HomeMy WebLinkAboutMiscellaneous - 26 EASY STREET 4/30/2018 (2)Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
$ 143500.00
m
$ -
$
174.00
Plumbing Fee
$
21.75
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
21.75
Total fees collected
$
317.50
26 Easy Street
313-15 on 9/26/14
Remove and Replace Cabinets Only
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for use=by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left ht front of Nous Left / Right rear of house, Left /right side of house, Left /
Right side of building, Left / Right fron _ of building, Left / Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner. kNk
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
4.
Date
Cesspool(s)
❑ Other (describe):
Effluent Tee Filter present? ❑ Yes No
State �,,�---7jp pie
Telephone Number
— 2. Quantity Pumped
0-IS-'eptic Tank
Gallons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No.
5. Condition of System:
�D47U\i
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Locatlo��w,lZere contents were disposed:
Waste Water
F5821
Vehicle License Number
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
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PUBLIC HEALTH DEPARTMENT
Town of North Andover
Community Development Division
CERTIFICATE OF
COMPLIANCE
As of: 9/6/13
This is to certify that the individual subsurface disposal system received a
SATISFACTORY INSPECTION of the:
Repair of D -box, Tee and Pipe from Tank to D -Box
By: Todd Bateson
At:
26 -Easy Street
Map 038 Lot 0165
North Andover, MA 01845
The Issuarpce of this certificate shall not be construed as a guarantee that the system will function satisfactorily.
r
Public Health Agent
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com
N
North Andover Health Department
Community Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 26 Easy Street MAP: 038
INSTALLER: Todd Bateson
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
INSPECTIONS
DBox and Tee, Pipe from Tank to D -Box: 9/5/13
TANK INSPECTION:
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
Comments:
SEPTIC TANK
LOT: 0165
❑ Contractor reports any changes to design plan
❑ Existing septic tank properly abandoned
❑ Internal plumbing all to one building sewer
❑ Topography not appreciably altered
LJ
Buying sewer in continuous grade, on
comp cted firm base
Cleano s per plan
Bottom o ank hole has 6" stone base
Weep hole ugged
1500 gallon to k has been installed
H-10 loading
Monolithic tank co
Water tightness of to
visual testing
ion
as been achieved by
Comments:
PUMP CHAMBER
OT,7,Mii i
CONTROL PANEL
Comments:
DISTRIBUTION -BOX
Comments:
❑ Inlet tee installed, centered under access port
❑ Outlet tee installed, centered under access port
(gas baffle/effluent filter)
❑ inch cover to within 6" of finish grade
installed over one access port
❑ Hydraulic cement around inlet & outlet
EMI
n
Bottom of tank hole has 6" stone base
Weep hole plugged
150Xgallon Pump Chamber installed
H-10 Ideding
Monoliths tank construction
Inlet tee ins`tglled, centered under access port
Pump(s) inst ed on stable base
Alarm float wor ' g
Pump On/Off floc we
Separate on/off float
Drain hole in pressure
cover at final gr
Iled over pump
access port
Water tightness of tank has been hieved by
testing
Hydraulic cement around inlet & outlet
❑ Alarm & Pump are on separate circuits
❑ Alarm sounds when float is tripped
❑ Location of control panel: basement
❑ Alarm signal located inside: basement
[� Installed on stable stone base
H-20 D -Box
❑"",A nlet tee (if pumped or >0.08'/foot)
Hydraulic cement around inlet & outlets
Observed even distribution
❑ Speed levelers provided (not required)
I r3
Commonwealth of Massachusetts Map -Block -Lot
038.00165
BOARD OF HEALTH --------
-erm
it No ------------
P
North Andover - BHP -2013-0879 ----------------------
P.I. FEE
F.I. $125.00
-----------------------
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Todd-Ba-teson---
----------------------------- - --------
--- ------------- ----- --- -
to (Repair) an Individual Sewage Disposal System. N IT& I �- '
at No TE
--26----EASY ------------SRET
----------------------------------------------------------------------------------------------------------------------------------------
as shown on the application for Disposal Works Construction Permit No. BHP -2013-087 �Augu013
------------- -- ——
-7 ------
Issued
7 ------
Issued On: Aug -29-2013 BOARD OF HEALTH
----------------------------------------------------------------------------------
Commonwealth of Massachusetts
Map -Block -Lot
038.00165
BOARD OF HEALTH
--- -------------------
Permit No
North Andover
BHP -2013-0879
----------------- -- ----
FEE
$125.00
-----------------------
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Todd B- -ateson
- - - ----------------------------------------------------------------------------------
to (Repair) an Individual Sewage Disposal System. 1 • atNo 26EASY STREET box,� � pl��Y�_rAAnk_QWCOPY
as shown on the application for Disposal Works Construction Permit No. BHP -20137087 Dated August -2-9,-2-0-1-3
Issued On: Aug -29 -2013
---------------------------------
BOARD OF HEALTH
65/5
F? °�.r". .. • 09
«• Town of North Andover
`+�'•�,; ;; :: �' HEALTH DEPARTMENT
1SSACHUSt�
CHECK DATE: yj I,q
LOCATION:
H/O NAME:W1
CONTRACTOR NAME:
ape
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)X
Septic Disposal Works Installers (DWI) $
❑ Title 5 Inspector $
❑ Title 5 Report $
❑ Other: (Indicate) $
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
I J
i
c,
°�ncHus�
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
VQ
Application for Septic Disposal System
Construction Permit -TOWN OF
NORTH ANDOVER, MA 01845
Application is hereby made for a permit to:
❑ Construct a new on-site sewage disposal system*
T--,ai-13
TODAY'S DATE
$ 250.00 - Full Repair
$125.00 - Component
❑ Repair or replace an existing on-site sewage disposal system*
�ffir or replace an existing system component — What?
A. Facility Information �' 6'� ' 0- aox
Address or Lot #
City/Town
2.- *TYPE OF SEPT SYSTEM*: 2013
➢ ElPump ravity (choose one)
***If pump sy , attach copy of electrical permit to application*** TOWN 0. NORTH ANDOVER
➢ Conventional System (pipe and stone system) HEALTH DEPARTMENT
➢ ❑ Infiltrator or Biddiff user (Gravel -Less) (Attach a copy of your certification to ins a _ is Wpeof systei
➢ ❑ Pressure Distribution S.A.S. (No D -Box)
➢ ❑ Pressure Dosed (D -Box Present) S A S
➢ ❑ Does the system require an effluent filter? Yes No
if yes, does plan specify make and model of filter? YES = (no further info. needed)
NO = (installer must specify brand of filter before DWC issuance)
What is the Make?
What is the Model?
2. Owner Information
Au1� S� l 1 % ���✓
Name ))
Address (if different from above)
City/Town
3. Installer Information
�a. le
Name
Address ✓
City/Town
4. Desianer Information
Name
Address
City/Town
State9A8' Zip Code
Telephone Number
Name of Company
BATMON ENTERPRISES, INC.
ANDOVER, MA 01810
State Zip Code
�T`7 ffg!s -01 �jv3
Telephone Number (Cell Phone # if possible please)
Name of Company
State
Zip Code
Telephone Number (Best # to Reach)
Application for Disposal System Construction Permit - Page 1 of 2
Application for Septic Disposal System
Construction Permit - TOWN OF
NORTH ANDOVER, MA 01845
PAGE 2OF2
A. Facility Information continued....
5. Type of Building:esidential Dwelling or ❑Commercial
B. Agreement
TODAY'S DATE
$ 250.00 - Full Repair
$125.00 - Component
The undersigned agrees to ensure the construction and maintenance of the afore -described
on-site sewage disposal system in accordance with the provisions of Title 5 of the
Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of
North Andover. I understand that until a final Certificate of Compliance has been issued by
this Board of h, the installed system is not approved.
Name Date
Application roved By: oard of Health Representative)
Name ° Date
Application Disappr6ved for/fhe following reasons:
For Office Use Only:
1.
Fee Attached.
Yes
No
2.
Project Manager Obligation Form Attached.
Yes
No
I
Pump System? If so, Attach copy ofElectrical Permit
Yes
No
4.
Reviewed approvalletter, all paperwork received.
Yes
No
5. Foundation As -Built. (new construction only): Yes_ No
(Same scale as approved plan)
6. Floor Plans? (new construction only): Yes No
Application for Disposal System Construction Permit • Page 2 of 2
MENTOBLIGATIONS
SEp-r.IC.Sy Roj MANAGE
.STF,MjNSTALL-Ek.P EcT
As fle -North Andover licOnsdd 1istallOf for the -c6nstMCOqti- for:the septic systezq*&t.the-proPerty it:
For plans by
(Ad4r6i of septic system)
Relative to tkipplication of And dated .
(in'staller's name)
Dated With revision
I understand the following obligations for management of this project:
tai d Board of Health approved plans, pioi to
1. As.theinstaUerIam.obligatedtQ6b MOPem - its an
performing anywork on I site.. I wast have the Ohroved glans andtheVcftnit-on site when mi
work is
;.
bei
d ec manager, or any
2. As or. and id-im
must. any g speedws; If homeowner, contractor. •Vro t
otherP erson ftotsissociated with =7 company s'ebe."es-aninspection and the system is not ready, then,
item three- 64 b eIr'stpplicable.
As.tl}* instiller,- Iatj.jeAj*cd to. have .the oecosgry work -completed-prioi....to theapplicable inspections as
itclicied4elow-I-xi.doll Wisfintgnibspection,without' mtkd6ft.. dfthc- items in acco*r*danc
4.
bf S. this is th0�#.(.V).."1Wpedt1oa- h ere is w.retainine *aX which
sho&b646 eArst T.heinstalls rffii4;t%e
quest the ihspecdda but ddies. not have to be present
b. Engineer'fteerzps.t-first, �Otheitfi4
��on for olevations,.ties, 'etc.
oUhand'6vef.W
tm* from the etigined must
be itibniitfed-to'-,the.Bo;md-ofl4 liiffi.t�lldr.cAls for -an I n*sp;ecdpn time. mus
ealth., a ;t -w_ Ms Installer 't
be Withl pU . i�p syst. electricalread
present for this.inspecti6P - . iil yand able to
cause; purap tovrork grid &n tion..
c. :Fin 4j:Glade —J1fts;tiU6r must re4uptin ecfioaVvh grading. -is' complete.- Installer does' not
have to be
As -the installa,'I und6tsland that only I- mi Of= the woik(o�her than triw in _l--r+equ='ed
yp pk excavafiom) and
to complete the m'stallatibn of the system i4entffied in tht attached applitation for installation.': j
5.. At the.instMer,,I'Uildersta: d
G.
steps:
b.
C.
d
'on -.site 4urinj thope:r&=iance of the fbllowizYg construction*
Detc=tinatioxithat.6'ePtopq etevadon of the excamdon has been reache . d -
rnspeedon of thelsjwd and stove -to he used.
Findimpecdon' hyBoaz4odredth staff orconsult=t'
Instaffa 6ftank taiWag wall anti other
dOJ2.. D -Box APOS, Stove, Vent, primp Oan)bet, ze
components.
.od27,,s )are
Undersiga6d Uceased Septic. In$taller.
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.
ILS
ILEI
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assess
26 Easy Street
Property Address
Paul Sullivan
Owner's Name
North Andover
Cityrrown
MA 01845
State Zip Code
Ak ...
is C-? 23 20A
TOWN OF NORTH ANDOVEI
icFar_ i M tyrARTMENT
9/5/2013
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
Name of Inspector
Bateson Enterprises Inc.
Company Name
111 Arailla Road
Company Address
Andover MA 01810
City/Town State Zip Code
978-475-4786 S115
Telephone Number
B. Certification
License Number
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needsq NeedsFurther Evaluation by the Local Approving Authority
1
1 9/5/2013
InsiflIvIsIgignatutj 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 - 3113 Title 5 official Inspection Form: Subsurface Sewage Disposal System - Page 1 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
26 Easy Street
Property Address
Paul Sullivan
Owner's Name
North Andover MA 01845 9/5/2013
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:
After permit from B.O.H., install new outlet tee, pipe to d -box & d -box, inspection from B.O.H., septic
system now passes Title 5 Inspection
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
6572
. O
3a .•.r ., . �c
1 — s
Town of North Andover
`�'• HEALTH DEPARTMENT
cHustt
CHECK #: (0 01 DATE:
LOCATION: S
H/O NAME:
CONTRACTOR NAME:
Type of Permit or License: (Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service - Type: $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal (Septic) Hauler $
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC Systems
❑ Septic - Soil Testing $
❑ Septic - Design Approval $
❑ Septic Disposal Works Construction (DWC) $
❑ Septic Disposal Works Installers (DWI) $
❑ Title 5 Inspector $
1 Title 5 Report X $ l U "
❑ Other: (Indicate) $
Health A en 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
ILEI
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Asses;
26 Easy Street
Property Address
Paul Sullivan
RECEIVED
Is
Ku- 26 201 I
utOVVN,0FNf1RTH,A OVER "I'—
Owners
„
Owner's Name
North Andover a -. MA 01845 8/20/2013 a
Cityrrown State Zip Code Date of Inspection rt�
7�C
Inspection results must be submitted on this form. Inspection forms may not be altered in an
way. Please see completeness checklist at the end of the form.
A. General Information
1. Inspector:
Neil J. Bateson
Name of Inspector
Bateson Enterprises Inc.
Company Name
111 Argilla Road
Company Address
Andover MA 01810
Cityfrown
978-475-4786
Telephone Number
B. Certification
State
S115
License Number
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 hurther Evaluation by the Local Approving Authority
v/j, -
8/20/2013
Inspector's S nature. Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17
Owner
information is
required for
every page.
t5ins • 3113
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
26 Easy Street
Property Address
Paul Sullivan
Owner's Name
North Andover MA 01845 8/20/2013
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):
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17
I
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
26 Easy Street
Property Address
Paul Sullivan
Owner's Name
North Andover
City/Town
B. Certification (cont.)
MA
01845
Zip Code
8/20/2013
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 Title 5 official Inspection Form: Subsurface Sewage Disposal System •Page 3 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
26 Easy Street
Property Address
Paul Sullivan
Owner's Name
North Andover MA 01845 8/20/2013
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well*".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for 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:
Outlet tee in septic tank, outlet pipe to d -box & d -box needs to be replaced.
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes
No
❑
®
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑
®
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑
®
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑
®
Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
t5ins • 3/13
Title 5 official Inspection 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
. ' 26 Easy Street
Property Address
Paul Sullivan
Owner owner's Name
information is
required for North Andover
MA 01845 8/20/2013
every page. Cityrrown
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 • 3113 Title 5 official Inspection Forth: Subsurface Sewage Disposal System • Page 5 of 17
111111111110
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
26 Easy Street
Property Address
Paul Sullivan
Owner Owner's Name
information is
required for North Andover MA 01845 8/20/2013
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
® ❑ 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): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms) 600
t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
26 Easy Street
Property Address
Paul Sullivan
Owner
Owner's Name
information is
required for
North Andover MA 01845 8/20/2013
every page.
Citylrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
2
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
1 1
Commonwealth of Massachusetts
OF UTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
26 Easy Street
Last date of occupancy/use:
Other (describe below):
Pumping Records:
Source of information:
01845 8/20/2013
Zip Code Date of Inspection
Date
General Information
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Type of System:
Pumped last Dec 2011, owner
gallons
►•/ •
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other (describe):
t5ins - 3/13 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 8 at 17
Property Address
Paul Sullivan
Owner
Owner's Name
information is
required for
North Andover MA
every page.
City/Town State
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
Pumping Records:
Source of information:
01845 8/20/2013
Zip Code Date of Inspection
Date
General Information
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Type of System:
Pumped last Dec 2011, owner
gallons
►•/ •
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other (describe):
t5ins - 3/13 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 8 at 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
26 Easy Street
,p
Owner
information is
required for
every page.
Property Address
Paul Sullivan
Owner's Name
North Andover
Cityrrown
D. System Information (cont.)
State
01845
Zip Code
8/20/2013
Date of Inspection
Approximate age of all components, date installed (if known) and source of information:
30 years old, 7/2.7/1983, as built plan
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer (locate on site plan):
Depth below grade: 1.8
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.):
4" PVC through wall, 3" PVC in house, no leaks visible
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
® concrete ❑ metal
U
feet
❑ fiberglass ❑ polyethylene ❑ other (explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate)
Dimensions:
10'x5'x4'
Sludge depth:
2„
❑ Yes ❑ No
t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 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
26 Easy Street
Property Address
Paul Sullivan
Owner's Name
North Andover
Cityfrown State Zip Code
D. System Information (cont.)
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
8/20/2013
Date of Inspection
N/A
a
N/A = Outlet tee off
N/A
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.):
Inlet tee ok. Outlet tee corroded off, needs to be replaced. Liquid level at outlet invert. No
evidence of leakage.
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
Dimensions:
Scum thickness
feet
❑ fiberglass ❑ polyethylene ❑ other (explain).
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
Commonwealth of Massachusetts
up
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
26 Easy Street
Owner
information is
required for
every page.
Property Address
Paul Sullivan
Owner's Name
North Andover
MA 01845 8/20/2013
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.):
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 per day
Alarm present: ❑ Yes ❑ No
Alarm level: 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
t5ins • 3113 Title 5 Official Inspection Forth: 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
26 Easy Street
Property Address
Paul Sullivan
Owner's Name
North Andover MA 01845 8/20/2013
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
N
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 cover broken & d -box filled with sand. Removed sand from d -box . Evidence of
carryover. Evidence of leakage. Corrosion holes in d -box. D -box needs to be replaced. Outlet pipes to
trenches needs to be water ietted.
Pump Chamber (locate on site plan):
Pumps in working order:
Alarms in working order:
❑ Yes ❑ No*
❑ 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 - 3113 Title 5 official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Forth - Not for Voluntary Assessments
26 Easy Street
Property Address
Paul Sullivan
Owner owner's Name
information is
required for North Andover MA 01845
every page. City/Town State Zip Code
D. System Information (cont.)
8/20/2013
Date of Inspection
Type:
❑
leaching pits
number:
❑
leaching chambers
number:
❑
leaching galleries
number:
®
leaching trenches
number, length:
❑
leaching fields
number, dimensions:
❑
overflow cesspool
number:
❑
innovative/alternative system
3 trenches 65'
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. Trenches needs to be water jetted .
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
t5ins - 3/13 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 Forth - Not for Voluntary Assessments
26 Easy Street
Property Address
Paul Sullivan
Owner's Name
North Andover
MA 01845 8/20/2013
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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
26 Easy Street
,p
Property Address
Paul Sullivan
Owner
information is
required for
every page.
Owner's Name
North Andover MA 01845 8/20/2013
Cityfrown 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
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17
� 3
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
26 Easy Street
Property Address
Paul Sullivan
Owner's Name
North Andover MA 01845 8/20/2013
City/Town 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: 3/21/1981
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:
Test pit data on design plan shows water .@ 5'
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
26 Easy Street
Property Address
Paul Sullivan
Owner Owner's Name
information is
required for North Andover MA 01845 8/20/2013
every page. CityrFown 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 • 3/13 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 17 or 17
Jummary Kecora Uara generates on U/(1ZU1 J 1:b4:19 NM Dy Karen Hanlon
Town of North Andover
Tax Map # 210-038.0-0165-0000.0
Parcel Id 12954
26 EASY STREET
SULLIVAN, PAUL & LETITIA
26 EASY STREET
N. ANDOVER, MA
01845
Page 1
Class 101 Single Family Property Type 1 Residential
Zoning2 1 Residential Zoning3 1 Residential
Size Total 1.09 Acres
FY 2014
UB Mailina Index
Name/Address
SULLIVAN, PAUL & LETITIA
26 EASY STREET
N. ANDOVER, MA
01845
UB Account Maint.
Account No Cycle
Bldg Id. 13987.0 - 26 EASY STREET
2100549 02 Cycle 02
UB Services Maint.
Account No. 2100549
Service Code
MISCFEE ADMIN FEE
WTR WATER
UB Meter Maintenance
Account No. 2100549
Type Loan Number Active/Inact. From
Payor
Occupant Name Active/Inactive
Last Billing Date 6/10/2013
Active
Rate Charge Multiplier/Users
0.635/8 7.82 1/
01 ALL METER SIZE /1
Serial No
Status
Location
Brand
Type
36207139
a Active
ERT HH
b Badger
w Water
Date
Reading
Code
Consumption
Posted Date
5/2/2013
255
a Actual
0
6/18/2013
2/6/2013
255
a Actual
0
3/13/2013
10/31/2012
255
a Actual
32
12/13/2012
8/6/2012
223
a Actual
52
9/26/2012
5/4/2012
171
a Actual
12
6/20/2012
2/7/2012
159
a Actual
13
3/14/2012
11/2/2011
146
a Actual
30
12/15/2011
8/4/2011
116
a Actual
29
9/14/2011
5/4/2011
87
a Actual
6
6/13/2011
2/3/2011
81
a Actual
9
3/15/2011
11/1/2010
72
aActual
16
12/13/2010
8/5/2010
56
a Actual
35
9/13/2010
5/5/2010
21
a Actual
10
6/9/2010
2/3/2010
11
a Actual
11
3/11/2010
11/7/2009
0
n New Meter
0
12/11/2009
11/7/2009
4314
r Replacement
17
12/11/2009
8/5/2009
4297
a Actual
1
9/11/2009
5/6/2009
4296
m Manual estimate
12
6/16/2009
2/4/2009
4284
m Manual estimate
15
3/16/2009
11/4/2008
4269
m Manual estimate
15
12/10/2008
MSG
8/5/2008
4254
a Actual
15
9/12/2008
5/6/2008
4239
a Actual
7
6/18/2008
2/4/2008
4232
m Manual estimate
14
3/14/2008
MSG
11/5/2007
4218
a Actual
14
1/15/2008
8/6/2007
4204
a Actual
22
9/14/2007
5/7/2007
4182
a Actual
11
6/26/2007
2/28/2007
4171
m Manual estimate
6
3/23/2007
Size
0.63 0.63
Until
YTD Cons
255
Variance
-100%
-100%
-33%
301%
3%
-60%
6%
373%
-30%
-47%
-52%
246%
-12%
-100%
-100%
1546%
-92%
-19%
-1%
0%
117%
-51%
0%
-36%
49%
215%
-37%
PIPE OUTOPH E
I I T T
?S.SS
7.4 l
PE i blTo O
-
It 1
4. ; 0
O P- I P
-.4s 6 U I L"T
5u5-5uR-P'Ac.,,F. D 5PobA1..
r�
2 cJ: i drat rA's 5Oclo•rEe, I .,j
E►�GI►jEF-E-S deGlllTECTS�Lar�D Pt-,&.j►-JEZf=> rlvSv2�EYp2s
IBJ O 2_T N LN. t'� PO V E tz O F P IG E PN, Z- K.r
�m
Commonwealth of Massachusetts
City/Town of I v
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health.. The System Pumping Record must
be submitted to the local Board of Health or other approving authority. .
A. Facility Information
.Important:
When filling out 1. System Location:
forms the
computer, use
only the tab key Address
to move your
cursor - do not
use the:return City/Town
State Z
key.
2. System 0 ner:
Address (if different from loc;
City/Town
me Number
71pCoCode'
B. Pumping Record
1: .Date. of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s)eptic Tank- ❑ Tight.Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned?
El Yes ❑ No
5. Condi ion of System:
6. System Pumped Btty"�
Name Vehicle License Number
Company .7. Locatiorubere contents were "posed:
http://www.mass.
t5form4.doc• 06103
System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
City/Town of
R 'C NE6
a System Pumping Record
sForm 4
�M
TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. Other fo A 'itnottt be
information must be substantially the same as that provided here. Before using this form, c ec 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: Ley- it ight front of house eft / Right rear of house, Left / right side of house, Left /
Right side of building, ig t front of building, Left / Right rear of building, Under deck
Address e�N ^
Cityrrown State Zip Code
2. System Owner: S�
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
State/ &'3—b
'3 — b t dip Code
Tele/pvhone Number L
Date 2. Quantity Pumped
Cesspool(s) eptic Tank
4. Effluent Tee Filter present? ❑ Yes U -No
5. Conditign oystem���
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Locale contents were disposed:
G.
Waste Water
Gallons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
F5821
Vehicle License Number
Date
t5form4.doc• 06103 System Pumping Record • Page 1 of 1
Location—�>•�-e-� -?
No. C/oDate
TOWN OF NORTH ANDOVER
o Certificate of Occupancy $
r, JACMUS t� Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $�
Check # %
`Building Inspector
' TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REP RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: ( IDATE ISSUED: 07pZ
SIGNATURE:
Building Commissioneffl for of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
S-1
1.2 Assessors Map and Parcel Number.
.3 JL ( (g -
Map Number Parcel Number
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Area Fronts ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide RegWred Provided
ReqWred Provided
1
1.7 Water Supply M.G.L.C.40. 34) 1.3. Flood Zone Information:
Public 0 Private 0 Zoe Outside Flood Zone ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
1.8 Sewerage Disposal System:
Municipal ❑ On Site Disposal System 0
2.1 Owner of Record
Name (P -- Address for Service
Signature Telephone
2.7 Owner of Record:
Name Print Address for Service:
Si ature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
Address
Signature Telephone
t
Not Applicable
License Number.
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable ❑
Company Name
Registration Number
Address
Expiration Date
Signature_ __ Telephone
SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes .......0 No ....... 0
SECTION 5 Description of Proposed Workcheck aH a cable
New Construction ❑ Existing Building 0 Repair(s) ❑ Alterations(s) ❑
Accessory Bldg. 0 Demolition • 0 Other 0 Specify
Brief Description of Proposed Work: /
ry
Al! !.r e 2U
I SECTION 6 - F.CTTMATFn CnNRTRITVTrniv rncme
to provide this affidavit will
Addition ❑
Item Estimated Cost (Dollar) to be
OFFICIAL USE ONLY
Completed by permit applicant
,
1. Building /
L/
(a) Building Permit Fee
0 a O
Multiplier
2 Electrical
(b) Estimated Total Cost of
✓
Construction
3 Plumbing
Building Permit fee (+) X (b)
4 Mechanical HVAC
�.
l (/
5 Fire Protection
6 Total 1+2+3+4+5
Check Number
CL'!'Ti/V►t '7 f%UJ _ D A IrT
OWNERS AGEIYT OR CONTRACT9R APPLIES FOR BUILDING PERMIT
as Owner/Authorized Agent of subject property
Hereby authorize
to act on
My behalf, i a�l�ttiattrl-s re�tive to-rk au t orized by this building permit application.
ice---- �`-.--11''
Si iature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1, ,as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are LTue and accurate; to the best of my knowledge
and belief
Print Name
Si ature of Owner/.Agent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1' 2 3
KU
SPAN
DIMENSIONS OF SILLS
DIIv1ENSIONS OF POSTS
DIMENSIONS OF GMDERS
HEIGHT OF FOUNDATIONTHICKNESS
SIZE OF FOOTING e X
MATERIAL OF CH JNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
t
I
y- /y w,'
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 or requirements.
******APPLICANT FILLS OUT THIS SECTION''********************�
14 APPLICANT \ r A v L- ��` L I U l'd Yy
LOCATION: Assessor's Map Number
SUBDIVISION
y STREET 9 (s
TOWN
HONE j 7L 3 0 ),L
PARCEL 461;S_'
LOT (S) S'A.
ST. NUMBER -;- 6
OFFICIAL USE ONLY **
CONSERVATION ADMINISTRATOR " DATE APPROVED
DATE REJECTED .
COMMENTS 12�&ngy,.g :bI Ek
TOWN PLANNER
COMMENTS
DATE APPROVED _
DATE REJECTED
FOOD IN C - R -HEALTH DATE APPROVED
DATE REJECTED
` T I PECT -HEALTH DATE APPROVED �� S
DATE REJECTED
COMMENTS®
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
Revised 9197 jm
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c11,S150A.
The debris will be disposed of in:
rU F w v t1 btq -, ` 'lb S L s�R i �� R J , a •.J c� l�'� c e' � �7
(Location of Facility)
1,24.4,
zu-t,�-
Signature of Permit Applicant
v/d ,-
Date
U
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
A
TOWN OF NORTH ANDOVER
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MGL c. 142 A requires that the "reconstruction, alteration, renovation, repair, modernization,
conversion, improvement, removal, demolition, or construction of an addition to any pre-existing
owner occupied building containing at least one but not more than four dwelling units ... or to
structures which are adjacent to such residence or building" be done by registered contractors,
with certain exception, along with other requirements.
Type of Work: Lep _P ore C Est. Cost--!/, a 0
Address of Work 1_; 2 6 A4 s � -r -r-
Owner Name: / cl /�� r�`a
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s): For office Use Only
Work excluded by law Pemit No.
Job under $1,000 Date
Building not owner -occupied
Owner pulling own permit
,Other (specify)
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS
FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION
PROGRAM OR GUARANTY FIND UNER MGL c. 142A.
Signed under penalties of perjury:
I hereby apply for a permit as the agent of the owner:
Date
Contractor Name
Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property:
// ,//Os
Date
Owner Name
The Commonwealth of Massachusetts
Department of lndustdal Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Please Print
71
I am a homeowner performing all work myself.
0 I am a sole proprietor and have no one worlting in any capadly
I am an employer providing workers' compensation for my employees
[`mean norma,
on this job.
Fafirxe to secure coverage as required under Section 25A ar AAOL can feed to the Imposition d catmint pensltive d.s Nne up to $1.500.01)
andtor ons yeah' imprisorrraat_as vred_aw_c b A paasttiesJa tips d m BTDP.VVDRK_ORDO ead_a flaw d.($100.flOjAA* apsioat.ms. I
understand that a copy of this statement may be forwarded to Office of Investigations of the DIA for coverspe verification.
I db hereby awtljr under the psinb and penafts or perjury t the Ink mean provided above is true and cat,
Print
Oftkial Lias only do r�bt write In this area to be completed by city or town offidar
City or Town
❑ Building Dept
❑Check X Immediate response !s urired 1:3 L kensfrig Board
Contact person: ❑ Selectman's Ofte
Phone ❑ Health Depatiment
❑ Other
Home.Design26 Easy 1st floor_ ) Thursday, April 14, 2005
Home Design i16 Easy 2nd floor �,7 Thursday, April 14, 2005
Home Design .-'26 Basement, l Thursday, April 14, 2005
Home Design 'House Porch ) Thursday, April 14, 2005
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nunun��ealtit U Massachusetts
Massachusetts
�5'ystertt 1'ttrt>ij� tecur
siFI 1 M-110 5�'6ter» �.oceuvn
U
G l�l u a b s s4-
Date of Pumping — Quantlty Pumped,
Cesspool: '*o ,� 1'es � Renfir Tanl•' �'� a Yes
ofts License N:
s%.stenFt umped by...
S
Contents transferred Io: .
vale _ Inspector
Ri� PP��N !�l
�� of N
i014�80�"
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: t � q`0 I
(example: left front of house)
S" U ov�
2;6' S6 S+
DATE OF PUMPING: �a �> I QUANTITY PUMPED GALLONS
CESSPOOL: NO YES
NATURE OF SERVICE: ROUTINE
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO:
SEPTIC TANK: NO YES
EMERGENCY
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
0
System Owner
('on monw alth of Massachusetts
Massachusetts
System Pumping Record
System Location
Date of Pumping: C�—Quantity Pumped: �� gallons
Cesspool: No ) Yes L) Septic Tank: No Yes_
System Pumped by: Felredea o&'0 61aed License #
Contents transferrred to : Greater Lawrence Sanitary District
Date: _ Inspector-
r"41999.
nspector'
f"41999
i
TO:
NORTH ANDOVER, MASS. July 28 1983
BOARD OF HEALTH
FROM: DESIGf1 ENGINEER Re: Soil Absorption
Sewage Disposal
System
This is to certify that I have inspected the construction materials of
said disposal system at Lot 3 Easy Street
Site Location
North Andover, Mass.
The grades and construction materials
specifications dated August 28 , 19
Reg. Pro
I.
fied in the plans and
Pt July 27 19 83
B
Board of Hesltll
North Ando
y • � I !
. f
PA_ti OK
SEPTIC MTIX ,
INSTALLATICH MH K LIST LOT
X AVATICN 0K FIdL
3. -.No PPC Pipe
Septic Tank
• . a. _Tees __L
-Oat Covers .
/ �et & To Clean
_ On Both Sides of Tank ✓: �.
.b. Cement Pipe to Tank - • ��•
5• . Distribution Box ---�J '-ld A%Alte-'
a. Covers & Box - No Cracks
b. - All Lines Flowing Equal Amounts
c. No Back Flow
Leach Field or Trench
a. Dimensions
Stone Depth _
r c:
"Capped lads
d. . Clean Double -Washed Stone
7• Leach Pit.?-
a/Dimen ionsbDepth
cPadsde Pipe to Pit - Both Sides
f. Clean Double Washed Stone
8. No Garbage Disposal / �*I` L
9. Final grading Inspection •� 53 � � ��GG��
10. Barricading Covered System
fl:
11.
As Built Submitted
_ a. Lot Location
b.. Dimen�i.ons of System
c. Location with Regard -to Pere Test
d. Elevations
e.' Water Table
Board of Health
N,j r tai 4-dc;c; yt;i', Mi s s
SMSURFACE DISPOSAL DESIGN CHECK LIST
LOT
APPROVED DATE DISAPPROVED DATE
Provided: Reasons:
/ f llhr- 11/,/1,?. - 1, 1 / f J. 4
Title
Reg 2.
Reg 6
FAIL
Cje,
submitted lan` ri show a I
P
he lot to be served-area,dimensions lot #,abutter
ocation and log deep observation hoes -distance ties
ocation and results percolation tests -distance to ties
esign calculations & calculations showing required leaching area
ocation and dimensions of system -including reserve area
xisting and proposed contours
cation any vat areas iAthin 1)01 of sewage disposal system or
disclaimer -check wetlands mapping
h) surface and subsurface drains within 100' of sewage disposal
system or disclaimer
(i) location any &-ainage easements within 1001 of sevage disposal
system or disclaimer -Planning Board files
(j) knom sources of inter supply within 2001 of sewage disposal
system or disclaimer
location of any proposed well to serve lot -1001 from leaching facility
(1) location of eater lines on property -101 from leaching facility
location of benchmark
driveways
garbage disposals
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
maxivum ground water elevation in area sewage disposal system
(s) plan must be prepared by a Professional R gineer or other
professional authorized by law to prepare such plans
Septic Tanks '
() eapac t es- 50% of flow, Crater table, tees, depth of tees,
access, pumping '
cleanout
101 from cellar wall or inground swimming pool -
(d) 25+ from subsurface drains
6-11
611,
4(k)
Reg 10.2Distribution Boxes
�,/) slope greater ME 0.08
Reg 10.4 b) sucp
I
Subsurface
Reg 15.1
15.4
15.8
3.7
Reg 14.1
14.3
14.4y
14.6
14.7
14.10
Reg 9.1
9.6
3siga Check List 'Page 2
FAIL I OK i '
Leaching Pits '
Leaching pits preferred where the installation is possible
a} calculati s of leaching area-udnirmzm 500 sq ft
/apacin drainage 2%
aterial
" splash pad
elbow
;g) no bends in pipe om d -box to pipe
Leaching Fi
;a) no gree an 20 minutes/inch
b) area- 900 sq ft
c) c ction of field
fid) face drainage 2 %
201 frrom cellar wall or inground and mning pool
Leaching Trenches
calculations of :Leacmng area -min 500 sq ft
spacing -4 ft min 6 ft with reserve between
dimensions
construction
stone
f) surface drainage 2%
Dounhi.11 S100 e
a) slope y—rx =_M be shown)
b) y/x X 150 - (to be shorn)
Ems
a) - approval
b) stand-by power
Important:
When filling out
forms on the
computer, use
only the tab key
to move your.
cursor - do not
use the return
key.
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
—RECEIVED
MAY 2 6 2009
NN OFNORTH ANDOVER
LTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forme - , e
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 front, left rear, left side of hous�ht fron ight rear, right side of house.
02 te c 6 s ti ��-
Address
R
Cityrrown State Zip Code
2. System Owner:
zL,I' [ I` vo,L^
Name
Address (if different from location)
Cityf town
State Zip Code
GS
Telephone Number
B. Pumping Record
1. Date of Pumping _ 2. Quantity Pumped:
Date Gallons
3. Type of system: 8 Cesspool(s) _ Septic Tank a Tight Tank
Other (describe):
4. Effluent Tee Filter present? Ll Yes M No If yes, was it cleaned? [ Yes [j No
5. Condition of
6. System Pumped By:
Neil Bateson
(-410t�xj' , 4�a4Y4 oof 4pe I 11(x'l
Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Q.L.S. Lowell Waste Water
F 5821
Vehicle License Number
of HAI& Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
TOWN OF
ti �yv�
DATE.
SYSTEM PUMPING RECORD
SYSTEM OWNER & ADDRESS
DATE OF PUMPING:
CESSPOOL: NO YES
SYSTEM LOCATION
(example: left front of house)
QUANTITY PUMPED:
(--�-)��GALLONS
SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste
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