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Miscellaneous - 30 SUMMER STREET 4/30/2018 (3)
30 Summer Street 7:57L I i f 1 MAP ##. _ LOT #__ _...._. ^ ^- ..f PARCEL ## STREET CONSTRUCTION APPROVAL HAS PLAN REVIEW FEE DEEN PAID? YES NO PLAN APPROVAL: DATE-__-_-- . ' DESIGNER: 2,C',�-L�2-fJ� /1�U— � PLAN DI-1 CONDITIONS WATER SUPPLY: TO4JN WELL WELL PERMIT DRILLER WELL TESTS: CHEMICAL DA 1 E (11-1-"RUVED BAC i'ERIA I DO I E (WIPRUVED BACTER,, A l l DA 1 E (1P�PRUVED COMMENTS: FORM U APPROVAL: APPROVAL TO ISSUE Yk.S NO DATE ISSUED_ CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL "��- III0 OTHER YES NO ANY vn LANCE' NEEDED YES NO - INAL BOARD OF HEALTH APPROVAL: DA I'll: �p 1=+Y : �j� l�gz� EPTI.C_ S_Y_SZEM_jNSTR4L.A.1.I_Q.N 5xt � �� F � " IS THE INSTALLER LICENSED? YES NO td fy $at >4 i't \ TYPE OF CONSTRUCTION: NEW REPAIR ,NEW CONSTRUCTION: CERTIFIED PLOT PL_nN REVIEW YE.S IVO CONDITIONS OF APPROVAL -� tJ0 �s q Y (FROM FORM U) ISSUANCE OF DWC PERMIT YES NO >'DWC PERMIT NO. INSTALLER:�(.�J'�P �� .•BEGIN INSPECTION , YES N0: EXCAVATION INSPECTION: NEEDED — �! GlyZg-e fir. 1li41 ' :,�, ;t• - It' {lit PASSED !~'� BY __—_ _——-- ----- ---- t sit•, CONSTRUCTION INSPECTION: NEEDED e A5 BUILT PLAN SATISFACTORY: APPROVAL TO BACK _B FILL: DATE: _. Y BY - FINAL GRADING APPROVAL: DATE at FINAL CONSTRUCTION APPROVAL. DATE. BY Am I A F �. I ' �epj OL/ , 1 w. , j :'�•.. Cf NORT 1ti 6456 � + P Town of North Andover '�'••,,,,,.. �' HEALTH DEPARTMENT ACHU CHECK#: -r� DATE: JT LOCATION: H/O NAME: CONTRACTOR NAME: balegmz�s� Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ) Title 5 Report $S5 ❑ Other. (Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer o,,�o oT� 6456 ~ �.r 0 Town of North Andover ` HEALTH DEPARTMENT ,SSMC NUSt� CHECK#: ,�� DATE: '�D I I LOCATION: 30, LA m a J`( s�t- - H/O NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) 0 Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $Yv Title 5 Report $ � ❑ Other:(Indicate) $ V Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer Commonwealth of Massachusetts Title 5 Official Inspection Form RECEIVED Subsurface Sewage Disposal System Form-Not for Voluntary Assessme s MAR 216 2013 .r 30 Summer Street To{IUN OF NORTH Property Address MALTH DEPARTMENT / David Greenwood Owner Owner's Name information is required for North Andover ma 01845 3/12/2013 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be si!b� :---= o}F �� = _� ____. s�E _ _= L __ g .r_i:i, :. cad... �.. � .^_y._� _==gas a€ mea way. Please see completeness checklist at�the end of the form. Important: When filling out A. General Information forms on the computer,use. 1. Inspector: only the tab key to move your Neil James Bateson cursor-do not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name �. 111.Argilla Road Company Address .Andover MA 01810 Cityrrown State Zip Code 978-475-4786 S115 Telephone Number License Number B. Certification I certify that I have persona!!-inspected the sewage disposa! system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 3/12/2013 Inspect es tignature Date The system inspector sha!l submit a copy of this inspection report to the Ap-r^,An^Au+h^ri;l(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10, 000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspiaction and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r< 30 Summer Street Property Address David Greenwood Owner Owner's Name information is required for North Andover ma 01845 3/12/2013 every page. Citylrown State Zip Code Date of Inspection B. Ce Liiicatiwon (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Beard of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 30 Summer Street Property Address David Greenwood Owner Owner's Name information is required for North Andover ma 01845 3/12/2013 every page. Cityfrown State Zip Code Date of Inspection B. C+er,iiiivctt,ivi➢ (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): . ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):. ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pays un':ess Board of 14oalth aetermlones in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Summer Street Property Address David Greenwood Owner Owner's Name information is North Andover ma 01845 3/12/2013 required for every page. City/Town State Zip Code Date of Inspection er+a i•_- B. Certiiik;OLiE�i- i (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: The system has a septic tank and soil absorption system (SAS)and the SAS is within 10.0 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. El 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 ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins-11/10 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .•.r< 30 Summer Street Property Address David Greenwood Owner Owner's Name information is required for North Andover ma 01845 3/12/2013 every page.. City/Town State Zip Code Date of Inspection B. Cer-ttifi icatiol a (cont.) Yes No El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes If the Vell water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To 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 aither`;es"or"no" to each of the ful;owing, in audition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 30 Summer Street Property Address David Greenwood Owner Owner's Name information is required for North Andover ma 01845 3/12/2013 every page. CityrFown State Zip Code Date of Inspection C. Checkli*z Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? Z _ ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently oras part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as,N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up?, ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] C. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110,gpd x#of bedrooms): 440 t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Xj Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 30 Summer Street Property Address David Greenwood Owner Owners Name information is required for North Andover ma 01845 3/12/2013 every page. Cityrrown State Zip Code Date of Inspection +ee__Ys 1 tez ±s rc n D. System 1 iiiii iii"Givl� Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage Yes 9 ( Y 9 (gPd))� Detail: Sump pump? ❑ Yes Z No Last date of occupancy: Current Date CommerciallIndustrial Flow Conditions: Type of Est ar:_ II;—n en IL: Qutr�lir�����.. Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No li Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments A 30 Summer Street Property Address David Greenwood Owner Owner's Name information is required for North Andover ma 01845 3/12/2013 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: November 2012, owner Was system pumped as part of the inspection? ❑ Yes Z No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 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)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts .: Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "t 30 Summer Street Property Address David Greenwood Owner Owner's Name information is required for North Andover ma 01845 3/12/2013 every page. Cityrrown State Zip Code Date of Inspection D. SyStat ia- Ir orir,aLL c)n (cont.) Approximate age of all components, date installed (if known)and source of information: 21 years old, 12/11/1992, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.3 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): 4" PVC through wall to septic tank. 3" PVC in house, no leaks visible Septic Tank(locate on site plan): Depth below grade: 1.3 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x 5'x 4' Sludge depth: 0.. t5ins-11/10 Title 5 Official Inspection Form:Subsurface sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 30 Summer Street Property Address David Greenwood Owner Owner's Name information is required for North Andover ma 01845 3/12/2013 every page. Cityrrown State Zip Code Date of Inspection D. Systelvi In ori—k-kation (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 21" Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Tape Measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete Elmetal Elfiberglass ❑ polyethylene ❑ other(explain): Dimensions: i 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: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of.Massachusetts n. Title 5 Official Inspection Form F Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 30 Summer Street Property Address David Greenwood Owner Owner's Name information is required for North Andover ma 01845 3/12/2013. every page. Cityrrown State Zip Code Date of Inspection D. Systern. Infoll matlrOn (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.): i Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No I Alarm level: Alarm in working order: ❑ Yes F1 No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 30 Summer Street Property Address David Greenwood Owner Owner's Name information is required for North Andover ma 01845 3/12/2013 every page. Citylrown . State Zip Code Date of Inspection D. System, InlOiiilatiloncont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box level&distribution equal. Evidence of light carryover. No evidence of leakage Pump Chamber(locate on siteplan): in Pumps working order: P 9 ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): i Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M r 30 Summer Street Property Address David Greenwood Owner Owner's Name information is required for North Andover ma 01845 3/12/2013 every page. Cityrrown State Zip Code Date of Inspection D. Systein Infu r inativin (cont.) Type: ❑ leaching pits number:. ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2 trenches 35'long ❑ 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.): Soil ok. Vegetation ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 • Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 30 Summer Street Property Address David Greenwood Owner Owner's Name information is required for North Andover ma 01845 3/12/2013 every page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,. etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 .Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s: r 30 Summer Street Property Address David Greenwood Owner Owner's Name information is required for North Andover ma 01845 3/12/2013 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ®hand-sketch in the area below 0 drawing attached separately IK t ��L Twh1: a Alcor1 L-9t))= 14513`` 4L4 II Lf PXK 3 t5ins,11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r( 30 Summer Street Property Address David Greenwood Owner Owner's Name information is required for North Andover ma 01845 3/12/2013 every page. Citylrown State Zip Code Date of Inspection D. Systienri Information (cont.) Site Exam: Z Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 4 feet . Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 11/6/1976 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board,of Health -explain: Design plan j ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Test pit data on design plan Before fling this inspection Report, please see Deport Completeness Checklist on next page. I t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i 30 Summer Street Property Address David Greenwood Owner Owners Name information is required for North Andover ma 01845 3/12/2013 every page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file . i i i t5ins•11/10 Title 5 Official Inspection Foran:Subsurface Sewage Disposal System•Page 17 of 17 Town of North Andover Tax Map # 210-065.0-0065-0000.0 Parcel Id 14432 30 SUMMER STREET GREENWOOD, DAVID GARNI, KRISTEN 30 SUMMER STREET NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.25 Acres FY 2013 UB Mailino Index Name/Address Type Loan Number Active/Inact. From Until GREENWOOD,DAVID Payor GARNI,KRISTEN 30 SUMMER STREET NORTH ANDOVER,MA 01845 UB.Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 16147.0-30 SUMMER STREET Last Billing Date 1/3/2013 3160191 03 Cycle 03 Active UB Services Maint. Account No.3160191 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 72.20 /1 UB Meter Maintenance Account No. 3160191 Serial No Status Location Brand Type Size YTD Cons 32945236 a Active 00 b Badger w Water 0.63 0.63 348 Date Reading Code Consumption Posted Date Variance 3/6/2013 512 a Actual 20 5% 12/6/2012 492 a Actual 19 1/9/2013 -48% 9/7/2012 473 a Actual 37 10/15/2012 129% 6/7/2012 436 a Actual 16 7/16/2012 10% 3/8/2012 420 a Actual 15 4/14/2012 -13% 12/5/2011 405 a Actual 16 1/17/2012 -13% 9/9/2011 389 a Actual 21 10/13/2011 21% 6/2/2011 368 a Actual 16 7/20/2011 -10% 3/3/2011 352 a Actual 17 4/13/2011 -7% .12/6/2010 335 a Actual 19 1/12/2011 -12% 9/7/2010 316 a Actual 23 10/15/2010 28% 6/3/2010 293 a Actual 17 7/15/2010 -4% 3/4/2010 276 a Actual 17 4/14/2010 33% 12/7/2009 259 a Actual 14 1/12/2010 -29% 9/3/2009 245 a Actual 19 10/15/2009 46% 6/3/2009 226 a Actual 12 7/20/2009 -20% 3/10/2009 214 a Actual 17 4/29/2009 45% 12/4/2008 197 a Actual 11 1/20/2009 -33% 9/5/2008 186 a Actual 17 10/10/2008 -34% 6/4/2008 169 a Actual 25 7/16/2008 69% 3/6/2008 144 a Actual 15 4/11/2008 26% 12/6/2007 129 a Actual 11 1/22/2008 -69% 9/13/2007 118 a Actual 39 10/12/2007 101% 6/12/2007 79 a Actual 20 7/20/2007 38% 3/8/2007 59 a Actual 14 4/16/2007 12% 12/5/2006 45 a Actual 12 1/19/2007 -47% 9/7/2006 33 a Actual 22 10/20/2006 159% Commonwealth of Massachusetts IwI Ufl City/Town of System Pumping Record NOV 2O 2Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for us&by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Locatio . Le Righ nt of house eft/Right rear of house, Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address Cityrrown State Zip Code 2. System Owner. Name Address(if different from location) City/Town Stat e Telephone Number B. Pumping Record 1. Date of Pumping Date �QuantiPumped: Gallons 3. Type of system: EDCesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No " 5. Condition of System: COU(2k�b 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Loca' ere contents were disposed: G.L S. Lowell Waste Water Sign a Haule Date t5form4.doc•06103 System Pumping Record•Page 1 of 1 '�N Commonwealth of Massachusetts RIECENt6\ City/Town of System Pumping Record NOV '16 2010 M SVB Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Locatio : Left front of ho , right front of house, left side of house, right side of house, Left rear of house, righ rear of house, left side of building, right rear of building, under deck. Cityrrown State Zip Code 2. System Owner: Name Address(if different from location) City/Town State /\Cis �p� 1 Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No 5. Condition qTf S stem: Cj-�- I V1'- 6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Loca ' ere contents were disposed: L.S.D well Waste VV.Rter Signattge cN Hhuler Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts RECEIV City/Town of System Pumping Record MAY 2 6 2009 Form 4 TOWN OF NORTH ANDOVER r _._ HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form,check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Locatio : Left fron, left rear, left sid o hous Right front, right rear, right side of house. forms on the computer, use only the tab key Address to move your —3o �ov'&V\NQ. cursor-do not use the return Citylrown State Zip Code key. ___-- 2. System Owner: co( e, Name Address(if different from location) City(rown State �Zi�C Telephoner Number 77 B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: 8 Cesspool(s) Septic Tank Tight Tank Other(describe): 4. Effluent Tee Filter present? Yes / If yes,was it cleaned? Yes No 5. Condition of System: I / 6. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatio W h=r=tents were disposed: L.S.D Lowell Waste Water igna ure of H u r Date / t5form4.doc•06/03 System Pumping Record•Page 1 of 1 ,C\ Commonwealth of Massachusetts RECEOILDi City/Town of System Pumping Record SEP 5 2007 Form 4 TO EN OF W,-,R rH p.'r)0\ic, DEP has provided this form for use by local Boards of Health. Other forms%ala be u�,,but the information must be substantially the same as that provided here. Before using this form, cheek�mth your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When1. System L tion: forms o they � \ forms on the computer,use only the tab key Address to move your L) cursor-do not City/Town St Zip Code use the return key. 2. System Owner: -� Name 11 Address(if different from location) City/Town State !, dip C e Telephone Number ( G B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): i 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: O � n `� 6. System Prped BY: Name Vehicle License Number Company " 7. Locatio�er contents disposed: �'�T X11cl,,V 60(:Z5�� SignaturjfofAa Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Q Commonweafth'of Massachusetts �� �� ��! Executive Office of Environmental Affairs 10:7:L artment of EnviDepronmental Protection VIIU— rnr F.WeldGovernoTrudy-Cox Secretary ArW Paul Cellucci U.Governor David B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAI,r SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: J O S U VY tr\Q C ress of owner. Date of Inspection: Name of Inspector. (If different) � (✓ elep- Company Name,Ad rens and Thone Number. �ATESON ENTERPRISES, INC. TEL:(508)475-1474 Excavating-Water&Sewer Lines-Septic Systems&Pumping Service FAX:(508)475-5451 CERTIFICATION STATEMENT 111 Argilla Road . Andover,Mass.01810 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes _, Needs Further Evaluation By the Local Approving Authority Fails B Inspector's signature: Dater #V The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C,or Dc A) S PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.304. Any failure criteria not evaluated are indicated below. III SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes, no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal,cracked, structurally unsound,shows substantial infiltration or exfiltration, or tank failure is iatminent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Winter Street a Boston,Massachusetts o21o8 P FAX(617)556-1049 0 Telephone(617)292-5600 i,v Printed on Recycled Paper I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinued) Property Address 30U rn m 0—C 8k. WOCJv h 4v"LL)ar Owner. Mr, I JN 01 aS Date of Inspection: 3 _a l B)SYSTEM CONDITIONALLY PASSES (continued) _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed Cj FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. S) OTHER t (revised 11/03/95) 2 r. s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinued) Property Address: SU m Uh 4P C- Owner. (`_ �) Date of Inspection: 2 _ D) SYSTEM FAILS: -1 l I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a ampool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: _, 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) c The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 3D �cA.)'v% Me-,C— Owner. . "C' , Iv 1 LY��QS 1`C Ctnc, Date of inspection: Check if the follo ve been done: _Pump' information was requested of the owner,occupant,and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates d t period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As lana have been obtained and examined. Note if they are not available with N/A. The or dwelling was inspected for signs of sewage back-up. e oes not receive non-sanitary or industrial waste flow �esite, inspected for signs of breakout. =ysw 'components,excluding the Soil Absorption System, have been located on the site. it nk manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, nal of construction,dimensions, depth of liquid, depth of sludge, depth of scum. ' The size and location of the Soil Absorption System on the site has been determined based on existing information or _�app by son-intrusive methods. wner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. i t. (revised 11/03/95) 4 f SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C �+ SYSTEM INFORMATION Property Address: JU V%VvN G.'i— Owner. xY Date of Inspection: FLOW CONDITIONS RESIDENTIAL• Design flow: yyy gallons Number of bedrooms: I Number of current residents: .4 Garbage grinder ryes or no): NO Laundry connected to system(yes or no):y Seasonal use(yes or no): AIO Water meter readings, if available: as t�v X00 C'4�c'7.S = 64�.SGb 5�36�� S - /�7 •� /� Mo CO Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: _gallons/day Grease trap present: (yes or no)_ Industrial Waste Bolding Tank present: (yes or no),_ Non-sanitary waste discharged to the Title 5 system: (yes or no) Water meter readings, Y available: Last date of occupancy: OTHER(Describe) Inst date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: F System pumped as part of inspection: (yes or no4ies If yes,volume pumped: (YOO Rallons Reason for pumping: rlS fD�L TY.PE OF TEM tatWdistribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components, date installed(if known)and source of information: Sewage odors detected when arriving at the site: (yes or no) Mo (revised 11/03/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEMA INFORMATION(continued) Property Address: � A'1M V�QS" '<A- /V®� / Date of Inspection: SEPTIC TAKE- (locate on site plan) J/ Depth below grade: Ito Material of ooaatruction:_/concrete,_metal_FRP—other(explain) Dimensions: l0 X S X y K • 5 = /5 � t o°�S Sludge depth: I� Distance from top of sludge to bottom of outlet tee or baffle: as Scum thickness: S" Distance from top of scum to top of outlet tee or baffle: ' 3 Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pump' condition of inlet and outlet tees or baffles, depth of liq��}}d level in relation to outetin ,s �f�,inttegrity, e ' enceof leakage,etc. �'K S� '�-s���'vh rc i �Q-+ �.e, ©It• G�(3''f-+-P�"t—ch'�'�CS��-. �-1� I✓1 e c C 4 e 1 L2cl k-S4t:1 Q GREASE TRAP:Yeo (locate on site plan) Depth below grade: Material of construction: _concrete_metal_FRP—other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: e Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) (revised 11/03/95) 6 :. + SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 3Q SV M M P—V No vA-Nn A U An� �� of Inspection: — 'e?1-7 TIGHT OR HOLDING TANK N OVM'_ (locate on site plan) Depth below grade: Material of construction:_concrete_metal_FRP—other(explain) i Dimensions: OArwityl.- , gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee,condition of alarm and float switches;etc.) DISTRIBUTION BOX- (locate on site plan) Depth of liquid level above outlet invert: Comments: TAif 1 vel sgd�distribution is equal, evidence oLwhds carryover,evidence of leakage into or out of box,etc.) 1/ �✓ C� rh��2�x1 u�1I . �a�l� Cp_X OvP�A; JWCSot PUMP CHAMBER hOhe--q rq�.�►-�e� S`i Aex� (locate on site plan) v V Pumps in working order:(yes or no) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 �' E • • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C S1YSTEMp INFORMATION(oontinued) Property Address: 3Q Sv w.r�"^e?-q- S',• IV o(��-� � J�� Owner. Mme. c C.•\p(�S ��� an O Date of Inspection: . $OIL ABSORPTION SYSTEM (SAS): f (locate on site plan,if possible;excavation not required, but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries,number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: ,, } Cowmen . (note cpnditi soil, of ure, el o£vcdui :coi#i of v��egetation, tc.) � I �V l r CESSPOOLS: yam! (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(cesspool must be primped as part of inspection) C Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc. (revised 11/03/95) g • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) Property Address: yv`m ems— S4. M, Owner. K C._!v\O Date of Inspection: ��j Q�C7 3-a�-(?rj SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' Ik 3 v-eo), A- 3 _ a5X93 A--Eo 0_(3D)c =11-53fl DEPTH TO GROUNDWATER Depth to groundwater:__ `__feet s 3 e-�" xetlmetapproximation:of determination or approximation: C4e 1 � Ct n (revised 11/03/95) 9 BATESON ENTERPRISES INC Septic Systems—Excsysting—Water R Seger Lines iii APgtllb aobd - AndoveP;ilAntbtichUb�IN oitlld �5tie►416-0m TitlO 5 Inspection Report Property Addreas e 3 Jit ti2� - �JQ"tA, "uQ-4--. Owner: tjNCAA6 Date Of Inspection : My keport cohtaihed hereih ado" riot bonetitute s guarantee of fututo usage and the fuhctionality of the exibtihq eeptid by9tom, Sutrh report issued herewith is merely based upon my bbaerVationsi and I hereby disCisit►i any f0kthOf bpefatfbti Of your current septic systems s Neff d4 tateadn 13atel3dn Entprpri.s�t# ttl�r< P P. 10 Of io Town of North Andover, Massachusetts Form No.3 c� IOVTN� BOARD OF HEALTH s 'f' �,S•,•�'''<� DISPOSAL WORKS CONSTRUCTION PERMIT SACMUSF Applicant NAME ADDRESS TELEPHONE Site Location Permission is hereby granted to Construct K) or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN,BOARD OF HEALTH Fee D.W.C. No. (� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS J I a s DEPARTMENT OF ENVIRONMENTAL PROTECTION yy 'tiM see TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 30 SUMMER STREET ��r' P y NpR• NORTH ANDOVER, MA 01845 TG�`��pe.FD Owner's Name: ROSE LUCERA Owner's Address: 30 SUMMER STREET PUG 2 G NORTH ANDOVER, MA 01845 Date of Inspection: AUGUST 18, 2003 " Name of Inspector: (please print) JAMES WRIGHT " Company Name: R.-J—IN—SPECT!ONS,— INC. MailingAddress: nnTE ncr•nnD STREET 0 METHUEN MA 01844 Number: Telephone .` 978-681 -8759 CERTIFICATION STATEMENT Town of North Andover, Massachusetts Form No.3 • NORTH BOARD OF HEALTH Ot tao I"1�0 OL 19 • F A DISPOSAL WORKS CONSTRUCTION PERMIT • ��SSA�MUS� Applicant licant NAME ADDRESS TELEPHONE Site Location Permission is hereby granted to Construct ( ) or Repair (-+-an' Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN,BOARD OF HEALTH Fee D.W.C. No. Town of North Andover, Massachusetts Form No.3 t kOoTM BOARD OF HEALTH ° 6, ° OL 19- DISPOSAL 9 I SAL WORKS CONSTRUCTION PERMIT ,SSACNUs�t 1 , ,I• i Applicant 4% // / /O'�y��a�UL./ NAME ADDRESS TELEPHONE '�• Site Location_ is i Permission is hereby granted to Construct ( ) or Repair (4--�an Individual Soil Absorption I • jI Sewage Disposal System as shown on the Design Approval S.S. No. I • I' is i• CHAIRMAN,BOARD OF HEALTH f I• Fee ��� D.W.C. No. � ��— COMMONWEALTH OF MASSACHUSETTS _ EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS s DEPARTMENT OF ENVIRONMENTAL PROTECTION y -t,y SVe TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 30 SUMMER STREET do NORTH ANDOVER, MA 01845 dFT.0OFH �1V4 Owner's Name: ROSE LUCERA Owner's Address: 30 SUMMER STREET NORTH ANDOVER, MA 01845 pUG 2 Date of Inspection: AUGUST 18, 2003 '. i Name of Inspector: (please print) JAMES WRIGHT Company Name:— II a INSRECTIONS,— INC. Mailing Address: ONE; OCP'OOD STREET o � o enr.�L 1 mrIrTt�nT MA 01844 Telephone Number:TI 978-681 -8759 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: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature j Date: g I F 6 3 The system inspector al bmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 Page.2 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 30 SUMMER STREET NnRTN ANDQVFR MA 0 1 R 4 5 Owner: ROSE LUCERA Date of Inspection: 8/18/03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete.all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. Syst Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be:replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the 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: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 30 SUMMER STREET NORTH ANDOVER, MA 01845 Owner: ROSE T. RA Date of Inspection: g 11 A/wi 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. I. System will pass unless Board of Hyakltaetermines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning inn'ner which will protect public health,safety and the environment: _ Cesspool or pri is within 50 feet of a surface water _ Cesspool oy rivy 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 w' in a Zone I of a public water supply. — The system has a septic tank and SAS e SAS is within 50 feet of a private water supply well. — The system has a septic tank d SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply w/ethod used to determine distance "This system passes ' 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: 3 P ge4of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 30 SUMMER STRFFT NORTH ANDOVER,MA 01845 Owner: RneF I,�•E�� Date of Inspection: 8/i 8/0-3 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes N B p of sewage into facility or system component due to overloaded or clogged SAS or cesspool L,.,-Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or o ged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or _ �spool 'uid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow ✓" Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number o mes pumped "portion of the SAS,cesspool or privy is below high ground water elevation55' . Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. y portion of a cesspool or privy is within a Zone 1 of a public well. _ �portion of a cesspool or privy is within 50 feet of a private water supply well. ::- �y 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 5m provided that no other pp �p fa►lure criteria /��/� are triggered.A copy of the analysis must be attached to this form.] / " {/(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will b necessary ecess to correct ary 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 owing: (The following criteria apply to large systems.' dition to the criteria above) yes no — _ the system is within 4 eet of a surface drinking water supply the system is wi in 200 feet of a tributary to a surface drinking water supply — _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or.answered "yes"in Section D above the large system has failed. The owner or operator of any.large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the Y appropriate regional onal oftice of the Department. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 30 SUMMER STREET NORTH ANDOVER MA 01845 Owner: ROSE LU FRA Date of Inspection: 8/18103 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yew-No _ Pumping information was provided by the owner,occupant,or Board of Health 1 Were any of the system components pumped out in the previous two weeks —�l Has the system received normal flows in the previous two week period? _ f Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? _ Were all system components, excluding the SAS,located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition ofthe ba es or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no / 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)[3 10 CMR 15.302(3)(b)] 5 Page 6 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 3o SjjmmF.R STRFFT UORT14 ANDOVER . MA 01 845 Owner:—RINSE LUCERA Date of Inspection: 8/i8 T0 3 FLOW CONDITIONS RESIDENTIAL Zooms):Number of bedrooms(design): Number of bedrooms(actualDESIGN flow based on 310 CTU�;3 (for example: 110 gpd x#of Number of current residents: S Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):z (if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): %tld Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no):_ Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sg8,e Grease trap present(yes or n Industrial waste holding p se (ye o):— Non-sanitary waste discharged to e system(yes or no):— Water meter readings,if availa e: Last date of occupancy/use: OTHER(describe): , GENERAL INFORMATION Pumping Records - Source of information: Was system pumped as part of the inspection(yes or no):— If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYP F 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): Approxim e�eof all components,date ins lied(if known)and s urce of information: Were sewage odors detected,when arriving at the site(yes or no): e !V 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: -Ifl crTMMF CmRFFT NORTH ANDGVF , MA 01845 Owner: ROSE T.TTC RRA Date of Inspection: R-11 R/fl BUILDING SEWER(locate on site plan) Depth below grade: _ Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) Depth below grade: Material of construction: / 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: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: �? j Scum thickness: i // Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: ; How were dimensions determined: el z"- � . Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leak�e,etc.): GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum t p of outlet tee or baffle: Distance from bottom cum to bottom of outlet tee or baffle: Date of last pump' Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 30 SUMMER STREET NORTH ANDO�—MA 01845 Owner: ROSE LUGERA Date of Inspection: Q i, Qin 3 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: ✓concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/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: (if present must be opened)(locate on sitelan P ) 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.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes o ��i� Alarms in working order(Jyzs"0 0): Comments(note condition of purr cha er ondition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 30 SUMMER STREET NORTH ANDOVER MA 01845 Owner: ROSE LUCERA Date of Inspection: 8/18/o3 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leac � g galleries,number: eaching trenches,number,length: %5 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.): 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 ofcesspoQK Materials of construction: Indication of groundwate mflo (yes or no): Comments(note condi on 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 il,sig of ydraulic failure,level of ponding,condition of vegetation,-etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 30 SUMMER STREET NORTH ANDOVER, MA 01845 Owner: RQSR LUC'ERA Date of Inspection: 8.11 A/n-I 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. T I i i r i I \ C �� Parge 1 l of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 30 SUMMER STREET hIORTH ANDOVPR MA 01845 Owner: RnSF T,il('FRA Date of Inspection: R/1 8.10"i—_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water t Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: 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) _�cessed USGS database-explain: You must describe how you established the high ground water elevation: 11 ,¶ ', '.v". ...,.?�......,!r ?:t ..o d,....� -�!:?2...._'.�..iiu•r�..::� 14t..._....,Pi.fa �t...�:-a .. :r����: e. . .. Connect Edit Terminal Help WATER BILLING HISTORY 3160191-LUCERA, t: ROSE METER 1t1: 3160191 x -----•---------------- 30 SUMM R ST 8 CYCLE SERUICE PRIOR CURRENT USE WATER SEWER FEES TOTAL Microsoft Outlook 1 2000-"13 10/01/1999 572 620 48 - 131.04 0.08 0.90 131.04 2 2000-23 01/05/2000 620 645 25 68.25 9_00 0.00 68.25 : ,... 3 2000-33 93/27/2000 645 666 2157.33 5.09 0_00 S7.33 4 2080-43 06/42/2000 666 685 19 51_87 0.00 0.08 51.87 0 5 2001-13 09/11/2009 685 706 21 57.33 0.00 11.00 68-33 6 2001-23 12/11/2840 706 729 23 62.79 0.00 11.00 73.79 downksadhdl 7 2001-33 93/27/2801 729 757 28 76.44 0.60 11.00 87.44 8 2091-43 86/14/2901 757 773 16 43.68 0.00 11.09 54.68: 4 2002-13 88/31/2001 773 789 16 39.52 0_90 5.55 45.b7 10 2092-23 01/24/2892 789 319 21 51.87 0_00 5.55 57.42 0". V 11 2002-33 04/08/2002 810 848 3814.02 0.08 5.55 119_57 Govem32 12 2002-4.3 06/06/2002 048 863 15 37.05 0.00 5.55 42.60 ='aLNE-= 13 2883-13 09113f2002 863 883 28 47.60 0_00 5.97 53.57 ::;., 14 2003-23 12/17/2002 883 921 38 113.16 0.80 5.97 119 13 15 2903-33 03/11/2083 921 950 29 81.80 0.00 5.91 87-77 16 2003-43 0611112003 950 979 29 80.38 0.00 5.97 86.35 f KV5 T014M REUIEW CHOICE 4 or <ENTER> MORE HISTORY: I'r. work iP ' New Microsoltc Microsoft •;: �SCEI�1r01k. o! Nebriork My Briefcase uellnel Signup Heigh6orhood p ~ ..F ... O Start . Inba% Telaet ... ��Telnet... A4VRS �MV-RS.., �� �� 9:57ANl cu AO 7 M http://ma.water.usgs.gov/ctii-reit-coiid/daWO3-06.ixt SUMMARY OF GROUND-WATER LEVELS JUNE 2003 PROVISIONAL (NOTE: Wells with * also available in real-time at top of Ground-Water Data page) WELL L START NET CHANGE DEPARTURE WATER LEVEL T I YEAR IN MONTH IN ONE FROM BELOW LAND- 0 T OF YEAR MONTHLY SURFACE P H RECORD MEDIAN DATUM 0 0 (FEET) (FEET) (FEET) (FEET) DAY MASSACHUSETTS ACTON 158 * TS 1965 + 0.21 + 3.04 + 1.58 16.56 30 ANDOVER 462 VS 1968 + 0.30 + 1.23 + 0.42 14.32 27 ATTLEBORO 83 VS 1964 + 0.27 + 0.89 + 0.83 3.22 24 BARNSTABLE 230 FS 1957 + 0.11 + 2.16 + 1.14 22.23 24 BARNSTABLE 247 FS 1962 + 0.12 + 3.19 + 1.00 22.98 24 BECKET 12 TS 1986 + 0.98 + 0.85 + 1.75 2.19 >> 24 BILLERICA 363 HS 1962 + 0.15 + 0.84 0.84 8.26 26 BLANDF'ORD 9 VS 1986 + 0.57 - 0.25 + 1.08 1. 64 24 BOURNE 198 FS 1962 - 0.44 ----- + 0.42 32.34 26 BREWSTER 21 FS 1962 + 0. 62 + 2.81 - 0.04 9.75 24 BREWSTER 22 * FS 1962 - 0.02 + 2.49 + 0.38 29. 95 30 CHATHAM 138 FS 1962 - 0.22 + 2.85 + 1.73 21.78 24 CHESHIRE 2 HT 1951 + 0.58 + 0.60 + 2.95 2.71 24 CHICOPEE 95 TS 1984 - 0.01 + 1.41 - 0.75 21.60 23 COLRAIN 8 VS 1965 - 0.98 - 0.32 + 0.45 18.13 25 CONCORD 165 TS 1965 + 0.41 + 1.92 - 1. 69 42.30 26 CONCORD 167 TS 1965 + 0.24 + 2.56 + 0.86 6.39 26 CUMMINGTON 13 VS 1986 - 0.06 + 0.35 + 0.69 4.55 24 DEDHAM 231 ST 1965 + 0.50 + 2.30 + 2.92 4.90 26 DEERFIELD 44 VS 1965 + 0.07 + 0.06 + 0.27 2. 64 20 DOVER 10 TS 1965 + 0.06 + 0.88 + 0.74 31.75 26 DUXBURY 79 * VS 1965 - 0.17 + 0.43 + 1.04 7.67 > 30 DUXBURY 80 VR 1965 + 0.16 + 0.79 + 1.35 20.80 > 23 EAST BRIDGEWATER 30 HT 1958 + 1.40 + 3.75 + 5.37 3. 63 > 23 EDGARTOWN 52 VS 1976 + 0.00 + 3.75 + 1.80 15.57 25 FOXBOROUGH 3 TS 1965 + 0.47 + 1.01 + 1.02 17.95 23 FREETOWN 23 TS 1964 + 0.33 + 1.89 + 0.76 12.33 23 GEORGETOWN 168 VS 1965 - 0.71 + 0.26 + 0.42 4 .41 27 GRANBY 68 VS 1954 - 0.19 + 1.42 + 1.32 6.36 23 GRANVILLE 5 TS 1965 + 0.40 ----- + 0.08 31.91 24 GRANVILLE 6 SS 1965 + 2.31 + 2.27 + 2. 69 3.03 24 GREAT BARRINGTON 2 VT 1951 + 0. 90 + 1.74 + 2.84 8.74 24 HANSON 76 VS 1964 + 0.11 + 0.95 + 0.78 4.13 23 HARDWICK 1 TS 1965 + 0.76 + 2.30 + 2.82 11. 91 22 HARDWICK 31 TS 1984 - 3.81 - 2.72 - 2.31 13.44 < 20 HAVERHILL 23 TS 1960 - 0.93 + 0.79 + 0.90 10. 64 27 HAWLEY 8 ST 1986 + 0.01 + 0.37 + 1.07 3.11 24 LAKEVILLE 14 * TS 1964 + 0.88 + 5.00 + 2.77 11.47 30 LEXINGTON 104 VS 1965 - 0.41 + 0.20 + 1.26 1.75 26 MASHPEE 29 FS 1976 - 0.18 + 1.79 + 1.12 6.88 26 MIDDLEBOROUGH 82 VT 1965 + 0.44 + 2.86 + 4.82 5..45 24 MONTGOMERY 19 SS 1986 + 0.44 + 0.52 + 0.94 0. 66 25 NANTUCKET 228 FS 1976 - 0.28 + 2. 61 + 1.51 22.29 24 NEW BEDFORD 116 VS 1964 + 0.27 + 0.57 + 0.75 3.52 24 NEWBURY 27 VT 1965 - 0.75 + 0.28 + 2.24 5.20 27 SUMMARY OF GROUND-WATER WATER LEVELS JUNE . 2003 PROVISIONAL (NOTE: Wells with * also available in real-time at top of Ground-Water Data page) WELL L START NET CHANGE DEPARTURE WATER LEVEL 1 of 4 8/15/2003 2:06 PNl Town of North Andover N°RTN Obit`°O '•1'�'O Office of the Health Department Community Development and Services Division 27 Charles Street "' °+,• .�° ' North Andover,Massachusetts 01845 "ss�cHuSet Sandra Starr 978.688.9540-Phone Public Health Director 978.688.9542-Fax C77RTjFjCArIE OF COW(01- qJVCE As of: August 15, 2003 This is to cert that the indvidualsubsurface disposalsystem repaired(Xl — Full System by Todd(Bateson at 30 Summer Street North Andover, W q 01845 has 6een installed in accordance with the provisions of Titre v of the State Sanitary Code and with the North Andover Board of-7fearth regulations. The Issuance of this certificate shaft not 6e construed as a guarantee that the system wirr function satisfactorily. 3'1J� Sandra Starr Bu6ric Yfealth Director BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 TOWN OF NORTH ANDOVER BOARD OF HEALTH �. Location Permit # Food Service $ Retail Food $ I Limited Retail $ Seasonal $ Disposal Works Installers $ Disposal Works Construction//$ Soil Testing $ 7; Design Approval Permit $ Dumpster Permit $ Burial Permit $ i swimming Pool Permit $ x Animal Permit $ Recreational Camp Permit $ Well Construction Permit $ Funeral Directors Permit $ Massage Establishment License $ Massage Practice License $ Suntanning Establishment $ Offal/Trash Hauler $ j Other 7 �. � �; ( Health Agent V�hi.te - Applicant Yellow - Dept. Pink - Treasurer �= I PP P DATE INVOICE AMOUNT 53-7119/2113 BATESON ENTERPRISES, INC. 7 318 ANDOVER, MA. 01810 PH:(978)475-1474 FAX:(978)475-5451 PAY �v �a DOLLARS TIME - GROSS INCOME SOCSTATE W O DATE TO THE ORDER OF AMOUNT TAX .SEC.. TAX NET AMOUNT •D�SCRI'Wl'ION r s �4 J, n FIRST ESSEX BANK,F.S.B. LAWRENCE, MA 01840 11'0073 La 11, 1: 2113 ? 1L9LI: 58l,140L5441112,11 a� APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: F- CURRENT INSTALLER'S LICENSE# LOCATION: �U -S� �'►R F S 1 LICENSED INSTA ER: g A,QIVa SIGNATURE: TELEPHONE# CHECK ONE:/ REPAIR: C/ NEW CONSTRUCTION: IFE N W CONSTRUCTION PLEASE ATTACH FOUNDATION AS-BUILT. ry A-n-'r Admini rative Use Only $ 5-W Fee Attached? Yes No Foundation As-built? Yes A No Floor plans on file? YeNo Approval Date: 64 C� (do INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North.Andover licensed installer for the construction of the septic system for the property at �D mac-. -....—,.ea relative to the pplication of joo� l' 2S�r+idated S 3 for plans by and dated with revisions dated I understand the following obligations for management of this project: 1. As the installer I am obligated to 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 two shall be applicable. 2. 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 request inspection when all grading is complete. Does not have to be on site. 3. As the installer I understand that persons or companies not associated with my company may not perform the work required by my company to complete the installation of the system j 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 in the Town of North Andover plus significant fines to all persons involved. 4. 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. d) Installation of tank; D-box, pipes, stone, vent, pump chamber, retaining wall and other components. 5. 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. ation.g UndersigneVicensed Septic Installer �Date: Disposal Works Construction Permit# ' i i I I 1 FORM 4• S�r STEM PUMPING RECORD SEPTIC & DRAIN SERVICE 107 FOREST STREET: MIDDLETON, MA 01949 (978) 774-2772 COMMONWEALTH OF MASSACHUSETTS A , MASSACHUSETTS SYSTEM PUMPING RECORD SYSTEM OWNER: SYSTEM LOCATION: �� �i,� '�,;i• VVI�� t" i �._......_. � ���� I 1) e'(o U t'✓` DATE OF PUMPING: (�/ ' UANTITY PUMPED: GALLONS CESSPOOL.: NO EYES F-] SEPTIC TANK: NO 0 YES 0 SYSTEM PUMPED BY: CURRIER SEPTIC <& DRAIN SERVICE CONTENTS TRANSFERRED TO: DATE: ( � �� / INSPECTOR: ��r lril NORSE ENVIRONMENTAL SERVICES, INC. s, 3 Pondview Place Tyngsboro, Mass. 01879 TEL.649-9932 J CERTIFICATION OF SUBSURFACE SEWAGE DISPOSAL SYSTEM INSTALLATION I , Steven Eriksen, A registered Sanitarian duly licensed by the Commonwealth of Massachusetts, License Number 886, and working as an employee for Norse Environmental Services, Inc. certifythat I have reviewed the information given to me b g Y the owner concerning the installation of the subsurface sewage disposal system at the referenced location and hereby certify that to the best of my knowledge and belief the information provided indicates that the work has been performed and completed in general accordance with the plans approved by the local Board of Health. No site inspections were performed by this office . Furthermore, all information provided appears to comply with the provisions of Title 5 of the Massachusetts Environmental Code ( 310 CMR 15. 00) and all applicable local regulations . LOT NUMBER: 3 STREET ADDRESS : Summer Street TOWN: North Andover, Ma . DATE: 12-11-92 ak"V l l{ CSF SIGNATURE: __ -- STEVEN r ERIKSEN T �; Sr4d1, AS-BUILT SURVEY Lot 3 Summer Street No. Andover, Ma. 4- 1" = 201 12-11-92 r Owner : James Graphoni Installer : Tim Melvin Location Elevation Top Foundation. . . . . .101. 0 I LOT 3 Tank Inlet. . . . . . . . . .96 . 89 l► Tank Outlet. . . . . . . . .96.71 �.Z 5 AC D-Box Inlet . . . . . . . . .96 . 49 D-Box Outlet. . . . . . . .96 . 29 Beg. Trench #1. . . . . .96 . 09 it if #2 . . . . . .96.09 End Trench #1. . . . . .95.91 it it #2 . . . . . .95.92 Bot. Trench #1 .. . . . .93 .91 it a #2 . . . . . . 93.92 tJcr� % �X . .p�E�►�1C� �5 -ZVA?IOQS 8y A. SHA 4-7 ± Tµ-3 O T!a-Z �2 (sect:ic�'� J= �=►ar�.�,E �d:En; �`k:aYs°. lJ M Z>L.0e_4TISIJ of SYS+Ew, TAkF_►J =Rohn All r=NVjp,,WeF ENVIRONEERS ,I�� �-��r'�, .� F�,ti`��►7,°N �A�v ALFRED A. SHABOO, P.E. P.O. Box 516,160 Pleasant Street, North Andover, MA 01845 • (508) 683-3893 CE2T/FY i yA7 /N� LoT 3 _ c��s�� ��w�>✓ c�M��Y W,rN Tc 2::�?N,N-% 73Y-Z qws MA Alyc--v � �u��r . �FFSEl-S �awN HeE • � T� Gl-E �� T L L.�aNS7�P.UcT�'2> 'S C// r . ST kW �o ► q-?�t — q 2' -f rn loo . c, b - TO sA � r � (o GREATER LOWELL MLS LAND FORM LIST NO. Lcr3 I /LS A PRICE $90,000 ZONED Residaltial f ' ` LOT SIZE 1.25± Ac Front: 150 ./'• J Depth: �c 380± Town: 14. Andove.r Addross: Simmer Street Direction: From center V. miles east- on Salem, right on Summer, 200yds on 1 .f1 OwrMr- I<J.J.-by Phone: 1'mc: P)// Id�:Illl:; �1I— IIII�.IIk�1 IIEIMAIIKS: Rold Sur: AsL)lka.LL Ass'd: 105,000 _ Build your dream house on this Tax Rt.: 1.25 acre lot located in one of Tax S: 960.75 North Andover's most desirable Paved Street: Yes locations. The land was tested Water Front: No and had all approvals in 1977. Cleared: MOSLI At Old data still on file. Must be Wooded: ltrretested and approved. Electric: Streeetet Gas: No Water: At Street Sewerage: Private Septic Realtor: CcnLury 21. I IeriLac e Rcal Es talc code No.: 46001 Phone: 692-6331 Reprosentative: Barry Gifford Plwne: 692-1931 Professional Fre: 3 %L s 3 % Book:. 1295 Page: 413 i PLAN REVIEW CHECKLIST ADDRESS 3 �✓/ ENGINEER L11 GENERAL 3 COPIES STAMP l/ LOCUSy� SCALE �— CONTOURS - PROFILE v SECTION !/ BENCHMARK L-' ELEVATIONS SOIL & PERC INFO WETS. DISCLAIMER WELLS & WETLANDS WATERSHED DISTRICT DRIVEWAY [/ WATER LINE r/ DRAINS �,zt►ns RESERVE AREA SCH40 SLOPE SEPTIC TANK MIN 1500G. . 17 INVERT DROP (// GARB. GRINDER(+200% EDF) 25' TO CELLAR MANHOLE TO GRADE V-' ELEV GW 04- D-BOX # OUTLETS `dL FIRST 2' LEVEL STATEMENT INLET glo •�Z OUTLET= 4:��'(2" OR . 17 FT) LEACHING 100' TO WETLANDS (// 100' TO WELLS 325' TO SURFACE H2O SUPP 35' TO FND & INTRCPTR DRAINS 4' TO S.H.GW_z 2% SLOPE L— 4' PERM. SOIL BELOW FACILITY L`� MIN 12" COVER FILL? if above natural elevation; 101if below) . TRENCHES MIN 660 2 ✓�' SLOPE (min . 005 or 6"/1001 ) ,cf >3 ' COVER? - VENT SIDEWALL DIST. 2X EFF. W OR D (MIN 61 ) e/ IS RESERVE BETWEEN TRENCHES? IN FILL? f/ MUST BE 10MIN. BOT 145 X LDNG Off ' 2+ SIDE ;O X LDNG = TOT (; � (L x W x #) (G/ft ) (DxLx2x#) ►� '�Ml�iliiiiiliMErliiiiii!'��,:7iiiiii. Q'i®i►� •. i:T■CiCC:ZCC�iCC�iC'iCCOC�`�' k ii■�iiiiiiisiiiiiiilri]iiii��i iiiiii�ii■irMiiiiiitJli�ii�:�liii� �� iit�Jn`Jiiidii■iiiiLdiiiG�iii!*�iii iiiiiiLiiiiiiLJ►�iiiiii�7ii�i I , Town of North Andover,,Massachusetts Form No. 1 NORTH BOARD OF HEALTH oZ q�O 19 ` APPLICATION FOR SITE TESTING/INSPECTION ACHUs���h Applicant �� 7Y► NAME ADDRESS TELEPHONE Site Location -�� Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time Du CHAIRMAN,BOARD OF HEALTH Fee I � ' Test No. ` S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. wi� �u 1u r u! b u �.b u ._, it r• n d!�o'!'i n. . . .. ..._ �r.�:�.R...1....�i� � — - - - -- t �. �. NORTI.j o o 0 town 0 Andover Ila N19An ` over,vi L TO or .h Mass., BOARD OF HEALTH PERMIT I LD V.41... , .. .��1. w.�r. r THIS CERTIFIES THAT. . ... .... .�.. ..... aBUIL DING INSPECTOR doom G) has permission to erect �r�.� �. �.> �f � � Rough- Chimney/,?— ou h- 9 j Chimney/,?— ��•/ � �� � ��"� to be occupied as.A .. ' � provided that the person accepting this permit shall in every respect conform to the terms of the application on filen LU BING 1 SPECTOR this office,and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of o �' Buildings in the Town of North Andover. PERMIT FOR FOUNDATION ONLY <� _ REMI AIM BY PARA, 114A-L B.C. Final VIOLATION of the Zoning or Building Regulations Voids this Permit. I.- f-, iI- R( S I N jJ PAID 0 ELECT 1 A NSPECTOR Rough� �^ UNLESS CONSTRUCTION STARTS Service � A Final PERMIT FOR FRAME/6UILDING ••• ` a/ BUILDING INSPECTOR GAS INSPECTOR DATE: FEE PAIt1 Permit Required to Occupy Building Rough Final Display in a Conspicuous Place on the Premises NIA FIRt DEPT. Do Not Remove Burner STREET No Lathingto Be Done Until Inspected and Approved b ��REET De 1�- P PP Y Smoke Det. l ee c0l#a Building Inspector AS-BUILT CHECK LIST and FINAL INSPECTION Proposed Elevations As-Built Elevation House 97-61 Tank IN 9 6 11 / 9� 8 q Tank OUT 96. 24g 96, 7/ D-box IN (9&/--• /Z 9�. "�!y D-box OUT 9,!5- '9'7 9� Trench Inverts Line 1 � 97- 5 � 0 Line 2 9�•��._ C/S, 9� Line 3 Line 4 Bottom of Exc. 913- 8 q3 Stone OK? D-box checked? Pipes cemented? Z--' FORDS U TOWN OF NORTH ANDOVER LOT RELEASE FO1k1 SUBDIVISION ASSESSORS MAP SUBDIVISION LOT(S) PERMANENT ADDRESS (ASSIGNED BY D.P.W. STREET APPLICANT PHONE DATE OF APPLICATION TOWN USE BELOW THIS LINE PLANNING BO • DATE APPROVED 77-4b TOW PLANNER DATE REJECTED CONSERVATION COkDIISSION DATE APPROVED __77 12A z1- CONSERVATION ADMIN. DATE REJECTED BOARD OF HEALTH DATE APPROVED HEALTH SANITARIAN DATE REJECTED DEPARTMENT OF PUBLIC WORKS DRIVEWAY PERMIT SEWER/WATER CONNECTIONS FIRE DEPT. 17 r��1�,,�iJ`:A'S��.�N �/�'^ ��✓ � `1,/'x/'7 RECEIVED BY BUILDING INSPECTION DATE This form shall be signed by the agents of the Planning and Health Boards, the Conservation Commission prior to the issuance of any building permits for the subject lot. This f J orm shall not releive the applicant from the compliance of any applicable Town requirement or Bylaw. t Town of North Andover, Massachusetts Form Dia s ` NOR*N BOARD OF HEALTH p G., o� 19 S _l G S•. o? ,Yl(�1 � °• ~ Y�'49 DESIGN APPROVAL FOR 14 SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant_ '_ hA'U Test No Site.1-ocation, (lit 3.' S-,- F Reference Plans and Specs tt Sl�b� (e93- 389.3 GINEER DESIGN DATE t Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. �. CHAIRMAN,BOARD OF HEALTH Fee Site System Permit No. 52-7 DATE_ 902. Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEE (�,��• PERMIT # ate 'J DATE RECEIVED /��q� APPLICANT ASSESSOR'S MAP ADDRESS PARCEL # LOT # ENGINEER - 171�1/d/7P�i�5. 227 c STREET ADDRESS 6 F3-3,N3 PLAN DATE REVISION DATE CONDITIONS OF APPROVAL: APPROVED DISAPPROVED /9"4 a) A%9 ©F EXcAVAT/oN To 51/44cJ41 oti -F.4jW REVIEW CONTINUED SHEET OF Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH 3�0. Z0 ' 19 ,1 p oaj- A * - } APPLICATION FOR SITE TESTING/INSPECTION SSACHUS���S Applicant GY1 NAME ADDRESS TELEPHONE Site Location Szo w _ - Engineer SvIla'60 NAME ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee Test No. � S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Form 4 -- System Pumping Record Commonwealth of Massachusetss Massachusetts System Pumping Record System Owner System Location ERICK LUCERA ERICK 30 SUM-,R ST 30 SUMMER STREET NORTH ANWVJER, MA 01845-4815 NORTH ANDOVER, MA 01845 (978) 683-2467 (978) 683-2467 l0SE F Type: Emergency Routine El Cesspool: W Yes Septic tank: IVo Yes Date of Pumping: d Quantify Pumped: Gallons System Pumped By: Wind River Enviromnentai, LLC Permit#: Contents transferred to: Contents Disposed at: Date: Pumper Signature: Condition of System/Other Comments ov Dep Approved frog► - 12/07/95 gip! �, Date..:).-. .. ... .. ... ..... 1 - i 40R 4VOL TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ,. "S C" This certifies that . . . . . . . . . . . . . . . . . . has permission for gas installation . .G fc�!. `��.5. . . . . . . . . . . . . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . U . .S ": .'.`:. . . . . . . . . . . . . . .. North Andover, Mass. Fee. v..: . . . Lic. No.. .. . . . . . . . .. . . . . . " GAS INSPECTOR Check# / 5 3 ;) 42 <'\ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO ®O GASFITTING (Print or Type) Mass. Date Wo Permit# 3 � q ?- Building Location -:;-; " JU M Ownees,Name LU664A Type of Occupancyf L�F.etT /(t�CJ New Renovation p Replacement ❑ Plans Submftted4.. Yes13 No [❑ N Y W 4; 4 v 2 A N Q N s o W J N � O V is Z = O }' ILI C 0. c : < cc C W z < S IC I W C W F' W F- C W O O .> U. t- J 1�r Wsr Z < 6 ¢ f �- m m z 0 z 0 to = < lid > W z. < Q < tu � 3 ds O v �' > G a H O SUB—BSMT. BASEMENT 1 ST FLOOR 2ND FLOOR 3RD FLOOR ' 4TH FLOOR STH FLOOR 8TH FLOOR 7TH FLOOR 8TH 'FLOOR Installing Company Name YANKEE GAS Check one: Cettiticate Address 140 SOUTH MAIN STREET Corporation 1 0 3 C MIDDLETON, MA 01949 G Partnership Business Telephone 978-774-2760 ❑ Firm/Co. Name of Ucensed Plumber or Gas Fitter WILLIAM R. HARRIS INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes X3 No ❑ If you have checked yes, please Indicate the type coverage by checking the appropriate box A liability insurance policy RX Other type of Indemnity❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit appllcation waives this requirement. Check one: Signature of Owner or Owner s Agent Owner❑ Agent❑ I hereby certify that all of the details and information I have submitted(or entered)in above application area and accurate to best of my knowledge and that all plumbing work and Installations performed under the permit Issued for Uri ap tics iia with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the r taws. t3y T of Ucense: Plumber Ngnature Of-Lkvd—O-Mumber or Gas iter Title fgGasfitter 3785 aster Ucense Number City/Town Joumeyman C