HomeMy WebLinkAboutMiscellaneous - 288 FOSTER STREET 4/30/2018North Andover Board of Assessors Public Access
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TO -7. =7 4 J�L7;��Tb) jl�F�
122"' Property
14 Record Card
Parcel ID: 210/104.D-0068-0000.0 Community: North Andover
SKETCH PHOTO
Click on Sketch to Enlarge Click to to -Enlarge
an
288 FOSTE—R STREET
Location: 288 FOSTER STREET
Dwner Name: GOLAND, TIMOTHY P
JENNIFER MAHONEY-GOLAND
Dwner Address: 288 FOSTER STREET
City: NORTH ANDOVER State: MA ZIP: 01845
Neighborhood: 5 - 5 Land Area: 1.12 acres
Use Code: 101 - SNGL-FAM-RES Total Finished Area: 2919 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 606,900 546,700
Building Value: 398,200 364,100
Land Value: 208,700 182,600
\4arket Land Value: 208,700
1
-hapter Land Value:
LATESTSALE
Sale Price: 324,900 Sale Date: 12/06/1998
krms Length Sale Code: Y -YES -VALID Grantor: JAMES DOWNES
Cert Doc: Book:05266 Page:0109
N
http://csc-ma.usNandoverPubAcc/jsp/Home.jsp?Page=3&Linkld=990378 8/6/2007
1 1 M
05
"W1
Important: When
filling out forms
on -the computer,
use only the tab
key to move your
cursor - do net
use the return
key -
Commonwealth of Massachusetts
City/Town of North Andover 0 nn I
System Pumping Record
TOWN OF
HEI%*.
Form 4 L_ .
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
same as that provided here. Before using this form, check with your
information must be substantially the e. The System Pumping Record must be submitted LO
local Board of Health to determine the -form they us ity within 14 days from the pumping, date in
the local Board of Health or other approving author
accordance with 310 CMR 15.351.
A. Facility Information
1., System Location:
— 6-2 k F . �i
Address
North Andover
Ciity/Town
2. System Owner:
Name
Address (if different Irom location)
cityf -io\rVn
Ma
State
01886
Zip Code
----------- zip Code
State
Telephone Number
B. Pumping Record
I .... .. .. __�r -
1 Dal Date 2. Quantity Pumped: Gallons
Le of Pumping
3. Type of system: E] Cesspool(s) kSeptic Tank F� Tight Tank E] Grease Trap
F� Other (describe):
4. Effluent Tee Filter present? F Yes F No -if yes, - was it cleaned? [] Yes E] No
5. Condition of System:
6. System Pumped By:
_vel_icle 1_:icense —Numle,
-iTa—me
Stewarts Septic Service
Company
7, Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
Signature of ReceiNting :acifity Date
t5form4.doc- 03/06
Systern pumping Record - paq(
Commonwealth of Massachusetts
City/Town of No andover
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CIVIR 15.351.
A. Facility Information
Important: When
filling out forms 1. System Location:
on the computer,
use only the tab 288 Foster St
key to move your Address TOWN
cursor - do not O;� Xun 8 h t,,�OOVER
No Andover MA HFALTH DEPARTMENT
use the retum
key. City/Town State Zip Code
2. System Owner:
Goland
Name
Address (if different from location)
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1
City/Town
State
Zip Code
Telephone Number
B. Pumping Record
1.
DateofPumping
Date
2. Quantity Pumped:
Gallons
3.
Type of system: El Cesspool(s)
2<Septic Tank El Tight Tank
4r—
El Grease Trap
El Other (describe):
4.
Effluent Tee Filter present? Yes
El No If yes, was it cleaned?
El Yes No
5.
Condition of System:
r
6.
stem Pumped By:
,bste.mPumped By -
Name
Vehicle License Number
Stewart's Septic Service
Qo-mpany
7.
Location where contents were disposed:
S . Plant, 20 So.
Kill Bradford, Ma 0 1835
Qwe-treatment
Signature of uler
Date
Signature of Receiving Facility
Date
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1
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Town of North Andover
HEALTH DEPARTMENT
CHU
D A T E:
CHECK #:
0
LOCATION: "Y
H/O NAME: 7��
CONTRACTOR NAME:
T-YRe
of Permit or License: (Check box)
0
Animal
$
0
Body Art Establishment
$
0
Body Art Practitioner
$
F-1
Dumpster
$
0
Food Service - Type.
$
0
Funeral Directors
$
0
Massage Establishment
$
0
Massage Practice
$
0
Offal (Septic) Hauler
$
0
Recreational Camp
$
0
Sun tanning
$
0
Swimming Pool
$
0
Tobacco
$
0
Tras4lSolid Waste Hauler
$
0
Well Construction
$
SEP77C Sustems:
0 Septic - Soil Testing $
0 Septic - Design Approval $
0 Septic Disposal Works Construction (DW0 $
0 Septic Disposal Works Installers (DW[) $-
0 Title 5 inspector $ -Y-
U, .1itle 5 Report $ �- d1_0
0 Other (Indicate) $
2557 C -AA
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
VQ
1\17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments --tt— lo
Subsurface Sewage Disposal System Form
Inspection results must be submitted on this form or on the o pection-F dated
1j'-" 1; Er
6/1512000. Inspection forms may not be altered in any way. fr -D
A. Certification I I
1. Property Information:
288 Foster St N. Andover
Property Address
Tim Goland
Owner's Name
288 Foster St
Owner's Address
N. Andover
Cityrrown
Date of Inspection:
2. Inspector:
N . Timothv White
AUG - 3 2007
TOWN OF No 'R F I I ANUOVER
HEALTH DEFARTfv',r--N'r
Ma 01845
State
7-27-07
Date
Zip Code
Name of Inspector
Homepro North shore
Company Name
PO BOX 101
Company Address
ROWLEY Ma. 01969
Cityrrown
1-978-948-8428
Telephone Number
Zip Code
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:
Z Passes [:] Conditionally Passes El Fails
R Needs Further Evaluation by the Local Approving Authority
Inspectors Signature
7-27-07
Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original_ should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
Shortcut to TITLE V.Ink.doc - 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System -
Page 1 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
288 Foster St
Property Address
N Andover
City/Town
Tim Goland
Owner's Name
Ma
State
7-27-07
Date of Inspection
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
01845
Zip Code
I have not found any information which indicates that any of the failure criteria described
in 310 CIVIR 15.303 or in 310 CIVIR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
13) System Conditionally Passes:
One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the E] for the following statements. If "not
determined," please explain.
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:
na
Shortcut to TITLE V.Ink.doc - 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System -
Page 2 of 16
3
Commonwealth of Massachusetts
Title 5 Official Inspection
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
288 Foster St
Property Address
N.Andover
Cityrrown
Tim Goland
Owner's Name
B) System Conditionally Passes (cont.):
Ma
State
7-27-07
Form
Date of Inspection
01845
Zip Code
El 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):
0 broken pipe(s) are replaced
n obstruction is removed
F1 distribution box is leveled or replaced
ND Explain:
na
El 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):
F1 broken pipe(s) are replaced
n obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
El 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
[:1 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
Shortcut to TITLE V.Ink.doc - 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System -
Page 3 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont)
9AR Fnqtpr St
Property Address
N. Andover
City/Town
Tim Goland
Owner's Name
Ma.
State
7-27-07
Date of Inspection
C) Further Evaluation is Required by the Board of Health (cont.):
01845
Zip Code
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:
R 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.
E] The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
El The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
n 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:
NA
** 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:
Shortcut to TITLE V.Ink.doc - 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System -
Page 4 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
288 Foster St
Property Address
N. Andover
City/Town
Tim Goland
Owner's Name
Ma
State
7-27-07
Date of Inspection
D) System Failure Criteria Applicable to All Systems:
01845
ZipCode
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes No
Yes No
Z 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.
Shortcut to TITLE V. Ink.doc - 11 /2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System -
Page 5 of 16
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El Z
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El 0
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 Y2day flow
El 0
Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
El Z
Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
El Z
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
0 N
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 certffied
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.]
Yes No
Z 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.
Shortcut to TITLE V. Ink.doc - 11 /2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System -
Page 5 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
288 Foster St
Or-opeq Address
N. Andover
City/Town
Tim Goland
Owner's Name
Ma.
State
7-27-07
Form
Date of Inspection
01845
Zip Code
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the
questions in Section D.
YES NO
El EJ the system is within 400 feet of a surface drinking water supply
El 0 the system is within 200 feet of a tributary to a surface drinking water supply
El El 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.
Shortcut to TITLE V.Ink.doc - 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System -
Page 6 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Checklist
288 Foster St
PropertyAddress
N. Andover
City/Town
Tim Goland
Owner's Name Date of Inspection
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Ma.
State
7-27-07
01845
Zip Code
YES NO
N E] Pumping information was provided by the owner, occupant, or Board of Health
Z Were any of the system components pumped out in the previous two weeks?
Z E] Has the system received normal flows in the previous two week period?
El 0 Have large volumes of water been introduced to the system recently or as part of
this inspection?
0 El Were as built plans of the system obtained and examined? (if they were not
available note as N/A)
Z E] Was the facility or dwelling inspected for signs of sewage back up?
Z El Was the site inspected for signs of break out?
Z n Were all system components, excluding the SAS, located on site?
0 E] 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?
0 0 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:
Z n Existing information. For example, a plan at the Board of Health.
0 El Determined i ' n the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]
Shortcut to TITLE V.Ink.doc - 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System -
Page 7 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information
288 Foster St
0 Yes
Property Address
No
N. Andover
Ma 01845
Cityrrown
State Zip Code
Tim Goland
7-27-07
Owner's Name
Date of Inspection
Residential Flow Conditions:
El Yes
Number of bedrooms (design): 4
Number of bedrooms (actual): 4
DESIGN flow based on 310 CIVIR 15.203 (for example: 110 gpd x # of bedrooms): 600 gpd
05 & 06 17,8821
gal = 244 GPD
5
Number of current residents:
El
Does residence have a garbage grinder?
0 Yes
0
No
Is laundry on a separate sewage system? [if yes separate inspection required]
El Yes
0
No
Laundry system inspected?
El Yes
0
No
Seasonaluse?
El Yes
0
No
Water meter readings, if available (last 2 years usage (gpd)):
05 & 06 17,8821
gal = 244 GPD
Sump pump?
Z Yes
El
No
still occupied
Last date of occupancy:
Date
Commerciallindustrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CIVIR 15.203): Gallons per day (gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
Industrial waste holding tank present?
Non -sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
Last date of occupancy/use:
Other (describe):
Shortcut to TITLE V.Ink.doc - 11/2004
El
Yes
Ej
No
El
Yes
E]
No
El
Yes
El
No
Date
Title 5 Official Inspection Form: Subsurface Sewage Disposal System -
Page 8 of 16
Commonwealth of Massachusetts
Title 5 Official Inspect on orm
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
288 Foster Sr
Property Address
N. Andover
City/Town
Tim Goland
Owner's Name
Pumping Records:
Source of information:
Ma
State
7-27-07
Date of Inspection
General Information
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
01845
Zip Code
last pumped July 5 2007 information from owner _
gallons
Type of System:
z Septic tank, distribution box, soil absorption system
F1 Single cesspool
F1 Overflow cesspool
r-1 Privy
0 Yes 0 No
11 Shared system (yes or no) (if yes, attach previous inspection records, if any)
El Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner)
El Tight tank. Attach a copy of the DEP approval.
El Other (describe):
Approximate age of all components, date installed (if known) and source of information:
20 vears old information from owner
Were sewage odors detected when arriving at the site? El Yes M No
Shortcut to TITLE V.Ink.doc - 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System -
Page 9 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
288 Foster St
Property Address
N. Andover
CityfTown
Tim Goland
Owner's Name
Building Sewer (locate on site plan):
Depth below grade:
Material of construction:
El cast iron Z 40 PVC
Ma.
State
7-27-07
Date of Inspection
16 in
feet
other (explain):
01845
Zip Code
Distance from private water supply well or suction line: 9ft from incoming water line to
outgoing sewer line in basement
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints & venting good condition no evidence of leakage
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
0 concrete El metal
25 in
feet
EJ fiberglass El polyethylene M other (explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of El Yes [] No
certificate)
Dimensions: 8 ft long - 54in wide - 5ft deep
1000 gal
Sludge depth: 2in
Distance from top of sludge to bottom of outlet tee or baffle 30in
Scum thickness lin
Distance from top of scum to top of outlet tee or baffle Glin
Distance from bottom of scum to bottom of outlet tee or baffle Win
How were dimensions determined? rulers& measuring rod
Shortcut to TITLE V.Ink.doc - 11/2004
Title 5 Official Inspection Form: Subsurface Sewage Disposal System o
Page 10 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
288 Foster St
Property Address
N. Andover
Cityrrown
Tim Goland
Ma
7-27-07
01845
Zip Code
Owners Name Date of Inspection
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
tank was not pumped - inlet & outlet baffles good condition - liquid at bottom of outlet invert - no sign
of leakage in or out of tank - no pumping needed
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
0 concrete El metal El fiberglass
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
feet
El polyethylene El other (explain):
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
NA
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
El concrete El metal
Shortcut to TITLE V. Ink.doc - 11 /2004
NA
n fiberglass El polyethylene E] other (explain):
Title 5 Official Inspection Form: Subsurface Sewage Disposal System -
Page 11 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
288 Foster St
Property Address
N.Andover
Ma 01845
Cityrrown
State Zip Code
Tim Goland
7-27-07
Owners Name
Date of Inspection
Tight or Holding Tank (cont.)
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
Date of last pumping:
gallons
gallons per day
El Yes 0 No
Alarm in working order: El Yes [I No
Date
Comments (condition of alarm and float switches, etc.):
NA
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
d- box was level - distribution was equal - no evidence of any solids carryover - no sign of leakage in
or out of d -box - d -box was 16 in below grade - size 20 x 20 in inside depth 14in CAUTION
SPRINKLER LINE RUNS ACROSS D -BOX COVER
Pump Chamber (locate on site plan):
Pumps in working order:
Alarms in working order:
Shortcut to TITLE V.Ink.doc - 11/2004
El Yes [] No
El Yes n No
Title 5 Official Inspection Form: Subsurface Sewage Disposal System -
Page 12 of 16
Commonwealth of Massachusetts
a UTitle 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
288 Foster St
Property Address
N. Andover
City/Town
Tim Goland
Ma.
State
7-2707
01846
Zip Code
Owner's Name Date of Inspection
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
na
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
leaching pits
number:
leaching chambers
number:
El
leaching galleries
number:
F1
leaching trenches
number, length:
leaching fields
number, dimensions: 1 field 20x40ft
800 sq ft
overflow cesspool
number:
innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
dry sand soil - no hydraulic failure - no ponding - system was under front lawn
Shortcut to TITLE V.Ink.doc - 1112004
Title 5 Official Inspection Fornn: Subsurface Sewage Disposal System -
Page 13 of 16
0 0
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
288 Foster St
Property Address
N. Andover
City/Town
Tiom Goland
Owner's Name
Ma
State
7-27-07
Date of Inspection
01845
Zip Code
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth — top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow E] Yes F71 No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
na
Privy (locate on site plan):
Materials of construction:
Dimensions
NA
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Shortcut to TITLE V.Ink.doc - 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System -
Page 14 of 16
Mzz
z
z
Commonwealffi of Massachusetts 1;
I
Title 5 Official Inspiection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System F,'orm
C. System 1"fbirmation (cont.)
')QQ 94%efdar Rt
Prope �y Add ss
KI AnAmpgar
Ma.
State
01845
Zip Code
Tim Goland -f-ZI-vI
Owner's Name Date of Inspection
Sketch Of Sewage Disposal
Wstern: Proviot @ sketch of the sewage disposal system including ties
to at least two permanent r I ee
.Werence landmaftoe benchmarks. Locate all wells within 00f t
Locate where public watipt supply enters the building.
fc�, -5'�EA
Shortcut to TM -E V.Ink.doc - 1 M2004
5 �-
ITitle 5 Official lnspdc1i00 IFOM Subsurface Sewage Disposal Systern -
Page 15 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
IWO
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
288 Foster St
Property Address
N. Andover
Cityrrown
Tim Goland
Owner's Name
Site Exam:
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water.
Ma.
State
7-27-07
Date of Inspection
Please indicate all methods used to determine the high ground water elevation:
z Obtained from system design plans on record
101
01845
Zip Code
If checked, date of design plan reviewed: Date
Observed site (abutting property/observation hole within 150 feet of SAS)
11 Checked with local Board of Health - explain:
n Checked with local excavators, installers - (attach documentation)
F� Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
From plans groundwater at 5ft 4in
Shortcut to TITLE V.Ink.doc - 11/2004 Title SO" Inspection Form: Subsurface Sewage Disposal System -
Page 16 of 16
4
PETER F. REILLY
AFFILIATED WITH F.P. REILLY AND SONS, INC.
206 ANDOVER STREET, SUITE 11
ANDOVER, MA 0 1810
(508) 475-4370
TOWN OF N RT I 'A-
I AMDOVER/
130AR OF
0
HH
FOAN 2 2
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM ----------
PART A - CERTIFICATION
Property Address:
Address of Owner (if different):
Name of Inspector:
15.000)
Company Name, Address, Phone #:
CERTIFICATION STATEMENT
288 Foster Street, North Andover, MA 0 1845
N/A
Peter F. Reilly
(I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR
F.P. Reilly & Sons, 206 Andover St., Suite 11
Andover, MA 01810 (508) 475-1237 / (508) 475-4370
I certify that I have personally inspected the sewage disposal system at this address and that the
information is true, accurate and complete as of the time of inspection. The inspection was performed
based on my training and experience in the proper function and maintenance of on-site sewage disposal
systems. The system:
V Passes
N/A Conditionally Passes
N/A Needs Further Evaluation By the Local Approving Authority
N/A Fails
Inspector's Signature: Date: January 3N9_8__
Pet4r F. Reihy
The system inspector shall submit a copy of this inspection report to the approving authority within
thirty (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 4egional
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. I i
INSPECTION SUMMARY:
A. SYSTEM PASSES: Check A, B, C or D
I have not found any information which indicates that the system violates any of the failure
criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION (continued)
Property Address: 288 Foster Street, North Andover, MA
Owner's Name: James Downes
Date of Inspection: 1/3/98
B. SYSTEM CONDITIONALLY PASSES:
N/A One or more system components need to be replaced or repaired. The system, upon completion of the
replacement or repair, passes inspection.
Indicate yes, no, or not determined (Y, N, ND). Describe basis of determination in all instances. If "not
determined", explain why not)
N The septic tank is metal, 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 conforming
septic tank as approved by the Board of Health.
N Sewage backup or breakout or static high water level observed 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):
N/A broken pipe(s) are replaced
N/A obstruction is removed
N/A distribution box is leveled 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):
N/A broken pipe(s) are replaced
N/A obstruction is removed
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 environment.
SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT
FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
N/A Cesspool of privy is within 50 feet of a surface water
N/A Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh.
2. SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF
APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT
- THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
N/A The system,has a septic tank and soil absorption system and is within 100 feet to a surface water
supply or tributary to a surface water supply.
N/A The system has a septic tank and soil absorption and is within a Zone I of a public water supply
well.
N/A The system has a septic tank and soil absorption and is less than 100 feet but 50 feet or more from
a private water supply well, unless a water 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 N/A (approximation not valid).
..Tjot4
jSp0SAV- "�4SIPEC d)
SE\N AGIE 0 -Tjot4 (Continue
C
Street, pndover
2.8 foster
yess" es 1)ownes delified
PropertV Pd' jam failure Criteria as
0 w net, s t4ame, 113198 jollovil d Ot "ealth
01 j0speCf10"* f the -the Boat
gate one of more o' -'jied be'joVV jailute.
oaf
ID - SIS-VEM FP'jj.S- the system violates on is ideOt' feet the
this deteff"' ed SPIS Of
Mined th8 basis lot ,0% be necesslitl to co vetloaded of clogg
I have deter 15.30. -the mine \jVhat t due to 30 0
T41 A in 310 CtAft ted to deter m componen watefs due to an
should be COntac into facility of syste surface
Bacv,up Of sewage ace of the ground or clogged SPIS Of
cesspool. 1 effluent to toe surf .0 ovefloaded Of
-,,tge otponding 0 cesspool' utlet Invert due to
j)ISCI clogged SPIS Of
Oaded Of 1 . bO4 above 0
ovetl disttibutIon day flow
static licluld level I, the nvert Of available volume e clogged Of obstfuctedpipeks)
cesspool essPool e C)� below 1 in the last yeal t4o-f due to g,oundwatef
T41A L:,Ciuld depth 10 c mote than 4 times below the hig
ed'. none
ecipi,ed Pumping pump cesspool Of PfIvy is ttibutafy to a
4,mbet Of times System, supply 0
Nov portion Of the Soil pbsOfPt%O0 . in ()() feet Of a surface wate
ele-43flon. W Supply w ell
i a cesspool of PfIvy Is a Private water
P'01 portion 0 Supply - . is within a 7 -one I of f supply well.
surface water I a cesspool Of PoVy feet Of a private \Jqate feet from a P,jvate
P, portion 0 thin of than been anajy7ed to be
t4l A 0\1 10, pf%vv is , I()() feet but gteat w ell has . c compoundso
I a cessPoo than . - 11 the latile Of9an'
Any portion 0 1 of Pfivv is less ter qua,' analysis bactefia, Vo
tAIN table Wa . of colijotm
offlon of a cessPOOO acceP analysis
P'ny P IV V\1 ell With n of W ell water
,qatef s le, attac copy ate nittogef'.
ce
acc . a nitto en and nitt above. to
ammo r addition to the ct - Iterla . a significant thteat
-TEV r P'll-S SysteM Is "s eist..
im a large systeM d the
rr GV- SS System) 3n following cond"'O
criter!3 apply to d of greater kLaTge of the
-The follow 109 10 1 ()()o gp nt because one Of mote 7 one
of systern is en\Jjfonme atef supply watef Supply of a mapped
Sig flow and the onwing WC ea kj\NFP1)
-The de n' eW I a surface sutlace dfln'�Ing d Af
VAIA. public health and Sal 400 feet 0 'butafy to a (Intef1m \Nellhea
is withi - 0 feet 01 a t" e area with the "Ice
-Vhe systeM * 11thin 2()() Ogen sensivi mpliance .0nal off
system IS V . "it( Into full co local teg'
-The . located in ell) and facility I consultthe
-The sNs%eM is f supply W the system Oease
1101 a public Wate shall bf-109 B 5.0() and ro.()O.
teM 1314 CM
any such systements 0
net of opeta+-O' w Ogtam teou,
-The OW ,eatment P a�jon-
,o.ndwatef lurthef . Injofm
of e 0EP lot
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART B - CHECKLIST
Property Address: 288 Foster Street, North Andover, MA
Owner's Name: James Downes
Date of Inspection: 1/3/98
Check if the following have been done:
V Pumping information was requested of the owner, occupant and Board of Health.
V 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.
N/A As built plans have been obtained and examined. Note they are not available with N/A.'
V The facility or dwelling was inspected for signs of sewage backup.
V The system does not receive non -sanitary or industrial waste flow.
V The site was inspected for signs of breakout.
V/ All system components, excluding the SAS, have been located on the site.
V 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.
V The facility owner (and occupants, if different from owner) were provided with information on the proper
maintenance of SSDS.
The size and location of the SAS on the site has been determined based on:.
V Existing information (Example: Plan at BOH). DESIGN PLAN ONLY
N/A Determined in the field if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable [15.302(3)(b)].
PART C - SYSTEM INFORMATION
FLOW CONDITIONS
RESIDENTIAL:
Design Flow (gpd/bedroom for SAS):
Number of bedrooms:
Current residents:
Garbage grinder:
Laundry connected to system:
Seasonaluse:
Water meter readings, if available:
Sump Pump (yes or no):
Last date of occupancy:
COMMERCIAL/INDUSTRIAL:
Type of Establishment:
Design Flow:
Grease trap present:
Industrial waste holding tank
Non -sanitary waste discharged the Title 5 system
Water meter readings, if available:
Last date of occupancy:
OTHER:
Describe:
Last date of occupancy:
600 gallons (per design plan)
4
2
yes
yes
no
246,000 gal. 1996-97 / 337 gpd (includes irrigation)
yes
current
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 288 Foster Street, North Andover, MA
Owner's Name: James Downes
Date of Inspection: 1/3/98
GENERAL INFORMATION
PUMPING RECORDS and source of information:
last pumping: about five years according to owner
System pumped as part of inspection: no
if yes, volume pumped: N/A gallons
Reason for pumping: N/A
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
NO Shared system (yes or no - if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Original system installed in 1978 when house was constructed
Sewage odors detected when arriving at the site NO
BUILDING SEWER: (locate on site plan)
Depth below grade: 12"- 16"
material of construction: V cast iron 40 PVC other (explain)
Distance from private water supply well or suction line N/A
Diameter: 4"
Comments: Condition of joints, venting, evidence of leakage, etc.)
Building sewer was watertight and appeared sound.
SEPTIC TANK: v/ (locate on site plan)
Depth below grade: 12"-14"
material of construction: V concrete metal FRP other (explain)
Dimensions: rectangular - 1,000 gallons
4" sludge depth
28" distance from top of sludge to bottom of outlet tee or baffle
3" scum thickness
5" distance from top of scum to top of outlet tee or baffle
12" distance from bottom of scum to bottom of outlet tee or baffle
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, recommendations for repairs, etc.)
Tank was watertight and functioning properly.
El
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 288 Foster Street, North Andover, MA
Owner's Name: James Downes
Date of Inspection: 1/3/98
GREASE TRAP: N/A (locate on site plan)
Depth below grade:
material of construction: concrete metal FRP 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
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, recommendations for repairs, etc.)
N/A
TIGHT OR HOLDING TANK: N/A (locate on site plan)
Depth below grade:
material of construction: concrete metal FRP other (explain)
Dimensions: N/A
Capacity: N/A gallons per day
Design Flow: N/A gallons per day
Alarm level: N/A Alarm in working order N/A
Date of previous pumping: N/A
Comments: (condition of inlet tee, condition of alarm and float switches, etc.)
N/A
DISTRIBUTION BOX: V (locate on site plan)
011 depth of liquid above outlet invert
Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of
box, recommendation for repairs, etc.)
The d -box was level and functioning properly. Five lines leaving box. Minimal solids carryover.
PUMP CHAMBER: N/A (locate on site plan)
N/A Pumps in working order (yes or no)
N/A Alarms in working order (yes or no)
Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for
maintenance or repairs, etc.)
N/A
_Vec-flo% FaW
SF -,,0Tq kGontinued)
\N PGe C)'SPOS PL INS
U5SUVkFP'CF_ fofkmp,
S r - VS-TEt' "�
? PJA I Andover, MA
28S foster Streetr t4ofth
t,j Pddress james C)OWnes not recluired, but
proper , t4ame'. j possible; e)(CaVatiOn
owner S Inspection' 113198 on site Plan, 1
t) ate Of ,, (locate
S -10A kSAS)"'. methods)
so Aj3SORP Tjot4 SY 0,_Intrus,Nje
IL O)e1mated bY . . not applicable
may be aP . ed to be Present, e)(Pla%n-
11 not deteft"' tAlp,
oet T41 A design Plan)
,Type P . Its and num' number 40', live Vines kper
leaclitt"g ,Mbefs and t4ip, s�jze 20
leacW11' alleties a" nuMbet one field,
leacl�tn be( length t4i A of vegetation'
trenc es, num,
leacW I ef �1�esstOris of ponding, condition
fiel s 00 ,,Mber hnology)
leac 'ame of tec
ve ' "�n lic failure, level
Ove five s ste ns of hyd(au
alter . . n of soil, s"g etc-)
�Onditic) fePaits,
knote c . ntenanc 1
Comments- lot mat I bteaVOut'
fecOmmendaf'ons . area Ne,e good, 10 evidence 0
ef leach'n
Soils OV
N1 A kjocate on Site plan)
ng
hing
jjjOVV
na
G r
CSSP001-S A
,jjgu,af%On - eft t4l A
number and cO Inlet Inv t41A
of 1-1quid to
dePth-top Ws layer
th olsol
deP I scum laye, getaf'00,
dePtV' ' - 1 cesspool of ve
dimensions 0 nsttucfjon kcessPOO' t4l A. of pondIng, condit'O
is of co tet Inflo'N . )
matena I gtoundWa of inspect'On
j06jcaf'O0 0 mped as Part f soil, signs of hyd(aul-Ic failute, level
must be Pu condifOn 0 or tePatfs' etc.)
Comments. - knote lot maintenance
tecOmmendattons
not applIcable
,,,A (locate n site plan) t41A.
Okjvy'. on t4l A condition of vegetaflon'
matetials Of constfucti t4lp, level of ponding,
dimensions dtaulic 4,jufe,
of solids s of Ih-4
dePtVI 0 of soll, sign - , etc-)
.OndItIO ce Ot tepaits
knote c ntenan
Comments- lot Mat
fecommendatiOtts
not apVcable
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 288 Foster Street, North Andover, MA
Owner's Name: James Downes
Date of Inspection: 1/3/98
SKETCH OF SEWAGE DISPOSAL SYSTEM:
indicate at least two permanent references, landmarks, or benchmarks
locate where public water system enters house
locate all wells within 100' N/A
Cr 0 roj t
Set"",
wo Ae,-
Teel(.
4-a n k,
Fr 0,14--
4e
SEPTIC TANK TIES: A to Inlet (1)
2 1'4"
B to Inlet
20'011
A to Center (C)
23'6"
B to Center
22'0"
A to Outlet (0)
26'0"
B to Outlet,
23'8"
D -BOX TIES: A to Box
43'9"
B to Box
42'5"
NOTE: The system is in the front yard.
0
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 288 Foster Street, North Andover, MA
Owner's Name: James Downes
Date of Inspection: 1/3/98
DEPTH TO GROUNDWATER
Depth to Groundwater 4' (below bottom of SAS)
Indicate all methods used to determine High Groundwater Elevation:
Y Obtained from Design Plans on record
Y Observation of Site (abutting property, observation hole, basement sump, etc.)
Y Determined from local conditions
N Check with Local BOH
N Check FEMA Maps
N Check pumping records
Y Check local excavators, installers
N Use USGS Data
Describe in words how High Groundwater Elevation was established:
Four feet separation indicated on septic design plan. Grade changes in the area
indicated no groundwater in the SAS.
m
�- C7 -T C, --p
I tjV ptpc- QuT OF HSP--
114to TAW/ -
V 91 FE. 1 tAT-Q D.
114y, PI PF- nt JT 0- psnx
PIPE; -
D OF:
4- L-
4 0
I C> (=). , C\ -I I
, � 5 - r va, E, C-- -"r
E5ulL-r
P140
5u
roydb-r
I NJ
A -o/ 17
ra t14 61 rIA e- r- lz!r> �-j I -FF- C-
.4 M, I Alj r---tz � P -A ::�, -
Location
�0. 3 Date
14ORTH TOWN OF NORTH ANDOVER
41
4L Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee J c, $
TOTAL
Check #
14 , '1 0
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
or,
BUILDING PERM[IT NUMBER:
17-3
DATE ISSUED:
AAA
SIGNATURE:
Building CommissiKer/12� 6t f Buildi�g—s Date
or o
.2E
SECTION 1 -SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
CGA
loq D
Map Number Parcel Number
1.3 Zoning Information:
1.4 Property Dimensions:
.Q4 r-7MQ,,-,,J 1,,
72:77
Zoning District Proposed Use
Lot Arei (so Frontage (ft)
1.6 WELDING SETBACKS (ft)
Front Yard J-7 Side Ya "R-� a T
Rear Yard /3 C-0
Required Provide Required Provided
Required Provided
1.7 Water Supply M.G.L.C.40. 5 54) 1.5. Flood Zone Information:
Zone Outside Flood Zone 0
1.8 Sewerage Disposal System:
Municipal 0 On Site Disposal System 0
Public 0 Private 0 1
1
SECTION 2 - PROPERTY OWNERSIDP/AUTHORIZED AGENT
2. 1 Owner of Record
Name (Print) Address for Service
9 -7
Signature Telephone
2.2 OwaervfRe—co-W: gox- 44 -:w+ -
Pao I'-- -T-4c- yc-c,]L.4� ity
Name Print Address for Service:
L:175 — Z �m
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES I I
3.1 Licensed Construction Supervisor:
License4 Construction Supervisor:
Address
Signature
3.2 Registered Home Improvement Contractor
Ev \/ I ezin
Company Name
Z<,,;�-o T-Lte-tiplit.0—
Address
Telephone
cl 7 8
Telephone
Not Applicable
License Number
Expiration Date
Not Applicable 0
/ 0 go 0
Registration Number
Expiration Dale
60
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F RM U - LOT RELEASE FORM
0
INSTRUCTIONS': This form is used to verify that all necessary approvals/permits from -
Boards and Depetments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
*APPLICANT FiLLS OUT THIS
LOCATION: Assessoes Map Number 10 � D_
SUS01VISION
STREET
FRECOMfAENQATIONS OF TOWN AGENTS
CONSERVATION ADMINISTRATOR
COMMENTS
PHONE
P ARC 'EL,
LOT (S)
ST. NUMEEIR 2-86
USEONLY'-%********.%**
.%L
DATE APPROVED
-z, -4� 00( CC)/\)
IT
TOWN PLANNER CATE APPROVED
DATE REJECTED
COMMENTS
FOOD INSPECTOR -HEALTH OATE.APPROVED
DATE REJECTED
SEPTIC INSPECTOR -HEALTH
COMMENTS
DATE APPROVED
DATE REJECTED-
PUELIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
rIO71-01
RECEIVED SYSUILDiNG iNSPECTOR DATE
Revised 9\97 im
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Please Print
Name:
Location:
Ci!Y am a homeowner performing all work myself. Phone
F-1
I am a sole proprietor and have no one working in any capacity
FI`am an employer providing workers' compensation for my employees working on this job.
--;1 1.
I %Vez/Va-C C-
ritV. /�.ts r=-vto 1-741 Phone #:
4#H�s Po z T-,
Company name:
Address
�. 6, Pnfirvt (A)(- /00Z//0( -,0V
Ci!y: � Phone#:
Insurance Co. Poligy #
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00
and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do herby certify under the pai and p Jt`es of t the inform n rovided above is true and correct.
) Date
S i g n at u re 77�7
C-1 t,
<. F S�l
Print name -Ev-e // Phone #
Official use only do not write in this area to be completed by city or town official' C] Building Dept
C]Check if immediate response is required Building Dept E] Licensing Board
[3 Selectman's Office
Contactpersom Phone A- E] Health Department
0 Other
FORM WORKMAN'S COMPENSATION
Typ-
'M� IMPROVEMENT CONTRACTORS R8GISTRiATION
ird of Building Regulations -And Standaids
One Ashburton' Place - Room
Boston,.Massachusetts 02108
)VEMENT CONTRACTOR
i
,on 107083 Expiration 07/29/00
WATE CORPORATION
tONMENTAL POOLS INC.
w -C. Everleigh 4�
rurnoike Road Unit 10
isford MA 018-1"4
I
f
NONE INPROVENEWCONTRACT'
R1918tra t: on !,070813
TYP# - PRIVATUCORPORATI'bo
Expiratio: 07/29/00
ENVIROXHU11AL POOLS INC.
Andrev C - Everl foh
W ZgWTurnpi ke 614d unit 101
Ao""Tp" Chslasford MA 01824
WC I -OF (�t6
4 6 'S
)n TS
1�
woo'
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PA -r E—=, 4,—eF'-r, 17-1
ioi.
Of
TOWN ON RTH m-rvpur.�L,
UA 1-1- j PUMPINQ UCOR-D
SYSTEM OWNER& ADDRESS
C�qe
SYSTEM L-XATIUN'
7L
k
VA It UY PVWNO:--I��-U Qu-ANTITY PUMPED:- /�.66V
�:bSSPOOL NO $00C Tank: Nu
NA rVRE SBRVICE: Rou'rIN
RUENC)*
0bSBJkVA*nQN3:
000D COt4VJTI0N
.<J., FULL 'rfj CovER
.HRAYY ()"A3B BAI'YLES IN PLACE
KOOT3
LBACKRE-LD RU`NBACK
SOLIDS,- FLOODED
SOLID CAKRYOVBR._._. OTIHER EXPLAIN
System Pw"d by
�o
VUMMENTS,
�-:VNI*Wrs rKANSYMBD ru
1GLI!
FAIL
OK
U/z
IHSTIALTATION CHECK LIST
Reasonst
LOT
oK k L
11 Distance To:
a. Wetlands
Drains
c. Well
Water Line Location
3. No PVC Pbe
4. Sep- tic Tank - - -
a. Tees ir-Length & To Clean Out Covers_ --
b. Cement Pipe to Tank - On Both Sides of Tank
5. Distribution Box
a. Covers & Box - No Cracks
b. A2_1 Lines no-Amg Equal Amunts
c. No Back Flow
6.1 Leach Field or Trench—
a. DimensioR)o
b. Stone Depth
a. CaMed Ends
do --Clean Double Washed Stone
7. Leach Pits
a: Dimsns* ns
b St
'o.
n epth
Leach/
D s
S t
Un
c q
P sh Pads
SO 'h
do s
e. Cem=nt Pipe to Pit Both Sides
Clean Double Washed Stone
8. No Garbage Disposal
9. Anal Grad -Ing Inspection
10. Barricading Covered System
,�Jl. As Built Submitted
a. Lot Location
b. Dimensions of SYstem
c. Location vith Regard -to Pere Test
do Elevations
e 0' Water Table
S DISPOSAL SYSTEM CHECK LIST
NORTH ANDOVER BOARD OF HEALTH
DISAPPROVED DATE TIME REASON
APPROVED b&TE PROVIDED
) Im
T i tl�e" 5
Reg. 2.5 Fail OK T submitted plan must show as a minumum:
the lot to be served (area, dimensions, lot //,abutters)
(Planning Board files)
(b) location and log of deep observation holes -distance
to ties
-distance
(c) location and results of percolation tests
to ties
-- �(d) design calculations & calculations showing required
leaching area
4, location and dimensions Gf system (including reserve
area)
LO existing and proposed contours
g 9 ocation of any wet areas within 100' of the sewage
disposal system ordisclaimer (check wetlands mapping)
(h)- surface and subsurface drains within 100' of sewage
L e�.1 disposal system or disclaimer
(( �ii) 1 ocation of any drainage easements within 1001 of
se�,iage disposal system or dis.claimer (planning board
files)
(j,) known sources of water supply.within 200' of sewage
1 system or disclaimer.
e
d
(j,
disposa
i����k) location of any proposed well to serve the lot (1001
from leaching facility)
location of water lines on property (101 from. leaching
facilities)
location of benchmark
driveways
garbage disposers
no PVC is to be used in construction
q) a profile of the system (elevations of basement, plumbE
pipe septic tank, distribution box inlets and outle-,.7s,
istribution field piping and any other elevations)
maximum gr.ound water elevation in area of sewage dispoi
system
(s plan must be prepared by a Professional Engineer or
other professional authorized by law to prepare such
plans
Septic Tanks
Reg. 6 L,-"- <a Capacities - 150% of flow, water table, tees, depth
of tees, access, pumping,
Cleanout
c4101 from cellar wall or inground swimming pool
4,
25' from subsurface drains
Anoover ourt)suriace 1-Lsposai s.�sLuin cae(;K ±lsL - t -age e
a
T),e:g. 10. 2
Reg.10.4
Reg. 11 .2
Reg. 11 .4
Reg.11 .10
Reg.11.11
Reg. 15.1
Reg. 15. 1
Reg. 15. 4
Reg. 15. 8
-Reg. 3.7
R 1
eg. 14.1
Reg.14.3
Reg.14.4
14.5
Reg.14 -6
Reg.14:-7
Reg.14.IC
Reg. 9.1
Reg. 9.6
Distribution Boxes
;;:�71
�a
slope greater than 0.08
(b) Sump
Leaching Pits
Leaching pits are Pre�ferre'd where the installation is
possible
(a qa-le'ulations of leaching area (minimum 500 S.F.)
(b ,.---Sp8Lcing
Surface drainage 2%
d Cgver material
S iV,4" 1pfask P,A
're r W C-1 0 0
rjkllchinR Fields (3)
9-1bGreater than 20 minutes/inch
Area (minimum 900 S.F.)
ZQ, Construction of field
d� Surface drainage 2%
e� 201 from,cellar wall or inground swimming pool
Leaching Trenches
(a Calculati-ons of leaching area (min. 500 S.F.)
(b Spac'ing-�4 ft. min. 6 ft. with reserve between)
(c D i . m - E rh'� s i o n s
d,)'- Constructiciri
'e) Stone
f) Surface drainage 2%
Downhill Slope_----
�a) S1 e ---7/X = (to be shown
b) 0-,o X 150 = (to be shown�
Y/
Pumps
(a) al
(b) �Undv-b7 power
TOWN OF NORTH ANDOVER
P/9 Y/O jh 14 tQ1 1.1 1? �RLTH DEPARTMENT
'�V
aQ11(" Q,
Q I I ry
A. F a 7 771 _nf n 4,7r� �,,i I
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A,I
y
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�Vp �0
it IAI towVqn)
r'q 7, 77
p .................
u
mping or d,
11 A.
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9
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MARA, - - - - - - - - - - - - - -
t
F4,
X
com
of Massachusetts
.V1:101 t Wn.of. NORTH ANDOVER, MASSACHUSETTS
y/Tb''.
SOtem PUrniping. Record
4'.
DEP has provided this form for use by lopal Boards of Health. The System Pumping Record mu!
be submitted to the local Board of Health or other approving authority,
Facility Information
Important:
When filling out . 1. System Locatlon:
forms on t1w
computer, use
only the tab key
Address
to move your
n
cursor -, do.not
use the return
U�7_rown
key'....
2. System Owner
Name
ryr�
State 7JP Code
Address (If different hm location)
City/Town State
Tlp Code
Telephone Number
V Pumping Record
I Date of Pumping 2. Quantity Pumped:
Date
Gallons
3,... Type of system: Cesspool(9) ept1c Tank Tight Tank
PIS
Other (describe):
4. Eftent Tee Filter present? Yes If �ei,*Vvas it cleaned? 0 Yes . 7 No
5. Condition of System:
Company
7. Locall%,where contents were . disposed:
I.. f',It A-v�, ; v�, , % -,
X
Signature of Hauler
http:/Avww.mass.90V/d``eP/Wate�/8ppro.Valstt5forms.:htm#lnspect
t5form4.ft- D6/03
Date
EN
System Pumping Record - Page I of 1
<�N Commonwealth of Massachusetts
City/Town of No.Andover
'o System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from e purnpin_g_date -in
accordance with 310 CMR 15.351.
A. Facility Information
,0 1 toil
.V 10 toil
Important:
When filling out 1 . System Location:
forms on the 4e
computer, use 4
only the tab key Address
to move your No.Andover
cursor - do not City/Town
use the return
key. 2. System Owner:
VQ / --) g ao�
Name '*_1
Address (if different from location)
City/Town
Ma
State
State
Telephone Number
B. Pumping Record,
� A _/0 - //
1. Date of Pumping W 2. Quantity Pumped
Date
3. Type of system: 0 Cesspool(s)
El Other (describe):
4. Effluent Tee Filter present? Ej Yes Ej No
5. Condition of System:
6. Svstem Pumped B
Name
Stewart's Septic Service
Company
TOWN OF NORTH ANDOVER
HEALTH OEPARTMENT
01810
Zip Code
Zip Code
Ir -n 6
Gallons
eptic Tank [] Tight Tank E] Grease Trap
If yes, was it cleaned? E] Yes E] No
Vehicle License Number
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
f
Signa r uler Date
j 16-10-11
ce
t5form4.doc- 03/06 Signa pa, iving Facility Date System Pumping Record - Page 1 of 1
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
VQ
Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
N10V 2 1 2U12
TOWN OF NORTH ANDOVER
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 within 14 days from the pumping date in
accordance with 310 CIVIR 15.351.
A. Facility Information
1. System Location: AS, 'F(
Address
North Andover
City/Town
2. System Owner:
Name
Address (if different from location)
City/Town
,4.
Ma 01845
State Zip Code
State
Telephone Number
Zip Code
B. Pumping Record
1 . Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: F-1 Cesspool(s) Septic Tank F-1 Tight Tank 0 Grease Trap
El Other (describe):
4. Effluent Tee Filter present? El YesEl No If yes, was it cleaned? n Yes El No
5. Condition of System:
6. Aystem Pumped By:
(Mime
1�fj
Name I Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature &-Receiving Facility
I
Date zo 0
Date
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1
Commonwealth of Massachusetts RECEIVED
City/Town of North Andover FEB 14 2017
TOWN OF NORTH ANDOVER
System Pumping Record
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 within 14 days from the pumping date in
accordance with 310 CIVIR 15.351.
4. Effluent Tee Filter present? r-1 Yes El No If yes, was it cleaned? Ej Yes 0 No
5. Observed condition of component pumped:
ped By:
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
qq$axai [Ist bradford ma
of Hauler
Signature of Receiving Facility (or attach facility receipt)
Vehicle License Number
i-5- 1-�
Date
Date
t5form4.doc- 11/12 System Pumping Record - Page 1 of 1
A. Facility Information
Important: When
filling out forms
1 . System Location:
on the computer,
FMkl 6�-�
use only the tab
key to move your
Address
cursor - do not
North Andover
use the return
key.
City/Town
State
Zip Code
2. System Owner:
E6
Name
Address (if different from location)
City/Town
State
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date
2. Quantity Pumped:
Gallons
3. Component: F1 Cesspool(s)
9-15eptic Tank 0 Tight Tank
El Grease Trap
El Other (describe):
4. Effluent Tee Filter present? r-1 Yes El No If yes, was it cleaned? Ej Yes 0 No
5. Observed condition of component pumped:
ped By:
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
qq$axai [Ist bradford ma
of Hauler
Signature of Receiving Facility (or attach facility receipt)
Vehicle License Number
i-5- 1-�
Date
Date
t5form4.doc- 11/12 System Pumping Record - Page 1 of 1
,C\ Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
VQ
RECEIVED
FEB 14 2017
TOWN OF NORTH ANDOVER
JJEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority Within 14 days from the pumping date in
accordance with 310 CIVIR 15.351.
A. Facility Information
1. System Location -
North Andover
Cityrrown State
2. System Owner-
i�dO 6� lan�A
Address (if different,from location)
City/Town
State
Telephone Number
B. Pumping Record
1. Date of Pumping 2 luantity Pumped:
Die
3. p nt: El Cesspool(s) El Zeptic Tank n Tight Tank
D 6
70ther (describe):
4. Effluent Tee Filter present? 0 Yes
5. Observed condition of 7 P
Zip Code
Zip Code
5 jz)
Gallons
Ej Grease Trap
No If yes, was it cleaned? El Yes El No
6. Srye�m---Pum ed B
p
I I
'� YV)
Name
Stewarts Septic 58 So Kimball St Bjdford Ma
Company
7. Location where contents were disposed:
2*o mill st brad#d ma 6 —
I k �.- /I A U
Sign$ture of Hauler
,3s,3 3-r-')
Vehicle License Number
/. /T /Irl
Date
of Receiving Facility (or attach facility receipt) Date
t5form4.doc- 11/12 System Pumping Record - Page 1 of 1