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M LT E-0
Parcel ID: 210/106.C-0115-0000.0
SKETCH
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11 Page I of I
00'*- Property
Record Card
Community: North Andover
PHOTO
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Location: 263 RALEIGH TAVERN LANE
Owner Name: EICHLER, L ROBIN
Owner Address: 263 RALEIGH TAVERN LANE
City: NORTH ANDOVER State: MA ZIP: 01845
Neighborhood: 7 - 7 Land Area: 1.01 acres
Use Code: 101 - SNGL-FAM-RES Total Finished Area: 2526 sqft
ASSESSMENTS CURRENTYEAR PREVIOUS YEAR
Total Value: 571,000 543,700
Building Value: 334,400 328,500
Land Value: 236,600 215,200
Market Land Value: 236,600
Chapter Land Value: I
LATESTSALE
Sale Price: 1 Sale Date: 01/21/1993
Arms Length Sale Code: A -NO -FAMILY Grantor: SAVY, JOSEPH
Cert Doc: Book:03647 Page:0169
http://csc-ma.usNandoverPubAcc/jsp/Homejsp?Page=3&Linkld=991343 7/24/2007
Commonwealth of Massachusetts
City/Town of
Sys,tem Pumping Record
Form 4
3,2014
TOWN Ut- NUK I H ANUOVER
HEALTH DEPARTMENT
DEP has provided this fbrTn'for use -by local Boards of–Hpalth. Other forms, may bebsed, but the
information- must be substantially the same -as 44gFFF—ov�bed here. Before using -this form. , check with your
local Board of Health to deterrofte–Q�--f6rm they use. The system Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left / Right front of house, Left jar of hous Left. / right side of house, Left
'gi hi re,�r of �hous
0
Right side of building, Left / Right front of building. LeC 1 6 building, Under deck
City,rrown
2. System Owner
State Zip Code
Name'
Address (if different ftom location)
Cityfrown Sta�e Code
"_7
Telephone Number
B. Pumping Record
I Date of Pumping 9. Qua tity Pumped:
DAe Gallons
3. Type of system.- Cesspool(s) 2'Septic Tank Tight Tank
Other (describe):
4. Effluent Tee Filter present? M Yes if. yes, was it cleaned? E] Yes E] No
'5. Condition of stem:
6. System Pumped By.
Nell. Batesbn
Name
Bateson Enter prises Inc-
-dompany
7. Location where contents- were disposed:
Waste Water
F5821
Vehicle License Number
e — —
Date
t5fbrrn4.doo- 06/03 SYstem Pumping Record - Page I of I
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for usen by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using Ahis 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
i rear
1. System Location: Left / Right front of house, Left4jjjiht �rear of �h-o-u-s-�-, Left / right side of house, Left
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address—
':w3 �7�'a-)j "
Cityrrown State Zip Code
2. System Owner
Name
AaCiress (IT
23 2013
B. Pumping
1. Date of Pumping
3. Type of system: E]
Stat 2e��e —(ez 6 Zip Code
Telephone Number
Date 2. Quantity Pumped: Gallons
Cesspool(s) 0-§eptic Tank El Tight Tank
El Other (describe):
4. Effluent Tee Filter present? Yes
, S-1 �o
5. Condition of System:
0 ���
6. System Pumped By:
If yes, was it cleaned? [] Yes [] No
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. LocaNtionwhere contents were disposed:
Lowell Waste Water
Date
t5form4.doc- 06/03 System Pumping Record - Page 1 of 1
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 PUM nViRyr - n
MRWVVF�ff e su, mitted to
the local Board of Health or other approving authority. V L;
A! Facility information
I
2
"A -
System Location:J--eft-frDi:�tat-house, right front of house, left sid otUduMN
d 0.- W1 %-'.Ib se(W
0=
rear of hq5s::ejright re-aY
left side of building, right rear
V11,
CityfTown State Zip Code
System Owner:
Name
Address (if different from location)
CityfTown
B. Pumping Record
1. Date of Pumping
3. Type of system: 11
stater
de
F7
Telephone Number
Date 2. Quantity Pumped: Gallons
Cesspool(s) a—S-e-ptic Tank F] Tight Tank
F] Other (describe):
4. Effluent Tee Fil ter present? F1 Yes E;41 �o If yes, was it cleaned? E] Yes n No
5. ConditionAof q stem:
y 7��
lud UO-i:2,t �
6. System Pumped By
Neil J. Bateson
Name
Bateson Enterr)rises Inc.
Company
7. Locati6n wh e contents were disposed:
,,15.�L.S. ,2oweIIA1VasteAater
of
F5821
Vehicle License Number
Date
t5form4.doc- 06/03 System Pumping Record - Page 1 of 1
7475 Date. ........
T �0
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that � .........
hA permission for gas installation ..... ...........
in the buildings of ... C--.4'? e r /,�xl. 1� .... RlY 6, :� "�-,
` ............
at j. North Andover,.Mass.
Fee. . :�P ... Lic. No..�V.-).—
Check # I I k y
GA44INSPECTOR
t
FIXTURES
LU LU
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
City/Town: W,
MA. Date: Permit#
Cd
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Building Location :a63 LgAT1100) LA/Owners Name: 04-Jf-�PA 1FAL-c0fte
Type of Occupancy: Commercial E] Educational F1 Industrial 0 Institutional El Residential El
New: El Alteration: E] Renovation: 0 Replacement: 2' Plans Submitted: Yes El No El
FIXTURES
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SUB BSMT.
BASEMENT
15' FLOOR
2Nu FLOOR
FLOOR
4"' FLOOR
J' FLOOR
FLOOR
FLOOR
8 1 H
FLOOR
Check One Only Certificate #
Installing Company Name:
flip-(
R6
bj.,o 'P�C�ityffown:-
El Corporation
Address:
State:
Business Tel: 91 ITI-131
Fax:
El Partnership
El Firm/Company
Name of Licensed Plumber/Gas Fitter:
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes [] No El
If you have checked Yes, pleas the type of coverage by checking the appropriate box below.
A liability insurance policy 7 Other type of indemnity [:1 Bond Ej
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
Sicinature of Owner or Owner's Aaent owner El Agent El
By checking this box E]; I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and
accurate to tne pest OT My Knowleage ana tnat all Plumbing work and installations performed under the permit issued for this application will be in
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
Type of License:
By El Plumber
Title El Gas Fitter Signature of Licensed Plumber/Gas Fitter
El Doster
City/Town 5�rjourneyman License Number: -2-,g4Fj—
APPROVED (OFFICE USE ONLY) Ej LP Installer I
0' F'-- "
0
PUBLIC HEALTH DEPARTMENT
Community Development Division
C(FRTj(FjC4r1-CF O(F Co
_11rDl- T ONM
L -P A-V 'j- J -.$.Ll J -
As of-.
June 15, 2007
,This is to certify that the individuaf subsu�(ace disposafsystem receiveda
SAT1ST,4CT0RT1YWECq70Yqf the:
Component Wypair — Distri6ution Bo.,V and Outfet Tee
compfetedby
ToddBateson
At:
263 Wgfe�yh Tavem Lane
Way 106. C — Tarcel 115
Xortfi.Andover 911,9 01845
The issuance of this certificate shall not 6e construed as a guarantee that the system will
function satisfactorify.
Susan T Sawyer
Pu6fic Yfeafth Director
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.com
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6-1,
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 263 Raleigh Tavern IAne_
— North Andever—
Owner's Name: — Robin Eichler RECEIVED
Owner's Address: _263 Raleigh Tavern Lane —
— North Andover, rdA 01845
Date of Inspection: 6/14/2007 AUG 2007
Name of Inspector: — Neil J. Bateson TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Company Name: Bateson Enterpri;es Inc.—
Mailing Address: _1 11 Argilla Road.
—Andover, MA 01810
Telephone Number: _( 978 ) 475-4786_
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15-340 of Title 5 (310 CMR 15.000). The system:
_X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Inspector's Signature: V Date: 6/14/2007
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or
DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments: After permit from B.OJII� install new outlet tee in septic tank and replace d -box,
inspection from B.O.11, septic system now passes Title 5 Inspection.
****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.
ttORTil
06
0
0 Z.
L^K1
.4
;�N
PUBLIC HEALTH DEPARTMENT
Community Development Division
%-/ A -j JL A -j U- i- j
YFRTI'F1CXrr1F OE C09141DUANCE
As of. -
June 15, 2007
7&� is to certify that the individualsu6surface disposalsystem receiveda
SAVS1FACTORTINS(PEMONof the:
Component Wypair— Distri6ution Bo.T. and outret Tee
compfeted6y.-
ToddBateson
A t:
263 Rah!�Yh Tavem Lane
911ap: 106. C — Parcel 115
NorthAndover, 911,9 01845
The issuance of this certificate shaff not 6e construed as a guarantee that the gstem wiff
-function sati�factorify.
T Sauyer
Wealth (Director
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
iAo
0
0 '
C�
CM
PUBLIC HEALTH DEPARTMENT
Community Development Division
f-YFRTj(FjCXr1-(F O(F C09VPLT OgVM
%_,.L -P , A -1-L
As of. -
June 15, 2007
This is to certify that the individuaf su6surface disposalsystem receiveda
SATISTACTORTINS(PECTIONof the:
Component Wspair — Dis-tri6ution Box andOutfet Tee
completedby
ToddBateson
At:
263 Wgk�yh Tavern Lane
Way 106. C — Parcell 15
5vortfi,xndover, qwA 01845
The issuance of th�s certifi'cate shad not be construed as a guarantee that the system wid
function sati�factorify.
T Sauyer
Ylealth (Director
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 918.688.9540 Fox 978.688.8476 Web www.townofnorthandover.com
-er
Z
PUBLIC HEALTH DEPARTMENT
(ommunity Development Division
C"//
QNSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: MAP: LOT:
INSTALLER:
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
INSPECTIONS
TANK INSPECTION:
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION: +
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
Existing septic tank properly abandoned
El Internal plumbing all to one building sewer
Topography not appreciably altered
Comments:
SEPTIC TANK
P V
I
Bottom of tank hole has 6" stone base
Weep hole plugged
1500 gallon tank has been installed
H-1 0 loading Monolithic construction
Water tightness of tank has been achieved
(Visual or Vacuum Test or Water held for 24hrs)
Inlet tee installed, centered under access port
Outlet tee (gas baffle or effluent filter) installed,
centered under access port
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthondover.(om
�4
Comments:
PUMP CHAMBER
Comments:
DISTRIBUTION -BOX
Comments:
. 16
0
cot.
PUBLIC HEALTH DEPARTMENT
(ommunity Development Division
El 24" inch cover to within 6" of final grade installed over
one access port, must be over outlet of tank if effluent
filter is present
Hydraulic cement around inlet & outlet
F1 6ottom of tank hole has 6" stone base
0 W p hole plugged
El Co o Tank installed. Size:
1000 allon Pump Chamber installed
H-1 oading Monolithic construction)
El Inlet t iinstalled, centered under access port
s
El Pump ; installed on stable base
R A fl
larm lo working
El Pump On/ floats working
El Separate on ff floats
0 Drain hole in ssure line
El 24" inch cover t within 6" of final grade installed over
pump access po
E:1 Water tightness of nk has been achieved
Visual testing
Hydraulic cement around inlet & outlet
Installed on stable stone base
Inlet tee (if pumped or >0.087foot)'447
Hydraulic cement around inlet & outlets
Observed even distribution
Speed levelers provided (not required)
1600 Osgood Street, North Andover, Mosso(huse"s 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.(om
A%jj �04',4t "_-
0
C �M�.
PUBLIC HEALTH DEPARTMENT
(ommunity Development Division
SOIL ABSORPTION SYSTEM (General)
7 . Bottom of SAS excavated down to 6 in into C soil
layer as provided on plan
e'
E] Size �f SAS excavated as per plan
E] Title 5 sand installed, if specified on plan
F-1 0 Mil HDPE barrier installed
E:1 taining wall (boulder / concrete / timber/ block)
Fin I cover as per plan
Comments:
SOIL ABSORPTION SYSTEM (Gravel-les� Chambers)
F-1 Brand and odel of Chamber Infiltrator Quick 4
0
el' of
Number of c mbers per row —9
El Number of row (trenches) _ 3
Laterals * stalle nd ends connected to header (and
vented if imn\pervio material above)
Elevations of lateral - and chambers installed as on
approved plan
Comments:
CONTROLPANEL. E:1 Alarm & Pump are on separaT circuits
El Alarm sounds when float is trip ed
F� Location of control panel:
El Rated for exterior if placed outs5\id
El Alarm signal located inside
Comments:
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
00-0—T
oq!
0
PUBLIC HEALTH DEPARTMENT
(ommunity Development Division
SYSTEM ELEVATIONS
INVERT INFIELD
PLAN INVERT ELEV.
Benchmark
Building �ewe OUT
S " ank IN
1K
epL T
Septic Tank OUT
Pump Chamb%IN
Pump C amber 0 T
0 T
Distribution Box INs
Distribution Box OUT
Lateral 1 INV
Lateral 1 TOP
Lateral 2 INV
Lateral 2 TOP
Lateral 3 INV
Lateral 3 TOP
Lateral 4 INV
Lateral 4 TOP
1600 Osgood Street, North Andover, Mossochusetts 01845
Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.com
of
PUBLIC HEALTH DEPARTMENT
Community Development Division
CRITICAL SETBACK DISTANCES
Mark those distances checked in the field against the design plan and regulatory
setback
1 Suction line 222(2)
2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02).
3 As defined in 3 10 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland
bylaws
1600 Osgood Street, North Andover, Mosso(husetts 01845
Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.(om
Tank
SAS Sewer
El
Property line
10
10
El
Cellar wall
10
20
El
Inground pool
10
20
El
Slab foundation
10
10
El
Deck, on footings, et'
C\
5
10 --
El
Waterline
10
10 101
El
Private drinking well
75
1001 50
El
Irrigation well
75
100
El
Surface Water
25
50
E-1
Bordering Vegetated Wetland
Salt Marsh, Inland / Coastal Bank'
75
100
El
Wetlands bordering surface
water supply or trib. (in Watershed)
1
150
Trib. to surface water supply
32
325
El
Public well
400
400
EJ
Interim Wellhead Prot. Area
El
Reservoirs
400
14 0 0
El
Drains (wat. supply/trib.)
50
00
Drains (intercept g.w.)
25
50
Drains (Other) Foundation
10(5)
20(10)
Drywells
20
25
1 Suction line 222(2)
2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02).
3 As defined in 3 10 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland
bylaws
1600 Osgood Street, North Andover, Mosso(husetts 01845
Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.(om
Disposal Works Construction Permit
Permission is hereby granted Todd -B -ate -son ----------------- -----------------------------------------------------------------
to (Repair -D -BOX & OUTLET TEE) an Individual Sewage Disposal System.
atNo - -2-6-3- RALEIGH _TAVERNLANE ----------------------------------------------------------------------------------------------------
as shown on the application for Disposal Works Construction Permit No. BHP -2007-016 Dated June 06, 2007
--- -------- --------- ---------
Issued On: Jun -06-2007
-------------- - ---------------------------------------------------------- ---
j0RTi4 41 Commonwealth of Massachusetts Map -Block -Lot
106.C- 0115 -
-----------------------
Board of Health
North Andover
Certificate of Compliance
cmust
THIS IS TO CERTIFYThat the Individual Sewage Disposal System (Repair -D -BOX & OUTLET T
by Todd Bateson
--- - - - - - - - --------------- -------------------------------------------------------------------------------------------------------------------------
Installer
at No 263 RALEIGH TAVERN LANE
- ------------------ --------- ----- ---------------------- : ------------------------------------------------------------------
has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the
application for Disposal Works Construction Permit No. - B -HP -2-007---0-1-6- - Dated ---- June 06,2007 ........
-------------------------------------------------------
Printed On: Jun -06-2007 Board of Health
---------------------------------------------------------
Commonwealth of Massachusetts
Map -Block -Lot
106.C- 0115 -
Board of Health
North Andover
---------------------
Pennit No
BHP -2007-01 64
- __
- --------------- --
P.l.
FEE
33 CHUS F.I.
$125.00
---------------------
Disposal Works Construction Permit
Permission is hereby granted Todd -B -ate -son ----------------- -----------------------------------------------------------------
to (Repair -D -BOX & OUTLET TEE) an Individual Sewage Disposal System.
atNo - -2-6-3- RALEIGH _TAVERNLANE ----------------------------------------------------------------------------------------------------
as shown on the application for Disposal Works Construction Permit No. BHP -2007-016 Dated June 06, 2007
--- -------- --------- ---------
Issued On: Jun -06-2007
-------------- - ---------------------------------------------------------- ---
j0RTi4 41 Commonwealth of Massachusetts Map -Block -Lot
106.C- 0115 -
-----------------------
Board of Health
North Andover
Certificate of Compliance
cmust
THIS IS TO CERTIFYThat the Individual Sewage Disposal System (Repair -D -BOX & OUTLET T
by Todd Bateson
--- - - - - - - - --------------- -------------------------------------------------------------------------------------------------------------------------
Installer
at No 263 RALEIGH TAVERN LANE
- ------------------ --------- ----- ---------------------- : ------------------------------------------------------------------
has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the
application for Disposal Works Construction Permit No. - B -HP -2-007---0-1-6- - Dated ---- June 06,2007 ........
-------------------------------------------------------
Printed On: Jun -06-2007 Board of Health
---------------------------------------------------------
,AORTof
of Permit or License: (Check box)
Town of North Andover
Animal
HEALTH DEPARTMENT
CHECK #: JW3- DATE-:
LOCATION:
$
H/ONAME:
Body Art Practitioner
CONTRACTOR NAME:
Type
of Permit or License: (Check box)
•
Animal
$
•
Body Art Establishment
$
•
Body Art Practitioner
$
0
Dumpster
$
0
Food Service - Type:
$
•
Funeral Directors
$
•
Massage Establishment
$
0
Massage Practice
$
•
Offal (Septic) Hauler
$
•
Recreational Camp
$
0
Sun tanning
$
•
Swimming Pool
$
•
Tobacco
$
•
TrashlSolid Waste Hauler
•
Well Construction
$
SEP77C Systems:
•
Septic - Soil Testing
$
•
Septic - Design Approval
$
9--'SO'eptic Disposal Works Construction (DWQ
0
Septic Disposal Works Installers (DWI)
$
0
Title 5 Inspector
$
0
Title 5 Report
$
0 Other (Indicate) $
24 53 -40
Health Agent Initials
I
'K%ite - Applicant Yellow - Health Pink - Treasurer I
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
Y-1)
Tn
Application is hereby made for a permit to:
F1 Construct a new on-site sewage disposal system*
[-] Repair or replace an existing on-site sewage disposal
K30kepair or replace an existing system component
A. Facility Information _T
-9 /_ --z R—,+ )- . AV.A_1&' AIV -
Address or Lot #
TODAY'S DATE
$ 250.00 — Full Repair
$125.00 - Component
RECEIVED
JUN - 4 2007
TOAN�Ut- NO�TFI`ANDOVER
HEALTH DEPARTMENT
City/T;vvn A/a -
2.- *TYPE OF SEPTIC SYSTEW:
0 Pump &iTravity (choose one)
***If pump system, attach copy of electrical permit to application'
E] Conventional System (pipe and stone system)
n Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install thisvype of system.
n Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement)
[] Pressure Dosed (D -Box Present) S.A.S.
2. Owner Information . A%_�
�z C.) E I '04=7"C_ c-, �-e_
Name
Address (if different from above)
_CiiY_r_rown_'
3. Installer Information
4.
/%f -_ 41j�YLl-5-
State Zip Code
Telephone Number
Name NameBMIMN ENTERP�Tm'Lr-7,-�'
L
1 Argijia-Re��
Address
IAI,+ Andover, MA 01810
_67it—yrrown State Zip Code
Telephone Number (Cell Phone # ifpossible please)
Name Name of Company
Address-
ut�ifoWn_
State
Zip Code
Telephone Number (Best # to Reach)
Application for Disposal System Construction Permit - Page I of 2
41
'ion for Septic Disposal SVstem
Applicat
C4'
Cc
I 44k�ae,.01; Construction Permit — TOVN OF
N
ORTH ANDOVE
_R
MA 01845
PAGE 2 OF 2
A. Facility Information continued....
5. Type of Building: Z_R"esidential Dwelling or FICommercial
i 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, and not to place the system in operation until a Certificate of Compliance has
beenissued is Board of Health.
#,,YW
xy,OW `7
Name Date
:7
Application Ap oved By: (Boar of Health Representative)
/v, - I
9 —,P — C)'_7
Name Date
Application Disapproved for the following reasons:
...... . ... . I-- ..............
For Office Use OnI
L Fee Attached? Yes2 No
2. Project Manager Obligation Form Attached? Yes,,,_/ No
3. PumpSystem? If so. Attach copy of Electrical Permit Yes No
4. Foundation As -Built? (new construction ronly): Ye s - No
(Same scak as approwdplan)
5. Floor Plans? (new construction only): Ye s - No
..w
Application for Disposal System Construction Permit - Page 2 of 2
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
C�14 3
(Address of septic system) For plans by
Relative to the application of
(Installer's name) And dated
Dated 4� — /-/"o 7
(I oday's date) With revisiot
I understand the f6flowing obhgations for management of this project:
1 . As the installer, I am obligated to obtain all permits and Board of Health approved plans pdor to
performing any work on a site. I must have the approved 121ans and the permit on site when any work is
being done.
2. As the installer, I must call for any and all inspections. If homeowner, contractor, project manager, or any
other person not associated with my company schedules an inspection and the system is not ready, then
item three shall be applicable.
3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as
indicated below. I understand that requesting an inspection, without completion of the items in accordance
with Title 5 and the Board of Health ieggktlons mgj result in a $50.00 fi�e being levied agaLinst me and/or
M compgay.
a. Botiom of Bed — Generally, this is the first OW) inspection unl . ess there is a retaining wall, which
should be done first. The installer must request the inspection but does not have to be present.
b. Final Construction Inspection — Engineer must first do their inspection for elevations, ties, etc.
As -built of verbal OK (or e-mail to: hnealitmhcdieptQtownofnorthandover.com) from the engineer must
be submitted to the Board of Health, after which M'staller calls for an inspec'don time. Installer must
be present for this inspection. With a pump system, all electrical work must be ready and able to
cause pump to work and alarm to function.
c. Final Grade — Installer must request inspection when all grading is complete. Installer does not
have to be on-site.
4. As the installer, I understand that only I may perform the work (otber than jim
ple excavation) and I am required
to complete the installation of the system identified in the attached application for installation. I further
understand that work done by others unlicensed to install septic systems in North Andover can constitute
reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of
North Andover. sigaificant fines to all persons involved are also possible.
5. As the installer, I understand that I must be on-site during the performance of the following construction
steps:
a. Determination that the proper elevation of the excavation has been reached
b. Inspection of the sand and stone to be used.
c. Final inspection by Board of Health staff or consultant
d InstaLlatron of tank, D -Box, pipes, stone, vent, pump chamber, retainbW waLf and other
components.
6. As the installer, I understand that I am solely responsible for the installation of the s3�stem as 12er the
approved 121ans. No instructions by the homeowner, general contractor, or any other persons shall absolve
me of this obligation.
Undersigned Lcensed Septic Installer:
(Name — Pnnt)
(Foday's Date) e — '7 '— ':: 5 r _'�
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 JUN 15 2007
System Pumping Record TOWN OF 11,10,RTH ANDOVER
i
Form 4 HEALTH DEPARTMENT
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:
Address Ai
Cityri-own State
2. System Owner: 7F--� c5AA-e�
Name
(if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: 0
Zip Code
state
776
� t-(, t (
-,,Z/ Code
-Teleph6ne Number
co 2. Quantity Pumped
Date
Cesspool(s) 4�j �Sepfic Tank
Other (describe):
4. Effluent Tee Filter present? [I Yes 0 -No
5. Condition of System,
v -\,t tzu-M
��e--"
Gallons
E] Tight Tank
If yes, was it cleaned? El Yes El No
6. )ed Br: //
Systerq PPyrrq 7F5-8.:�-
V11
Name Vehicle License Num
13CL�ov-\
Company
7. Locati where content we disposed:
t5form4.doc- 06/03
Date
- c:::) -7
System Pumping Record - Page 1 of 1
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$
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HEALTH DEPARTMENT
CHECK #:
DATE:
LOCATION:.
0
H/ONAME:
$
CONTRACTOR NAME: C—�a-e J-,A�
Type
of Permit or License: (Check box)
0
Animal
$
0
Body Art Establishment
$
0
Body Art Practitioner
$
0
Dumpster
$
0
Food Service - Type.
$
0
Funeral Directors
$-
0
Massage Establishment
$
0
Massage Practice
$
•
Offal (Septic) Hauler
$
•
Recreational Camp
$-
0
Sun tanning
$
0
Swimming Pool
$
0
Tobacco
$
0
TrashlSolid Waste Hauler
$-
0
Well Construction
$
SEPTIC Sustems:
0 Septic - Soil Testing $
0 Septic - Design Approval $
11 Septic Disposal Works Construction (DWQ $
0 Septic Disposal Works Installers (DWI) $
0 Title 54nspector $
Q.. �itle 5 Report $
0 Other. (Indicate) $
24 61
Health Agent Initials.
White - Applicant Yellow - Health Pink - Treasurer
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS Z21-4
DEPARTMENT OF ENvIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 263 Raleigh Tavern Lane-
- North Andover—
Owner's Name: Robin Eichler
Owner's Address: 263 Raleigh Tavern Lane —
— North Andover, MA 01845
Date of Inspection: —6/l/2007—
Name of Inspector: —Neil J. Bateson—
Company Name: Bateson Enterprises Inc.—
Mailing Address: 111 Argilla Road —
— Andover, NU 01810
Telephone Number: _( 978 ) 475-4786_
RECEIVED
JUN 12 2007
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper ftinction 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
_X_ Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
I ai
Inspector's Signature: 31�4 Date: —6/l/2007—
C, U
1he 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
DER The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments:
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Page 2 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 263 Raleigh Tavern Lane-
- North Andover—
Owner: Eichler
Date of inspection: 6/1/2007
Inspection Summary: Check AB,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 3 10 CMR 15.303 or in 3 10 CMR 15.304 exist. Any fitilure
criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
—X 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 (YN,ND) in
the for the following statements. If "not determined" please explain. Outlet tee in tank & d -box needs
replaced.
—N 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:
N Observation of sewage backup
or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken,
settled or uneven distribution box. System will pass inspection if (with approval of Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
N 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:
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 263 Raleigh Tavern IAne_
- North Andover -
Owner: Eichler
Date of Inspection: 6/1/2007
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require finiher 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(l)(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
�urface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone I 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
r;n-:-vate water supply well". Method used to determine distance —
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Page 4 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 263 Raleigh Tavern Lane_
North Andover
Owner: – Eichler–
Date of Inspection: 6/1/2007
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following for all inspections:
–No– Backup of sewage into facility or system compon due to overloaded or - clogged SAS or cesspool
–No– Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
–No– Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
–No– Liquid depth in cesspool is less than 6" below invert or available volume is 1/2day flow.
–No– Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped _.
–No– Any portion of the SAS, cesspool or privy is below high ground water elevation.
–No– Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
–No– Any portion of a cesspool or privy is within a Zone I of a public well.
–No– Any portion of a cesspool or privy is within 50 feet of a private water supply well.
–No– Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
_Tiq (Yes/No) The system &Lk I have determined that one or more of the above failure criteria exist as described
in 3 10 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to
determine what will be necessary to correct the failure
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd-
You must indicate either "yes" or "no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
— — the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area – IWPA) or a mapped
Zone 11 of a public water supply well
if you have answered "y&' 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 3 10 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
Page 5 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 263 Raleigh Tavern Lane—
North Andover
Owner: Eichler
Date of inspection: —6/l/2007—
Check if the following have been done. You must indicate "yes" or "no7' as to each of the following:
Yes No
—Yes— — Pumping information was provided by the owner, occupant, or Board of Health
— —No— Were any of the system components pumped out in the previous two weeks ?
—Yes— — Has the system received normal flows in the previous two week period ?
— —No— Have large volumes of water been introduced to the system recently or as part of this inspection ?
—Yes— — Were as built plans of the system obtained and examined?
—Yes— — Was the facility or dwelling inspected for signs of sewage back up ?
—Yes— — Was the site inspected for signs of break out ?
—Yes— — Were all system components, excluding the SAS, located on site ?
—Yes — — Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the
condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of
scum ?
—Yes — — Was the facility owner (and occupants if different from owner) provided with information on the
proper maintenance of subsurface sewage disposal systems ?
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Yes No
—Yes— — Existing information.
Yes Determined in the field (if any of the failure criteria related to Part C is at issue approximation of
distance is—unacceptable) [3 10 CMR 15.302(3)(b)]
Page 6 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 263 Raleigh Tavern Lane-
- North Andover -
Owner: Eichler
Date of inspection: 6/1/2007
FLOWCONDMONS
RESIDENTUL
Number of bedrooms (design): 4 Number of bedrooms (actual): -5-
DESIGN flow based on 3 10 CMIC-15.203 600
Number of current residents: 2
Does residence have a garbage griinder ('yes or no
Is laundry on a separate sewage system (yes or no o
Laundry system inspected (yes or no):
Seasonal use: (yes or no): -No-
Water meter reading: -Yes-
Sump pump (yes or no): -Yes_
Last date of occupancy: _ Current
COMMERCUL11NDUSTRUL
Type of establishment:
Design flow (based on 3 10 CMR 15.203): ____gpd
Basis of design flow (seats/persons/sqft,etc.):
Grease trap present (yes or no): _
Industrial waste holding tank present (yes or no):
Non -sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER (describe):
GENERAL E1FORMATION
Pumping Records
Source of information: -Pumped 2005, owner
Was system pumped as part of the inspection (yes or no): - No -
If yes, volume pumped: _ gallons -- How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
__X_ Septic tank, distribution box, soil absorption system
Single cesspool _ Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Irmovative/Altemative technology. Attach a copy of the cur -rent operation and maintenance contract (to be
�b—tained 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 24 years old, owner
Were sewage odors detected when arriving at the site (yes or no): -No-
Page 7 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 263 Raleigh Tavern Lane–
North Andover
Owner: Eichler
Date of inspection: 6/1/2007
BUELDWG SEWER – X – (locate on site plan)
Depth below grade: –24"
Materials of construction: cast iron — X — 40 PVC —other
Distance from private water supply well or suction line:
Comments (on condition ofjoints, venting, evidence of leakage, etc.) _ 4" cast iron thru wall, 3" PVC in house,
no leaks visible.
MQ'-�Offt.w4wl
Depth below grade: –12" –
Material of construction: –X– concrete _ metal ___fiberglass __polyethylene
If tank is metal list age, _ Is age confirmed by a Certificate of Compliance (yes or no): (attach a copy of
certificate)
Dimensions: 101x 5' x 4'–
Sludge depth. 5"
Distance from top of sludge to bottom of outlet tee or baffle: –22" –
Scum thickness: –4"–
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee oTbaffle: –17"
How were dimensions determined: Jape 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 _ Outlet tee badly corroded needs replaced.. Depth of liquid
at outlet invert. No evidence of septic tank leaking. _
GREASE TRAP: _(locate on site plan)
Depth below grade: _
Material of construction: —concrete —metal —fiberglass ___polyethylene other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 263 Raleigh Tavern Lane-
- North Andover—
Owner: — Eichler—
Date of Inspection: 6/1/2007
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 ____9ther(explain):
Dimensions:
Capacity: _gallons
Design Flow: gallons/day
Alarm present (yes or no):
Alarm level: Alarm in working order (yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
DISTRIUBUTIONBOX — X — ( locate on site plan
Depth below grade —18"—
Depth of liquid level above outlet invert: —0—
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.) _P -Box badly corroded, needs replaced. Evidence of leakage. Evidence of
carryover._
PUW CHAMBER: (locate on site plan)
Pump in working order (yes or no):
Alarm in working order (yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.)-
Page 9 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 263 Raleigh Tavern Lane
— North Andover—
Owner: — Eichler—
Date of Inspection: 6/1/2007 5
SOIL ABSORPTION SYSTE d (SAS): —X— (locate on site plan, excavation not required)
If SAS not located explain why:
Type
leaching pits, number:
leaching chambers, number:
leaching galleries, number:
—X— leaching trench, number, length: —3 trenches 321 long_
leaching field, number, dimensions:
overflow cesspool, number:
innovative/alternative system Typetname of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):—Soil ok Vegetation ok No sign of ponding to surface. —
CESSPOOLS:
Number and configuration: _
Depth — top of liquid to inlet invert:
Depth of sludge layer:
Depth of scum layer: _
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow (yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Page 10 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 263 Raleigh Tavern Lane
— North Andover—
Owner: Eichler
Date of linspection: 6/1/2007
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
A to Tank = 21'9"
A to D -Box = 24'
B to Tank = 812"
B to D -Box = 111
Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 263 Raleigh Tavern IAne
– North Andover–
Owner: Eichler
Date of Inspection: 6/1/2007
SITE EXAM
Slope _ No _
Surface water No
Check cellar Dry
Shallow wells No
Estimated depth to ground water _4' –
Please indicate (check) all methods used to determine the high ground water elevation:
_X_ Obtained from system design plans on record - If checked, date of design plan reviewed: 11/811982
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain: _
Checked with local excavators, installers- (attach documentation)
Accessed USGS database -explain: _
You must describe how you established the high ground water elevation: –As per design plan, no water 4'below
trenches—
Summary Record Card generated on 5/29/2007 1:00:55 PM by Lisa Warren
Page 1
Town of North Andover
Tax Map # 210-106.C-01 15-0000.0
263 RALEIGH TAVERN LANE
EICHLER, ROBIN
263 RALEIGH TAVERN LANE
N.ANDOVER,MA
01845
Class 101 Single Family-
Property Type
1 Residential
Size Total 1.01 Acres
FY 2007
UB Mailing Index
Name/Address
Type Loan Number
Activelinact. From
Until
EICHLER, ROBIN
Payor
263 RALEIGH TAVERN LANE
N.ANDOVER,MA
01845
UB Account Maint.
Account No Cycle
Occupant Name
Active/inactive
Bldg Id. 14146.0 - 263 RALEIGH TAVERN LANE Last Billing Date 3/16/2007
2100130 02 Cycle 02
Active
UB Services Maint.
Service Code
Rate Charge
Multiplier/Users
MISCFEE ADMIN FEE
0.635/8 7.82
1/
WTR WATER
01 ALL METER SIZE 59.47
/1
UB Meter Maintenance
Serial No Status
Location Brand
Type Size
YTD Cons
16944460 a Active
ERT HH METE METE
w Water 0.630.63
0
Date Reading
Code Consumption
Posted Date
Variance
5/3/2007 895
a Actual
10
-18%
2/21/2007 885
a Actual
19
3/23/2007
-63%
11/2/2006 866
a Actual
34
12/2212006
-54%
Trouble Code:03
8/21/2006 832
a Actual
111
9/13/2006
742%
5/4/2006 721
a Actual
11
6/2012006
-14%
Trouble Code:03
2/2/2006 710
a Actual
13
3/13/2006
-85%
11/2/2005 697
a Actual
80
12/14/2005
8%
Trouble Code:03
8/11/2005 617
a Actual
84
9/1212005
582%
Trouble Code:03
5/912005 533
a Actual
11
618/2005
-21%
2/14/2005 522
a Actual
15
3/15/2005
63%
11/16/2004 -507
a Actual
10
12/17/2004
-86%
Trouble Code:03
8/10/2004 497
a Actual
64
9/20/2004
195%
Trouble Code:03
5/17/2004 433
a Actual
23
6/14/2004
65%
2/17/2004 410
a Actual
16
4116/2004
0%
11/6/2003 394
n New Meter
0
11/6/2003
0%
Tel: (978) 475-4786
Fax: (978) 475-5451
BATESON ENTE"RJSES, INC.
Excavating -Water& Sewer Lines -Septic Systems & Pumping Service
I I I Argilla Road Andover, Mass. 0 1810
Title 5 Inspection Report
Property Address: 263 Raleigh Tavern Lane, North Andover
Owner: Eichler
Date of Inspection: 6/1/2007
My report contained herein does not constitute a guarantee of future usage and the functionality of the existing
septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further
operation of your current septic system.
Neil J. Bateson
Bateson Enterprises, Inc.
Of
FOWN OF NORTH ANDOVE�,
UA 11 �YSTEM PUMPINQ R.BCopj�)
SYSTEM OWNER & AD
DATE OF PUuvi)jni 115
LOCATI
Ack
TY PUMpE[)._._
Sop4jC J'Mk No
NA rVKE� OF seRyICE:
(Jb3hAVA'nom; I
0OOD CONDITION FULI-'TYJ covf�R
REAVY oxWB BAMES IN PLACL..
ROOTS L&ACK eL p R UN R A I'le
DA%;"61-VE SOLIDS FLOODED
-SOLrD CAKXYQYU , — OTHER EXPLAIN
��*wm
(-;7L,
vumml4Nrs.
,�u?q rwns
Y Es
RECEIVED
JUN 0 3 2005
TOWN uF- i�GRTH ANDOVER
HEALTH DEPARTMENT '
Commonwealth of Massachusetts
Massachusetts
Sy lecord
System Ownet Systein Location
2��G:3
DRte of P uIllping:
Cesspool: No Yes
Quafitity Pumped: /,,� gallons
Septic Tank: No Ll Yes lzot��
System Ilumped,by: . varede,
License
Coolentstransrertredlo: Greater Lawrence Sanitary District
Date: Inspector:
h
Sys(em Owner
R� c)kk
Commonwealth of Massachusetts
V4'j'&A" Massachusetts
System Pumping Record
System Location
"3
7
lt-a-�
Dateoffluniping: jc)--Cr)0-9/� QuafitityPumped: /5�� gallons
Cesspool: No Yes Septic Tank: No
System Pumped by: Felecoolt grmeo�wdej License #
Contents transretured to : Greater wrence Sanitary District
Date:
Inspector:
Yes
TE "V
2 2 !,--Ig
0.
Commonwealth of Massachusetts RECEIVED
lugCity/Town of JUN 16 2008
System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
I HEALTH DEPARTMENT j
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
Important:
When filling out 1 . System Locart':
forms on the
computer, use
only the tab key Address
to move your
cursor - do not Gityrrown state Zip Code
use the return
key -
2. System Owner
Name
Address (if different from location)
Cityrrown State ?jp Code
; G�
Telep-Fione Number
B. Pumping Record
0-0
1 . Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: El Cesspool(s) 9-860—ti-c-*'Tank El Tight Tank
El Other (describe):
4. Effluent Tee Filter present? El Yes 9'1400— lfyes,wasitdeaned? 0 Yes El No
5. Condition of System:
6. System P
Name Wii—de License Number
Comparty-
7. Location wh t t c
ncon en
Hauler Date
t5form4.doc- 06103 System Pumping Record - Page 1 of I
I
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 -k (j -E I -VE D
System Pumping Record
Form 4 JUN 7 2009
DEP has provided this form for use by local Boards of Health. Ottfe 'UTIAe
ir
itted io
17
information must be substantially the same as that provided here. Be- u g thm I I
local Board of Health to determine the form they use. The System Pu ing eCor MR
;g
the local Board of Health o . r other approving authority. FEB - 4 2010
A. Facility Information
1. System Location: Left front left rear, left side of house. Right
Ad dress
Cityrrown
2. Syste Owner: 6k�
Name
T WN OF NORTl ANDOVER
LT�
A H DEPA
right rear Ig SI
'A
Zip Code
Address (if different from location)
Cityrrown Sta t4_7qu-- ?de
Telephone Number
B. Pumping Record
6-1
1
1. Date of Pumping
Date
2. Quantity Pumped:
Gallons
3. Type of system: L]
Cesspool(s) a-Se'ptic Tank
Tight Tank
Other (describe):
4. Effluent Tee Filter present? El Yes Ej*�<o If yes, was it cleaned? [j Yes No
5. Conditiop of Sys
item:
6. System Pumped By:
Neil Bateson
Name
Bateson EnterDrises Inc
Company
7. Location where contents were disposed:
-- -::7)
,It -L. S. D' - Lowell Waste Water
t5form4.doc- 06/03
of
F 5821
Vehicle License Number
Date
System Pumping Record - Page I of I