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MUM.,
Page 1 of 1
Location: 267 BOXFORD STREET
Owner Name: MEMMOLO, ROBERT
MEMMOLO, AMELIA
Owner Address: 267 BOXFORD STREET
City: NORTH ANDOVER State: MA Zip: 01845
,Neighborhood: 5 - 5 Land Area: 2.10 acres
:Use Code: 101-SNGL-FAM-RES Total Finished Area: 2356 sqft
ASSESSMENTS CURRENTYEAR PREVIOUS YEAR
Total Value: 541,600 559,200
Building Value: 335,900 353,500
Land Value: 205,700 205,700
Market Land Value: 205,700
Chapter Land Value:
http://csc-ma.us/PROPAPP/display.do?linkld=1464958&town--NandoverPubAcc 4/16/2009
967
MAP # LOT
PARCEL # STREET
HAS PLAN REVIEW FEE BEEN PAID? NO
PLAN APPROVAL: DATE pp. BY
DESIGNER: PLAN DATE: ----O/
CONDITIONS- ......
WATER SUPPLY: TOWN
WELL PERMIT.- D R I LLE R-54 . .... ....... ........... ........
I...-..-.-.-- . ... ............ .... ....... -
WELL TESTS: CHEMICAL DATE APPROVED
BACTERIA I DATE APPROVED
BACTERIA II DATE APPROVED
COMMENTS:
T clr- U E
FORM U APPROVALs APPROVAL TO IV— NO
DATE ISSUED BY
CONDITIONS:
FINAL APPROVAL:
ALL PERMITS PAID Y
WELL CONSTRUCTION APPROVAL S
SEPTIC SYSTEM CONSTRUCTION APPROVAL �
.OTHER YES
ANY VARIANCE NEEDED
FINAL BOARD OF HEALTH APPROVAL3
YES
DATE: I
NO
NO
NO
NO
"4
TEM
1-1. Q N
NO
I S THE I NSTALLER LICENSED?
REPAIR
OTYPE OF CONSTRUCTION:
NO
:,i�NEW,CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW
YES NO
CONDITIONS OF APPROVAL
(FROM FORM U)
YES NO
PERMIT
SSUANCE OF DWC
R:
INSTALLE
WC PERMIT N
0.
s
BEG I N,.I NSPECT ION YES NO:
NEEDED:-
SPECTION:
EXCAVAT I ON I N
BY
j,')jq. 'PASSED
OU
NEEDED:
CONSTRUCTI ON INSPECTION:
�,.4 14
YES:
'AS.BUILT PLAN SATISFACTORY:
DATE. ----.-By
APPROVAL -TO BACKFILL:
�0, BY
GRADING APPROVAL: DATE
�FINAL.
DATE. By
CONSTRUCTION APPROVAL:
Commonwealth of Massachusetts
CityfTown of NORTH ANDOVER, MASSACHUSETTS
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.
Important: A. Facility Information REC - ED
RECEIVED
When filling out 1 System Location: 2�
forms on the
computer, use (D
only the tab key Address
A u
TOWN OF NORTH ANUU
j
TME T
Tow �H OFPA:
R
to move your JEALTH OF RT*
_jEP,LT _pA ,,ENT
cursor - do not d
use the return City/Town State Zip Code
key.
4. System Owner:
1 ;,76
Name
Address if different from location)
Cityfrown State Zip Code
Teleph:)ne Number
B. Pumping Record
1 . Date of Pumping
—44— — 2. Quantity Pumped:
Date
3. Type of system: 0 Cesspool(s) * 54eptic Tank El Tight Tank
Ej 'Other (describe):
4. Effluent Tee Filter present? -�—Yes No If yes, was it cleaned? F1 Yes E] No
5. Condition of System:.
(a C -)o Ck
6. System Pumped By:
aK-�Cv-)
Name Vehicle License Number
( kb A I&% :DfAkcy�,
Cdmpa—ny I
7. Location where contents were disposed:
(—Qj V,-) e Al \ ft -0 Ott,-\ix(a I /
Q
Sign.ature of Hauler
hftp,//www.mass.gov/dep/water/approvaIs/t5forms.htm#inspect
t5form4.doc- 06/03
oj
Date
System Pumping Record - Page 1 of 1
i maz
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
IL If
F25�4'11
Comm.onwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETI
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
1 - System Location:
2 & -?
Address
K),
City/Town State Zip Codi
2. System Owner:
Name
— b-7 07JUi � SV
Address (if different from location)
0,
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system:
El (describe):
State
Zip Code
Telephone Number
�,(j -7 lo Co
Date/ 2. Quantity Pumped:
Gallons
Cesspool(s) XSeptic Tank El Tight Tank
4. Effluent Tee Filter present?_0 Yes [] No
5. Condition of System:.
If yes, was it cleaned? X'Yes El No
6. System Pumped By:
Name Vehicle License Number
Company I, Owl n S
7. Location where contents were disposed:
(2pwl OAf A, I
6ign ' ature of Hauler
hftp,//www.mass.gov/dep/water/approvals/t5forms,htm#inspect
'5form4.doc- 06/03
r
— Y� 7 /.0(,
Date I / —
System Pumping Record * Page I of 1
DelleChiaie, Pamela
From: DelleChiaie, Pamela
Sent: Thursday, April 16, 2009 10:41 AM
To: 'info@aspenenvironmentalservices.com'
Subject: Info. Request - Septic - 267 Boxford Street - Health Dept. File
Attachments: FW: Well and Septic Information - 267 Boxford Street; FW: Septic As -Built - 267 Boxford
Street; RE: Septic As -Built - 267 Boxford Street
Diane,
Per your request at 3:15 p.m. yesterday afternoon, I have attached copies of the file on this property
previously scanned and e-mailed to a Kathy Messina back in December 2008. Please call the office if you have
any further questions. Thank you.
Pamela DelleChiaze
Health Department Assistant
TOWN OF NORTH ANDOVER
Health Department
1600 Osgood Street
Building 20; Suite 2-36
North Andover, MA 01845
978.688.9540 - Phone
978-688.8476 - Fax
pdellechiaie@townofnorthandover.com - E-mail
http://www.townofnorthandover.com - Website
Notes:
If copied to BOH Memhers - Reference Copy Only - no response requested at this time
DelleChlaie, Pamela
From: DelleChiaie, Pamela
Sent: Tuesday, December 16, 2008 11:36 AM
To: 'Kathy Messina'
Subject: RE: Septic As -Built - 267 Boxford Street
As I recall from the Title 5 1 saw in the file, it was old, and they are only good for two years. The mortgage company will
require a new one. The homeowner needs to hire a Title 5 Inspector licensed in the Town of North Andover. Please visit
our website to reference regulations and forms: www.townofnorthandover.com.
Pamela DelleChiaie
Health Department Assistant
Town of North Andover
978.688.9540 - Phone
978.688.8476 - Fax
From: Kathy Messina [mailto:kmessina@cherrytreetitle.com]
Sent: Tuesday, December 16, 2008 11:13 AM
To: DelleChlaie, Pamela
Subject: RE: Septic As -Built - 267 Boxford Street
Hi Pamela
Thanks for sending over this information, does this mean that we will need to do a title v to sell the property?Do you have
a copy of the last title v that was approved?
Thanks!!
Kathy Messina
Cheffy Tree Title Company lic
220 broadway suite 402
lynnfield ma 01940
tel.781.346.6354 fax.781.346.6355 toll free. 888.613.TREE
www.chenytreetitle.com
From: DelleChiaie, Pamela [mailto:pdellech@townofnorthandover.com]
Sent: Tuesday, December 16, 2008 10:56 AM
To: kmessina@cherrytreetitle.com
Subject: FW: Septic As -Built - 267 Boxford Street
Hello,
Sorry for the delay on this — our power went out on Friday, and they just reset the scanner. This is the As Built. Will
send the other septic info. In the next e-mail.
Pamela
North Andover Health Dept.
From: noreply@yourcopier.com [malito:noreply@yourcopier.coml
Sent: Tuesday, December 16, 2008 11:35 AM
To: DelleChiaie, Pamela
Subject: Septic As -Built - 267 Boxford Street
4'198
CONTRACT -OR NAME:
Type
of Permit or License: (Check box)
Town of North Andover
Animal
$
emus
HEALTH DEPARTMENT
CHECK #: DATE;
LOCATION:
Body Art Practitioner
$
H/O NAME
Dumpster
•
CONTRACT -OR NAME:
Type
of Permit or License: (Check box)
•
Animal
$
•
Body Art Establishment
$
•
Body Art Practitioner
$
0
Dumpster
•
Food Service - Type:
$
•
Funeral Directors
$
•
Massage Establishment
$
0
Massage Practice
$
•
Offal (Septic) Hauler
$
•
Recreational Camp
$-
0
Sun tanning
$
0
Swimming Pool
$
13
Tobacco
$
•
Trash/Solid Waste Hauler
$-
•
Well Construction
$
SEP77C Systems
•
Septic - Soil Testing
$
•
Septic - Design Approval
$
0
Septic Disposal Works Construction (DWQ
$
11
Septic Disposal Works Installers (DWI)
$
0 Title 5 Inspie-ctor
$
Zlfi-tl-e
5 Report
$
0 Other (Indicate) $
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
41
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.
40—T)
V�I�Ihl
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
267 Boxford Street
Property Address
Joe Lily
Owner's Name
North Andover
City/Town
MA 01845 05/08/2009 "
State Zip Code 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. [—RECEIVED I
A. General Information
I . Inspector:
Daniel Briscoe
Name of Inspector
R.A. Briscoe Inc.
Company Name
61 Garrison Street
Company Address
Groveland -
City/Town
978-372-2200
Telephone Number
B. Certification
MA
State
N/A
License Number
JUN 2 2 2009
TOWN,QF NORTH ANDOVER
HEALTH DEPARTMENT
01834
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 [I Conditionally Passes F-1 Fails
F� Needs Further Evaluation by the Local Approving Authority
Z6
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DER 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 - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page I 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
267 Boxford Street
D, 1+ A 1414
.H. Y
Joe Lily
Owner's Name
North Andover
MA 01845 05/08/2009
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:
XI 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:
F� 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.
F1 Y E] N [I ND (Explain below):
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17
M
E Mill
ILWMI
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
267 Boxford Street
Property Address
Joe Lily
Owner's Name
North Andover MA 01845 05/08/2009
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.): AM
0 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):
El
broken pipe(s) are replaced
7 Y
[I N
El
ND (Explain below):
El
obstruction is removed
[I Y
El N
[I
ND (Explain below):
E]
distribution box is leveled or replaced
[] Y
E] N
[]
ND (Explain below):
Ej 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):
[I broken pipe(s) are replaced El Y El N D ND (Explain below):
El obstruction is removed [I Y F� N El ND (Explain below):
C) Further Evaluation is Required by the Board of Health: 1W
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(l)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
[I Cesspool or privy is within 50 feet of a surface water
F1 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 17
MINE,
Owner
information is
required for
every page.
Title 5 Offidial Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
267 Boxford Street
Property Address
Joe Lily
Owner's Name
North Andover MA 01845 05/08/2009
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any) AM
determines that the system is functioning in a manner that protects the public health,
safety and environment:
f-] 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.
F-1 The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
F The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes
No
E]
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
El
�K
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 1/2 day flow
t5ins - 09/08
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
267 Boxford Street
Property Address
the system is within 200 feet of a tributary to a surface drinking water supply
Joe Lily
the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Owner Owner's Name
Area — IWPA) or a mapped Zone 11 of a public water supply well
information i's
required for North Andover
MA 01845 05/08/2009
every page. City/Town
State Zip Code Date of Inspection
B. Certification (cont.)
Yes
No
Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
El
N
Any portion of the SAS, cesspool or privy is below high ground water elevation,
El
Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
El
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.,
EJ
X
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 A)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 11 of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17
L
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
267 Boxford Street
Property Address
Joe Lily
Owner's Name
North Andover MA 01845 05/08/2009
CityfTown 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
D. System Information
Residential Flow Conditions:
Number of bedrooms (design):
Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17
Pumping information was provided by the owner, occupant, or Board of Health
El
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?
-E]
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?
El
Was the site inspected for signs of break out?
X1 El
VVere 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.
Ei
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):
Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
267 Boxford Street
Property Address
Joe Lily
Owner Owner's Name
information is
required for North Andover MA 01845 05/08/2009
every page. City[Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
Does residence have a garbage grinder? Yes 7 No
Is laundry on a separate sewage system? [if yes separate inspection required] El Yes �R No
Laundry system inspected?
Seasonaluse?
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump?
Last date of occupancy:
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
Industrial waste holding tank present?
Non -sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
Gallons per day (gpd)
Yes No
Yes No
El Yes Ej No
Date
7
Yes
7
No
El
Yes
[]
No
El
Yes
D
No
15ins - 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
267 Boxford Street
Property Address
Joe Lily
Owner Owner's Name
information is
required for
every page,
City/Town
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
Pumping Records:
Source of information:
MA 01845 05/08/2009
State Zip Code Date of Inspection
General Information
Was system pumped as part of the inspection?
If yes, volume pumpe�:
How was quantity pumped determined?
Reason for pumping:
Type of System:
gallons
Date
Septic tank, distribution box, soil absorption system
Single cesspool
11 Overflow cesspool
El Yes k1 No
El Privy
El Shared system (yes or no) (if yes, attach previous inspection records, if any)
F� Innovative/Alternative technoloay. Attach a cor)v of the current ooeration 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.
El Other (describe):
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
267 Boxford Street
Property Address
Joe Lily
Owner's Name
North Andover
City/Town
MA 01845 05/08/2009
State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all comp9nents, date install d (if known) ar�d source of information:
01J �71, 7 �5 — 1,41. 1 �
Were sewage odors detected when arriving at the site?
Building Sewer (locate on site plan): Ye 5
Depth below grade:
feet
Material of construction:
El cast iron' 40 PVC El other (explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan): Yef
Depth below grade:
Material of construction:
Erconcrete EI metal
feet
El Yes X No
[] fiberglass 7 polyethylene 7 other (explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) [I Yes E] No
15-00 15 f
Dimensions: I I
Sludge depth: . i
15ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17
Owner
information i's
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
267 Boxford Street
Property Address
Joe Lily
Owner's Name
North Andover
CityfTown
MA 01845 05/08/2009
State Zip Code Date of Inspection
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
How were dimensions determined? A
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grease Trap (locate on site plan): /V4'
Depth below grade:
Material of construction:
El concrete El metal
feet
[I fiberglass El polyethylene El other (explain)�
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
n; f f k f+ f + k f� f fl f � 1- "1
1-� I %ji I I U %J1 I I V OVIU1 I I V V U1 I I U UU U I-IV V1 cl r,
Date of last pumping: Date
15ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
267 Boxford Street
05/08/2009
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): IV6
Depth below grade:
Material of construction:
El concrete 0 metal El fiberglass El polyethylene. El other (explain):
Dimensions:
Capacity: gallons
Desinn Flow:
gallons per day
Alarm present: El Yes F� No
Alarm level: Alarm in working order: El Yes El No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
* Attach copy of current pumping contract (required). Is copy attached? D Yes El No
15ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17
Property Address
Joe Lily
Owner
Owner's Name
information is
required for
North Andover MA 01845
every page.
City/Town State Zip Code
05/08/2009
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): IV6
Depth below grade:
Material of construction:
El concrete 0 metal El fiberglass El polyethylene. El other (explain):
Dimensions:
Capacity: gallons
Desinn Flow:
gallons per day
Alarm present: El Yes F� No
Alarm level: Alarm in working order: El Yes El No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
* Attach copy of current pumping contract (required). Is copy attached? D Yes El No
15ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17
Owner
information i's
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
')A7 Rnyfnr(i Sti-pet
Property Address
Joe Lily
Owner's Name
North Andover
Citv/Town
MA
State
01845 05/08/2009
Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site % plan):Ve
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.):
0 a.,;
4 C,
Pump Chamber (locate on site plan): 101
Pumps in working order: F-1 Yes . E] No
Alarms in working order: 0 Yes E] N o.
Comments (note*condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required): Yef
if SAS not located, explain why:
t51ns - 09/08 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 Form Not for Voluntary Assessments
267 Boxford Street
Property Address
Joe Lily
Owner Owner's Name
information i's
required for —orth Andover MA 01845 05/08/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
leaching pits
number:
leaching chambers
number:
leaching galleries
number:
leaching trenches
number, length:
El
leaching fields
number, dimensions:
El
overflow cesspool
number:
El
innovative/alternative system
�1- - 5-0 ,
Type/name of technology:
Comments (note corrdition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):/V4
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 D No
t5ins - 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
267 Boxford Street
Property Address
Joe Lily
Owner Owner's Name
in formation is
required for North Andover MA 01845 05/08/2009
every page. City[Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of pondi ng, condition of vegetation,
etc.):
Privy (locate on site plan): P/�
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
267 Boxford Street
Property Address
Joe Lily
Owner's Name
North Andover
MA 01845 05/08/2009
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
E] hand -sketch in the area below
[X drawing attached separately
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
267 Boxford Street
Property Address
Joe Lily
Owner Owner's Name
information is
required for North Andover MA 01845 05/08/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont)
Site Exam:
El Check Slope
0 Surface water
Check cellar
El Shallow wells
Estimated depth to high ground water: feet
Please ind"icate all methods used to determine the high ground water elevation:
Obtained from system design plans on record
If checked, date of design plan reviewed: Date
Observe� site (abutting property/observation hole within 150 feet of SAS)
El Checked with local Board of Health - explain:
El Checked with local excavators, installers - (attach documentation)
El Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
4/0
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 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
267 Boxford Street
Property Address
Joe Lily
Owner's Name
North Andover
MA 01845 05/08/2009
Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
fS Inspection Summary: A, 6, 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 - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17
04 -0
r
W F
h -D
cs
.4
I V
ETd WdT T:20 600C 2 T -jdU 9602-489K6: 'ON XdJ : W08-:1
ELEVATIONS TAKEN AT TOP Or PlIbl'
THIS IS T6 CONFIRM THAT I HAVE
INSPECTED THE CONSTRUC11ON Of' THE
DWVLI.ING iZI.EV.:
SAID PISPO AL SYS' M LOCATED ON
TANK IN: 114 -Is
TANK OUT: ol &V -*ft
A -A
LOT I e
THE S SPECIFIED IN THE
0-11ox IN: f1546
PL 0 s ATIONS DATED
D-13OX OUT:
Y Cm lo?&A SOC.. INC.
.x
n
A ROSATI
END oF DISIRIOU71ON
LINI- A:
40, 8�4
__UA_TE__
C:
RtFXF.C--r7OSATl
AS—BUILT SEWAGE DISPOSAL
MARCHIONDA & ASSOC,, INC,
SYSTEM PLAN
ENGINEERING AND PLANNING CONSULTANTS
62 MONTVALE AVE., SUITE I
IN
STONEHAM, MA. 02180
t�cwl-4) Ar) ve 1
(617) 438- 6121
AS PREPARED FOR
S(',ALE: I DATE: 7- In q
LM A FILE N o.: 0 1
I V
ETd WdT T:20 600C 2 T -jdU 9602-489K6: 'ON XdJ : W08-:1
j
ARGEO PAUL CELLUCCI
Governor
fl. Rt/0()(j et\.
Property Address: ;2,�?
COMMOIN-WEALTH OF MASSACHUSETTS
ExECUTnT OFFICE OF ENWIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE VVINTER STREET, BOSTON MA 02108 (617) 292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC110'N'F6RM
PART A
CERTIFICATION
Name of Owner_4*4,�//m
-f fl- I
Date of Inspection: 6- 1 q- 01 -- —
Name of Inspector: JPIease Print) ,�,j
I DEP approved system ins rsuant to Section 15.340 of Trde 5 131
prctor pu ,
Company= 14_jq19t1111rA_ )flo -t-1 <__
Maling Address: IC4,Ap S r H
Teleptioria Number:
CMR 15.000)
TRUDY COXE
Secretary
DAVID B. STRUHS
Commissioner
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address a/d that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on WY training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
ton y e
Needs Fuhther Evaluat* 8 th Local Approving Autho I y
Failsj 7
Inspector's Signature: /Dater
The System Inspector shall submit a copy of this inspection report 0-th Approving Authority (Board of Health or DEP)within thirty (30) days of
completing this inspection. If the system Is a shared systern or has,'a."Usign flow of 10,000 gpd or greater, the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be- sent to the
system owner and copies sent to the. buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
j JUN
revised 9/2/98 Page I of 11
0 Prinled or, R ecyded Paper
I t 04 -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
DAVY A
CERTIFICATION (continued)
"roperty Address!' 13o,4rbu Sf AA100
Owner: z4W2,-0e 0 o
Date of Inspection:
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES: -,�
1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
c,it,
_,i, not evaluated are indicated below.
NTS.
/OMME
B. SYSTEM CONDITIONALLY PASSES:
One or more �ystem components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion oVthe repla.cem I ent or repair, as approved by thi Board, -:of Health'�-Iwill pass.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. It "not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; of
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water levelobserved in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four 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
01
revised 9/2/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION Icontinued)
Property Address: "Co " g '- '",
Owner:
Date of Inspection:
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 11)(b) THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of 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 IAND PUBLIC WATER SUPPLIER, IF ANY) DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
— The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid).
3) OTHER
Z-
r -
revised 9/2/98 Page 3 of 11
A
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
-5 1—
Property Address:
Owner:
Q
Date of Inspection:
D. SYSTEM FAILS:
You must indicate eit deeA or "No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CIVIR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility. or system component due'to an overloaded orclogged 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 cesspdol.,
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater e4evation.
Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
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:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No' t,
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)
The owner or operator of tiny such system shall upgrade the system in accordance with 310 CIVIR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART 8
CHECKLIST
Property Address: OW7 16ay,,`0v`0
Owner:
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
No
.
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and' the system has been receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
As built plans have been obtained and examined. Note ifthey are not available with N/A.'
frsewa�ge
The facility or dwJllirig was inspected for signs of back-up. N,
The system does not receive non -sanitary or industrial waste flow,
The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
Existing information. For example, Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
1 5.302(3)(b)]
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenancs-of
SubSurface Disposal Systems.
revised 9/2/98 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Sroperty Address:
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design fIovAi:_g.p.d./bedjoy(n1.
Number of bedrooms (design): "-f Number of bedrooms (actual):_
Total DESIGN flow
Number of current residents -
Garbage grinder (yes or no): 0
Laundry (separate system) (yes or no'/'/46; If yes, separateinspection required
Laundry system inspected (yes or no)
Seasonal use (yes or no):
Water meter readings, if ;v7ilable (last two year's usage (gpd):
Sump Pump (yes or no):
,Last date of occupancy��O.�12v, qP
COMMERCIALfINDUSTRIAL
Type of establishment:
Design flow: gpd Based on 15.203)
Basis of design flow
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:_
nT14FR- tripmr-rihPI
Last date of occupancy:_
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)_
If yes, volume pumped: I
gallons
Reason for pumping:
TZ��F'SYSTEM
Septic tank /di stributio n box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system lyes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Attach copy 6bup to date operation and.maint�nance contract
A p, Val
Tight Tank Copy of DEP p ro
Other
APPROXIMATE AGE of all components, date installed Jif known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)
revised 9/2/98 Page 6 of It
Ifoperty Address*
Owner.*
Date of Inspection:
BUILDING SEWER:
Mocate on site plan)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION fcontinued)
166 X r -a IL9
Depth below grade:
Material of construction: cast iron 40 PVC — other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, -etc.)
SEPTIC TANK-XA(.-5-'
(locate ?pl'an) , J.,
Depth below gradeAf
Material of construction: 4, 'concrete —metal —Fiberglass _Polyethylene _other(explain)
If tank is metal, list age _ Is.age confirmed by Certificate of Compliance (Yes/No)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were determined:
'ornments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
ovirlpnrp nf leakaae. etc.1
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction: —concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Scum thickness? V
Distance from top of scum to top of outlet teeor baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
revised 9/2/98 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION fco"nued)
&19
-roperty Address: 6Z 156"e 1 0
Owner:
Date of Inspection:
TIGHT OR HOLDING TANKJI/ ATank must be pumped pr I ior to, or at time of, inspection)
(locate on site plan)
Depth below grade:
Material of construction: —concrete —metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacity:_ gallons
Design flow: gallons/day
Alarm present_
1,Alarm level: 1,Alarm in working order: s— No
Y4
Date of previous umping:,
Comments:
(condition of inlet tee, condition of alarm and float, switches, etc.)
DISTRIBUTION BOX: e5
(locate on site plan) le
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
At / 6 o - ro zle / 7-1 aw eve,/ Z I 2:f -t
PUMP CHAMBER:
(locate on site plan
Pumps in working order: (Yes or No)
Alarms in working order (Yes or No)
Comments:
(notecondition of pump chamber, condition of pumps anda
r k�- ppurtenan , ces,, etc.) IF
revised 9/2/98 Page 8 of I I
N,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'Foperty Address: 267 X fz 0 5 1 A/d if 0'rl�
Jwrw:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):—
(locate on site plan, if possible; excavation not required, location may be approximated by non -intrusive methods)
If not located, explain:
Type:
leaching pits, number:_
leaching chambers, number:
leaching galleries, number:
leaching trenches, number, length:
leaching fields, number, dimensions: k
overflow cessp� Cl, number:
Alte'r t native syS461m: y i..41 y
Name of Technology:
Comments:
Inote condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.)
H Yo &,-I= L., L't C, 0 let
77 opqr Ali Wmaz
CESSPOOLS: f
(locate on siteTlan)
Number and configuratiot
Depth -top of liquid to inlet invert:
Depth of solids layer:
)epth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: r,
onsiepan
(locate it I
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
revised 9/2/96 Page 9 of 11
SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
2- SYSTEM INFORMATION lcontinued)
Noperty Address: ,-'Optiq
Jwner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
0
]do
V
revised 9/2/98 Page 10 of I I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
operty Addr'ess: :5
jwner:
Date of Inspection:
0 0
NRCS Report name
Soil Type
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE Ei4M Slope
Surface water
Che04C
ellar
Shallow wells
Estimated Depth to Groundwaterl� Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site (Abutting property, observation hole, basement sump etc.)
L000"Determined from local conditions
Checked with local Board of health
C hacked FEMA Maps
Checked pumping records
Checked local excavators, installers
ir
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
9-
V
revised 9/2/98
Page 11 of 11 k
0 ,
Town of North Andover, Massachusetts
E7 1
DW-J/A N U %J F " /A I" I
19
APPLICATION FOR SITE TESTING/INSPECTION
Form No.1
Applicant '5:i�chs 5 7 -
NAME ADDRESS TELEPHONE
Site Location -57-
Engineer
NAME ADDRESS TELEPHONE
Test/inspection Date and Time
CHAIRMAN, BOARD OF HEALTH
Fee /00 Test No. :i�
S.S. PermitNc/ZZj0-,—D.W.C. No. 5�� C.C. Date -9145, �.�No. 141it 19L,
dA11 f / 9eP 'A%rf C-4'rc-r
H
p rF;N n
pfiuu, , E , bb",
CHECIII-151 F-013
PLAN REQUIREMENIS
FOR
SUBSURFACE SEWAGE DISIDOSOL SYSIEVIS
TOWN OF NO. ANDOVER BOARD OF HEOL'111
MARCII, 1990
L.o,.q..q.P-....M.,a. p (Suggested Scale: V = 20001)
- . ..... .... .. _ _.
- - ---- -- .11, - A . Locus identified.
...... . . .. . .......... B . Streets and names within 1/2 mile.
C. North,arrow and scale.
S i te.-P 1.4.n. .(Suggested Scale: 1" 201
A. Lot to be served, 'lots dimeri!:;iorim ayid aren.
B . Fronting street.
C. North arrow and scale.
. Assessor9s designation.
E . Abutters names and lot numbers.
..........................
F. Easements.
G. Property lines.
Footprint of proposed hounn to be served showing
garage (attached or detached).
I. Where applicable setbacks to house.
Number of proposed bedrooms.
Location and type of inateri,--jj. (it- known) of
driveway.
L. Water service livie from we I
M. Location of propc.--Sed WpIl
N. Location of deep observation holos; a;id porcolatiori
tests.
(0. Existing and proposed contouri�,.
Bench marks (2) and ,ties to prop,-)!-,rtj �,y�---,trjjj
leaching facility from bei -sell rju.irj<E� or ottlew-
permanent physical fp,--Atures pt.c.)
Location and dimenqion-, of ny-ntrm tArjj(,
pipes and leachirQj facility) including the reserve
area.
. ...... -Z R. Profile and'section arrows.
Location of any streams, uater bodies, surface and
subsurface drains, known SOLIrces of water supply
within 200-feets and 1-IfItIAndr, within 100-fert
(locate wetlands, specify type of' resource Arid show
100 -foot buffer zone line if applicable).
Erosion control devices as required by Con. Comm.
Board of Health or Planning Doard with detail and
description of device proposed.
13
9
3. Pe.sA_An_..C.al.cuIat ions and Notes
.... .... ... . . . . .... ... .................. ..... ...... . .............. . . ......... .. .. ............................. .........
___Z�.A. Pei�colation rate used for design.
0011 log results - designate various strata depths
and description, depth to ledge and/or groundwater
if encountered.
C. Date of percolation and deep hole tests.
D. Number of bedrooms.
__7Z -E. Calculations for leaching area requirements.
4. Profileof
...................
. . . . . . . . . .................. M
Syste (Suggested Scale: I" = 41)
A.
Finished floor of hou--;(-.
Invert elevations at tiouse, septic tarik (inlet P,
outlet), and distribUtion box.
Length, type and grade of pipe and length' of
leaching facility.
/-..D.
Elevation of ledge and/or groundwater.
Elevation of bottom of leaching f,--kcility.
Existing and proposed grade5.
Slope (breakout) requirement and calculations.
H.
Scale.
5. (Suggested Scale: V = 41
Elevations of various components.
Existing and proposed grades.
Type, dimensions and stone and syntem components
specifications.
D. Elevation of ledge and/or groundwater.
E. Elevation of bottom leaching facility.
Dimensions.
.............. G. Slope (breakout) requirements and CaICUlations.
//.H. Scale.
6. R-01.0 kt i qnA 1.1-..-.N..o..t,�e..s.l.....alnl.d -O.ther...Detai.1 s
A. Owner' s name, address and phone number.
Applicant's name, address and phone number.
Engineer -Is na!me, address and phone riumber.
D. The designer should
indicate any notes or special
conditions peculiar, to the site of' interest to the
Board, Installer or Owner,.
Plans should be dated. Any revised plans after, the
initial submission should show a revision date and
abbreviated explanation of the revisic.n.
F. If a pump system, type, make, mode.l, operation head
and pump rates should be provided. fill reqUired
alarm, power and float switch d.-.ita f5hoLlld be.
provided for review and approvzkl.
System components (septic tank, D -box, etc.)
details should be provided if other than standard
as required from local suppliers. Component spec
should be indicated somewhere on the plans for
standard items.
Reviewed and recommended by:
REVIEW FORM
FOR
SUBSURFACE SEWnGE Disroc-,)nL SYSTEM Pl-fiNS
TOWN OF NORTH ANDOVER BOARD OF HEVIL-111
n — -j- 1 0 /7 . ,
RRQPERTY..-PL(jN-RST * A '
ASSESSOR'S MAP
STREET LOCATION
CHECKLIST DEFICIENCIES
OTHER
. ...... .. . .... ...........
RQQpmmEJ lum.s
RECOMMENDED DENIAL
REASONS
..... .......
--PL(IN DAIE
4 1 1
REASONS (CONT.)
RECOMMENDED
COND IT I
I
Board of Health
North Andover, Mass
Loto,T)/
Applicant
Water Supply Town well Approved Date
S.S.-J �6 Septic System Design
'4 'Ile
Approved Date Approving Authority
CONDITIONS+
Disapproved Date
Reasons=
DWC Septic System Installation
Excavation Inspection
Final Inspection
Approved
Date
Date
Additional Inspections (if any)
Disapproved Date
Reasons
Pass Fail
Approving Authority
Final Approval Da+e Approving Authority
WELL DATABASE
AM ';�- 40
,DRESS:
AGE OF 1;�`ET WELL DRILLER -
__2
<7
WELL FER-MIT --
'WELL LOCATION: 0
===-W= PERN11T DATE:-:�2—/ DE= OF WELL:
=HOFW=- b. DUG
OF WATEREEkRING ROCK -
HIGH MANGAIi-ESE: Y
=GEIRON: y
y N
Ol
r7a
WE= DAT-AEASE
ADDRESS: cl, /2
AGE OF WELL. WELX&MLER:
WELL PERNLET 4: LOCATION: /4/,
'WELL P-7R."L\= IDA TE: DEPTH OF WELL: CPO
TYPE OF 'WELL: DRILLE b. DUG
TYPE OF WATER. BE &',/CK.: -
WATER ANALYSIS DATE: HIGH iyLANGAlFESE: Y
HIGH IRON: y OTI-EER CONTAI�/MqANTS: y IN
(Z:)
Tewksbury Water Treatment Plant Laborato
Massachusetts State Laboratory Certification # 94 126
Lewis W. Zediana Plant Chemist
Tewksbury Water Treatment Plant
71 Merrimac Drive
Tewksbury, MA. 01876
February 7, 1991
Wilmington Pump Supply
639 Woburn Street
Box 517
Wilmington, MA. 01887
Dear Sirs,
The results of the analysis of the water samples submitted on January 30, 1991
from Flintlock Inc. Lot #11 North Andover, MA. may be found below:
Test & Result.
Total Coliform: Absent
Color: 1.6 Hazen Units
Tunbidity: 0.55 NTU
pH: 8.04
Alkalinity: 79.6 mg/L as CaCO3
Hardness: 123 mg/L as CaCO3
Sodium: 6.8 mg/L
Iron: 0.06 mg/L
Manganese: N.D. mg/L
Conductivity: 265 umho/cm
N.D. None Detected
State Limit MCL Type
Absent Primary
15 Secondary
1 - 5 Primary
6.5 - 8.5 Secondary
No Limit
No Limit
20 mg/L Primary
0.3 mg/L Secondary
0.05 mg/L Secondary
No Limit
0
Analyst: Ab4lVA
VI/
Lewis W. Zediana
Folu-1 U
TOWN OF NORTH ANDOVER
LOT RELEASE FORM
SUBDIVISION
ASSESSORS MAP / Z,2 Z /�
SUBDIVISION LOT(S)
PERMANENT ADDRESS
STREET
ASSICNED BY D.P.W.
111IONE S–
APPLICANT
DATE OF APPLICATION
TOWN USE—BECW�IHIS LINE
PLANNING BOARD
TOWN PLANNER
CONSERVATION COMMISSION
CONSERVATION ADMIN.
BOARD OF HEALTH
DEPARTMENT OF PUBLIC WORKS
DRIVEWAY PERMIT
SEWER/WATER CONNECTIONS
FIRE DEPT.
RECEIVED BY BUILDING INSPECTION
DATE
DATE, Al'PItOVE-11)
DAI 11 REIJECIE
DA11" APPROVED
DAIE REJECTED
-DATE A111MVED
DATE REJECTEU
This form shall be signed by tile a�, ' ents of tile 111�iiiiiliig aiid llefl.tli llolrds,
the Conservation Commission prior to tile ISSU,11)(-C Of ally bl-llldlll�, 1)e'-1111 tS
for the subject lot. This form shall not retelve tile applicant from the
compliance of any applicable Town requiremeiit or Bylaw.
s-2
ELEVATIONS
TAKEN AT
TOP OF PIPE
THIS
IS TO CONFIRM THAT I HAVE
INSPECTED THE CONSTRUCTION OF THE
DWELLING ELEV.:
SAID
DISPOSAL SYSTEM LOCATED ON
TANK IN:
15t'. I s
LOT
TANK OUT.
Of
TH
S SPECIFIED IN THE
D -BOX IN:
D -BOX OUT:
1 5
D S ATIONS DATED
CM"VA SSOC'., INC.
END OF DISTRIBUTION
LINE A:
8:
C:
D:
I A
AS—BUILT SEWAGE DISPOSAL
SYSTEM PLAN
I N
Nnrf-h vc,
AS PREPARED FOR
J.
ROSATI
NO. 854
DATE
MARCHIONDA & ASSOC., INC.
ENGINEERING AND PLANNING CONSULTANTS
62 MONTVALE AVE., SUITE I
STONEHAM, MA. 02180
(617) 438-6121
SCALE: 1", 410' DATE: 7- 10 q I
M & A FILE No.: -;510 1
115 00
S (3 'x/ - r
ELEVATIONS TAKEN AT TOP OF PIPE THIS IS TO CONFIRM THAT I HAVE
INSPECTED THE CONSTRUCTION OF THE
DWELLING ELEV.: SAID DISPOSAL SYSTEM LOCATED ON
TANK IN: rws LOT It 4;of-X St'
TANK OUT: THE S SPECIFIED IN THE
D -BOX IN: PL. D S ATIO�S DATED
D -BOX OUT: IS"> -q5 y SSOC., INC.
J.
MAP," R 0 SIA. T
END OF DISTRIBUTION No. 854
LINE A:
B:
C:
DATE
D:
AS -BUILT SEWAGE DISPOSAL
SYSTEM PLAN�
IN
w'r-14) VC -
01 j�i
AS PREPARED FOR
MARCHIONDA & ASSOC., INC.
ENGINEERING AND PLANNING CONSULTANTS
62 MONTVALE AVE., SUITE I
STONEHAM, MA. 02180
(617) 438-6121
SCALE: 1", 410' DATE: 7-10 ql
M & A FILE No.: -
0 1
Department of Environmental Management/Division of Water Resources
WATER WELL COMPLETION REPORT
WELL LO
GEOGRAPHIC DESCRIPTION
0 S E W of
(feet) (circle)
A -09 -
City/To
Well own
IF.
(road)
Aricirps A
W 0'
S E W of
OT"Td
(mi. ih tenths) (circle) 011—
Board of Health permit: yes Ur—no
E]
intersect. w (road)
WELL USE o�—
WELL DATA t
Domestic 6§'Iublic [3 Industrial
Total well depth ft.
Monitoring 0 Other
Depth to bedrocl ft.
aller-bearing rock /unconsolidated material:
Method drille
Date drilled
Descri 'tion
p
CASI NG
Water-bearinglee,-1
1) From 1� To
Type
2) From—To
-9
Length 2 Dia(.I.D.)—in.
—,Jft.
Length into bedrock I V f t.
3) From— To
Gravel pack well: dia.
Protective well seal: Screen: dia.
Grout -[3 Othe Slot $�— length —from— i
PUMP TEST
411 4? /
Static water level bel?w land surface ft. Date
Drawdown.A44811,1., after-piumping i r. m i n. a t gpin
How measured 4&-L Recovery f t. a f terA h r.— min.
LOG of FORM TIONS COMMENTS
'Materials F To A 1*7
Driller
Wil— 11
BOARD OF 1111ALTH
Ha s s
Town of North Andover
Dote
APPLICATION FOR WELL & PUHP PER111'r
ation is hereby made for permit to drill a well U.
o install (-.) a pump sy tem.
on: Address
ontrac
ontractor
Addrese. 0, d4e- �31 -
App lication i..s
Lot.
T,
1
Les L
:ONTRACTOR (To �e complielted at tillic of pump
used for -
if Well if
Size of C,asing__
:er of Well
into Bed Rock
Depth Casing
of Bed Rock
No Date of Testing 1?
!al Tested? Yes —Wc
Well Ended in W11.1 -t- riaterial
Delivers Gals.11er Hin. for 0
to Water 1,9 0 .
IS -19 I Af
M;i . 114�� , a L GPH
feet a --
)wh fter ,t�
9d
:)f Completion u C
Sign r e ontractor
INSTALLER f -i lIcd ip-)�cfore
b IN 10— 1/ ,>11)
.114 7 , &- , pu Fype Used
'Name Pum
GPM Size of ..Ta
PuMp Delivers -1st'C
Material Used in Well: Cast Iron C.n]v;iniZCd
pit or Pitless.Adapter
leeve used to protect pipe? Ycs (-) NOU "'yPe or 1�3111e k�cll Se'
T�-
-------------
repbr-t. �ubmitued to 1�oard of 11caltil—
Water analysi'�
release given tDowner of -record & Bldg- Insp
NUMj','.F.R k FEE
.ZJ 7:2-7 .4 THF- Q-Mfvi�ONWEALTH OF MASSACHUSET7S
.... ..... ...
....... ..... of .... ........................................
Thi,4 is to Certify that ........ Z-
...... ................... * ............ .......................................
N*ME
............................................................ ....................... -- ...... .............................
. ...........
ADDRESS
IS HEREBY GRANTED A LICENSE
For------------------ ---------- ..... ............................. . ....... .................
...... .... ..... .. V
S . .. ......
.................................... ............. ------- -------- ......... ................ ..................... .
............... ....... ........ : ............ �z4p -
........................................... ..........................................................
"I'lliA licen'w i. -i granted in conformity with tile Statutos and ordinances rclatin, thereto, and
Cxp I res.. � ................................ ................ imlcs�i sooner snspended or revoked.
<� I- - '
.................. ...... ........ .
...................... . 11 .. .. ........ ..... ... . ....
......... ZI 191 .................. ... ...... .... .. .. .............
.......................... - ...... ...... . ..... .. ................
0 -
................. ..... ...... .. ........ . ......
)RM 43.1 HORBS 8c WARREN, INC,
BOARD OF M"ALTH
Town of North'Andover,Hass-
9 F
19
Dat:e
APPLICATION FOR WELL & PUHP FEM-11T
tion is hereby made for permit to drill a well
install a pump sy tem
n: Add'ress It
IN
ntractor
App lication is
Lot .11
5?
rel .
NTRACTOR (To e complie`tbd at t:jIIIc of 1) t . Imp test)
Well used for
Well
'a s j.118
X of Well b� Size,of C (al a
into Bed Rock
if Bed Rock Dept:h casing
[I Tested? Yes No Date of. TeSt,ing
Well E.ndcd in W1_Ia-t-
I)e I iver s. Gals.1'er Hin. for 0
-6 Water- 0 r-- --I,, ��_
At 15-191 Af G P� I
AM "L�� - a t
feet a e qrl�
,7 ft r
Completion
a Cotitractor
6r
jioc fol:c .4%_t
ISTALLE� be- f .1led i .. n
'Name Pum rype Used
CP Size of
Pump Delivers
aterial Used in Well: Cast Iron GnIv.,inized
it or pitiess Adapt6r
eeve used to protect pipe? Ycs N0( I,yl)e or Nlame Well Scal
pat C
ater analysi-s repbr-t �ubmitted to 1�0�lrd of
-elease given tD owner of r . ecord & Bldg. Insp
NUMj7FP. k FEE
THE -C-1MM-(--)NvVEALTH OF MA�:i�--,ACHUSET7S
0 .... ..... ..
.............. ........ ..............
...............
This is to Certify that ....... .. ................................ .... ........... ..............
............................. ..........................
................... .......... — ........ .......................
ADDRESS
IS HEREBY GRANTED A LICENSE
For....... ......... ....... ... ............. �17 ......... ......................... .........
-----------
4
v ............. —
----- yv/ ..... ..... Is
.......... - ....................... ........ .................... ... I .........
................ ....... ........................... ................... ...................................... ..... .... ......... ....... .................
ill confol-Illiti, with the statiftos and ordinances relatin, therao, and
Xfo I I -c -'s .................. ............... .............. llfllc-8.,a sooner slispeil(le(I or rcvoked.
...............
............ ..... . ------ - - ---
........ ...... .... .
.................. ... ...... .... ... .. . .. .............
........................... ------ ------ . ..... .. ........ - ............
................. ..... ...... .. ..... .. . ......
�ORM 4,93 H013RS WARREN. INC.
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1, Z,.- FORM U - LOT RELEASE FORM
G6
INSTRUCTIONS: This form is used to verify that all necessary approvals/perrr8s from
Boards and 2--partments having jurisdiction have been obtained. This does not relieve
the applicant andlor landowner from compliance with any applicable or requirements.
APPLICANT FILLS OUT THIS SECTION
Z- VAL 1 -kA -f z-4
/APPLICANT N/�7k/ J JV& �4 y,6 C L,!� —'0 1) �;) "V
PHONE -0 8? g
t'LOCATION: Asseswrs Map Number 1 0 A PARCEL_
VSUIEIDIVISION WA LOT (S)
�STREET
ST. NUMBER ,�, u,
REC
t/,Co
DATIONS OF, TOWN AGENTS:
ATION ADMINISTIkATOR
COMMENTS
MA
USE ONLY
DATEAPPROV�ED�. �U�,
DATE REJECTED
TOWN PLANNER DATE A PRO ED
DATE REJECTED
COMMENTS
FOOD INSPECTOR -HEALTH DATE APPROVED
-Z7 DATE REJECTED
OR -HEALTH
COMMENTS
DATE APPROVED
DATE REJECTED
PUBLIC WORKS - SEWER/WATER CONNECTIONS
ORIVEWAY PERMIT
' 2 -
bZFIRE DEPARTMENT 'C2� e�� -4- '/ Z .(9d4r
RECEIVED BY BUILDING INSPECTOR DATE
REC, Is T-ERED `L-ul \/-AL ASSOCIATES
ND SUR VE Y'OR 0 REGIS T -ERE, pROFESSION,4 L ENGPIE- ER
'4KE- _kD' IVA' 0/'960
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. . . . . . . ... ........... ..........
FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: T If-Al*l- Phone
LOCATION: AsSessor's Maio Nuriber Parcel
Subdivi-s-'Lon Lot(s)
Street St. Numter 2L 7
Use Onl�,,r
RECOMMENDATIONS OF TOWN AGENTS:
Date Approved
Ccns ar-:a---- ion Administrator Daze Re7ected
C c-,=, e n' 4 -- S
Town Planner
Cc=—.en':s
Fcc# inspec-zor-inle-a-Ith
Ser': --c ins= ec-::z r-Hea
C --=e----=
Wc.-.*,-:s - sewer,'water c--nnec----:cns
- d--iveway pe= -Jt
F4..re Demart-lent
Daze Arnroved
Daze Re7ec--ed
Daze Ancroved
Daze Re`:ec--=-d
I
Date Anpr=ved
Daze Re-iec'zea
Received by Building Inszector - Daze