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Home My WebLink AboutMiscellaneous - 25 SUNSET ROCK ROAD 4/30/2018 (2)�f = E � ° 7 I OO tNn C ,n R w c-- D m 0 --4 Q N 0 oil H o C) n o 0 H w ", H H j t MAPS # PARCEL # STREET _'� CONSTRUCTION APPROVAL HAS PLAN REVIEW FEE BEEN PAID? YES NO PLAN APPROVAL: DATE 7-110 G APP. BY. DESIGNER: PLAN DATE,-��k/ CONDITIONS -19 bl AJG T i 7 op-.- WATER SUPPLY :\ �WN j WELL WELL PERMIT DRILLER._...-_ _.__....__.__.__..___.._...._.. _._._........ WELL TESTS: HEMICAL DALE APPRUVED...._____.___.___._.___. BACTERI UA I E OPPRUVE D BACTERIA Ii DATE (IPPRUVED-.__-______..__ COMMENTS: FORM U APPROVAL: APPROVAL TO ISSUE YES NO DATE ISSUED ZZile-7� BY j CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID WELL CONSTRUCTION APPROVAL SEPTIC SYSTEM CONSTRUCTION APPROVAL OTHER ANY VARIANCE NEEDED FINAL BOARD OF HEALTH APPROVAL: YES NO YES NO YES NO YES NO YES DATE 1 NO BY: DATE: ooaRnvaL TO BACKFILL: };. ELT IQ S_jF, ... 9LT.QL! 'INSTALLER LICENSED?...'.""'.'.' THE INSTALL`+ �; ', YES NO ..; - OF- CONSTRUCTION: ? ' NEW REPAIR' .TYPE _ •REVIEW :..NEW CONSTRUCTION:-,. CERTIFIED PLOT PLAN (�-- E5� NO : CONDITIONS OF..APPROVAL. * ... YES NO (FROM FORM U) ;.. _`ISSUANCE OF DWC PERMIT _ ES NO '��a •..•`� +INSTALLER: PERMIT N0. L:- _ BEGIN INSPECTION :• YES N0: `,EXCAVATION. INSPECTION: :NEEDED: PASSEDBY ' CONSTRUCTION INSPECTION: NEEDED: AS BUILT PLAN SATISFACTORY: Ss1 _ DATE: ooaRnvaL TO BACKFILL: 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. _Q Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Sunset Rock Road Property Address al Grimes Owners Name North Andover City/Town MA 01845 State Zip Code 3/23/2016 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: Neil J. Bateson MAR 2 9 2016 TOO OF NORon TMENVER Name of Inspector Bateson Enterprises Inc. �. Company Name 111 Aroilla Road Company Address Andover Citylrown 978-475-4786 Telephone Number B. Certification MA State S115 License Number 01810 Zip Code 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 urther Evaluation by the Local Approving Authority 3/23/201E Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ***This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under. the same or different conditions of use. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ..'" 25 Sunset Rock Road Property Address al Grimes Owner information is required for every page. Owner's Name North Andover MA 01845 3/23/2016 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old" or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. " A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 3/13 Title 5 Official Inspection Forth: 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 25 Sunset Rock Road Property Address al Grimes Owner's Name North Andover Citylrown B. Certification (cont.) MA 01845 Zip Code 3/23/2016 Date of Inspection ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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 • 3113 Tittle 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 25 Sunset Rock Road Property Address al Grimes Owners Name North Andover MA 01845 3/23/2016 City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ 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 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 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 % day flow t5ins • 3/13 Title 5 Official Ins pectian Form: Subsurface Sewage Disposal System •Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Sunset Rock Road Property Address al Grimes Owner Owner's Name information is required for North Andover MA 01845 3/23/2016 every page. City/Town 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 • 3/13 Idle 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Owner information is required for every page. Commonwealth of Massachusetts T11 itle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Sunset Rock Road Property Address al Grimes Owner's Name North Andover MA 01845 3/23/2016 Cityfrown 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): caan t5ins • 3/13 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 25 Sunset Rock Road D. System Information Description: Number of current residents: 3/23/2016 Date of Inspection Does residence have a garbage grinder? Property Address Yes al Grimes Owner owner's Name information is required for North Andover MA 01845 every page. Cityrrown State Zip Code D. System Information Description: Number of current residents: 3/23/2016 Date of Inspection Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Yes Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins • 3113 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 • '�L\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Sunset Rock Road Property Address al Grimes Owner Owner's Name information is required for North Andover MA 01845 3/23/2016 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Pumped 2014, owner 1500 gallons Measured tank. Inspect tank & tees Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool El 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): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 8 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 25 Sunset Rock Road Property Address al Grimes Owner's Name North Andover Citylrown D. System Information (cont.) MA 01845 State Zip Code 3/23/2016 Date of Inspection Approximate age of all components, date installed (if known) and source of information: 20 years old, 9/23/1996, 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): ❑ Yes ® No 1.6 feet Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" PVC through wall to septic tank, 3" PVC in house, no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal ❑ fiberglass 0.6 feet ❑ 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'x 4' Sludge depth: 1" ❑ Yes ❑ No t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments " 25 Sunset Rock Road Property Address al Grimes Owner information is required for every page. t5ins • 3/13 Owner's Name North Andover Cityrrown D. System Information (cont.) MA 01845 State Zip Code 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 32" 13" 3/23/2016 Date of Inspection 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 tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: feet ❑ fiberglass ❑ polyethylene ❑ other (explain): 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 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 '�L\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Sunset Rock Road Owner information is required for every page. Property Address al Grimes Owner's Name North Andover Citylrown MA 01845 State Zip Code 3/23/2016 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: gallons gallons per day Alarm present: ❑ Yes ❑ No Alarm level: 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 • 3113 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 25 Sunset Rock Road Property Address al Grimes Owner's Name North Andover MA 01845 3/23/2016 City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert L Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D -box level & distribution equal. No evidence of leakage. Evidence of light carryover. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): " If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 3/13 Title 5 Official Inspection form: Subsurface Sewage Disposal System • Page 12 of 17 Owner information is required for every page. t5ins • 3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Sunset Rock Road Property Address al Grimes Owner's Name North Andover Cityrrown D. System Information (cont.) MA 01845 State Zip Code 3/23/2016 Date of Inspection Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: 0 leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system 2 trenches 77' long 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 25 Sunset Rock Road Property Address al Grimes Owner's Name North Andover MA 01845 3/23/2016 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 - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 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 25 Sunset Rock Road Property Address al Grimes Owner's Name North Andover MA 01845 3/23/2016 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 p �kN_ SIC, D(\ Q �t_o n t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 Commonwealth of Massachusetts ' 1 1111 itle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Sunset Rock Road Property Address al Grimes Owner Owner's Name information is North Andover MA 01845 3/23/2016 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 4 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: 5/4/1994 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Design plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: As per test pit data on design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Sunset Rock Road ,p Owner information is required for every page. Property Address al Grimes Owner's Name North Andover MA 01845 3/23/2016 Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Summary Record Cad generated on 3-241206 3:48:58 PM bi Kenn Hagor. Pepe 1 - Town of North Andover Serial No Status Tax Map # 210-106.A-0219.0000.0 Brand - Parcel Id 17360 35076163 a Active ERT HH 26 SUNSET ROCK ROAD v1 Water C.63 0.63 1693 Date ALLEN & DIANE GRIMES Code Consumption Fasted Date 28 SUNSET ROCK ROAD 31W2015 1148 a Actual NORTH ANDOVER, MA 0184 Class _ 101 Singlia Family 1732 Property Type i Rgcldenllel Zoning2 1 Res'dential •58% Zoning3 1 Residential Size TOW! 1.34 Ac rah 101 10/1612015 64% FY 2016 1588 aActual 66 US Mailing Index 240% 3/11/2015 1533 Name/Address 70e Loan Number Active/InacL From Until ALLEN & DIANE GRIMES Owner a Actual 24 25 SUNSET ROCK ROAD -600k Q/1112014 1493 NORTHANDOV€R, MA 01845 123 10/1512014 208% FIERAMOSCA, MICHAEL. Previous Customer Inactive 5119006 40 25 SUNSET ROCK ROAD 204% 3/1112014 1330 NORTH ANDOVEK MA 13 4111/2014 -70% 01845 1317 aActual 42 Account No Cycle Occupant Name Activallnact!'ue Bldg Id. 17661.0 - 25 SUNSET ROCK ROAD Last Billing Date 1!812016 3170351 03 Cycle 03 Active US Services Maint. A=unt No. 3170351 Service Code Rate Charge Multlplier/Usors MISCFEE ADMIN FEE 0.63 518 7.82 1/ WiR WATER 01 ALL METIER SIZE 203.27 /1 Ue Meter Maintenance Account No. 3170351 Serial No Status Location Brand Type Size YTD Cons 35076163 a Active ERT HH METE METE v1 Water C.63 0.63 1693 Date Reading Code Consumption Fasted Date Variance 31W2015 1148 a Actual 16 -62% 12/10/2015 1732 aActual 43 1/20/2016 •58% 9/911015 1689 aActuai 101 10/1612015 64% 6/1012015 1588 aActual 66 7/24/2015 240% 3/11/2015 1533 SAcdual 16 4012016 -33% 12/11/2014 1517 a Actual 24 1/1512015 -600k Q/1112014 1493 aActual 123 10/1512014 208% 6/11/2014 1370 aActual 40 711612014 204% 3/1112014 1330 a Actual 13 4111/2014 -70% 12/1042013 1317 aActual 42 1117ri014 -50% 9/1212013 1275 aActual 86 10/1512013 55% 6/12/2013 1180 aActual 55 7124/2013 166% 3/13/2013 1134 aActual 21 &12212013 -3% 12/11/2012 1113 aActual 21 1/912013 -68% 911312012 1092 aActuai 187 10/15,7012 352% 6/1 212012 805 a Actual 40 7116/2012 53% 3/1412012 665 &Actual 27 411412017. •2% 12/121201/ 838 aActual 27 111712012 72% 911 2120 11 ell eActuol 101 10/1312011 5810. 6/7/2011 710 aActual 60 7/2012011 351 ck 3/812011 660 a Actual 13 4113/2011 -6911/> 12/912010 637 aActual 38 1/1212011 -7,5% 9/10/2010 589 aActual 163 10/15/2010 1191% 617/2010 435 &Actual 53 7/15/2010 182% 3/912010 383 aActual 19 4114/2010 -33% 12/812009 364 &Actual 28 1/1212010 -61% Commonwealth of Massachusetts UwToWn of . 973 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 / Right front of douse, Left AlEht rear of house?Left / right side of house, Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address c� 5 City/Town l state Zip Code 2. System Owner. Name' Address (if different from location) City/rown ' State Zip ; Telephone Number e j B. Pumping 1. Date of Pumping 3. Type -of system: ❑ ❑ Other (describe): "; D3- 147 Date 2. Quantity Pumped: Cesspool(s) eptic Tank Gallons r ❑ Tight Tank 4. Effluent Tee Filter present? Cl Yes 9-9-0 If yes, was it cleaned? ❑ Yes ❑ Na '5. Condition of System: 6: System Pumped By: Neil. Bateson Name Bateson Enterprises Inc Company 7. Location where contentgwere disposed: Lowell Waste Water F5821 Vehicle License Number Date 0=4.doc* 06/03 System Pumping Record - Page 1 of 1 '" 'a310f1231SN0a N3HM i III is N=it1/V% 2�3n0aNb H12i0N Jl11WN0JN00-NON 0 J111W2l0JN00 d0 SMHI AS ONINOZ d0 N011VNlV4U313Q JNINOZ•3H1 HIM 3HI UOd Si 3sn H0f1S aNtY JlldWOO NMOHS jo �r AINO U0103dSNI JNIaim 3Hl =10 S13Sd=10 3H1 3sn 3HI UO=l 3HV NMOHS S13S3=i0 1bH1 kJI-LU30 1 00'512iNID O I £ QNd SNOUVOI3IO3dS Nth Id MU OZ • O3NOO Q3SfI s'IbRidlyw 3I-LI.1.VHL QMH IN21NI UaNJIS3Q MU NIVA 3DNVCrdODDV NI N33H SVH J av-do'IdNH mu CNV NOI.LofilusNOz) MU lylu QNB' Ni3.LSAS livsOdSIQ SIH.L 3o NOI.LofilUSNOD a ll Q3.1 USNI 3AVH I ,LVHL AIDED AUHHH I I 0 Z# b£'Z9i=HDM91.L GNH.f J# 017'Z9 T=HDI MU (INN Z@t°R.Z9i=Xog *Q .Lflo „ i0'£9I= XOH'QAII,l 05'£91=?IIS l iflo tiL' £9 i = xl�Id.L ILII 'MII £ i '179 i='HSH IMAM SNolJLVn'JgE[ JO HzSVi -s ;eW •J8AOPub UPON Peon MOPEGw J99c] 09 ,ot SOHO 'S Wej:j s1'f .S'Td.�] SOWD 'l RODS 96/£Z/6 NO iiineSd 96/17/9 :31d(l .Ot, =J:31VOS 'dW `U.3n0'aNd H1210N NI 031VO01 Mdld 101d 031=1112130 RRISAS ")tJ,dRS DMR -SV �,\ N b L t lOZ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS /''C DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: _25 Sunset Rock Road_ North Andover_ Owner's Name: _Vanessa Fieramosca_ Owner's Address: _25 Sunset Rock Road _ North Andover, MA 01845_ Date of Inspection: _4/1/2008 Name of Inspector: _Neil J. Bateson_ Company Name: _Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, MA 01810_ Telephone Number: _ (978) 475-4786_ RECEIVED APR 0 9 2008 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 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 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 Needs Further Evaluation by the Local Approving Authority it Inspector's Signature: )6c�Date: 4/1/2008 _ 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. Notes and Comments: ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 25 Sunset Rock Road_ North Andover Owner: _ Fieramosca _ Date of Inspection: _4/1/2008 _ Inspection Summary: Check A, B, C, D or E / ALWAYS complete all of Section D A. System Passes: X 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. Answer yes, no or not determined (Y,N,ND) in the 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. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain: pumping more than 4 times a year due to broken or obstructed pipe(s). approval of the Board of Health): ND explain: Title 5 Inspection Form 6/15/2000 broken pipe(s) are replaced obstruction is removed 2 The system required The system will pass inspection if (with 1 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 25 Sunset Rock Road- - North Andover_ Owner: _Fieramosca_ Date of Inspection: _4/1/2008 _ 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 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 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, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection Form 6/15/2000 Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 25 Sunset Rock Road- -North oad__North Andover_ Owner: _Fieramosca _ Date of Inspection: _4/1/2008 _ D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: _No_ Backup of sewage into facility or system component due to 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 _No_ Liquid depth in cesspool is less than 6" below invert or available volume is 1/2 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 _ Any portion of the SAS, cesspool or privy is below high ground water elevation. —No— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. No_ Any portion of a cesspool or privy is within a Zone 1 of a public well. No— Any portion of a cesspool or privy is within 50 feet of a private water supply well. No— 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 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, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No_ (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described m 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. You must indicate either "yes" or "no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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 11 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. Title 5 Inspection Form 6/15/2000 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 25 Sunset Rock Road _ _ North Andover _ Owner: _Fieramosca_ Date of Inspection: _4/1/2008_ Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No _Yes_ 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? _Yes_ Has the system received normal flows in the previous two week period ? No_ Have large volumes of water been introduced to the system recently or as part of this inspection ? _Yes_ _ Were as built plans of the system obtained and examined? _Yes_ _ Was the facility or dwelling inspected for signs of sewage back up ? _Yes_ _ Was the site inspected for signs of break out ? _Yes_ _ Were all system components, excluding the SAS, located on site ? _Yes_ _ 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 ? _Yes_ _ 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: Yes No _Yes_ _ Existing information. _Yes_ _ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] Title 5 Inspection Form 6/15/2000 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 25 Sunset Rock Road- -North oad__North Andover_ Owner: _Fieramosca _ Date of Inspection: _4/1/2008 _ FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): _4_ Number of bedrooms (actual): _4_ DESIGN flow based on 310 CMR 15.203 _660_ Number of current residents: _2 Does residence have a garbage grinder (yes or no): No Is laundry on a separate sewage system (yes or no): No _ Laundry system inspected (yes or no): Seasonal use: (yes or no): _No_ Water meter reading: _Yes_ Sump pump (yes or no): _No_ Last date of occupancy: _ Current_ COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): ___gpd Basis of design flow (seats/persons/sgft,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): GENERAL INFORMATION Pumping Records Source of information: _Pumped May 2007, owner _ Was system pumped as part of the inspection (yes or no): _Yes_ If yes, volume pumped: _1500_ gallons -- How was quantity pumped determined? _Measured tank_ Reason for pumping: Inspect tank & tees_ TYPE OF SYSTEM _X 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) Tight tank _ Attach a copy of the DEP approval Other (describe): _ _ Approximate age of all components, date installed (if known) and source of information _12 Years old, 9/23/1996, as built plan _ Were sewage odors detected when arriving at the site (yes or no): _No Title 5 Inspection Form 6/15/2000 Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 25 Sunset Rock Road_ _ North Andover _ Owner: _Fieramosca _ Date of Inspection: _4/1/2008_ BUILDING SEWER _ X _ (locate on site plan) Depth below grade: 18" Materials of construction: cast iron _X_ 40 PVC _other Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.) _ 4" PVC thru wall, 3" PVC in house, no leaks visible SEPTIC TANK: X Depth below grade: _6" _ Material of construction: X_ concrete _ metal _fiberglass _polyethylene _other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): , (attach a copy of certificate) Dimensions: _10' x 5' x 4' Sludge depth: _2"_ Distance from top of sludge to bottom of outlet tee or baffle: 25" _ Scum thickness: _3" 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: 18"_ How were dimensions determined: _ 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 tee ok. Outlet tee ok. Depth of liquid at invert. No evidence of leakage. _ GREASE TRAP: _(locate on site plan) Depth below grade: 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: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Title 5 Inspection Form 6/15/2000 Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 25 Sunset Rock Road _ North Andover_ Owner: _Fieramosca _ Date of Inspection: _4/1/2008_ TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX_X_ Depth below grade _2"_ Depth of liquid level above outlet invert: _ 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.) _D -box level & distribution equal. No evidence of leakage. Light carryover, pumped d -box to clean. _ PUMP CHAMBER: _ (locate on site plan) Pump in working order (yes or no): _ Alarm in working order (yes or no): _ Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Title 5 Inspection Form 6/15/2000 Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _25 Sunset Rock Road _ —North Andover_ Owner: _Fieramosca_ Date of Inspection: _4/1/2008_ SOIL ABSORPTION SYSTEM (SAS): _X_ (locate on site plan, excavation not required) If SAS not located explain why: Type _ Leaching pits, number: _ Leaching chambers, number: Leaching galleries, number: X Leaching trench, number, length: _2 trenches 77' long_ Leaching field, number, dimensions: Overflow cesspool, number: Innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.):—Soil ok. Vegetation ok. No sign of ponding to surface. _ CESSPOOLS: Number and configuration: Depth — top of liquid to inlet invert: Depth of sludge layer: Depth of scum layer: _ Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): 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.): Title 5 Inspection Form 6/15/2000 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 25 Sunset Rock Road _ —North Andover_ Owner: _Fieramosca _ Date of Inspection: _4/1/2008_ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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 Title 5 Inspection Form 6/15/2000 10 to .1= 64' tot=70'4" to D -Box =113'6" :o 1= 23'6" :o2=24' :o D -Box = 59'2" Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 25 Sunset Rock Road _ _ North Andover_ Owner: _Fieramosca_ Date of Inspection: _4/1/2008 _ SITE EXAM Slope _ Slight _ Surface water _ No _ Check cellar _ Dry _ Shallow wells _ No _ Estimated depth to ground water _ 4'_ Please indicate (check) all methods used to determine the high ground water elevation: _X_ Obtained from system design plans on record - If checked, date of design plan reviewed: _5/4/1994_ 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: _ No water found 4' below system as per test pit data on design plan _ Title 5 Inspection Form 6/15/2000 11 Summary Record Card genraated on 4/412008 2:26:41 PM by Lisa Evans Page 1 ' Town of North Andover Tax Map # 210-106.A-0219-0000.0 25 SUNSET ROCK ROAD FIERAMOSCA, MICHAEL L Since Jan 2003 VANESSA FIERAMOSCA 25 SUNSET ROCK ROAD NORTH ANDOVER, MA 01845 Class 101 Single Family Size Total 1.34 Acres FY 2008 UB Mailing Index Name/Address Type FIERAMOSCA, MICHAEL Payor 25 SUNSET ROCK ROAD NORTH ANDOVER, MA 01845 UB Account Maint, Account No Cycle Bldg Id. 17681.0 - 25 SUNSET ROCK ROAD 3170351 03 Cycle 03 Property Type 1 Residential Loan Number Active/Inact. From Occupant Name Active/Inactive Last Billing Date 3/28/2008 Active UB Services Maint. Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 64.62 /1 UB Meter Maintenance Serial No Status Location Brand Type 41975299 a Active ENC F.RT. ? w Water Date Reading Code Consumption Posted Date 3/7/2008 2661 a Actual 18 4/11/2008 12/11/2007 2643 a Actual. 63 1/22/2008 9/5/2007 2580 a Actual 119 10/12/2007 6/18/2007 2461 a Actual 52 7/20/2007 3/15/2007 2409 m Manual estimate 20 4/16/2007 12/8/2006 2389 a Actual 14 1/19/2007 Trouble Code:03 9/12/2006 2375 a Actual 115 10/20/2006 Trouble Code:03 6/14/2006 2260 a Actual 26 7/10/2006 3/8/2006 2234 a Actual 18 4/17/2006 Trouble Code:03 12/21/2005 2216 a Actual26 1/17/2006 9/20/2005 2190 a Actual 121 10/14/2005 Trouble Code:03 6/13/2005 2069 a Actual 28 7/15/2005 3/25/2005 2041 m Manual estimate 30 4/5/2005 12/14/2004 2011 a Actual 155 1/14/2005 Trouble Code:03 9/24/2004 1856 m Manual estimate 30 10/8/2004 6/11/2004 1826 m Manual estimate 20 7/30/2004 4/16/2004 1806 a Actual 21 5/17/2004 Trouble Code:03 12/15/2003 1785 n New Meter 0 12/15/2003 Size 0.63 0.63 Until YTD Cons 0 Variance -68% -57% 175% 165% 28% -87% 382% 13% -17% -77% 249% 18% -84% 570% -20% 109% 0% 0% Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating -Water& Sewer Lines -Septic Systems & Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 25 Sunset Rock Road, North Andover Owner: Fieramosca Date of Inspection: 4/1/2008 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. Neil J. Bateson Bateson Enterprises, Inc. Town of North Andover, Massachusetts Form No. 3 BOARD OF HEALTH NoRTN oL 0AiNdift9 �,'•�,,,,-o..•`� DISPOSAL WORKS CONSTRUCTION PERMIT '23A HU Applicant TELEPHONE NAME ( ADDRESS Q Site Location Permission is hereby granted to Construct (v) or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. 1 —� Fee MA ., , - — -- ----- D.W.C. No. 0� l APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: � — J``'( CURRENT INSTALLER'S LICENSE#� LOCATION: ,se� LICENSED INSTALLER: SIGNATURE: CHECK ONE: REPAIR: NEW CONSTRUCTION: Ir IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. $75.00 Fee Attached? Foundation As -Built? Approval Administrative Use Only Yes ✓ No Yes v No Date: 9 �6 FORM U .- LOT RELEASE FORM laxaq 30q r.00 k IN. T UCTIONS: This form is used to verify that all necessary approvals/permits from Bo , s and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT \\vim c. xr-�ln PHONE_ LOCATION: Assessor's Map Number & PARCEL SUBDIVISION r LOT (S) SC6 STREET S ✓1� -Rc� ST. NUMBER *****************************************OFFICIAL USE ONLY*********************************** RECOAAMENDATIONS OF TOWN AGENTS: CONgERVATION ADMINRATOR DATE APPROVED DATE REJECTED COMMENTS A,DDCOu&A by CL 07 S�� Da - re--con5frwlcl-o.,I VIP W04 TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR -HEALTH DATE APPROVED I 0 DATE REJECTED SEPTIC INSPECTOR -HEALTH COMMENTS C.��It pu- ,p l DATE APPROVED DATE REJECTED ! j 6 PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT ie.5 N0+ - RECEIVED BY BUILDING INSPECTOR DATE Revised 9\91 jm Town of North Andover Office of the Health Department Community Development and Services Division 27 Charles Street North Andover, Massachusetts 01845 Sandra Starr Health Director July 18, 2002 Ron Trecartin, North East Builders, LLC. 11 Overlook Drive Danvers, MA 01923 Telephone (978) 68&-9540 Fax (978) 688-9542 Re: Application for a 12'X24' Sunroom addition at 25 Sunset Rock Road, N. Andover, MA Dear Adrian: Your application for a sum oom addition at 25 Sunset Rock Road has been reviewed by the Health Department. The application was denied on July 18, 2002 for the following reasons: 1. X Missing information 2. X Passing Title 5 inspection of septic system may be required 3. X Location of structure may not be acceptable To address the problem(s): If # 1 is checked, please supply: a. Floor plan of the existing house and the existing house with the proposed addition b. Certified plot plan showing house, septic system and proposed project in scale. The plot plan submitted did not correspond with the floor plan. If #2 is checked: a. Have the septic system inspected by a certified Title 5 inspector to determine the size of the system and whether it is operating properly: OR b. Tie-in to municipal sewer If #3 is checked: a. Relocating or amending the project may be necessary. Please feel free to call the Health Office at 978-688-9540 with any questions you may have. Sincerely, ll'oe rian J. LaGrasse Health Inspector = Cc: Building Department File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535 FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section*****************APPLICANT: �L�r;A� Phone 7S-~ i1--7J7_ c 7J[_ LOCATION: Assessor's Map Number Parcel Subdivision 1 -IT Lot(s) ja Street 1(;lf�- , St. Number ************************Official Use Only************************ RECOMMENDATI9 S PF TO NTS: Conservation Administrator Comments Date Approved �z r �� Date Rejected V_R Date Approved Town Planner Date Rejected Comments Food Insp�ecnto--yyr-----Health Septic Inspector -Health Comments Date Approved Date Rejected Date Approved &z,119,L 5 Date Rejected Public Works - sewer/water connections�r� 2,-772-25 - driveway permit Fire D partment ceived by Building Inspector Date FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT:. Phone �� LOCATION: Assessor's Map NumberParcel r Subdivision Lot(s) _ Street St. Number ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Conservation Administrator Date Approved Date Rejected Comments Town Planner Date Approved Date Rejected Comments Food Inspector -Health Date Approved Date Rejected Septic Inspector -Health Date Approved Date Rejected Comments Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date Appli Town of North Andover, Massachusetts Form No.2 BOARD OF HEALTH x-319 �U DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Site Location LoT -t� i Test No. Cj,L- Reference Plans and Specs. ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. �u Fee CHAIRMAN, BOAR OF HEALTH Site System Permit No. ...�: �- .'i^"`'\ +t � rR 'qY x` n ,�` tc`as r"4a^'wt <, ,^ .C.�•.r•.._.-_ :`..____ _ BOARD OF HEALTH 120 MAIN STREET TEL. 682-6483 NORTH ANDOVER, MASS. 01845 Ext23 January 30, 1995 Mr. Thomas Neve 447 Old Boston Road Topsfield, MA 01983 Re: Lot #18 Sunset Rock Road Dear Tom: This is to inform you that the proposed plans for site referenced above have been disapproved for the following reasons: 1) System does not have two (2) passing perc tests in the leach area. 2) System fill 84 feet(+-) from the wetlands; 100 feet required. If you have any questions, please do not hesitate to call the Board of Health Office at the number above. Sincerely, Sandra Starr, R.S. Health Administrator SS/cjp DATE a Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER y OjS FEE- SUBSURFACE DISPOSAL DESIGN REVIEW IG�J RECEIVED /f / PERMIT = DATE ..�.--- APPLICANT �' %3/IIcJS z ASSESSOR'S MAP ADDRESS ENGINEER(�y c� ADDRESS -447 OLD -L oSTDti 1L PLAN DATE /Z /az ? ,/- CONDITIONS OF APPROVAL: APPROVED DISAPPROVED PARCEL T LOT` STREET = 5 w-se7-- -�Cpr-4 'Fb ToPsl--16--e-6 o196,3 REVISION DATE � � � � �D E • � LbT, - 5 ysTcM -Dotes /V07- ;57 V07S /STEM v 619,7,�o 7-16 � -7-:;' ,9 5 5 /ti G /DO PLAN REVIEW CHECKLIST ADDRESS �Qr' %� ��iUS�T� ENGINEER GENERAL ' f 3 COPIES C/ STAMP L� LOCUS �_ ' NORTH ARROW "----SCALE �-- CONTOURS C, ----'PROFILE e-� SECTION �� BENCHMARK t�5�5 SOIL & PERC INFO ELEVATIONS WETS. DISCLAIMER WELLS & WETLANDS( WATERSHED? _A�a DRIVEWAY L/ (Elev) WATER LINE FDN DRAIN v SCH40 L/ TESTS CURRENT? SEPTIC TANK MIN 1500Gy .17 INVERT DROP GARB. GRINDER(+200% EDF) 25' TO CELLAR V' MANHOLE TO GRADE ELEV GW D -BOX SIZE # LINES d`- FIRST 2' LEVEL STATEMENT INLET % .gjj - OUTLET `� _ ,Ab (2" OR .17 FT) TEE REQ'D? LEACHING MIN 660 GPD? RESERVE AREA ✓ 4' FROM PRIMARY?t,� 2% SLOPE,-- 100' LOPE,--100' TO WETLANDS`_ 100' TO WELLS L-*" 4' TO S.H.GW f 35' TO FND & INTRCPTR DRAINS i/ 325' TO SURFACE H2O SUPP 4' PERM. SOIL BELOW FACILITY MIN 12" COVER t/ FILL?(25' if above natural elev; 101if below) BREAKOUT MET? TRENCHES MIN 660 gpd SLOPE (min .005 or 6"/1001) ✓ >31COVER?-VENT — SIDEWALL DIST. 2X EFF. W OR D (MIN 6') y IS RESERVE BETWEEN TRENCHES? IN FILL? ---- MUST BE 10' MIN. V 4" PEA STONE?L--' BOT X LDNG + SIDE 9a� X LDNG = TOT (L x W x #) (G/ft2) (DXLx2x#) (G/ft2) Copyright 0 1993 by S.L. Starr FV 0 z rA W E 2 Ri M H o °� ox x o z W LA- zw Q A u N mS4 A d o acu a \ w ¢ w w z o o a O v w cn C p O C w cG U x P- c p w W D0 m G v o uj om u .o ® c 0 c LZCDv C H v c) CLc 0 ev CDCO o o m H vi Z Ea C o n N E.S o m o "r cm C C . 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