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HomeMy WebLinkAboutMiscellaneous - 259 DALE STREET 4/30/2018 (2)i North Andover Board of Assessors Public Access KOR7y 22 •,.. ..., .e oG swcuvs Return to the Home rage click on logo New Search Sales Summary Residence Detached Structure Condo Commercial Comparable Sales e . y Page 1 of 1 Tovm of Worth Aamdover Ekoard Of i 8$eSSoYS 7Z Property Record Card Location: 259 DALE STREET Owner Name: QUERZOLI, STEPHEN LYNNE M QUERZOLI Owner Address: 259 DALE STREET City: NORTH ANDOVER State: MA ZIP: 01845 Neighborhood: 6 - 6 Land Area: 1.1 acres Use Code: 101 - SNGL-FAM-RES Total Finished Area: 3019 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 559,300 595,100 Building Value: 349,900 363,400 Land Value: 209,400 231,700 Market Land Value: 209,400 Chapter Land Value: LATEST SALE Sale Price: 357,000 Sale Date: 08/31/1994 Arms Length Sale Code: Y -YES -VALID Grantor: EAGLE, KIM A Cert Doc: Book: 04119 Page: 0245 http://csc-ma.us/NandoverPubAcc/j sp/Home.j sp?Page=3&Linkld=1177811 6/4/2008 Ot NORTN Town of North Andover HEALTH DEPARTMENT ,SSACMUSt� CHECK #: �� DME: LOCATION: /-/., H/O NAME: CONTRACTOR NAME: 3336 %i 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) $ ❑ Title 5 In ctor $ the 5 Report $ ❑ Other. (Indicate) $ 17 _,,e 4ldl, Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer a' 4. 4 t d c i O w O Z 3 J J O I d O w w v i = ar co U J O O O I A v 0 0 m O y i LO Li H N a � N C v o E O N EE y N U d o e d O v i = ar � try C ai E a� v y d w O z z z J A v 0 0 m O y i LO Li H N a � N C v o E O N EE y N U d o e 1 °f °RT .,� 3 J J G •° 1 Town of North Andover HEALTH DEPARTMENT ,SS4CMUSt CHECK #: �`DATE: ,� LOCATION: a37/f da H/O NAME: CONTRACT( 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) $ ❑ Title 5 Inspector Report $ $� itle 5 ❑ Other: (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer 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 Asses; 259 Dale Stree Property Address Steve Querzoli Owner's Name No. Andover City/Town MA 01845 State Zip Code ERECI-iv- entAY 2 9 2008 F NORn H ANDO VER 5/21/08 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector: Benjamin C. Osgood, Jr. Name of Inspector New England Engineering Services, Inc. Company Name 1600 Osgood Street Suite 2-64 Company Address No. Andover City/Town 978-686-1768 Telephone Number B. Certification MA State License Number 01845 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 fu'9 ction and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Sec6\ n 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes , Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspec s Signature S_-21—OS 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. TITLE 5 FORM MASTER.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 15 =idi= Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 259 Dale Street Property Address Steve Querzoli Owner's Name No. Andover MA 01845 5/21/08 City/Town 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. 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 TITLE 5 FORM MASTER.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of '15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 259 Dale Street Property Address Steve Querzoli Owner's Name No. Andover MA 01845 Cityrrown State Zip Code B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: 5/21/08 Date of Inspection ❑ 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 ❑ obstruction is removed ND Explain: 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. TITLE 5 FORM MASTER.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 15 Commonwealth of Massachusetts ugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 259 Dale Street Property Address Steve Querzoli Owner Owner's Name information is required for No. Andover MA 01845 5/21/08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El 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 ❑ 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. TITLE 5 FORM MASTER.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 259 Dale Street Property Address Steve Querzoli Owner's Name No. Andover City/Town B. Certification (cont.) MA 01845 State Zip Code D) System Failure Criteria Applicable to All Systems (cont.): 5/21/08 Date of Inspection Yes No No ❑ g Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ 2. Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ �R Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet the system is within 200 feet of a tributary to a surface drinking water supply 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 ❑ is 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. TITLE 5 FORM MASTER.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 259 Dale Street Property Address Steve Querzoli Owner Owners Name riformationis required for No. Andover MA 01845 5/21/08 for every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ❑ [91"' Pumping information was provided by the owner, occupant, or Board of Health ❑ Q' 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? ❑ Q,,- Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ [D,-' Were as built plans of the system obtained and examined? (If they were not i 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? ❑ Yes No ❑ [91"' Pumping information was provided by the owner, occupant, or Board of Health ❑ Q' 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? ❑ Q,,- Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ [D,-' 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? ❑ D 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: ❑ Br 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)] TITLE 5 FORM MASTER.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 259 Dale Street Property Address Steve Querzoli Owner information is required for every page. Owner's Name No. Andover MA Cityfrown State D. System Information 01845 5/21/08 Zip Code Date of Inspection Residential Flow Conditions: 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 residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Sump pump? Last date of occupancy: 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? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Last date of occupancy/use: Date Other (describe): ❑ Yes ❑ No ❑ Yes R No ❑ Yes F� No ❑ Yes R No ❑ Yes ,'E] No e.� r - �: 7 Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No TITLE 5 FORM MASTER.DOC • 08/06 Mille 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 15 Commonwealth of Massachusetts M Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 259 Dale Street Property Address Steve Querzoli Owner Owner's Name information is required for No. Andover MA 01845 5/21/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: 0 01l N .01— / gallons ❑ Yes ❑ No Type of System: IR 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: + Were sewage odors detected when arriving at the site? JQ Yes ❑ No TITLE 5 FORM MASTER.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 259 Dale Street Property Address Steve Querzoli Owner Owner's Name information is required for No. Andover MA 01845 5/21/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer (locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t" -,e - Septic Tank (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal 2 - feet feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? TITLE 5 FORM MASTER.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 15 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 259 Dale Street Property Address Steve Querzoli Owner Owner's Name information is No. Andover MA 01845 5/21/08 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 9 r D 00 J' -t- t iy>.?c c i —1 0111-11r, R! W —I tt� 4-jeA- P rte' . Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle feet ❑ polyethylene ❑ other (explain): Date of last pumping: Date 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): TITLE 5 FORM MASTER.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 15 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 259 Dale Street D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: Design Flow: Alarm present: Alarm level: gallons 5/21/08 Date of Inspection gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): Pump Chamber (locate on site plan): Pumps in working order: Alarms in working order: ❑ Yes ❑ No ❑ Yes ❑ No TITLE 5 FORM MASTER.DOC • 08/06 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 11 of 15 Property Address Steve Querzoli Owner Owner's Name information is required for No. Andover MA 01845 every page. City/Town State Zip Code D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: Design Flow: Alarm present: Alarm level: gallons 5/21/08 Date of Inspection gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): Pump Chamber (locate on site plan): Pumps in working order: Alarms in working order: ❑ Yes ❑ No ❑ Yes ❑ No TITLE 5 FORM MASTER.DOC • 08/06 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 11 of 15 Commonwealth of Massachusetts p . Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 259 Dale Street D. System Information (cont.) 5/21/08 Date of inspection Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: Property Address Steve Querzoli Owner Owner's Name information is required for No. Andover MA 01845 every page. City/Town State Zip Code D. System Information (cont.) 5/21/08 Date of inspection Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields 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.): S-%sTcwt 7`-► ©c O✓( TITLE 5 FORM MASTER.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 259 Dale Street Property Address Steve Querzoli Owner's Name No. Andover MA 01845 Cityrrown State Zip Code D. System Information (cont.) 5/21/08 Date of Inspection 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 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 FORM MASTER.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 259 Dale Street Property Address Steve Querzoli Owner information is required for every page. Owner's Name No. Andover Cityrrown D. System Information (cont.) KAA J IO IC 01845 5/21/08 Zip Code Date of Inspection 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 FORM MASTEkDOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 15 f Commonwealth of Massachusetts a w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 259 Dale Street Owner information is required for every page. Property Address Steve Querzoli Owner's Name No. Andover City/Town D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells .AA AAf1AY 5/21/08 Date of Inspection Estimated depth to ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: D IV vt, t _1;1 e --4/L. 4( til E TITLE 5 FORM MASTER.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 15 PC 4bo A s, 5-6T t"V PlDr /JUT dC WCiE lit i! Al. 0.O�r TO it,jy. 1�E T4F'i z [ -31! PaOX_._ t !4� 0 2 �� AvErZ. A 4 E gTor.t6 -2Ef'TH 152-r� owe u IL -r YSTE,M __- ItJ o c2 4 KAr'1llp.!`sK.i A'S f E. E W f5 A. t?,G N I -r e c - r4 S ti 4 rpt two v � Q ST N c> .G1. r.► V Ov E �, C A of Health ,drth AnOverzMass. •. A% -z_ - BEPT'IC SISTIEK INSTALLATICK CHECK LIST DISOP—RUM easonst ito-j ✓fie"w OK 1. Distance Tot a. Wetlands b. Drains c. Well Lvw(3�►J6 41 2. Water Dine Location I r wr LOT Pa G! 34- N OK FAIL 3. No PVC Pipe ?�. Septic Tank a. _Tees -_Length & To Clean Ont Covers. b. Cement Pipe to Tank On Both Sides of Tank OP.01&k 5. Distribution Box a. Covers & Box - No Cracks b. All bines Flowing Equal Amounts c. No Back Flow 6. ' beach Field or Trench a. Dimensions b. Stone Depth c. Capped 'Ends d. Clean Double Washed Stone 7. beaYh a.s b.th ds d.pe to Pit - Both Sides f. Clean Do a Washed Stone Ike- 8. No Garbage Disposal 9. Final Grading Inspection 10. Barricading Covered System 11. As Built Snbmitted a. hot Location . b. Dimensions of System c. Location with Regard -to Pere Test d. Elevations e; Water Table Rvard of r g1th North kn,loversHass SUBSURFACE DISPOSAL DESIGN CHECK LIST h LOT # � a,& APPROVED DATE DISAPPROVED DATEazdl Provideds Reasonss r � y Title V I FAIL (CSC Reg 2.5 Reg 6 Reg 10.2 Reg 10.4 The submitted plan must show as a minimum: a) the lot to be served-area,dimensions lot # abutters 1b location and log deep observation hoes -distance to ties C1 location and results percolatim tests -distance to ties design calculations & calculations showing required leaching area location and dimensions of system -including reserve area 1 existing and proposed contours g) location any vest areas within 1001 of sewage disposal system or disclaimer -check wetlands mapping W ourface and subsurface drains v►ithin 1001 of sewage disposal system or disclaimer i) location any drainage'easemonts vithin 100' of sevnge disposal system or disclaimer-Plmming Board files J) knova sources of cater supply within 2001 of sewage disposal e system or disclaimer k) location of any proposed well to serve lot -1001 from leaching facility 1) location of water lines on property -101 from leaching facility in) location of benchmark n) driveways o) garbage disposals p no PVC to be used in construction q) profile of system -elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and Other elevations maximum ground water elevation in area sewage disposal system s) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Septic __Tanks a) cap— acitios-1150% of flow, water table, tees, depth of tees, access, punpine ' b) cleanout c) 101 from cellar wall or in.ground swimming pool - d) 251 from subsurface drains Distribution Boxes a) slope greaten 0.08 b) sump a!; -- rface Dem Ch,-�ck Ust _ -� Page 2 FAIL I OK I _ + Reg 11.2 11.4 11.10 11.11 Reg 15.1 15.4 15.8 3.7 Leaching Pits Leaching pits are preferred where the installation is possible a) calculations of leaching area-Wa nimum 500 sq ft b) spacing c surface drainage 2% d cover material eR�x2 �ar11" splash pad f tee at elbow g) no bends in pipe from d -box to pipe Leaching Fields a) no greater than 20 minutes/inch b) area -minimum 900 aq ft c) construction of field d) surface drainage 2 % e) 201 from cellar wall or inground swimn ng pool li Leaching Dxnches Reg 14.1 c ons o leaching area -min 500 aq ft 14.3 71�d) spacing-Is ft min 6 ft with reserve between 14.4 dimensions 14.6 construction 14.7stone 1tt.10 8 surface drainage 2% Downhill S2:22e slope y x = to be shown) b) y/x X 150 - (to be shown) s Reg 9.1 a) approval 9.6 u b) stand-by power WATERSHED RESIDENTS QUESTIONNAIRE 1. Name 2. Street Address c2 3. How many members are in your household? Gi What type of sewage disposal system do you have? ❑ cesspool 14 -'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? 21" yes ❑ no ❑ do not know 6. How old is your sewage disposal system? P'/ 0-5 years ❑ 6-10 years ❑ 11-20 years ❑ over 20 years ❑ do not know 7. Has your sewage disposal system been rebuilt or repaired? ❑ yes Z no ❑ do not know If yes, approximately how long ago? years. What was done? 8. How frequently is your sewage disposal system pumped out? ❑ annually ❑ every 2-4 years ❑ every 5-10 years ❑ over 10 years W never, 9. Have you had any problems with your sewage disposal system? El yes P�/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 kocedishwasher garbage disposal dehumidifier drain sump pumptoilet roof/pavement drains shower/bathtub 11. Please state the brandand type (liquid or powder) of detergent you use for: dishwasher clotheswasher4W – C 12. Does your property have a lawn? Dyes ❑ no If yes, approximately what size? ❑ less than 1/4 acre ❑ 1/4 acre ❑ 1/2 acre ❑ 3/4 acre P 1 acre ❑ more than 1 acre (Specify) acres 13 How often do you fertilize your lawn? No. of applications per year Season(s) of the year 14. Please state the brand and type (liquid or granular) of lawn fertilizer you use: lid Check here if your lawn is maintained by a professional landscape contractor. .— 0- dA Z ..�►_ . / St,8I0 VA 'aanopud gI-ION W11S uteA OZI 'IIeH LIMOI gjjPaH 3o pJUoq zanopuV gIJON : V6/ ry yi a North Andover Board of Health Town Hall, 120 Main Street North Andover, MA 01845 d r � z� y y C) O x C!P6 Carl yx rm y d z� x z z SEPTIC SYSTEM INSPECTION FORM ADDRESS 2 �g "L)p, LJ DATE INSPECTED � PROPERLY FUNCTIONING? Z N WEATHER CONDITIONS COMMENTS: WATER OVALI Y TES i Eb ? IZES01-TS? DYE TEST PERFORMED? Y N DATE? SKETCH: TO: NORTH ANDOVER, MASS. G 19 BOARD OF HEALTH FROM: DESIGN ENGINEER Re: Soil Absorption Sewage Disposal System This is to certify that I have inspected the construction materials of said disposal system at '64--lill Y),azz-- Site Location North Andover, Mass. The grades and construction materials a specifications dated'-)�mf�19j g Reg. Prof.En ied my plans and ti an i 41 t 190,2r-- GECINASe 0 anitarian a r -t a Ln cn 7D ^� cD CA I h -6 cn . .(D 0 -fi L_r . - i soucu's SEWER COM DATE OF SERVICE ZIMB SERVICE INC. PLETE SEWER -SEPTIC SERVICE INVOICE CUSTOMER NAM (508/ 683-5709 Methuen, MA (508) 937-9889 Dracut, MA (603) em, NH 39 Salem, NH (508) 470-1400 Apdover, MA (508) 851-8839 Tewksbury, MA M 33 x•(508) Billerica, Billerica, MA BILLING ADDRESS CITY STATE ZIP PHONE: 7 JOB ADDRESS IF DIFFERENT THAN BILLING ADDRESS ADDRESS[ STATE ZIP DESCRIPTION OF WORK G ;tJ *A- /5' MA V 461 W J VACUUM PUMP ❑ SEPTIC TANK GALS. ❑ CESSPOO ❑ OVERALL SYSTEM ❑ DRYWELL ❑ BASEMENT ❑ FAILED SYSTEM DRAIN LINES CLEANED ❑ MAIN LINE: FT. ❑ BATHTUB: FT. ❑ KITCHEN SINK: FT. ❑ TOILET BOWL: FT. ❑ FLOOR DRAIN: FT ❑ VANITY: FT. ❑ OTHER LINE: FT. WORK ORDER AUTHORIZATION USE ONLY ON CHARGES GUARANTEES PARTS LABOR OTHER OTHER INVOICE AMOUNTS I hereby authorize you to perform the above described services and 1 agree to pay the amounts indicated to the right. I hereby certify that I am duly authorized to order and approve the work requested. Interest @ 1.5 per month 18% per annum on past due balances. SIGNATURE TITLE $ K TERMS OF PAYMENT TYPE OF SERVICE TAX EXEMPT n TAX TOTAL CASH ❑ RES/COMM ❑ INDUSTRIAL ❑ CHECK CHARGE El PLUMBING ❑ `Q $ / Zr F_ JOB COMPLETION This is to acknowledge completion of the above described work which has been DATE CUSTOMER SIGNATURE 'S NAME w u+ s D ,q