) are replaced N/A obstruction is removed N/A distribution box is leveled or replaced ND explain: 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): N/A broken pipe(s) are replaced N/A obstruction is removed OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART A - CERTIFICATION (continued) Property Address: 244 Dale Street, North Andover Owner's Name: O'Toole Date of Inspection: 8/4/2006 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 the public health, safety and 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: N/A Cesspool of privy is within 50 feet of a surface water N/A Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh. 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: N/A The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. N/A The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply well. N/A The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. N/A The system has a septic tank and SAS the SAS is less than 100 feet but 50 feet or more from a private water supply well.**Method used to determine distance N/A This system passes if the water well water analysis, performed at a certified DEP laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. A copy of the analysis must be attached to this form. 3. Other N/A OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART A - CERTIFICATION (continued) Property Address: 244 Dale Street, North Andover Owner's Name: O'Toole Date of Inspection: 8/4/2006 D. System Failure Criteria applicable to all systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. No Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. N/A Liquid depth in cesspool less than 6" below invert or available volume <'/2 day flow. No required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: once No Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. N/A Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. N/A Any portion of a cesspool or privy is within a Zone I of a private water supply well. N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well. N/A 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 laboratory, for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen is less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form). N/A The system fails. I have determined that one or more of the above failure criteria exist as defined in 310 CMR 15.303, therefore the system fails. The property owner should contact the Board of Health should be contacted 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. You Must indicate either "Yes" or "No" to each of the following: (The following criteria apply to a large system in addition to the criteria above) N/A The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No N/A The system is within 400 feet of a surface drinking water supply N/A The system is within 200 feet of a tributary to a surface drinking water supply N/A The system is located in a nitrogen sensitive area (Interim Wellhead 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 such 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. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART B - CHECKLIST Property Address: 244 Dale Street, North Andover Owner's Name: O'Toole Date of Inspection: 8/4/2006 Check if the following have been done. You must indicate either "Yes" or "No" as to each of the following: Yes . No N/A Pumping information was provided by the owner, occupant, or Board of Health. No Were any of the system components pumped out in the previous two weeks ? No Has the system received normal flow in the previous two week period ? No Have large volumes of water been introduced to the system recently or as part of this inspection? N/A Were as built plans of the system obtained and examined ? (If they were available note as N/A) Yes Was the facility or dwelling was inspected for signs of sewage backup ? Yes Was the site was inspected for signs of breakout ? Yes Were all system components, excluding the SAS, located on the site ? Yes Were the septic tank manholes uncovered, opened and the interior of the septic tank inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum? N/A Was the facility owner (and occupants of if different from the owner) provided information on the proper maintenance of subsurface sewerage disposal systems ? (house vacant- owner deceased) The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes No N/A Existing information. For example, a plan at the Board of Health. N/A Determined in the field if any of the failure criteria related to Part C is at issue (approximation of distance is unacceptable) [15.302(3)(b)]. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION Property Address: 244 Dale Street, North Andover Owner's Name: O'Toole Date of Inspection: 8/4/2006 FLOW CONDITIONS RESIDENTIAL: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms: Number of Current residents: Does the residence have a garbage grinder (yes or no): Is the laundry on a separate sewerage system (yes or no): Laundry system inspected (yes or no): Seasonal use (yes or no): Water meter readings, if available (last 2 years usage [gpd]): Sump Pump (yes or no): Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of Establishment: Design Flow gpd (based on 15.203): Basis of Design Flow (seats/persons/sq.ft., etc): Grease trap present (yes or no): Industrial waste holding tank present (yes or no): Non -sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER: (Describe) PUMPING RECORDS N/A 3 N/A 3 no yes (if yes, separate inspection required) N/A no about 50 gpd no current N/A N/A N/A N/A N/A N/A N/A N/A N/A GENERAL INFORMATION Source of Information: N/A (owner deceased) Was system pumped as part of inspection (yes or no): no if yes, volume pumped (gallons): N/A How was quantity pumped determined ? N/A Reason for pumping: N/A TYPE OF SYSTEM Septic tank/distribution box, soil absorption system (plus separate gray water dry well.) Single cesspool Overflow cesspool Privy 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 the system owner) Tight Tank Attach a copy of the DEP Approval ✓ Other (describe): crushed stone dry well for gray water only (clothes and dishwasher) Approximate age of all components, date installed (if known) and source of information: original system installed in the 1950s. Install date of gray water system unknown. Were sewerage odors detected when arriving at the site (yes of no): no OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 244 Dale Street, North Andover Owner's Name: O'Toole Date of Inspection: 8/4/2006 BUILDING SEWER: (locate on site plan) Depth below grade: about 20" - 24" Materials of construction: cast iron ✓ 40 PVC other (explain) Distance from private water supply well or suction line N/A Diameter: 4" Comments: Condition of joints, venting, evidence of leakage, etc.) Building sewer was watertight and appeared sound at foundation. SEPTIC TANK: N/A (locate on site plan) Depth below grade: N/A Material of construction: concrete metal Fiberglass Polyethylene other (explain) If tank is metal, list age N/A Is age confirmed by Certificate of Compliance N/A (Yes/No) Dimensions: N/A Sludge depth: N/A Distance from top of sludge to bottom of outlet tee or baffle: N/A Scum thickness: N/A Distance from top of scum to top of outlet tee or baffle: N/A Distance from bottom of scum to bottom of outlet tee or baffle: N/A How dimensions were determined: N/A Comments: (on pumping recommendations, of inlet and outlet tees or baffle condition, structural integrity, liquid level as related to outlet invert, evidence of leakage, etc.) Not Applicable GREASE TRAP: N/A (locate on site plan) Depth below grade: material of construction: concrete metal FRP other (explain) Dimensions: N/A Scum thickness: N/A Distance from top of scum to top of outlet tee or baffle: N/A Distance from bottom of scum to bottom of outlet tee or baffle: N/A Date of Last Pumping: N/A Comments: (on pumping recommendations, of inlet and outlet tees or baffle condition, structural integrity, liquid level as related to outlet invert, evidence of leakage, etc.) N/A OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 244 Dale Street, North Andover Owner's Name: O'Toole Date of Inspection: 8/4/2006 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: N/A material of construction: concrete metal Fiberglass Polyethylene other (explain) Dimensions: Capacity: Design Flow: Alarm Present (yes or no): Alarm level: Alarm in working order (yes or no) Date of last pumping: N/A N/A gallons N/A gallons per day N/A N/A N/A N/A Comments: (condition of alarm and float switches, etc.) N/A DISTRIBUTION BOX: N/A (locate on site plan) N/A depth of liquid above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc.) Not Applicable PUMP CHAMBER: N/A (locate on site plan) Pumps in working order (yes or no) N/A Alarms in working order (yes or no) N/A Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) not applicable OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 244 Dale Street, North Andover Owner's Name: O'Toole Date of Inspection: 8/4/2006 SOIL ABSORPTION SYSTEM (SAS): ✓ (locate on site plan, if possible; excavation not required) If SAS not located, explain why: Type leaching pits, number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number ✓ alternative system (name of technology) N/A N/A N/A N/A N/A N/A crushed stone dry well for gray water Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) There was a separate dry well for gray water, which was connected to the clothes washer and also the dish washer appeared to be connected. There was no sign of a tank, only pipe leading to a crushed stone dry well. The top of the dry well was excavated and the crushed stone was clean and dry at the top, no sign of hydraulic stress. It's location is shown on the following page. Soils in area of SAS appeared normal, no signs of breakout. CESSPOOLS: N/A (locate on site plan) Number and configuration N/A Depth -top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow (cesspool must be pumped as part of inspection) N/A Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc.) not applicable PRIVY: N/A (locate on site plan) Materials of construction Dimensions Depth of solids N/A N/A N/A Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc.) not applicable OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 244 Dale Street, North Andover Owner's Name: O'Toole Date of Inspection: 8/4/2006 SKETCH OF SEWAGE DISPOSAL SYSTEM: Provide a sketch of the sewerage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100'. Locate where public water supply enters the building. APP. WATER PORCH HOUSE GARAGE L.__.__ _moi A B DECK SEPTIc REAR C' TANK YARD 1 i a D -Box SAS SEPTIC TANK TIES: A to Center (C) 28'10" B to Center 160" D -BOX TIES: A to Box 3918" B to Box 2717" DRY WELL TIES: A to Well 3216" B to Well 1310" NOTE: The system is in the rear yard. There is no access cover to the dry well, only a pipe laid into crushed stone. The sketch shows the approximate location the pipe enters the dry well. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: Owner's Name: Date of Inspection SITE EXAM 244 Dale Street, North Andover O'Toole 8/4/2006 Slope gently sloping in area of system (yard slopes more dramatically downward away from system) Surface water none observed Check cellar dry Shallow wells none observed Estimated Depth to Groundwater >1" (below bottom of SAS - per original design plan) Please indicate (check) all methods used to determine the high ground water elevation: N Obtained from Design Plans on record - if checked, date of design plan reviewed: N/A Y Observed site (abutting property, observation hole within 150 feet of SAS) Y Check with Local Board of Health - explain: information on file Y Check local excavators, installers - (attach documentation) N Accessed USGS Database - explain: website too complicated You must describe how you established the high ground water elevation.* The soils and grade changes in the area indicate no groundwater in the SAS. However, the precise groundwater elevation cannot be determined for certain without a soil evaluation test. *Inspector's Note: Soil Evaluation is the currently recognized method for determining or establishing the high groundwater elevation. Since I am not a licensed or certified soil evaluator, I am not qualified to determine or establish the high groundwater elevation beyond the public information available, such as recent design plans of the site or the nearby area. My estimation of the high groundwater elevation is based on a due diligence effort to obtain all available information both on and off the site and my experience as a certified subsurface disposal system inspector. (see attached Disclaimer) DISCLAIMER This passing septic inspection under Massachusetts Title V is in no way a guaranty or warranty of the inspected septic system. The inspection is a "snapshot in time" and does not constitute a complete assessment of the quality or potential longevity of the septic system. The pass/fail criteria are specific and outlined in detail in this report. Under the limited criteria of a Title V inspection, it is impossible to determine how long any septic system will last. The inspector made a diligent effort to certify the septic system based on the criteria required under Title V. Under Massachusetts Title V, soil evaluation is the accepted method of determining the high groundwater elevation. This inspector is not a certified soil evaluator and is therefore not qualified under Title V to determine or establish the high groundwater elevation. The method used to estimate the high groundwaterfor this inspection was based on the public records and methods of observation described on the previous page. Groundwater levels can vary greatly from season to season, year to year and soil evaluation is considered the most reliable method of groundwater determination under Title V. Peter F. Reilly Inspector August 4, 2006 08/16/2005 16:06 9783742337 HAVERHILL HEALTH DEP PAGE 02/02 VV! Llff .4fuu a..f. .rr - • ----- -- rlcw 421 %Z- z• r _� ,, � � �� �i� �� ��� �� ��. S �, �'� -� �`� 3.� r �� i �� ����1 D� / _ ��'�� GS t= c� � r cam- , ,. �. ' : SG vS-`j i C� �'�� .-- c> ,p n� C- �„_ 7 �--� �- .s „�, ���[, ;� �, f- l� s s . ,,�- ' �. SEPTIC SYSTEM INSPECTION FORM ADDRESS 2 4q D:�t,�e DATE INSPECTED '56- ` PROPERLY FUNCTIONING? Y� N WEATHER CONDITIONS COMMENTS: NATER QUALITY TES, E -b . lzeso TS? DYE TEST PERFORMED? Y N DATE? SKETCH: C c 1. Name WATERSHED RESIDENTS QUESTIONNAIRE I c�4R_ d f 7o- a c Z 2. Street Address '�Y_ Sr 3. How many members are in your household? 4. What type of sewage disposal system do you have? ❑ cesspool 2r�septic tank and leaching area ❑ connection to municipal sewer ❑ other (describe) ❑ do not know 5. Are the plans (drawings) for your sewage disposal system on file with the Board of Health? ❑ yes ❑ no [P-�do not know 6. How old is your sewage dis oral system? El 0-5 years El 6-10 years ❑ 11-20 years D over 20 years 2do not know 7. Has your sewage disposal system been rebuilt or repaired? ❑ yes ❑ no [?"'do not know - If yes, approximately how long ago? years. What was done? 8. How frequently is your se�waae disposal system pumped out? El annually El every 2-4 years Levery 5-10 years ❑ over 10 years ❑ never 9. Have you had any problems with your sewage disposal system? ❑ yes no If yes, what problems? ❑ repeated pump -outs needed ❑ system clogs, backs up, or drains slowly ❑ odors ❑ sewage surfaces through ground 10. How many of each appliance are connected to your sewage disposal system? washing machine dishwasher garbage disposal dehumidifier drain sump pump toilet roof/pavement drains shower/bathtub 11. Please state the brand and type (liquid or powder) -of detergent you use for: dishwasher clotheswasher A L C 12. Does your property have a lawn? If yes, approximately what size? ❑ less than 1/4 acre ❑ 1/4 acre ❑ more than 1 acre (Specify) k- yes ❑ no �1/z acre ❑ 3/4 acre ❑ 1 acre acres 13. How often do you fertilize your lawn? No. of applications per year Season(s) of the yearS.o,?/Ar6- t 14. Please state the brand and type (liquid or granular) of lawn fertilizer you use: S c e T 7S aR'o n/!/Ci/°Z ❑ Check here if your lawn is maintained by a professional landscape contractor. MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza Boston, Massachusetts 02108-1904 (617)723-3800 Ma Only (800) 392-6108. FAX (800)851-8424 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec.36 NORTH ANDOVER HEALTH DEPT. NORTH ANDOVER TOWN HALL NORTH ANDOVER MA 01845 Re: Insured: RONALD & GAIL NASTASIA Property Address: 244 DALE STREET, NORTH ANDOVER, MA 01845 Policy Number: 1005278 Type Loss: Water Damage: Plumbing Systems Date of Loss: 10/16/2007 Claim Number: 245839 Claim has been made involving loss, damage or destruction of the above captioned propert, which may either exceed $1000.00 or cause Massachusetts General Laws, Chapter 143, section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 313 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. MPIUA Claims Division CMA00021 10/19/2007