HomeMy WebLinkAboutMiscellaneous - 3 BRECKENRIDGE ROAD 4/30/2018s3
4F
C)
m
Is MM
C) 22
Ol
m
M
z,
Z4
fk
31
-o
T�-
A f
j!
-.k
-V
IC
.,- V-
zt4
fj
4
C)
m
Is MM
C) 22
Ol
m
M
No Andover J&S Development dba
1600 Osgood St Stewart's Septic
Building 20 Suite 2-36 Andover Septic
No. Andover, Ma 0 1845 58 South Kimball Street
Bradford, MA 01835
Date Name & Address
Gallons Comments
`I-Ma� Patter reAty 81 Sawmill Rd
1600 Good
2-May-lMul6a J�550 Sharpners Pond Rd
KY
1500 Good
-A
Greene 62 Willow Ridge Rd
1000 Good
3-May,11�c-r'o-"-ss2s-�2-59 Grandville
�-,O--n4l.15 Sherwood Dr
2500 Good
1500 Xsolids HG
Wj'k"
9-MayX , al , lal�r%40 Foster St
1500 Good
1 0 -May Ve'=er�r� 444 Salem St
1500 Xsolids
15-May,'Dirahh Brenkin ridge Rd
1500 Good
�:OjpprijT75 Stone Cleave Rd
1500 Good
16 -May Martin 701 Forest St
1500 Good
. ' , rM'u"r—PH-u-.6 Carleton Lane
1500 Good
18 --May andefgraaf--267 Old Cart Way
1500 Good
t-60no,21 98 Tnok St
1000 Rh
21-May-tomic6i .15LaconiaCir
1500 Good
�eti 4 2 Cross Bow
N7*Ma6.Y*tarbon6ll1560 Salem St
1500 Good
1000 Good
29 -May Thurber 210 Farnum St
1500 Good
Y�Qlea�(�.O�5 Winter green Dr
1000 Good
TOWN 0,':,NC)R,rH ANDQV�R.
HEALTH DEPARTMENT
78
101
COMMONWEALTH OF MASSACHUSETTS
ExECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 3 Brekenrid2e Road
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: & Ad Date: L-0 3–
AV pn� .&
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.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use. NOTE: This Title 5 is NOT a guarantee/warranty of the future function of the septic
system.
North Andover, MA 01845
REC�
RECEIVED
Owner's Name:
Ken Diraffael
Owner's Address:
Same
JUN 2.7 2005
Date of Inspection:
06-06-2005
'TOWN OF
Name of Inspector: (please print) John Soucy
HEALTH
LTt�
DE F
Company Name:
Soucy Sewer Service, Inc.
Mailing Address:
830 Livininton Street
Tewksbury, MA 01876
Telephone Number:
978-851-8839
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: & Ad Date: L-0 3–
AV pn� .&
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.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use. NOTE: This Title 5 is NOT a guarantee/warranty of the future function of the septic
system.
I
Page 2 of I I
K—
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 3 Brekenridge Road
North Andover, MA 01845
Owner's Name: Ken Diraffael
Date of Inspection: 06-06-2005
Inspection Summary: Check A,B,CD or E / ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 3 10 CMR
15.303 or in 3 10 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the "Conditional Pass" section need to be replaced or
repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes, no or not determined (YN,ND) in the for the following statements. If "not determined" please
explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
— The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
ND explain:
Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 3 Brekenridge Road
North Andover, MA 01845
Owner's Name: Ken Diraffael
Date of Inspection: 06-06-2005
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is
failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b) that the
system is not functioning in a manner which will protect public health, safety and the environment:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the
system is functioning in a manner that protects the public health, safety and environment:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
— The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
— The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
— The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
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 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:
I
Page 4 of I I
K -
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 3 Brekenridee Road
North Andover, MA 01845
Owner's Name: Ken Diraffael
Date of Inspection: 06-06-2005
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following for all inspections:
Yes No
X 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
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X -- Liquid depth in cesspool is less than 6" below invert or available volume is less than V2day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped
X 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.
X 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. [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.]
... 2Lo_ (YesNo) The system fails. I have determined that one or more of the above failure criteria exist as
described in 3 10 CMR 15.303, therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either "yes" or "no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
— — the system is within 400 feet of a surface drinking water supply
— the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped
Zone 11 of a public water supply well
If you have answered "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 3 10 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
Page 5 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 3 Brekenridee Road
North Andover, MA 01845
Owner's Name: Ken Diraffael
Date of Inspection: 06-06-2005
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
x _ Pumping information was provided by the owner, occupant, or Board of Health
— x Were any of the system components pumped out in the previous two weeks ?
x — Has the system received normal flows in the previous two week period ?
— x Have large volumes of water been introduced to the system recently or as part of this inspection ?
x Were as built plans of the system obtained and examined? (If they were not available note as N/A)
x Was the facility or dwelling inspected for signs of sewage back up ?
__.I_ Was the site inspected for signs of break out ?
x Were all system components, excluding the SAS, located on site ?
__.&_ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the
condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of
scum ?
x _ Was the facility owner (and occupants if different from owner) provided with information on the proper
maintenance of subsurface sewage disposal systems ?
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Yes No
x _ Existing information. For example, a plan at the Board of Health.
— __&_ Determined in the field (if any of the failure criteria related to Part Cis at issue approximation of
distance is unacceptable) [3 10 CMR 15.302(3)(b)]
I
Page 6 of I I
N
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 3 Brekenridee Road
North Andover, AM 01845
Owner's Name: Ken Diraffael
Date of Inspection: 06-06-2005
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 440
Number of current residents: 2
Does residence have a garbage grinder (yes or no): no
Is laundry on a separate sewage system (yes or no): no [if yes separate inspection required]
Laundry system inspected (yes or no): no
Seasonal use: (yes or no): no
Water meter readings, if available (last 2 years usage (gpd)): see attachment
Sump pump (yes or no): no
Last date of occupancy: ecent
COMMERCIAL/INDUSTRIAL N/A
Type of establishment:
Design flow (based on 3 10 CMR 15.203): gp d -
Basis of design flow (seats/persons/sqft,etc.):
Grease trap present (yes or no): _
Industrial waste holding tank present (yes or no):
Non -sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: Home Owner
Was system pumped as part of the inspection (yes or no): yes
If yes, volume pumped: 1500 gallons -- How was quantity pumped determined? Gage on truck
Reason for pumping: P ection and annual service.
TYPE OF SYSTEM
Septic tank, distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be
obtained from system owner)
— Tight tank _ Attach a copy of the DEP approval
— Other (describe):
Approximate age of all components, date installed (if known) and source of information:
15 years old
Were sewage odors detected when arriving at the site (yes or no): No
Page 7 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 3 Brekenridze Road
North Andover, MA 01845
Owner's Name: Ken Diraffael
Date of Inspection: 06-06-2005
BUILDING SEWER (locate on site plan)
Depth below grade: 28"
Materials of construction: X cast iron 40 PVC __other (explain):
Distance from private water supply well or suction line: 75'
Comments (on condition ofjoints, venting, evidence of leakage, etc.):
SEPTIC TANK: x (locate on site plan)
Depth below grade: 12"
Material of construction: X concrete —metal —fiberglass ___polyethylene —other
(explain)
If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of
certificate)
Dimensions: 6'x 11'
Sludge depth: 339
Distance from top of sludge to bottom of outlet tee or baffle: 3895
Scum thickness: 211
Distance from top of scum to top of outlet tee or baffle: — 7"
Distance from bottom of scum to bottom of outlet tee or baffle: 15"
How were dimensions determined: — Tgpe & Sludge Tool
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) N/A
Depth below grade: _
Material of construction: —concrete —metal fiberglass ___polyethylene —other (explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
I
Page 8 of I I
N
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 3 Brekenridee Road
North Andover, AM 01845
Owner's Name: Ken Diraffael
Date of Inspection: 06-06-2005
TIGHT or HOLDING TANK: _ (tank must be pumped at time of inspection)(locate on site plan) N/A
Depth below grade:
Material of construction: —concrete —metal fiberglass ___polyethylene other (explain):
Dimensions:
Capacity: _____gallons
Design Flow: gallons/day
Alarm present (yes or no):
Alarm level: Alarm in working order (yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
DISTRIBUTION BOX: X (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.): Replaced D -Box with new one, see permit enclosed.
PUMP CHAMBER: _ (locate on site plan)
Pumps in working order (yes or no):
Alarms in working order (yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Page 9 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 3 Brekenridee Road
North Andover, MA 01845
Owner's Name: Ken Diraffael
Date of Inspection: 06-06-2005
SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan, excavation not required)
If SAS not located explain why:
Type
leaching pits, number:
leaching chambers, number:
leaching galleries, number:
X leaching trenches, number, length: (3) trenches
—leaching fields, number, dimensions:
overflow cesspool, number:
innovative/alternative system Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.): No Sign of Hydraulic Failure.
CESSPOOLS: _ (cesspool must be pumped as part of inspection)(locate on site plan) N/A
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 or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY: (locate on site plan) N/A
Materials of construction:
Dimensions:
Depth of solids:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Page 10 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 3 Brekenridze Road
North Andover, 1%1A 01845
Owner's Name: Ken Diraffael
Date of Inspection: 06-06-2005
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
V-
4
.. ..........
........... ..... . .
.............. ...... . .............. . .
4i
. ........... ............. ........ .... ...... ............. . . ..........
.... ........ .............. . . . ... ........
............. ............. .. ........... ............. ........... .............
...... ....... .............
I .. ........ .. ......... . .......... .......... ..........
�A
;V . ...... . ... ..... ....................
v
.... ...... . ....... . ..... ....
.............
q4; VPW/
... ...... . . ..... .... .......
......... .
. .......... . ......
. ...... ... .............. ..
I
Page 11 of 11
A01
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Property Address:
Owner's Name:
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar x
Shallow wells
PART C
SYSTEM INFORMATION (continued)
3 Brekenridge Road
North Andover, MA 01845
Ken Diraffael
06-06-2005
Estimated depth to ground water 4' down.
Please indicate (check) all methods used to determine the high ground water elevation:
X Obtained from system design plans on record - If checked, date of design plan reviewed: AMst 170' 1987
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain:
Checked with local excavators, installers- (attach documentation)
Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Hi,gh around water elevation determined from design plans done on 8-17-1987.
W
7 Ip
Y11
14�
1 7-1
174
17
W FAM
ON
HANCOCK SURVEY ASSOCIATES, INC.
0�1 .
235 NEWBURY STREET - ROUTE I NORTH DANVERS, MA 01923 (508) 777-3050 / 283-2200 / (617) 662-9659
FAX: (508) 774-7816
139 BEACH ROAD SALISBURY, MA 01950 (508) 462-3036 / 352-7590
FAX: (508) 462-5547
#3675
December 12, 1988
Board of Health
Town Hall
120 Main Street
No. Andover, MA 01845
ATIN: Mr. Michael Graf
Re: Subsurface Sewage bisposal System
Lot 3, W&Q&vxy Street
- Stecu"VIV1614<
Dear Mr. Grar:
I hereby certify that the subject system was installed as shown on the
enclosed as -built sketch.
Please call if you have any questions.
VVT/bc
Enclosure
cc: Mr. Ken DiRaffael
c/o Kenwood Development Corp.
4 School Hill Jane
North Reading, MA 01864
truly yours,
10�--
Any lien perfected pursuant to section three A, or to section nine of chapter one hundred and
forty-three or section one hundred and twenty-seven B of chapter one hundred and eleven, shall
extend to and may be enforced by the city or town against any casualty insurance policy or policies
covering any loss, damage, or destruction pursuant to which the proceedings to perfect the lien were
initiated. i
No insurer shall be liable to any insured owner, mortgagee, assignee, city or town, or other interested
party for amounts disbursed to a city or town under the provisions of this section, or for a mounts not
disbursed to a city or town under the provisions of this section.
On this date, I caused copies of this Notice to be sent to the persons named above at the. addresses
indicated above by First Class Mail.
I
Cunningham Lindsey
Catastrophe Department
c1cat@cl-na,corn
800-867-3885
Cunningham Lindsey U.S., Inc.
P.O. Box 703689
Dallas, TX 75370-3689
Telephone (888) 738-8714 Facsimile (214) 488-6766
CLCAT@CL-NA.COM
"****'****************AUTO'*3-DIGIT 018
7§0 T3 P1 95000058980
Building Commissioner or
Inspector of Buildings
120 MAIN STREET
N ANDOVER, MA 01845
C I unningam fA
L,nd?
X
Form of Notice of Casualty kpss.to Building
Under MASS. GEN. LAWS Ch. 139.. Sec 3B
2668343
266834302
BAY STATE INSURANCE COMPANY
ICE DAM
2/18/2015
ANTONIO & KERRY RICO
3 BRECKENRIDGE RD
Claim has been made involving loss, damage, or destruction of the above captioned property, which
may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6, to be
applicable.
If any notice under Massachusetts General Law, Chapter 139, Section 3B is appropriate, please direct it
to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss
and claim number.
Section 3R.Aft insurer shall pay any claims (1) covering the loss, damage, or destructio�s,tq,a building or
other structure, amounting to the one thousand dollars or more, or (2) covering any loss, damage or
destruction of any amount, which causes the condition of a building or other structure to render section
six of chapter one hundred and forty-three applicable, without having at least ten days previously given
written notice to the building commissioner or inspector of buildings appointed pursuant to the state
building code, to the fire department or arson squad of the city or town and to the board of health or
board of selectmen of the city or town in which the same is located. If at any time prior to the payment
the said city or town notifies the insurer by certified mail of its intent to initiate p roceedings designed to
perfect a lien pursuant to section three A, or to section nine of chapter one hundred and forty-three, or
section one hundred and twenty-seven B of chapter one hundred and eleven, the said payment shall not
be made while the said proceedings are pending; provided, however, that said proceedings are initiated
within thirty days of receipt of such notification.
Claim Number:
Policy Number:
co
Company Name:
C)
co
0)
Cause of Loss:
co
to
0
Date of Loss:
Insured:
Property Location:
C I unningam fA
L,nd?
X
Form of Notice of Casualty kpss.to Building
Under MASS. GEN. LAWS Ch. 139.. Sec 3B
2668343
266834302
BAY STATE INSURANCE COMPANY
ICE DAM
2/18/2015
ANTONIO & KERRY RICO
3 BRECKENRIDGE RD
Claim has been made involving loss, damage, or destruction of the above captioned property, which
may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6, to be
applicable.
If any notice under Massachusetts General Law, Chapter 139, Section 3B is appropriate, please direct it
to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss
and claim number.
Section 3R.Aft insurer shall pay any claims (1) covering the loss, damage, or destructio�s,tq,a building or
other structure, amounting to the one thousand dollars or more, or (2) covering any loss, damage or
destruction of any amount, which causes the condition of a building or other structure to render section
six of chapter one hundred and forty-three applicable, without having at least ten days previously given
written notice to the building commissioner or inspector of buildings appointed pursuant to the state
building code, to the fire department or arson squad of the city or town and to the board of health or
board of selectmen of the city or town in which the same is located. If at any time prior to the payment
the said city or town notifies the insurer by certified mail of its intent to initiate p roceedings designed to
perfect a lien pursuant to section three A, or to section nine of chapter one hundred and forty-three, or
section one hundred and twenty-seven B of chapter one hundred and eleven, the said payment shall not
be made while the said proceedings are pending; provided, however, that said proceedings are initiated
within thirty days of receipt of such notification.
10
qb
�c
�sl
0
;A
Z
rq
CD
C>
z
4.
t,
IQ
;oD
i�
-7t
T
�o
CD
a
C>
In.
C
0
0
u
U
a
kf)
0
z
W W
>
C�
Z Z z
u u
kn
C)
CL
00
m
r-
kn
ci
Q05
ci
Q,
;A
Z
rq
CD
C>
z
4.
t,
IQ
;oD
i�
-7t
T
�o
CD
a
C>
In.
C
0
0
u
U
a
07-26-12;17:41 19786888476 # 19/ 19
HANCOCK SURVEY ASSOCIATES, INC. JOB
235 Newbury Street (Route I North) SHEET OF
DANVERS, MASSACHUSETTS 01923
(617) 771-3050 (617) 662-9659 CALCULATED BY—,,-_ DATE—._._.
(617) 352-7590 (617) 283-2200
CRECKED BY—
DATE-
BCALE—
T-j
. ............ L ..........
.. ..........
........ .... ...... ...... . ........... 14-
. ..... .....
........... .............
. . ......... . ........... . ............
. ...... ...
............ .. . ....... .............. 7� ...... .... I ...... ....
�21. 1 c!2<4
...... ...... .. ... ... .... ........... 1- A. I . ... ... .. )
. ..........
............. ..... ... ..
............. ....
.. . ... ...........
. ... ......
... .... ....... ...... . ............. . . . . .....
........ ........ . ........ ... ..
. .....
...... ... .......... . ... 'j ... ....... ..... ..... .. ....... . Z
. .......... . .........
............. .... ...... .. . .......... . . ...... .... ...... ... .... ......
.... ....... ........... . . ...... . ....... ... ............... ... .. . . ............ - ----- --- .......... ..
. . ....... ... . ..... . . ....... .......... . L .... ...... . ...... ... .... ... .... ......... . ... . ....... .... ... ....
-�5 tl
............ .
....... ... . ...... ...... -------- . ........ . ..... — .... .. .... , ... . ....... . ...... ........... ... ........ .... ........ .. . ........ ........... ..............
ur, --�F
..... ....... .
... . ...... . . ... . . ........
............. ......... ... lv��`04 i Q 141—:'
...... .... ............ ....... ...... ..... ...... . .. ......... .. ............ . ......
..... ........... ..... . ........
-a . . . . ..... ........ . . .........
............ ....... ....... ..... ..... ......... . ..
......... . .. .............. ......... . . ........
'r4 ... ...... . . . ... ... ; . 6c:>: - I r
..... .... ... ...........
e? i 474
�Yul - I--- �' I lll��'�---�� ... ... ....
... ... ..... . . .. . ........ -------- .. .......... — ------
.. .... .... ..
... . ........ .. ......... 4-f�"...." . ....... j�c ......... .
..... . ..... . ... ...... ..... .... .
. . ......... ...... ... ....
. . ......... . . .......... ........ .... .. . .... ..... .................
.. . ................. .......... ..........
.... ... ... -
k rV4T 6$4.$ i
. . ........... .......... ... . ......
W4
........ ..... .... .... ... .. i .4 ........... . ..... ..... . .. . . .. ..... . .. .. ... r .............. . . ... . .......... ........
7ZE 4 C�4
............ .... ........... . ...... ..... . ...... ... ... ........
4 .... . ....... ... ...... ..
�71 1
.... .. ....... 1- '77
........... .................. . . 'I"..l'...! ....... .. .. j .... ...... .
IT
. ..... ....
. . .. ...... p . ................ . . .......... .... ... . ..... .... ........
....... ... ... . ........
......... .... ............. .. ... .... . .... ...... ............. . .... ...... ... ...... . . . .... .. ....... ....... ... .... .. . . ....... ....... ............ .......... ..... ......
1 ............. .......... . . ... ...... ..
.. .. . .. ... .. . ........ . . ...... .......... .
I . ........ . ......... ....
.. . ...... .. . ..... .
. .......... ....... ...
... ........
1,41
.... .......
.... ....... ... ...... ..... ........ .. ........ - ............ ... .. ......
.. . ... . .. ........ ............
............ ...... .. . .
.. ...... . �2.... . . . . .....
....... .... .7 1.4-Z..
L-, I -c
- ry
... .......... .... ........ ....... ..... . ... ... . ...... .
.. . ............. .. ... .... ....
... .. ....... ..... .
. .. ... .......
............ . .... . . .... ...... .. ..
. ......... .... ..
w -F-�
....... .... . . . .... . ........ .. .....
.. .. . .... ......
.. . . ... .. .. . ....... ......... ..
j C-4,
62'i 1
0
Town of North Andover
HEALTH DEPARTMENT
ACH
CHECK D A T E:
LOCATION:
H/0 NAME:
CONTRACTOR NAME:
Type
of Permit or License.lCheck box)
0
Animal
0
Body Art Establishment
$
0
Body Art Practitioner
$
0
Dumpster
$
0
Food Service - Type.
$
0
Funera I Directors
$
0
Massage Establishment
$
0
Massage Practice
$
0
Offal (Septic) Hauler
$
0
Recreational Camp
$
0
Sun tanning
$
0
Swimming Pool
$
0
Tobacco
0
TrashlSolid Waste Hauler
0
Well Construction
$
SEP77C Sustems:
0 Septic - Soil Testing $
[I Septic - Design Approval $
0 Septic Disposal Works Construction (DWC) $
0 Septic Disposal Works Installers (DWI) $-
0 �Titie Inspector
Z3,1 Title 5 Report $
0 Other (Indicate) $
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
DelleChiaie, Pamela
From: DelleChiaie, Pamela
Sent: Thursday, July 26, 2012 1:50 PIVI
To: 'Mottola, Rosemary'
Cc: Sawyer, Susan
Subject: I.R. - 3 Breckenridge Road, North Andover
Attachments: 20120726131933985.pdf
To: Rosemary Mottola
978-269-2250
Hello Rosemary,
Ashley from Stewarts was kind enough to fax tI
North Andover. Here is a scanned copy of thati
May. . not have a c—T qf it prior to this in i
,We arg-stffl looking into that, but here—i–s-61-e Fco
a copy which I also provided to her. So, I think
Pamela DelleChiaie
Health Department
Town of North Andover
1600 Osgood Street I Bldg. 20 1 Suite 2-36
North Andover, MA 01845
Phone 978.688.9540
Fax 978.688.8476
Email Pdellechiaie@townofnorthandover.com
Web www.TownofNorthAndover.com
Tq
V -0--e
1
iridge Road,
Ler it was sent in
cpnt- t -r% rnnfirm
N
I
DelleChiaie, Pamela
From:
Sent:
To:
Cc:
Subject:
Attachments:
To: Rosemary Mottola
978-269-2250
Hello Rosemary,
0 0
DelleChiaie, Pamela
Thursday, July 26, 2012 1:50 PM
'Mottola, Rosemary'
Sawyer, Susan
I.R. - 3 Breckenridge Road, North Andover
20120726131933985.pdf
Ashley from Stewarts was kind enough to fax the Title 5 Report right over to me for 3 Breckenridge Road,
North Andover. Here is a scanned copy of that report. There was some confusion as to whether it was sent in
May. -J -did not have a copy of it prior to this in my file, and asked her to lookup the check she sent to confirm.
We ar
- S-sra looking into that, b�t e��reis�ecoi3��int��emean�time.�SO,���-br�S�StO-D-De�V�C
a copy which I also provided to her. So, I think ev-e-ry-6-n—e-i`sa1F`setnow? If so, have a great afternooni-O
Pamela DelleChiaie
Health Department
Town of North Andover
1600 Osgood Street I Bldg. 20 1 Suite 2-36
North Andover, MA 01845
Phone 978.688.9540
Fax 978.688.8476
Email ode I lec hia ie0townof northa ndover.com
Web www.TownofNorthAndover.com
07-26-12;17:41 ; 19786888476 0 # 1/19
r=�P--Vry
Owner
Information lo
required for every
page,
Important' When
filling out forms
on 11ho mmpujor.
u9e only the 111b -
key to move your—
cursor - do not
use the return
key,
VQ
Ummonwealth"Of Massachusetts
,Title.,5 Official' Inspection Form
SubsU66e Sewage Disposal SyStem porm - Not for Voluntary Assessments
3 Breckenridge Rd
Properly x1dress
Kenneth Diraffsel
owneft Nome" ........
No Andover Me 01845 511212012
avi/T-OA state Zip Code —
D8tG Of Inspection
Inspection results must be submitted on this form, 11111815ur-tion forms may not be altered In any
Way. Please see completeness checklist at the end of the form.
A. General Informatio"--n
1. Inspoetor,
John DIVinnzo
Name of Inspector
Stewart 8800 Service
Company Nirrio
68 South Kimball
CornpAny Address
Bradford Ma
UWIoWn
978-372-7471 A
Telephone Nvmbor
B. Certification
V Iola;;
State Zip Code
8113386
License Number
I certify that I have pe'reonally inspected the sewage disposal system at this address and that the
information reported below Is true, Mutate and complete as of the'time of the Inspection. The Inspection
was pprformed based on my training and experlenoo in the proper function and mainterianca Of on s4e
sewage disposal systems, I am a DEP approved system inspector pursuant to Section 15.340 of
Title 8 (310 CMR 16,000). The system, I
Passes M Oonditionally Passes El FaIlt
Needs Further Erluation by the Local Approving Authority
511212012
Date
The stem inspector shall subAlt a copy of this Inspection report to the Approving Authority (Board
of Heab or OEP) within 30 days of completing this firlispectior'i. 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 odginal should be sent to the system owner
and copies sent to the buyer,,If appIlIcable, and the approving authodty,
""This report only describes conditions at the time of ins&btion 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 difforant conditions of use.
INns, 11110 Tft 5 OKOW Inspedori Fartw SOWMfift S&*tab Oisposat $nWn , P"o I vf 17
07-26-12;17:41
Owner
Intomintlon Is
required for every
page.
N
19786888478 0
Cor�monwealth of Massachusetts
Title 5 Official Inspection Form
Sub-surfaco Sewage Disposal System Form - Not for Voluntary Assessments
3 Breckenridge Rd
Property Address
Kenneth Diraffael
Owner's Name
No Andover
cityrrown
B. Certification (cont.)
Ma 01845 6/1212012
state Zip Code Date of Inspection
Inspection $ummary; Check A,B,C,D or E I always complete all of Section D
A) System Passes:
1 have not found any Infonnation which Indicates that any of the failure cdtorla aesembed
in 310 CMR 15.303 or in 310 CIVIR 16,304 exist. Any failure criteria not evaluated are'
indicated below.
Comments.,
8) System Conditionally Passes:
# 2/ 19
El one or more systein components as described In the'Conditional Pa6s" 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"yee', �no' or unot determined" (Y, N, NO) for the following statements, If "not
determined," please explain.
The sepfic tank is rnetal and over 20 years old* or the septo tank (whether metal or not) is structurally
unsound, exhibits substantial Infiltration or exfiltratlon 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 structuraily sound, not leaking and If a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
El Y El N F1 ND (Explaln below):
---- - - - — - ----------
Mint - I U10 TDOSOM0101 LnsP&a0nF61ft SubWace 86"94 Dispagai gy&Wn -Page 26111
107-28-12;17:41 0 19786888476
COMM011wealth of Massachusetts
Title 5 Official Inspection Form
Subsurfaco Sowago bleposall Syatom Form -Not for Voluntary Assossments
3 Breckenridae Rd
Noporty AddreaB
Kenneth Diraffael
Owner Ownere NHme
Information Is
required for every ' No Andover
page. OftylTown
B. Certification (cont)
8) System Conditionally Passes (cont.):
Ma 01845 6112/2012
siate Zip Code Date of Inspedion
# 3/ 19
Observation of sewage backup or break out or high static. water level In the distribution box due
to br0k8n or obstructed plpe(G) or due to a broken, settled or uneven distribution box. System will
pass Inspection If (with approval of Board of Health):
El broken plpo(u) are replaced El Y D N [I ND (Explain below)-.
0 obsbuction is removed El Y El N El ND (Explain below):
El distribution box Is leveled or replaced El Y [j N El ND (Explain below),
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):
El broken p1pe(s) are replaced n Y El N 0 NO (Explain below):
[I obstruction is removed [I Y Q N Ej ND (Explain below):
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 nocordanco with 310 CMR
16.303(l)(b) that the system is not functioning In a manner which will proter,'t public health,
safety and the environment:
Cesspool or privy is within 60 feet of a surface water
Cesspool or privy Is within 80 feet of a bordering vogetatted wetland or a salt marsh
i5MA - 1 Ili D InUeS OffscW JnrpocSm Form: Suhuffaea S&Mbgo 131spoWtAtoln, Pqp'40 17
07-26-12;17:41
N
19788888476
!a\- , Com monwealth of Massachusetts
9929&1r� Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form - Not for Voluntary Assessment$
3 Breckenridge Rd
Property Address
Owner
Information Is
required for ovory
page -
Kenneth 01raffeel
Owner's Name
No Andover
cityrrown
B. Certification (cont.)
Ma 01846 6/12/2012
Vit—i 2Jp Code Date of Inspection
# 4/ 19
2. System will fall unless the Board of Health (and Public Water Suppliar, If any)
determines that the system Is functioning in a manner that protects the public health,
safety and environment.,
El The system has a septic tank and soff absorption system (SAS) and the SAS Is within
100 feet of a surface water supply or tributery to a surface water supply.
D The system has a septic tank and SAS and the SAS Is wIthIn a Zone I of a public water
supply,
D The system has a septic tank and SAS and the SAS Is within 60 feet of a private water
supply wel I.
D The system has a septic tank and SAS and the SAS is less tlian 100 feet but 50 feet or
more from a pdvate water supply wall-.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP ceriltied laboratory, for fecal
coliform bacteria Indicates absent and the presence of ammonia nitrogen and nitrate nitrogen Is equal
to or less than 6 ppm, provIded that no other failure criteds 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 #11 Inspections:
Yes No
[j Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspol
El 0 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 dlstdbution box above outlet invert due to an overloaded
or clogged SAS or cesspool
E, Liquid depth in cesspool is less than 6' below invert or available volume Is less
. . ....... . .. . . ....... thein Y2 day flow
tsm - 1 lilt) TITJQ 5 0.1ME4 Jnspadion Famr, Subvirfaca &maga 016paW Eyajam. P" 4 of 17
07-26-12;17:41
M
�Qx - Comimonwealth of M80840husefts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
3 Breckenridge Rd
PropertyAddress
Kenneth Diraffael
Owner Owneer, Name ----------
InforMation is
requlmd for every No Andover Ma 01845 811212012
page. cayfrown stato Zip Code Oate of . lilepootion
B. Certification (con)
19786888476
#
Yes No
E]
Required pumping more then 4 Hines In the last year NOT due to clogged of
obstructed pipe(s), Number of times pumped:
Any portion of the SAS, cesspool or privy Is below high ground water elevation,
Ej M
Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
El N
Any portion of a cesspool or privy Is within a Zone 1 of a public well.
El M
Any portion of a cesspool or privy Is within 60 feet of a private water supply wall,
El El
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 n1trilte 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 formj
El 0
The system Is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd,
The syetern ffiJ11. I have determined that one or more of the aWve failure
critefle exist as described In 310 CMR 15.303, therefore the system falls. 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 it
4es ign flow of 10,000 gpd to 16,00 0 gpd.
For large systems, you must Indicate eher 'yes" or 'no" to each of the follom(ing, In addition to the
questions in Section D,
Yes No
El F1 the system is within 400 feet of a surface drinking water supply
0 El the system Is within 200 feet of a tributary to a surface drinking water supply
El n the system Is located In a nitrogen sensitive area (Interim Wellhead Protection
Area — IWPA) or a mapped Zone I I of a public water supply well
](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 18,304, The system owner should contact the appropriate
regional office of the [)apartment. I
ISMS - I U10 MOOS OMMinepedonftmt 8VMdjk;A0 $"a 0j"ajSysjBm.pa0 a oily
07-26 12; 17:41 0 19786888476 0
�L\ C*inmonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage nisposal System Form - Not for Voluntary Assessments
3 Breckenrldoe Rd
(gins - 11110
C. Checklist
Me 01846 511212012
State ZIP Code Date of InspectiroWn'
# 6/ 19
Check if the following have been done. You must indicate "yes" or "no' as to each of the following:
Yes No
Properly Address -
Kenneth Diraffael
Owner
5��Ff–; - "ao
inforrnallon Is
required for every
No Andover
— .
Pago.
cityrrown
(gins - 11110
C. Checklist
Me 01846 511212012
State ZIP Code Date of InspectiroWn'
# 6/ 19
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): .4 - ------ Number of bedroorns (actual): .4
DEMN flow based on 310 CMR 16.203 (for example: 110 gpd x # of bedrooms): 440 apd
Ua 6 Olftldl IMP696h F61ft SLIUUdac* SftsoB oNpoaal ayateM, pfip a of t?
Pumping information was provided by the owner, occupant, or Board of Health
Were any of the system components pumped out In the previous two weeks?
0 El
Has the system received normal flows In the prextious two week period?
E] Z
Have large volumes of water been introduced to the system recently or as part of
this inspection?
M r]
Were as built plans of the systein obtained and examined? (if they were not
available note as N/A)
21 El
Was the facility or dwelling Inupooted for signs of sewage back up?
Z L1
Was the Site Inspected for signs of break out?
F1
Were all system Goinponents, excluding the 8AS, located on site?
Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or toes, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
X E]
W&S 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 ftl Absorption System (SAS) on the site has
been determined based on:
19 El
Existing Informavon. For example, a plan at the Board of Health.
Determined In the field (if any of the failure criteria related to Part G Is at issue
approximation of distance Is unacceptable) [310 CMR 15,302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): .4 - ------ Number of bedroorns (actual): .4
DEMN flow based on 310 CMR 16.203 (for example: 110 gpd x # of bedrooms): 440 apd
Ua 6 Olftldl IMP696h F61ft SLIUUdac* SftsoB oNpoaal ayateM, pfip a of t?
07-26-12; 17:41 0 19786888476 0 7/ 19
0
,g\— - Corhmonwealth Of M2668chusefts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System rorm Not for Voluntary Assessmentr',
Breqkenrldae Rd
PropartyAddress
Kenneth Diraffael
Ownar Owner's Name
information Is
required for every No Andover Ma .01846 5112/2012
Wrown State ZIP COTO
D. System Information
Description:
.. . ........ . . . ...
Number of current residents:
Does residence have a garbage grinder? Yes No
Is lavndryon a separate Sewage system? [if yes separate Inspection required] yes No
Laundry system inspected? yes NO
Seasonaluse? Yes No
63 GPD
Water meter readings, if available (last 2 years Usage (gpd)):
Detail:
Water meter readlngl_.
Sump pump?
Last date of occupancy:
Comm arcialfindustrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 16.203):
Basis of design flow (seats/personstsqft, 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 E No
Occupied
Date
Yes No
Yes No
Yer, No
TW& 6 01WAI Inepection FOM SubSUMIC9 OW"v 015POSed Syslem - Pa
. go 7 of V
07-28-12; 17:41 0 19786888476 0 # 8/ 19
SL\ - Conimollw0alth of Massachusetts
I tslzglgp� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form � Not for Voluntary Assessments
3 Brackenridge Rd
Property Address
Kenneth graffael
Owner Owner�s Name . . ...... ------ ........
Information Is
required for every No Andover Ma- 01646 6/12/2012
page. Cityrrown state Zip Code Date of Inspection
D. Systom Information (cont.)
Last date of occupancyluse-
Dale
Other (describe below):
General Information
PUMPIrlo Records:
Source of information:
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Type of System:
Andover
gallons
:Lapu Measure
Inspect tank
C9 Yes [3 No
0 Septic tank, distribution box, soil absorption system
El single Cesspool
0 Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, If any)
Innovative/Altemative technology. Attach a copy of the current operation and
maintenance contraot (to be obtained from system owner) and a copy of latest
Inspection of the UA system by system operator under contract
Tight tank. Attach a copy of the DEP approval.
Other (describe):
TAqi Offidal Inspiaon Fm SubiOaw Swap DIN -50 Swlem - Pago a or 17
07-26-12;17:41 0 19786888476 0 # 9/ 19
Coifimonwealth of Maesachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
3 Breckenrildpa Rd
PropertyAddress
Kenneth Diraffael
Owner Owner's Namo
Informalion Is No Andover
required for every MR 01845
....... — 6/12/2012
page. cl�lrown State Zip Code Date of , Inopectlon
D-. System Information (cont.)
Approximate age of all components, date installed (if known) and source of Informatlon:
,?iY2 �Rs-- .............
Were Sewage odors detected when arriving at the site? L1 Yes 0 No
Building Sewer (locate on site plan):
Depth below grade: 21
feet
Material of construction:
0 cast iron El 40 PVC El other (explain):
Distance from private water supply well or suction line: foot
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade:
Material of construotion;
concrete El metal
ell
feet
Ej fiberglass Ej polyethylene EJ other (explain)
If tank is metal, list age; years
Is age confirmad by a Certificate of Compliance? (attach a copy of certificate)
Dimensions;
Ql"A aL Aa 61%
El Yes E3 No
t5ma - '11110 '111*5 OMM InHWOM Pwm; 6ubviOnas Sawzga DisM31 System - Page 9 of 17
07-26-12; 17:41 ; 0 19786888476 0
Cofiimonwealth Of Massachusetts
Title 5 Official Inspection Form.
SUbsurface Sewage Disposal SYstern Form , Not for Voluntary Assessments
3 Breckenridge Rd
Property Address
Kenneth Diraffael
Owner Owner's Name . ......
informawn is
req utred for every No Andpyer Ma
Pago. cityrrom
D. System Information (cont.)
Septic Tank (cont)
01846 511212012
Zip Code 68—te —0f hispedion
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
29"
-0
641
1411
# 10/ 19
How were dimensions determined? Tape Measure, SIugj�42djq.____.._
Comments (on pumping recommendations, Inlet and Outlet tee or baffle condition, structural Integrity.
liquid levels as related to outlet invert, evidence of leakage, etc.);
Both Raffles in good shape, No leakage, liquid level good
Grease Trap (locate on site plan);
Depth bolovy @rade-,
Material of construction -
0 concrete 0 metal
Dlmenslon�:
Scum thickness
.............. — -- — ------ ---------------------
feet
El fiberglass 0 polyethylene E3 other (explain):
Distance from top of scurA to top of outlet tee or baMe
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
16ins - 11110
Date
'rl*# 0 ObWid Inypedion Fomi. Submlw Smew DjDpo4w 3W9M - p9p ig OfI7
07-26-12; 17:41 0 19786888476 0 # 11/ 19
C0tnm0nW0a1th of Massachusefts
Title 5 Official Inspection Form
Subsurfaco SOWage DISPOSel Syatarn Foran - Not for Voluntary Assessments
PrOPerty Addre3s
Kenneth 01raftel
Ownor Owneev Name
Infounallion is
required for every No Andover — -------- Ma 01845 5/1212012
page. Chyfrown State Zip codo Date of IrmpecJlan — -------------
D. System Information (cont.)
Comments (on pumping recommendations, Inlet and outlet tee or baffle conditfon, Structural integrity,
liquid levels as related to Outlet Invert, evidence of leakage, etc.):
Tight or Holding Tank (tank MUSt be pumped at time Of inspectiop) (locate on site plan):
Depth below grade:
Material of construction:
D concrete F1 metal fiberglass El polyethylene other (explain):
Dimensions:
Capacity:
Design r1ow:
Alarm present:
Alarm level,
gallons
gallons per day
Oye$ ONO
Alarm In working order; Ll Yer, U No
Date of last pumping: Date
Comments (condition of alarm and float Switches, eto,),
* Attach copy of current pumping contract (required). Is copy attached? El Yes C] No
Ions 6 1 ilio Tft" OM61 YWP-U0nF0nn 0~a04W1M8PMpPzW 6ysigm-Pags ii of j?
07-26-12; 17:41 0 19786888476 # 12/ 19
Commonwealth of Massachusetts
Title 5 Official Inspection Form
SUbSUrfaCe Sewage Disposal System Forrn - Not for Voluntary Assessments
3 Breckenridge Rd
Propa4 Addross
Kenneth Diraffael
Owner6;�ees ---------- .... . ... ............... ........
Information is
required for every No Andover Ma 01845 6/12/2012
page. CiWoW11 state Zip Code Date of Impa rAjo. n.
D. System Information (cont.)
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 dIstrIWlQn to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Dist, Box level, no solids qgMLover. no leakage.
Pump Chamber (locate on slte plan):
Pumps In workIng order;
Alarms In working order:
0 Yes 0 No
El Yes 0 No
Comments (note condition Of PUMP ch=10ef, COndition of pumps and appurtenances, etc.):
Soll Abnorptlon System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
thm t I I110 Me 5 OM*l Inapiaon VOM SUbsWwg U&W Disposat System - Pago 12 6(17
07-26-12;17:41 19786888476 # 13/ 19
0 0
�LN Commonwealth Of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Msessments
3 Breckenrldoe Rd
P(opedy Address
Kenneth Dfraffael
Owner Owners Name
lArmalion is
requIred for every No Andover Ma 01646 6/1212012
page- cliyrr(Ayn -gi—aie '21P CM9 Unto of Inspection
U. ystem Information (cont.)
Type:
0 leaching pits
number: . .....
El leachlno chambem
number
leaching galleries
number:
leaching trenches
number, length: 3- 3 X 551
leaching fields
number, dimensions. ---
overflow cesspool
number.,
E] innovative/altemativG system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of pondIng, darnp soil, condition of
vegetation, etG,):
No Hydraulic failure no ponding, no damp solls
COSSP0018 (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 srum layer
Dimensions of cesspool .......
Materials of construallori
IndleationoTgroundwa rinflow El Yes [I No
MAO - I 1110 M8601fldsl irAP6WMF0(4'L SUDWaO8 S&&990010069431" - P4106 i36r 17
07-26-12;17:41 ;
19786888476
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface SGwQ90 Disposal System Form - Not for Voluntary Assessments
� Breckenridge Rd
Property Address
ow"r Kenneth Diraffael
InfomiaWn Is Owners Name
required for evo ry No Andover Ma 01845 5/12/2012
page. Qtyffown State zip coo Date of Inspection
D. System Information (cont.)
# 14/ 19
Comments (note condition of soil, sign5 of hydraulic failure, levol of ponding, condition of vegetation.
etc.):
PAVY (locate on site plan) -
Materials of construction: ---------------- ...................
01mensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condltlon of vegetation,
etc.):
15ins - I U10 TMOBOtEdal hnsPec6on Form; SubmW&O S666A6 M608818y&m - P&2* 14 of J?
07-26-12; 17:41 0 19786888478 0!
�C\. Commonwealth of Massachusetts
kulRfflFW0M= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - NotforVoluntary Assessments
6ate of In6pootlon
# 15/ 19
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. 1-008te
where publiG water supply enters Me building. Check one of the boxes below.
U hand -sketch In the area below
ED drawing attached separately
(WAA. I itio Me a omdal hweeft FWMI S)UbsLk(AG* S"o (NOPM1 &Atom - pilog low 17
3 Breckenridge Rd
PropertyAddress
Kenneth Diraffael
Owner
OWer's Name
information is
requfrad for every
No Andover — ------------------ Ma 01845
page,
chyrrown -state Zip Code
D. System Information (cont.)
6ate of In6pootlon
# 15/ 19
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. 1-008te
where publiG water supply enters Me building. Check one of the boxes below.
U hand -sketch In the area below
ED drawing attached separately
(WAA. I itio Me a omdal hweeft FWMI S)UbsLk(AG* S"o (NOPM1 &Atom - pilog low 17
07-28-12; 17:41 0 19786888478 0! 16/ 19
�QN COMMOnwealth of Mkesachweft
Title 5 Official Inspection Form
SubsurracG Sewage Disposal SYStern Form - Not for Voluntary Assessments
—Breckepridge Rd
Pluparty Mdrelis
OWAer Kenneth 131raffeel ---- - ---
Information is Owners Name
requIred for every No A� �Mr Ma 01846
page, chyrrown — 6/1212012
State Zip Code Date of In
Dff SysteW —16�formatjon'�C�Ont,)
Site Exam-,
Check Slopa
$Urface water
Check cellar
Shallow wells
UiMated depth to high ground water 4t .........
feet
Please Indicate All methods Used to deteiTnine the high ground water elevation:
to Obtained fr6m SYStem design plans on record
If checked, date of design plan reviewed; 10-18-88
Date
ObsOrved site (abutting ProPerty/obServation hole within 150' feet of SAS)
Checked with 100al Board of Health - eXplain:
.E�Iled files
Checked with local excavators, InstAllers - (attach documen,tation)
AccMed USGS databa$O - explain:
You must describe how you established the high ground water elevation:
System d08iqn plans drawn. by Hancock Survey
Before filing this Inspection Report, Please see Report Completenes: 9 Checklist on 11ext page.
111% 6 Official Inspection rrf)ll: &beurrKe SOW196 Di"al sygay) - P80 18 0117
07-26-12; 17:41 0 19786888476
.tN COmMOnWealth Of MaseachUtDetts
Title 5 Official inspection Form
Subsurface Sewage n1sposal Syetem Form - Not for Voluntary Assessments
3 Breckenridge Rd
Property Address
Onneth Diraffael
Owner ers Name
Information is
required for eVery No Andover Ma
page. cityrrown State
E. Report Completeness Cheeklist
# 17/ 19
01845 6/12/2012
,7115-00de Date of IrwpeR-Ion
Inspection Summary: A, B. 0, 1), or E checked
Inspection Surnmary U (System Failure Criteria Applicable to All Systems) Completed
SyStOM Information — EstlrnaW depth to high groundwater
Sketch of Sewage 1116posal System either drawn on page 15 orattached In separate file
'nL*5 ()MOW b1&PeCH0hF0vA; SubsWacA Sowageoispoulaysteln.pagg j? or I I
07-26-12; 17:41 0 19786888476 9 18/ 19
T�ANCOCIC SUIRVEY ASSOCIATEDS, INC.
235 NRWOURY STRI!ET 11 ROIFrE I NOR'rH T)ANVh0PgS. MA 0102.1 (5081777-aOISO/ (617) 96;1.96BO
130 13EACH ROAD -9ALIRBTJRY, MA ()lD.5() VAX: (608) 774-7819
OSOW 409,30361552-75$0
#3675 FAX, (008) 452-5547
Boaxd of Heaw, r1em1ber 12, 198a
T(Nm Hall
120 Main Street
110- Andover, MA 01845
ATTN: Mr. Michael Graf
R"' S'S'Surfam SswagG Wspwal Systm
10t 3, %wJbUgy.' street
cd�emv-
Doer Mr. Grqa�: vlrlr-.z
I hereby mrt�� that the subject 6ystell, was
enolosed as -built sketch. irOtdll�d aS shmi on the
pleass call if YOU 1-AVe any opat;tjoym.
WTAC
Enolomure
Cc: Mr. Xen DiRaffhel
C/O Nenwood Developj*mt CC>Xp.
4 gdlool Hill Lane
NOrth Readblq, MA 0.1964
t
ve�y tnay youm,
DelleChiaie, Pamela
From: Mottola, Rosemary [i iM—bv—erTl—vi—ngc
Sent: Thur �dday J
-�012 12:37 PM
s' ay' le, Pam,
Delle la
To: C ie, Pam�
.R _
. - 3 Breckenride Road, North Andover
Subject: R �A. R. 3 Breck
Ok thank you!
0
ary; aegonvo#Wa
Transoction Mdnqge&*,
FF
P:978.26 .22$0,-�,Efox:.-,..9,�8,526§.215,0
�Mbttol4r@ 100 er, 9XQM -A,
a V
115 _C In. I - I I -
From: DelleChiaie, Pamela [mailto:pdellech(�)townofnorthandover.com]
Sent: Thursday, July 26, 2012 11:48 AM
To: Mottola, Rosemary
Subject: I.R. - 3 Breckenride Road, North Andover
To: Rosemary Mottola
978-269-2250
Dear Rosemary,
I pulled the file for 3 Breckenride Road, and I do not see that we have a current Title 5 Report included. You
may want to check with Stewarts Septic on behalf of your client to see if they submitted a copy to us for our
files. The only updated information I found was a septic pumping report dated May 15, 2012. Thank you.
Pamela DelleChiale
Health Department
Town of North Andover
1600 Osgood Street I Bldg. 20 1 Suite 2-36
North Andover, MA 01845
Phone 978.688.9540
Fax 978.688.8476
Email ydel lechia ie0townof no rtha ndover.com
Web www.TownofNorthAndover.com
Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more
information please refer to: hftr)://www.sec.state.ma.us/l)re/l)reidx.htm.
Please consider the environment before printing this email.
I
Commonwealth of Massachusetts
City/Town of No andover
System Pumping Record
Form 4
DEP has provided this form foruse by local Boards of Health. Other forms may b e 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.
City[Town
ivia,
A. Facility Information
Important: When
filling out forms
1 System ation:
on the computer,
use only the tab
key to move your
Address_-�
cursor - do not
No Andover
use - the retu , rn
key.
City/Town
2. System Owner:
Name
Address (if different from location)
City[Town
ivia,
—S.tate
F
State
Telephone
Zip.Code-
-REC-EIVED
JUN
TOWN OF NORTH ANDOVER
B. Pumping Record
1 . Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: El Cesspool(s) :E!r—Septic Tank El Tight Tank 0 Grease Trap
Other (describe):
4. Effluent Tee Filter present? El Yes M-1ho If yes, was it cleaned? E] Yes F� No
5. Condition of Syptem-
C&YL
6. ��stem Pumped.By:
cy� Ef c� 7
t4—a—me
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's PA-trQatment Plant, 20 So. Mill Bradfoi
SignaturV of �ecelving Facility
Vehicle License Number
Ma 01835
Date
Date
t5form4.doc- 03/06 \ I System Pumping Record - Page 1 of 1
07-26-12;17:41 01 19786888476 # 19
commonWealth. of MassachusetW
Title..'5 Officiat Inspection Form
SU Disposal System Form Not for Voluntary Assessments
3 Breckenr dge-Rd
Kenneth Diraffael
Owner Owner's Name
information is
required for every No Andover Me 01845 5112/2012
page, CIty/Town n
State Zip Code Date of Inspectlo
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.
Important: When
fillIng out forms A. General Information
on the computer.
use only the tab inspector,
key to move your-- -
cursor - do not John DiVincenzo
use the return Name of Inspector
key.
dr,-. _ftwart S�ptlq Service
Company Name
58 South Kimball
Company Address
Bradford Ma 01835
Cityrrown State Zip Code
978-372-7471 S113386
Telephone Nvmber Uc7nse -Number"-
B. Certification
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 funcfion and maintenance of on site
sewage disposal systems, I am a DEP approved system inspector pursuant to Section 15,340 of
Title 6 (310 CMR 15.000). The system,
0 Passes El Conditionally Passes El Falls
El Needs Further Evaluation by the Local Approving Authority
5/1212012
Date
The #stem inspector shall subM!t a copy of this Inspection report to the Approving Authority (Board
of Hi�alth 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,)f applicable, and the approving authority,
""This report only describes conditions at the time of inso6tion and under the conditions of use
at that time. This Inspection does not addriess how the system will perform in the future under
the same or different conditions of use.
t5ins , I Iito nuo s omew Inapedon Form! Subtufface, S�96 Qigpaml Systwn -Pagel of 0
07-26-12; 17:41 ; 19786888476 ;0 # 2/ 19
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
3 Breckenridge Rd
Property Address
Kenneth Diraffael
Owners Name
No Andover
Cityrrown
B. Certification (cont.)
Ma 01845 5/12/2012
State Zip Code Date of inspection
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes.,
1 have not found any information which indicates that any of the failure cHteria 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:
El 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 "yee, '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 -
El Y El N El ND (Explain below):
16iris - 11110 TIfle 5 Official Insposbon roteri; Subsurface 89"ge Dispasal $yztern - Page 2 of 17
07-26-12;17:41 ; 19786888476
0
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
B. Certification (cont.)
B) System Conditionally Passes (cont.),
5112/2012
6ate of inspectiorl.
# 3/ 19
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). -
3 Breckenfldge Rd
[I Y
Oroperty Address
[j ND (Explain below)�
Kenneth Diraffael
Owner
Owners Name
information Is
required for every '
No Andover Ma 01845
page.
�_Iiy_rrown State Zip Ooda
B. Certification (cont.)
B) System Conditionally Passes (cont.),
5112/2012
6ate of inspectiorl.
# 3/ 19
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). -
--- - ---------
- - — -----------------
F1 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):
E] broken pipe(s) are replaced El Y [:1 N 1-1 ND (Explain below):
El obstruction is removed Y L] N L] ND (Explain below):
— - - --------
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
16.303(l)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
El Cesspool or privy is within 50 feet of a surface water
El Cesspool or privy is withi n 50 feet of a bordering vegetated wetland or a salt marsh
MIM - 1 Ill D Title 5 Offtlal Imp2ation Fom: Subsurface Sewage Dloposel Systelp - ft9Q. 3 of 17
broken pipe(s) are replaced
[I Y
[I N
[j ND (Explain below)�
obstruction is removed
El Y
El N
El ND (Explain below):
El
distribution box is leveled or replaced
Ej Y
Ll IN
[I ND (Explain below),.
--- - ---------
- - — -----------------
F1 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):
E] broken pipe(s) are replaced El Y [:1 N 1-1 ND (Explain below):
El obstruction is removed Y L] N L] ND (Explain below):
— - - --------
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
16.303(l)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
El Cesspool or privy is within 50 feet of a surface water
El Cesspool or privy is withi n 50 feet of a bordering vegetated wetland or a salt marsh
MIM - 1 Ill D Title 5 Offtlal Imp2ation Fom: Subsurface Sewage Dloposel Systelp - ft9Q. 3 of 17
.07-26-12; 17:41 ; 19786888476 ; 0 # 4/ 19
Owner
information Is
required for every
page.
Commonwoalth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
3 Breckenridge Rd
Property Address
Kenneth Diraffael
--- — ----------- -- ---
Owner's Name
No Andoyer Ma 01845
Cityrrown state Zip Code
B. Certification (cont.)
Date of Inspection
2. System will fall 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:
El 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.
El The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply,
The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well",
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered, A copy of the analysis must
be attached to this form -
3. Other:
D) System Failure Criteria Applicable to All Systems,
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes
No
Lj
Z
Backup of sewage into facility or system component du e to oveNoaded or
clogged SAS or cesspool
El
0
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
Fj
F1
Liquid depth in cesspool is less than 6" below invert or available volume is less
than Yz day flow
t5jns - 1 ih 0
Title 5 Offthal Irispeclim F�: Subsurface Sewage Disposal System - Page 4 of 17
07-26-12; 17:41 ; 19786888476 ;0 # 5/ 19
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
3 Breckenridge Rd
Property Address
Kenneth Diraffael
Owner Owner's Name
Informdon is
required fbr every No Andover
page. Cityrrown
— ------------
Ma 01845 .5/12/2012
_i6ta Zp Code Date of Inspection
B. Certification (cont.)
Yes No
11
z
Required pumping more than 4 times in the last year NOT due to clogged or
0
obstructed pipe(,g), Number of times pumped:
11
Any portion of the SAS, cesspool or privy is below high ground water elevation.
E] M
Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
El M
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 60 feet of a private water supply well.
El El
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.]
EJ N The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd�
L] Z The system falls '. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure,
E) Large Systems, To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the
questions in Section D,
Yes
No
El
11
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
11
EJ
the system is located In a nitrogen sensitive area (Interim Wellhead Protection
Area — IWPA) or a mapped Zone I I 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
151na - I 1A 0 'rjus s Oftlel Inepeotlon Form: 17
07-26-12;17:41 19786888476 ;
0 0
!L� Commonwealth of Massachuseft
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
3 Breckenridoe Rd
Property Address
Owner Kenneth ------
information is wrier's Nam*
required for every No Andover 01846 5/12/2012
page. 6�rrown ' — State Zlp Code Date of Inspection
C. Checkfis-i
# 6/ 19
-1
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)i -- - ---- Number of bedrooms (actual): .4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 alod
AM - I illo 'ritiB 6 owiciai Indipadori Fotft Subduftoe Sewage Djapoaal SysteM , psgb 6 of 17
Pumping information was provided by the owner, occupant, or Board of Health
Were any of the system components pumped out in the previous tvvo weeks?
E El
Has the system received normal flows in the prexdous two week period?
El Z
Have large volumes of water been introduced to the system recently or as part of
this inspection?
[D E]
Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
M Fj
Was the facility or dwelling inspected for signs of Sewage back up?
Was the site inspected for signs of break out?
Were all system components, excluding the SAS, located on site?
E El
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?
Z El
Was the facility owner (and occupants if different from owner) provided with
information on the proper maintenance of Subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on. -
Existing information. For example, a plan at the Board of Health -
Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15,302(5))
D. System Information
Residential Flow Conditions:
Number of bedrooms (design)i -- - ---- Number of bedrooms (actual): .4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 alod
AM - I illo 'ritiB 6 owiciai Indipadori Fotft Subduftoe Sewage Djapoaal SysteM , psgb 6 of 17
07-26-12;17:41 ; 19786888476
0 0
#
7/ 19
�L� Commonwealth of Masrachusetts
lugTitle 5 Official Inspection Form
t Subsu rface Sewage Disposal System rorm Not for Voluntary Assessments
3 Breckenridqe Rd
property Addre5s
Kenneth Diraffael
Owner neer, Name
information is
required for every No Andover Ma .01846 5/12/2012
page, CltyfTown State Zip Code Date of Inspection
D. System Information
- -
- ------
Description:
— - - - --------
Number of current residents:
Does residence have a garbage grinder?
0
Yes M
No
Is laundry on a separate sewage system? [if yes separate inspection required]
0
Yes [D
No
Laundry system inspected?
Ll
Yes Ej
No
Seasonaluse?
0
Yes [0
No
Water meter readings, if available (last 2 years usage (gpd)):
.63 GPD
Detail:
Water meter readings
----- - -- —
- -----------
Sump pump'?
El
Yes E
No
Last date of occupancy'
Occupied
Date
Commercial/industrial Flow Conditions:
Type of Establishment:
— — --- - ----------
-
Design flow (based on 310 CM R 15.203): Gallons per day (gpd)
Basis of design flow (seats/persons/sqft, etc.):
Grease trap present?
Industrial waste holding tank present?
Non -sanitary waste discharged to the Title 5 system'?
Water meter readings, if available:
0 Yes El No
Lj Yes 0 No
0 Yes 0 No
tsim - I Mo Title, 5 Official Inspection Form: Mourfaw Sqwoga Disposal System 4 Page 7 of 17
07-26-12;17:41 ; 19786888476
0
Commonwealth of Massachusetts
FTitle 5 Official Inspection Form
t Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
3 Breckenridge Rd
Property Address
Kenneth Diraffael
Owner Owner's Name
Information Is
required for every No Andover Ma 01845
page, Cityrrown State Zip Code
D. System Information (cont.)
Last date of occupancy/use.-
Date
Other (describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection?
Andover Speitc,
5/12/2012
Date of Inspectlon
Z Yes 0 No
If yes, volume pumped: 1500 - — ---------
gallons
How was quantity pumped determined? Lape Measure
Reason for pumping.- Inspecttank
Type of System:
19 Septic tank, distribution box, soil absorption system
El Single cesspool
El Overflow cesspool
El PHVY
El Shared system (yes or no) (if yes, attach previous inspection records, if any)
L1 Innovative/Alternative technology, Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
0 Tight tank. Attach a copy of the DEP approval.
El Other (describe):
# 8/ 19
t6lr* - 11/10 711a 5 Official Inspeclim Form: SubAUffStS SeWa0a Disposal System - Page 8 Or 17
.07-26-12;17:41 ; 0 19786888476 ;0
Commonwealth of Massachusetts
Title 5 Official Inspection Form'
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
313reck enridoe Rd
Property Address
Kenneth Diraffael
Owner Owners Name
information Is
required for ovM No Andover
page. aR—row,n
Ma .01845
State Zip do—de
5/12/2012
Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
,23 years
Were sewage odors detected when arriving at the site?
Building Sewer (locate on site plan):
Depth below grade: 21
feet
Material of construction -
El cast iron [140 PVC E] other (explain):
Distance from private water supply well or suction line, foot
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan) -
Depth below grade:
Material of constructiom
0 concrete El metal
61,
feet
# 9/ 19
L1 Yes 0 No
El fiberglass El polyethylene [i other (explain)
It tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate)
Dimensions:
Sludge depth,
0 Yes [I No
t5ina - i Vi 0 Title 5 01ficial Inspeotion Form; Subsurfame Sawage Disposal System - Page 9 of 17
07-26-12;17:41 19786888476
0 0
Commonwealth of Massachusetilz
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
3 Breckenddge Rd
D. System Information (cont.)
Septic Tank (cont.)
01845 5/12/2012
Date of Inspecifo—n
Zip ode
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
29"
.P
5" __'
1411
# 10/ 19
How were dimensions determined? Tape Measure, Slugp,lLdRt___
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, Structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Both Baffles in good shape, No leakage, liquid level good
Grease Trap (locate on site plan)-,
Depth below grade,
Material of construction:
El concrete El metal
Dimensions:
Scum thickness
El fiberglass
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
t5ins - 1111D
feet
Lj polyethylene El other (explalq
Date
TIU95 Official Inspechm Form: Subdutface Sewage oloposa Systelp - p9gg I q of 17
Property Address
Kenneth Diraffael
Owner
Owner"s Name
information is
required for every
No Andover
page.
61—tyr—rown- State
D. System Information (cont.)
Septic Tank (cont.)
01845 5/12/2012
Date of Inspecifo—n
Zip ode
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
29"
.P
5" __'
1411
# 10/ 19
How were dimensions determined? Tape Measure, Slugp,lLdRt___
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, Structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Both Baffles in good shape, No leakage, liquid level good
Grease Trap (locate on site plan)-,
Depth below grade,
Material of construction:
El concrete El metal
Dimensions:
Scum thickness
El fiberglass
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
t5ins - 1111D
feet
Lj polyethylene El other (explalq
Date
TIU95 Official Inspechm Form: Subdutface Sewage oloposa Systelp - p9gg I q of 17
07-26-12;17:41 19786888476
0 0
Commonwealth Of Massachuseft
tur0 Title 5 Official Inspection Form
W $ubsurface Sewage Disposal System Form - Not for Voluntary Assessments
fzv
3 Brackenridge Rd
Property Address
Kenneth Diraffael
Owner Owner's Name
information is
required for every No Andover Ma 01845 5/1212012
page. CltylTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan),
Depth below grade: — --------
Material of construction:
El concrete El metal fiberglass polyethylene other (explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: El Yes 0 No
Alarm level: ------- Alarm in working order:
Date of last purnping: Date
Comments (condition of alarm and float switches, etc�):
D Yes L1 No
* Attach copy of current pumping contract (required). Is copy attached? 0 Yes D No
jltns - I I/10 Title 5 04fidal ln8PWl0nF0Mt: 8ut*Urrace Sewage Disp9sial Syrram. Pap i I of I?
.07-26-12;17:41 0 19786888476 0
<L
. N Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Ma 01845 6/1212012
State Zip Cod4o Date of Inspection
# 12/ 19
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.):
Dist, Box level, no solids carry ov r, no leakage._
Pump Chamber (locate on site plan):
Pumps in working order L] Yes R No
Alarms In working order: El Yes 0 No
Comments (note condition of pOmp chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins - 11/10 TWO 5 MUM Inspedon Form; Skibsurf2ca Smwaga Disposal System - Page 12 d 17
3 Breckenridge Rd
PropertyTd-d-ri�i—
Kenneth Diraffael
Owner
Ownees Name
information is
required for every
No Andover
page,
citytrown
D. System Information (cont.)
Ma 01845 6/1212012
State Zip Cod4o Date of Inspection
# 12/ 19
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.):
Dist, Box level, no solids carry ov r, no leakage._
Pump Chamber (locate on site plan):
Pumps in working order L] Yes R No
Alarms In working order: El Yes 0 No
Comments (note condition of pOmp chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins - 11/10 TWO 5 MUM Inspedon Form; Skibsurf2ca Smwaga Disposal System - Page 12 d 17
07-26-12;17:41
14
, _N Commonwealt
�IftTitle 5 C
, Subsurface Sewa
'%3� � Breckenridge Rd
Property Address
0 19786888476 0
h of Massachusetts
fficial Inspection Form
ge Disposal System rorFn - Not for Voluntary Assessments
Owner Owners Name —
information is
required for every No Andover Ma 01845 6/12/2012
page. Cftyrrown State Zip Code —
D. System Information (cont.) Uate of Inspection
Type:
# 13/ 19
El leaching pits
number:
El leaching chambers
number:
Ll leaching galleries
number:
leaching trenches
number, length: 3- 3 x 55,
leaching fields
number, dimensions: ---
El overflow cesspool
number:
innovativelalternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure,
level of ponding, damp soil, condition of
vegetation, etc,):
No Hydraulic failure no,ponding no damp soils
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 El Yes El No
Esing - 11110 _M16 5 01fidal Inapeefion Foffhx SubaUrfaOO SeWSOO DISPOSal SYMOM - Page 13 OVI 7
.07-26-12;17:41 ; 0 19786888476 ;0
!L\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
3 Breckenridge Rd
-�-roperty Address
Kenneth Diraffael
Owner Owner's Name
information is Kf A A
required for every W " WV01 Ma 018.45 5/12/2012
page. Cityrrown State Zip Code Data of inspection
# 14/ 19
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction: — - -------- --
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, conditon of vegetation,
etc.),
-----------
- - ----------
- - --------------
- ----- - -----
t5im - 11/10 Title 8 Offioial Inispection Fwm: Subtni4ave SepwaAb Disooilal Byatem - pag,6 14 of 17
.07-26-12;17:41 0 19786888476 ;0
Commonwealth of Massachusetts
Title 5 Official Inspection Form
5 5
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
3 Breckenridge Rd
Property Address
Kenneth Diraffael
Owner Owner's Name
information is
required for every No Andover
page, City/Town
Ma 01845
state Zip Code
5./12/2012
Data of Inspwlon
# 15/ 19
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:
El hand -sketch in the area below
Z drawing attached separately
TiVe 5 Official inspection rorm: Subsurfam Sawaae Disposal 8yatem - Palle 15 of 17
07-26-12;17:41
19786888476
COmmonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
3 Breckenridcle Rd
Property Address
Kenneth Diraffael
Owner Ownar's —Name
information is
required for every No Andover Ma 01846
page, City/Town -State —
D. System Information (cont.) Zip Code
5/12/2012
Date of inspection
Site Exam-,
Check Slope
Surface water
Check cellar
Shallow wells
Estimated depth to high ground water: W — — ---------
feet
Please indicate all methods used to determine the high ground water elevation -
Obtained from system design plans on record
If checked, date of design plan reviewed:
Date
L1 Observed site (abutting property/observation hole within 156 feet of SAS)
Checked with local Board of Health - explain:
Pulled files
0 Checked with local excavators, installers - (attach documentation)
11 Accessed USGS database - explain. -
You must describe how you established the high ground water elevation-.
Syst�m design plans drawn, by Hancock Survey
# 16/ 19
Before filing this Inspection Report please see Report Completenet.;s Checklist on next page.
(Sins . 11110 TINS 5 Offidal lnsp�fian Pon: tkWurface 3&wap Disposial Syglorn . pegfj a a, 17
07-26-12;17:41 ; 0 19786888476 "0 # 17/ 19
�L� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
3 Breckenridge Rd
Property Address
Kenneth Diraffael
Owner Owners Name
Information is
required for every No Andover Ma .01845 5/12/2012
PAge. Cityrrown state Zl�-Code Date of Inspe�t-lon'
E. Report Completeness Checklist
0 Inspection Summary: A, B, C, D, or E checked
Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
System Information — Estimated depth to high groundwater
0 Sketch of Sewage Disposal System either drawn on page 15 or attac;hed in separate file
(Sing - 11/10 Me 5 WOW Inspection Form: Subkud'kG0 Sewage DiBPOsal SYstcrl I PIGI 17 of 17
07-26-12; 17:41 0 19786888476 ;0 # 18/ 19
HANCOCK SURVEY ASSOCIATES, INC.,/.
- Y-WIZIP
235 NPWBURY STAI!ET 6 Mrm I NORTH T')ANVF,'RS. MA 01928 1508) 777-3050/ 283-2200 / 16 17) 615;P-9659
139 BEACH ROAD SAT�ISj3Lrry, MA ()195() VAX: (508) 774-781 a
MOW 462,3036 / 352-7591)
#3 675 FAX! (508) 49,2-5541
DecGmber 12, 1988
Boaxd of 1jealth
TMm Hall
120 Main Street
NO- And0ver, MA 01845
ATTN: 1W. Michael Graf
Re: Subsurfaca SGWage Dispo8al System
J-Ot 3, Wagdbugy qtXnet
Dear IvW. C�ra
.T hereby ceft'fy that the subJect syst8lu was installed as shown on t:he
enclosed as -built sketch.
Please Call if you I -ave any W(�sti -
01 ts.
Ve7 truly Yours,
Enclosure
cc: Mr. Xen DiRaffael
C/o Y8rmood Developtent Cb:Lp.
4 School Hill Lane
North Readixq, MA Ola64
HANCOCK SURVEY ASSO(Q INC.
235 Newbury Street (Route 1 North)
DANVERS, MASSACHUSETTS 01923
(617) 777-3050 (617) 662-9659
(617) 352-7590 (617) 283-2200
JOB
SHEET NO.
OF
CALCULATED BY DATE
CHECKED BY DATE
SCALE
304RD OP LOT
A'�PU �f4NYT j (L
WELL
A�L� '56PI-IC SYSTEAq
ITY.
�LAA) 51 6A-)
f!
Te
10 e[U, I OA-,) ZWIL-) H
PLO, L '5fP'rf 6 Si:5TCM W S -TO QATI OAJ
FINAL IVSp6-�-'Floo
U/3T (o - 5 \—a 7
AVDITIO)JAL- JA)5FbCl,(o�J5 (IpAtjy)
DIS/3Pef<o\j&D DA T -C --
RAL 16PPF16VAL
1245 -7�
-V-045S El F4 I L-
tOW'N OF NORTHANDOVER
1. �
/DA 1! SYS"I't-M PU MPIN-GiRECORL
STF 'Al
YS VFM OWIT ER & A' DRESS CX- I o tL
Ra ?,t'oa 4
,3 a reae-1) r, d, Rd -
x fv) 01016 vle4 Ina
QUANTI ry PumpEr,,:
DATE OF VIJMPIN(' �141W--- A
No. y E S.. Septic Vajik: NO_
NA, I t �RL OF S U' KVIC'E: ROUTIN
� )B S E R�'A H () NS
OOD CONDI HON FULLTO COVU,
HEAVY GRIE'ASF PAITLES IN PLA(J-,
ROO PS' LEACHFIELD RUNBACK
EXCESSIVE� SOLIDS FLOODED
S01-ADCARRYOVER. 011lfl? EXPLAIN
'�Ysfejll Pumpt'-d by
M F N
(,'ON I LN PS FRANSH-ARED
I RECtj�VED
AUG 0 9 2004
DEPA�fA;E—N�
06� ?W.,
y ll��,4�
�,�F
J -O "-�o c 14 A W�
40 Ir cio
IPIL
L
(§(c mt�j
P-KNILTI) -nil AROA'AsloW tl!ok",Aw Dlmsxs�- 3Nq
;cowum
out
J -*.bo Awk 41, -11WKI.
(--3tt� Trip t�j��?
lkg-qo) Ilkw. th-141 �ii i�=<- hm;, \mft fir.) po- Alum 'onfirru. I co "'u-N-Im. acw& �k d-w-Awai-I um
ACD%M�tIt"u.6bQ.)) . a.,, '111tv
O -L
ca lbul- �l
1-ilynkc lit 4raw",
Town of North dover
Health Dep&tment Date: e5�
Location:
(Indicate Address, if Residential, or Name of Business)
Check#:
lype of Permit or Licens : (Circle)
> Animal
$_
> Dumpster
$
> Food Service - Type._
> Funeral Directors
> Massage Establishment
> Massage Practice
> Offal (Septic) Hauler
$
> Recreational Camp
$
> SEPT[C PERMITS:
El Septic - Soil Testing
Lj Septic --Design Approval
��S �fic
Disposal Works Construction (DWO
5 4�11676
El Septic Disposal Works Installers (DWII)
> Sun tanning
> Swimming Pool
$
> Tobacco
> TrashlSolid Waste Hauler
> Well Construction
> OTHEM (Indicate)
864 i1eilth Agent Initials
White -Applicant Yellow -Health Pink -Treasurer
0 'TOWN OF NORTH ANDOVER *Tbf
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
400 OSGOOD STREET
NORTH ANDOVER, MASSACHUSETTS 01845
978.688.9540 — Phone
Susan Y. Sawyer, REHS/RS 978.688.9542 — FAX
Public Health Director healthdeptgtownofnorthandover.com e-mail
www.townofnorthandover.com - website
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE:
les—
LOCATION:
LICENSED INSTALLER NAME:
PLEASE PRIV
C___�SIGNATURE:
� CHECK ONE:
FULL SYSTEM REPAIR:
TELEPHONE#
COMPONENT REPAIR (indicate what parts):
NEW CONSTRUCTION:
r1k,
If NEA�� CONSTRUCTION, please attach the Foundation As -Built Plan.
S250.006"J.�5 Fee Attached? No
Project Manager Ob i n From Attach Yes No
Foundation As -Built? Yes No
Floor Plans9 es No
Approval of Health Agent
($250)
INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction of the septic system for the
property at .6", 001,I)Aa relative to the application
of 'n for plans by —and
dated with revisions dated
I understand the following obligations for management of this project:
I . As the installer I am obligated to obtain all permits and Board of Health approved plans prior
to performing any work on a site. I must have the approved plans and the permit on site
when any work is being done.
2. As the installer I must call for any and all inspections. If homeowner, contractor, project
manger, or any other person not associated with my company schedules an inspection and the
system is not ready then item three shall be applicable.
3. As the installer I am required to have the necessary work completed prior to the applicable
inspections as indicated below. I understand that requesting an inspection, without
completion of the items in accordance with Tile 5 and the Board of Health Regulations may
result in a $50.00 fine being levied against my company.
a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done
first. Installer must request the inspection but does not have to be present.
b) Final inspection – Engineer must first do their inspection for elevations, ties, etc. As -built or
verbal OK from engineer must be submitted to Board of Health, after which installer calls for
inspection time. Installer must be present for this inspection. With pump system all electrical
work must be ready and able to cause pump to work and alarm to function.
c) Final Grade – Installer must re q*uest inspection when all grading is complete. Does not have to be
on site.
4. As the installer I understand that only I may perform the work (other than simple excavation)
required to complete the installation of the system identified in the attached application for
installation. I further understand that work by others unlicensed to install septic*systems in
North Andover can constitute reasons for denial of the system, and/or revocation or
suspension of my license to operate in the Town of North Andover; significant fines to all
persons involved are also possible.
5. As the Installer I understand that I must be on site during the performance of the following
construction. steps:
a) Determination that the proper elevation of the excavation has been reached.
b) Inspection of the sand and stone to be used.
c) Final inspection by Board 'of Health staff or consultant.
d) Installation of tank, D -box, pipes, stone, vent, pump chamber, retaining wall and other
components.
6. As the installer I understand that I am solely responsible for the installation of the system as
per the approved plans. No instructions by the homeowner, general contractor, or any other
persons shall absolve me of this obligation.
Undersignefit'Lionsed Septic Installer
Date:
Disposal Forks ConstructiokPep(nit #
AORTN
6221
0
Town of North Andover
HEALTH DEPARTMENT
S" CHUS
CHECK #: jjj� DATE: z
-:74 r�()
LOCATION: '�3 c �_-e r) R; (A 12�:t
\j
H/O NAME:
CONTRACTOR NAME:
TyRe of Permit or License: (Check box)
0 Animal
$
0 Body Art Establishment
$
0 Body Art Practitioner
$
0 Dumpster
$
0 Food Service - Type:
$
0 Funeral Directors
$
0 Massage Establishment
$
0 Massage Practice
0 'Offal (Septic) Hauler
0 -.-Recreational Camp
$
0 Sun tanning
0. Swimming Pool
$
0 Tobacco
$
0 TrashlSolid Waste Hauler
$
0 Well Construction
$
SEPTIC Systems:
0 Septic - Soil Testing
$
0 Septic - Design Approval
$
0 Septic Disposal Works Construction (DWQ
$
13 Septic Disposal Works Installers (DWI)
0 Title 5 Inspector
$
Title 5 Report
$
0 Other (Indicate)
Ifea'Ith Agent Initials
pp n
White - A lica t ow -Yellow - Health Pink - Treasurer
4 ot