Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Miscellaneous - 31 SUGARCANE LANE 4/30/2018
31 Sugarcane Lane -= 210/106.A-0242-0000.0 i 4� :do- +_•Z, -i`''` ty ,f Y,,. A#n '�ri{ '� °sF - S,' �• !`.F�Qh.-�".P ' v. -d "`ply.# ,`�y7y r�"4t-�f' � s''� ' cam.e1�.�Ali + *'��F '� d 4;xar'$ ? t'a�^• �5f�,r�w`r u e d•�f' AS,..� f ':Fc� 1r 'r5T g'��- d'"'� . ✓'�♦v.".:y ` �,¢♦ ry[• cY� ''a.zCa °'r' s'r,�" a �yTSt'jrNiijn' �4x':.^ .$a �{,,,Z�,:,+'nt•f.\ S .` t sA�` y y .`.s r .r `p'1h 4 �'� x i L eyes. .ry.u4 t 3' re• "r,t.0 r.. � .fir .' _".a.-,v1N, qft sr C.w S .F,i't'. { ay,..c,r•.. s Y , 1 f.t.,p� �`2�, ��v`''�y�x�rr�r'Cr,r "'p'��, irt�,`'" r`'�' �4'''�a`S�s�i`t��f.fr.♦'r�u�ak�-'�{�S �a'r �5 Y-_ ��,•.Zyp')4`�i ♦ ♦ t ':. r iY i `ham, r• !'§r '�;'l.t'rY,a6,w,�&•�tx:.?1tr'e Vii;��ryq; S i,4'str"'"�' ,x,, `?'_ t ,`� rc ' rt ����4f MAP # rl 19 t a,-i. ^��fr' 1'S3`!?�s.�` .,, ra:'.1 S r 4�x vea,4 s-h etz a 1. � �,,,� '�`i� �x "".•^t����I r y y _ .F, uV 'T_Jr azs,3f•��* Ye�zi :`�`;�' `� r�T� .��`4"'"♦• zr t ?VSs a`"ai5y x Yr)Y� 'r sY srT��"a�r'�rk �s".a J t ,.,+° t. 4' i.. k +r ' ' ,� r" •`S C S u d -4 r' i�• ,* ''„ n r. d /'W' > , t 1 PARCEL # ?" ♦ T*L� z ,x STREET f��; G L�A/Y� 1 5�'At�:u,� ��.� {P?'fit+.,�'��{ 3 'r f :-c t :S1 i axt d �•f t .4�,.�. �� tit.-4' ., ; � w�� , J 1 t s} :• 2 } r,r , irS ;k�Q�fi1�L�M�+I_6{1• n�G�IOeH6 r 1 y. F Cyd Xr%kv,' .'tyr>• P"<•,.' i• -A l r .k �'� �� r'F= _,. 1 17`r ,4+ sr qi i r .• t PLAN REVIEW ,FEE BEEN PAID? '`T NO 1 � t I' � "` •.T. .y r S ,..t}`:�3 �` ^.-r aY �i?.,n.` �r�sc��''i '- - '.. t, r •ia t d:.rt fn�.F{ s',�i Vin...,; - , t • r` �'",• PLANA rs ' DATE s � - , "' ARP. BY 1 _a A.p�J '�1�•♦9c SrrEY�'_� } ; a '�_a Xrk Txt' y t .h .� � n DESIGNER a T PLAN DATE,I el 4 h'S F r r:,.;, r .: 1 .�. ..1r a - rY i -r>'! }♦a ' - t. „, -, 1 `CONDITIONS ���I�, } � ,� } -r'" h r i� A t 4�! �SF^"��+I'�.�'i=�?�YG�`e it i"-` �' ; d •f y�?_J t3t lS�.��'�,•-.F� �``i�it d"�;! t� .; - - , �.�:1 '� 4't• 't r a-Z ♦k,t`7 ;t,r.;t/3,�4`.�.: r5r }y. xz�d.`,(C.y ^4 g "tSS''. , � ' k'•x d U T.l t 1v Y'%.y. 1 adc'.+t Y S�} i i c}>�r�,y.Y.q L e♦; :�s �1 _�♦ • � •♦ ., WATER SUPPLY:` 'I 1 i S y` :,.i �f.i• Yy�/«' ��F:;'i S t 1� ,`"`•s,.'K tS�f �a.,'s �F.: f l `+ � ..:, yam:. _ WELL PERMIT s WELL TESTS CHEMICAL ,' , DATE APPROVED v ♦? �r` BA FERIA I z DATE APPROVED__•__�___� rBACTERIA I` r DATE APPROVED ` COMMENTS.: r _ o FORM U APPROVALa APPROVAL TO ISSUE YE NO DATE .ISSUED eYj� L� _ -_ COND IT IONS a FINAL APPROVALa ALL°PERMITS PAID YE NO +WELL. CONSTRUCTION APPROVAL , NO SEPTIC SYSTEM CONSTRUCTION .APPROVAL-C— ES NO :OTHER YES NO ' ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: BY:� iS'KK.s- 4 i^IMg--n� ` , -- :{iii r-mrj-"v.' -,-.I'.t{3• m f-',W rf.'t'• K'h�.�,y� r,v, it :�.G.A ll . '.{ l�Yk4_ ,i3`t1 J�4'r.�k.. 'S}',`+ 'r, t.` 1 Y. �. ��51i`�t:� "'l, t* ...tc Rr.'•EI Y.'r ry uifFvfY'.>�,##;; ,q.*t '..i=Fvf �kc -'�'�3r yc,% I ';2 f� ,f 7k:-'x,� ,,,. yt4tN.r1l�.t r f('r�..4�fa D, zg i q�„ I:.�F,{ ttj. n,' + .vS J�k. F}h" s.v ;' 7`�.L J�`.s' °% �' r`At- Ztll a�'�i.:% '1. ."�,{ e + l I., '. yP311�•:>���1 .Y -�a'�., si� { ��• � ,i 'A{, 4.'9 ', '�'-`" I 1 `, #a .�..�„�f,cgtie ir��'i,,.,,��s. ... + 3kx�{k-7 :•ye''.{,a +fin.": � xt�t rrt .. , teW4�ibI .ryF... �,Z ` � ,�+{r4}�„�jv�,, t.'.. �,.�{*r ,:�.' { ,, "`[ ,��" `i '4:i;i ��..{{�r'71M de`tk a T ,x.+yS `ufr i<Jr t^„A• ,s t•° -_{.9k , v ;k.�-t t k t c,`�`I tX' f: t ^Rig,,[� Y i e r ,,,{ }iY .4'_19..1"r t�,, a N at g *.,.t ,Jc� t K",:+. �r..k 9�' 't t a a t 1. t ,' ,� <t s ,� ,�:4+ky",,p7J}F�C7t{>s y,k�gY 'A J,.�1i.`'wfi-ak ''�&'..✓3€wF, '. t. ,s - 4 r a 1. s.^; is,n "Syy...k`"•J ° E"„+. J nl v,. --: h q;D t{' 'At te?'kA 't'xS+nu�'iy a ,", >rt'c1 Y'� ;',,,,.:p t. EPT G SQL IEM�.N�I 4_44_tl[�N r `k ''�:�' �w � ..>{ ` ` �x R.' ".� 1x--,. '£�?J,.V,,t.l !t' h: M r"-4�'{a';s'.4 i 'mix'.ay;, 1 . a. '�t•. IH i F gq t.'`"i's.. �;� s, :qp , , .. _ ,y,'XF. .4.-�R �t 1.? n a r.Ni s h. ;2"` T?ss"4YL'Y', 3_'r,}q�9 L,i .Syr "'fi. # !`'E tkn {r. j.tt c a - r,:. i r , .-;d':.s t3 't s K Y r. tII 1�� t� a17 ! �e3 :' ?.I,� ,3, ,;pr, .. Xa} <,,# n r } j tai + k ti r 4 {�4f t' a r c k .s t ,• �- -j 'THE ;INSTALLER LICENSED? ` �I �? t ,. �yk r t ' ` pI �, ,by YE NO,� �r 3�r 7 c e� kT',. �o-�k f» " i I F t 7t }t aty l��+� ,,, {� fitq� k i t !' f,..v.;..,.,,'cr•Lay; } �vf qr } 1 •. , ,*, ?�,..f rc,e y,_�k�T 't{ iT de'.:.-1��"r P„�F'r.$ Y'c 4; rc..i rC.,73t k`'a. J{; rK�*' '1•.(` i :''' ..1.-_�y -r'i t 2 , r 3k�'cCsv yc ; s, ,.:td' 'y . )�a_s._�r`4 i�; -e='± :i:.?,�Fisa. �-E a•.. x ti".14 ti ',bu sr�..: 's� L ,, . � r S I t ' 'Es,ze.,` `i1> k ~ t•. - • }yJ-.i"A s #.� 4 jai ;y. k ' x 4. fs .t' ,w 'i� } , J _ ,:�, 4` TYPE' OF_ CONSTRUCTION , ' r .t�`•a_ .. i ,,,, , -` N w REPAIR `s «`ter ''t t�;4 4" 3� "u rs a 1-' t- j ., {. 3 t:?t J W, i k, t c; t�11 .-3 r; ,,1 "§,',pp; U Ar t kS t, ': 3: t t r 5t:`�i '"y�'F, „��' Ery�.n yri.,Y. a t1. _.• `� ...'- „{^ l' �r'y..t'y',S ::a$:rr' �y�<'t(.>i1 •;!'°X'Y.k �' .rY `7.'..! t _ z; � a&'NEW CONSTRUCTION. CERTIFIED PLOT.�.PLAN,lREVIEW EYES N0 �7 '. I al - i t - nL t D xy ct, art ti �. `^ ,,} r- 3 f t' - ,-,? ''� :CONDITIONS :OF APPROVAL sae` ' T YES NO ! rr 1 i sd is Y " y Mfr v 3 y r,, `�Y Il ifs.f ai q ae3 �2Y.: t r:,;- i;ti 7i.., E. ; r -..�,rr aJX�,Sz"t` t-r }.'� r r 111, I r ,da� t,rdk K, .mt,t 1 , aY.+. , n''r jt y`, 4 A S �`"5Yf-+�. �,t i „�,? S ': f t.�.,- 7 �, n NN ��.a§ t � , �;f ,ts ', ,' (FROM FORtM� U)r. ���t ,„� #� ,r, �`� 2 ,� . + -J. ..�:.h�,t -{,s+'t 5w{'^'E't'x, S c`ve'sF6�Fn� :: :icer '; '' Rt!�f'' ; ,15 #`~ a<`t': s' .,w,a �4 ,M"S{'i i.. _}.a ,. y F-'.. s .1. ` ,. �"j, '14 -a�.q J-;Y,,*"`�R;,v "'A", Z '" ._--� ,vi�t_yi Y;,?r ^I,x r'� ,,, ...,�� xa�.N� "'. kt xr(' :r- h t ,t..•, , r M v >,i t"IT rc inyd', .#� -i 9 '.i: : ,n' 'k.l. Y C K $� sa ,( ➢F . y'fx J i., '- `� ISSUANCE OF DWC 'PERMIT `?�� 'fj (<p$�} .'.-„_p,� ,}ty�'�r'r>�,y� H� Yi x YES N0 z .lt• k r k�' q - >r p iC..a { s;.. y.J"idr ��:'ttt �-.•;{ '{� ?„,�'S"`K}S tS , Tn ; S<..y",x :.,. y -: 'J k '�-Ott, ryt t n J T €e,� } tr.4 7�S-`'14: } 1, .fit. {`�a 4' �J4 x t,`�t-9 yr Y�A� r•#o;,.f. s°�•' C`r p. i.,. + , fi df�gtf"1{+ .r. Y .. '3A.l.r..:' (s r�' a 1, s t f'-�Y. Z'_;fb', k Rr i; Z7 it:: { 'v �t '; * r ,� W r" zxant 'T K • I r ; DWC ' PERMiT -N0. ®r ��} . ,2� � ;�, �INSTALLER. '! J/i' r .tv' �" '� 1"a?';'� i f t 1 K 8 F; .a^ '. y{y ,+ rr .rf�'�,#5 t Y' - v'- '. I },� .•C k',f w. J' F mcr .r' t t it t a F;t`i -.} � S Z4,"- s ,''�, s J;r, a'i i F` FJ.: S}s 'C`R I�'.R, ! F to P s It -9 T{' w 24 �.,,,p{,,JJ'^ w-jrg {.>". d �T l tL� �.*t `i i�E` t-yi ft Y;� \i t d F }" .. M q f { a ,15 1* x ys fz^e }Sf r;�3;....,;<. S .:, !.:r`." , r F f , 'f , 'a cam.K-+,a;y4 til <, s :.n 7 `r `i 6'-tEGIN 'INSPECTION a tK L YE NO: '' ,�+ a 7 . a ." u a 4J,r,.,,r+7:t-ary 'c' >x� 3. r' � § r+i Y` �,i, K,.c ,S ,,-4+ rNr r -a 7 >- .; ' }, f i,± Y ..y., �}-} t,p.;?..:vj,+.Y d,i..,tr +fl� .. t'7�- .r' vi}-. .� a: ,,,r €. - I , X -o� EXCAVATION INSRECTION• = r NEEDED: `'�� "'` ' i J t x �'T. r xy r c a a c `�s r l rs.,i. is �*« a '�^v s st b r y>s � > ,.i da{ n r ._ u r st a k. :.ta -, J xK✓ 7•t" r "S,. F y t.`c�'x a t ^`'i` arc ux, c `d'F'2�tF d�'4-•:'em " t f ' t s.� ''t m °�' ''a ' n n g �,,,. !t u +. s..- a ..-4.2, ,, �prs• rc '� t r .y�'.. ` - Lia t Y �'f' 'w+d :,zJ a { Y, ;� ys 5 ,3 r r tk• v �n `^ A {v �{. J "4Pr ', R vs�:..Ci'1 t { F } �.,ts}t j, i.a'' 7J 1� i>Y r �;., ( M1 rF v<4 a .t, r ,. f ` !-. #t e + J 'a, _ xgfx tY,, ,i A- :sar-x+t -.� t.i. :' r ar.'., t.l�ii �t off,.*,{ .:.'t S(.rw' to ,'�i P _ r. t.lv r. y t t h r,. - - rxr,^r i.1r:a Y/'' �r Y' tY t 7:. y k -x.:S.X k'Ets :.Yfty s rL.i'#a LS' �'• Se �M�t.,�'*vs a t:, vC ,Lt::2 .,z'. L>_ 'T }'F t+7y ,y r{ t t sf\ ..� q '.t n xji. )s 3z [e' ,{^. Y - v {. .. 4' v I'-' �`$`' ' ' °..n".*-Y, .." i dot n.`.'X' �y,. :..,q C "yid-' x u .r ' +ate �"c" .� Sp .. �tr�y'' j vizi, , .«� .s t { a 3 , ::"ti t,��1'.�';., ;-' t r�"i.. L. ,t.tr.v s c r i s s,q r :a ) - x.£�i Yt,S 1 y,{i Jt}n.w�i �, ti • S s i• ;. J a r,., �4'2j' PASSED R,-I ,.. , ..`i Y _'{f. e .:1 s`-G i.,; .tt�_ xBY r+l�- d Sts'.+rt.J ., ,#r ?n ('{, y;': J :}z 4, :ct>,Y°.3 Ys Y!• rryK r .4 ,i'1s't -_ � �}a Z ,�e.. ". . t-,t.,s- 'M*k ST�Y;",:FAy'°ii. , '.f.`y"W ;x 11�w,tL.'ih. a _ .l' tis! ,N4, � � el 1 r `i'Si. + , "� 'CONSTRUCTION INSPECTION11 : � NEEDEDa ' } {J � F -"a` r•:..'`„, 3b £i Nr K"t y'�.'+".ryt�_�,,_''__c"k.� � £t,;t',.3;: u , e1->q.. F a�44. s',iq.�^ �- �a,,,1J y.",:,:g: 1.., . ;._f ;1,a i ..; . a F }k k a sf-e, baa ' ,` >.t" YF{vy{ 1 ,.i'i �,h ..f➢ k ,,5. 4 !, -? t ' !l i.Yry h.'V x,9 r,{ . . -S}.2 .�d ,F`, u _,r 3 K F t•*f ff ",.��4 -'X 1 ,4ryCY 'F w..,,tt . Ft 'l�+Yst r r* t�a�' �.1,','{ t 't tit•G tf f a j). 3 4 . K ver - F e �,.'e��'� �.,tr s<s y i-Y"v j< t.: �k i s t„ n *rs••- n r�'- {c fs-.: 1k' i -°•_ ,k ,�, .,, ,�„ g } ry-, ' i - ;Y 'Z ° ?�It rti-a tY-" +'.. ' rr $ 'N. t, a if e_,: k +t.7 s FS Lk s-,� r u •• y 6 , •7' v�{.YCW"nj�t k 4 tr {.f t -. t 't sy s yat Y r F �+ z x F s S kA` c xr. pr t %, v3Trry2 s� ?�EE. t t. + 7 c. R"rzi './`X,p' j..x{ `S,. ':"( cd i;:' r fh r _ - r •�,t Y.. ,t ,T;+ -* ' ' s.V _` vK�s 7� S* .� .1 z e etS r-:$i 3 94 4 t` t i'{ py :;�.1 I t- -.:1 `7. i eFrw-, S A}, L1- ti_"} i It/ 4 i A t f .� e ^'b'C .at-.4d'Y,.?q' j�4 t sr r•"r}- X -.. e. + I v ?. S- ) "t L n }j h ,"47� t{ J {;.'. l .d w" 1 s }I x '{-'.ik fF..p 7. Y ''I - 4 i s f<f+s s Wil '. ¢t.Y :.+,.t,; h.. -r,,L; 'j,.1 '� a , a'4 .14. ,J t} n^..{gyp,s a tv`5� ,.>t'I• 'T - t l 51�.�"" .. ^e e V J,, i -c:.5k f '.'�' t,�`"` Y-r. ;, ' ,`x' (� .Y,k' >. - ',c, , J'. m n _ x 1 11 r t c . ,w t+ pt sJt,v' ,,.,`- F S J ',3 ..y t S^t. ... : " ;;,x4'Ss =s��, °rS= '& `} w', `. J. i y� },7 . ,, 7 "� � , AS BUILT 2PyLAN SATISFACTORY: ��, YES:' =t Sit •y #-.N t, a�+. t 9';. £ � '^'r /-f 3 ♦ -_t Y y t t7 :, 1 C.`a a b { 11 1. 'r tf t 4i-§. t , t �..i" 9 as c5 k 1.L a e 1: su t .s '� i -c -? {sem G Z.i. q.L- , ,F i•. ..r.; `' 3 ,{� ".:t '� ,,,{:,f ;w 5 .- - .t.tn`z•.{ ti .•'?a'a.. J ra e ! �I .+ s t Jf 2 °u c X i,zr4 F� atl� � F. ' 11 . APPROVAL. TO BACKFILL: DATE: Y - i� � ,� r a}jL�1� ,i - f{ f t�'. J i sM - '� .7'_. y n '- 3,f y`}' 1 ft' S. Y,,,t�:.;k . ! r �, t b 2{r „, si e t"_;` , t,;-`,3� - i ..:., ,v x .a `t °_ yt' t ,J .�-IFINALGRADING APPROVAL: DATE B_Y ' 1 - 7N s~ :8: r.J L.ya. ,, .. -t. +. .rY r. `+ .7, - } t J..I YY ` 5 •� £..4 y{ s 1- t �`-,_._.:+. ,§,+ ' , _ s .1 .i }j t. k �t7{ r` ':.a;"'n ,T,s. r -, • r fi 'y to DATE• (o � BY e .FINAL? CONSTRUCTION APPROVAL. �, , - 2 e ,tc s I..' I {'`' �,. ?I r a e s c t r, ` N. s fr.. r -, - ).'* u t J/1.1I�.i } a a s t .,e I:! , 1. # ,� i l-is r a3 .{ 4 -� , r'�,' 7 >,R,! r'F�L.; * 1. - a.•- `w rri{1{ -} t a f tl x - I- �.. , `a' f Csp ''. _J a r +I i 1., �' r ,�6s x ' �., 5 q { X7 t .v..Cr i Y y ' -~ y e tr1. {° Ak Y, ? K 1 M - x } 'u + s T ,3 hM. i i t N"..� .y° a__ t, , �,,y � r:. r 5tR x y £ W SJ�' :. ,,`4 isr3 'J ..•e.,r ..:, ` zT f _. i s „f,-'' r h_ x.?t' -•2i ,.' .r 44� t11.11" t' .r.. a?t , _t t r -y* i ��3tb'� r - r4'- l t`,c ',.�, t{ .{r {max .\ r 4-. 'tt fr. .. ,,. J.:i y�u..> t '-,,�qy fN> Fa _ _ + 6,k cv,�k Asi .ri... t 1 t t r + iLL ,1] t ;i 3. 5 $' d.4 41 i J;j,,1�F7 ty {R ,�41'i+_ j) r ;�t'7 yr >-f� f"-.,i )f ➢ .. t t '}lz •'�s+:.. hl , '" r "Z Y {.r` '., i< r k l.7,, p f�6 i_ s"i ;� ;,.tY-•,�4 ,;-a J v r� f- .f w p, t i` �'�,Cpa ';n �' s x . ism t _a e r.. T t t• . e },�r:Nr `i+r a u+.. ar: , ,! #, _ 1. i 3<) a tf.. 5 L.s i pal a� 5-' Sx�/ „f = X1''%. h - c . k , J 'r J i g 4 . t, e:_ ° '+, y. it p ; v a i + I ` jj L.i 4 4 t.f` �: rk t - J f ry ,* , e'. k s a ,S 7 -,,. 1. ; X '< {�.a r, Y F 4 I ', e - q t .t ry a 'k,-ars > o- J •',v 'k t v 1 ., n .. ! - . +... . .. ., . :. ;{ . Commonwealth of Massachusetts N W Title 5 Official Inspection Form v Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 31 Sugarcane Lane Property Address Gary Colello Owner Owner's Name information is required for every North Andover MA 01845 3/23/2017 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information �� ��® C .1%4 so filling out forms on the computer, c� use only the tab1. Ins eCtor: G key to move your cursor do not p Neil James Bateson use the return key. Name of Inspector Bateson Enterprises Inc. ! ` N r� Company Name 111 Argilla Road Company Address Andover MA 01810 Cityrrown State Zip Code 978-475-4786 , SI-15 Telephone Number j License 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 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 ❑ N d Further Ev luation by the Local Approving Authority f 3/23/2017 Inspec or' SignatI66 Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer; if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use ! at that time.This inspection does not address how.the system will perform in the future under the same or different conditions of use. i I t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form j Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 31 Sugarcane Lane Property Address Gary Colello Owner Owner's Name information is required for every North Andover MA 01845 3/23/2017 page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: After permit from B.O.H., install new septic tank, risers cover on inlet& outlet covers, new d-box with riser cover, inspection from B.O.H., septic system now passes Title 5 Inspection. 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. 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.cloc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form t _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments µM 31 Sugarcane Lane Property Address Gary Colello Owner Owner's Name information is required for every North Andover MA 01845 3/23/2017 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 ❑ drawing attached separately o /4 .g — ' E J� Ott t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I i : Commonwealth of Massachusetts City/Town of . h. W System Pumping.Record Form 4 yt� DEP has provided this form for use by local Boards of Health. Other forms maybe'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 forrh they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility. Information 1. System Location: Le �ght- i'ont , Left/Right rear of house, Left/right side of house, Left/ Right side of building, ilding, Left/Right rear of building, Under deck Address City/Town State Zip Code 2. System Owner. cz)(� Name' l �( Address(if different from location) City/Town ' Stater Zip Code f `7/14 -3D27 Telephone Number .B. Pumping Record 1. Date of Pumping gate / 2. Quantity Pumped: Gallons 3. Type-of.system: ❑ Cesspool(s) a<eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes LSO If yes, was it cleaned? ❑ Yes ❑ Na i 5. Condition of System: ct a Jf IIT 6: System Pumped By: Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents-were disposed: - .GLS: Lowell Waste Water '1Y QN. Sign a c I f HaulDate t5formCdoc•06/03 System Pumping Record•Page 1 of 1 : Commonwealth of Massachusetts _ Cityffown of . SYstem Pumping.Record Form 4 ilk DEP has provided this form for use-by local Boards of Health.Other forms maybe 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 I. System Local tio Le 'g fro t of ikildirig, Left J Right rear of house, Left/right side of house, LeftRight side of buil Ing, Left/ ron Left/Right rear of building, Under deck Address Citylrown State - Zip Code 2. System Owner. Name' Address(f different from location) citylrown Code F Telephone Number 1J .B. Pumping Record 1. Date of Pumping gate 2. Quantity Pumped: Gallons i 3. Type-of system: ❑ Cesspool(s) M-43 �cTank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes o If yes,was it cleaned? ❑ Yes ❑ No, 5. Condition of System: A ,� \a 6: System Pumped By.- Nell. y:Neil.Bateson F5821 Name Vehicle license Number Bateson Enterprises Inc- Company ncCompany 7. Lo ' Fwi ere contents-were disposed: 4signe Lowell Waste Water WUDate f i 06=4.doe-06/03 System Pumping Record•Page 1 of 1 :4L Commonwealth of Massachusetts _ City/Town of . System Pumping.Record Foran 4 DEP has provided this form for use by local Boards of Health. Other forms may be'used,but the information-must be substantially the same as that provided here. Before using.this form,check with your local Board of Health to determine the form they use.The.System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility. Information 1. System Location: Left/Right front of house, Leff/R► ht rear of house eft/right side of house, Left Right side of building, Left/Right front of building, Left/Right rear o building, Under deck . Address City/rown State Zip Code 2. System Owner. Name' Address(if different from location) Cityrrown State P Zip Code ; Telephone Number ' i .B. Pumping Record 1. Date of Pumping �— 2. QuantiPumped: �` �✓ Date p Gallons i 3. Type-of system. ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes If yes,was it cleaned? ❑ Yes ❑ No ' 5. Condition of System: 6: System Pumped By: Neil.Bateson - F5821 Name Vehicle License Number Bateson Enterprises Inc' Company 7. LocatioDiFhece contents-were disposed: CLS, Lowell Waste Water Signk4e qt HaulerU Date ` t5form4.doc•06/03 System Pumping Record•Page 1 of 1 �J S�T2T`EIIj646 77'70d PUBLIC HEALTH DEPARTMENT Town of North Andover Community and Economic Development Division CERTIFICATE OF. COMPLIANCE As of: March 23, 2017 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: D-Box & Tank Repair of an On-Site Sewage Disposal System By: Bateson Enterprises, Inc. At: 31 Sugarcane Lane Map 106.A Lot 242 North Andover, MA 01845 Th ance of this ce cat hall not be c trued as a guarantee that the system will function satisfactorily. Michele Grant Public Health Agent 120 Main St.,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web www.northandoverma.gov �A°Ra'TED ASN North Andover Health Department (ommunity and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 31 Sugarcane Lane MAP: 106.A LOT: 242 INSTALLER: Bateson DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: 3-23-2017 - DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ® Bottom of tank hole has 6" stone base ® Weep hole plugged ® 1500 gallon tank has been installed H-10 loading ® Monolithic tank construction ® Water tightness of tank has been achieved by visual testing ® Inlet tee installed, centered under access port ® Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ® Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Watertightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROLPANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX ® Installed on stable stone base ® H-20 D-Box ❑ Inlet tee (if pumped or >0.08'/foot) ® Hydraulic cement around inlet & outlets ® Observed even distribution ® Speed levelers provided (not required) ® Schedule 40 PVC Pipe Comments: i , i ,' .� � �1� � r �-~t�-��. �-ef -�. + � Commonwealth of Massachusetts Map-Block-Lot 106.A0242 ----------------------- BOARD OF HEALTH Permit No North Andover BHP-20 17-033----- ---ossa - 8 � + P.I. FEE F.1. $175.00 ----------------------- DISPOSAL WORKS CONISTRUCTION PERMIT Permission is hereby granted Bn atesoEnt - --------------------------------------------------------------------------------------------------- to(Repair)an Individual Sewage Disposal System. at No -----3SUGARCANE LANE 1----------------------------------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP-2017-033 ated March 20,2017 ------------ _! -COP- ----------------- Issued On:Mar-20-2017 BOARD OF HEALTH s � Application for Septic Disposal System 3-0.0 -J'7 TODAY'S DATE Construction Permit - TOWN OF NORTH ANDOVER, MA 01845 $ ir 425 001-Comp n-Full `ent Application is hereby made for a permit to: FI:Construct a new on-site sewage disposal system* ❑Repair or replace an existing.on-site sewage disposal system* a0eeair or,replace an existing system component—What? RZ k C(.. ao)c A. Facility Information Address or Lot# citylrown i4,4 RECEIVED /'JA 2:*TYPE OF SEPTIC SYSTEM*: M A R 2 0 2017 ➢ ❑Pump cavity(choose one) *"if pump system,attach copy of electrical permit to applications*' TOWN OF NORTH ANDOVER ➢ (Conventional System (pipe and stone system) HEALTH DEPARTMENT ➢ ❑Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to install_this type of system_) ❑Pressure Distribution S.A.S.(No D-Box) ➢ ❑Pressure Dosed(D-Box Present)S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No It yes, does plan specify make and model of filter? YES=(no further info. needed) NO-=(installer must specify brand of filter before DWC issuance) W Aatis the Mabe? W Aat is the Moda'E 2. Owner Information Mame 3 J Suc�.�r��e 1�.• -- Address(if different from above) City/Town State Zip Code Telephone Number 3. Installer Information Name Name of Cori or (4 ( iFRffi'ON ENTERPRISES,INC Address �— I Aft!©OVER, MA 01810 Cityrrown State Zip Code k-/ y F'l "'70.3 Telephone Number(Cell Phone#if possible please) 4. Desulner Information Name Name of Company Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 .,, T , App ica#ion..for Septic fig -�v . ,. —� TODAY S DATE Construction Pe.rrrtit $:250 00 T Full Repair �,s4w�► ORT14 ANDOVIBI MA :01.845 _;Sazs.00.-Com.Ponent . _ PAGE 2 OF 2 A. Facility-Information continued.... s. Type•of Buifding:, Residential Dwelling or E]Commercial B. Agreement The underslgned agrees to-ensur.e.the construction and maintenance of the afore-described on-site sewage disposal systen;In accordance with the provisions of Title 5 of the Env/ronmental Code,as well as the Local Subsurface Disposal Regulations for the Town of North Andover,and not to place;the System In operation until a Certificate of Compl/ance has been Issued this Board of Health. Nam s Date plication Appro y: (Board_of-Hes/t/i Representative) Name Date Application Disapproved.for the following reasons:" For Office Use OMv ' Z "Fee AmichedP Yes No 2.. ProjectMarlaget Obligation Form AtwchedP Yes NO. 3.: PAID System lfsoJ Attach c, y ofElecrriCal Permit', Yes ' No 4. FouadatroftAs Bui P(new contraction•ronly). Yes No (Same scale as approyedplan) — 5. FloorPlans?(hear construction-only). Y.es No • �lpplfcatton{or•p(sppsat 5ysterit:Donstrcictiori Perna Raae 2 rif ' SFP"�`IC SYS�`]�1ViiN�!'dL-T. �C•�RQ il � � N'�'�pBI.iGd�'I{3NS . Aa fb*.Npt&Aadavarlic=et#&iatalteY f�;r tC strac n f*••tl*aep&"Stm fet&&pmopettyat: � ? 't$on by zm dit4ppbadm ef L:1.4e3e-IJ �^ cc AM ditd Diwd _ wft ievidpw oma (Lm w ..�_._ I uadethe fol2owlnW bougatlow fat taaaagement ofINS I!ngece i. As the fast I am.ebligstal ip,6bftis sIIpeapb.ndBocl afHe #h Rppm pft to � g aay:vcA ca a site: m •L=b'st wu*Xmay and Via: I£l groje ct manaSet►ar scop **a pa m notg"ocbftd vf&my coaniay g In bqbc�aa and the sys wtmcjdj ib= •a1111xpCable. .'` Aebxd&t xitqux�ped to haveey .pIW1a the •aPPk fes ss . ift All agi" . . t.d!ri via-) a F nothaYe tabGptesm�t . b. — o �►e,Eb OIC"(ar a msil t _h TOR el hm the et must ba fubmittied tct te.8oead'ofHe ►s l: for:ii dine.7asiliu must bepttt r tp , tb ►soo; �t= be yand shte to . 'camse��p•tccs�idzo ••' • - ' G �— t IIer amt re `iaep a�o�he tIl$ & rn pine: WWla does spot . have#obte.' - • . .- , 4. Asibe inotslim'I�d that Wf(now"dwA tt�ix m p the ast dt�n of fife sp beg ht#tib. ppl 'Exieiatz Udon j• , ACdbn!r fifl IR 92 5.. Ab thi iaanUle�Y mail I s�aaii obi pu of thiefs�cm. mac. • '� • ..�ea - a Deadamt thAt.d're p�etek�e�a�a�ft�e attosr�-bs�p seaG6e,at- - b. lwpetiYaa aftbemadaadstp be weal . c 'Prrsl�rapr�ott6yBoae�alo!�fq�tslrrA�ttt'coadr�r� • . • • - d Ia�Aella crt af�rtalr+A. esng p , ,Rant,p, oktmb&. mll wd other . uadena septic.I� : Cry . j'_ . i oR,N, 7794 Town of North Andover �,.'•,,,,o.. ,' HEALTH DEPARTMENT ,s34cmu CHECK#: DATE: LOCATION: �.�U H/O NAME: CONTRACTOR NAME: 62an Z�) (n 6 2x 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 $ ❑ TrasIVSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ �❑f Title 5 Inspector $ 1 Title 5 R ort $ /7.5 Ly ❑ Other:(Indicate) $ Health-Agent Initials White-Applicant Yellow-Health Pink-Treasurer i D T � 521 � 1 - i Commonwealth of Massachusetts . ; Title 5 Official Inspection Form M Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 Sugarcane Lane Property Address Gary Colello Owner Owner's Name information is required for every North Andover MA 01845 3/6/2017 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information �r�� filling out forms on the computer, 011 use only the tab 1. Inspector: 10 key to move your cursor-do notuse Neil James Bateson key. Name return Name of Inspector Bateson Enterprises Inc. N� Company Name 111 Argilla Road Company Address Andover MA 01810 City/Town State Zip Code 978-475-4786 SI-15 Telephone Number License 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 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 ❑ Need/ Further Evaluation by the Local Approving Authority 3/6/2017 Inspectors Signatu Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system 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 tothe system°owner-and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6116 Title 5 Official InspectionForm:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "< 31 Sugarcane Lane Property Address Gary Colello Owner Owner's Name information is required for every North Andover MA 01845 3/6/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ 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 Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ® Y ❑ N ❑ ND(Explain below): Liquid level in tank 6"below outlet invert, evidence of tank leaking. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts AmS Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 Sugarcane Lane Property Address Gary Colello Owner Owner's Name information is required for every North Andover MA 01845 3/6/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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 pass unless Board of Health determines 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 jt5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 Sugarcane Lane Property Address Gary Colello Owner Owner's Name information is required for every North Andover MA 01845 3/6/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) 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 1 of a public water supply. 0 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: Septic tank&d-box needs to be replaced. Riser needs to be install on d-box. 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 Y2 day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 ' N Commonwealth of Massachusetts utTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 31 Sugarcane Lane Property Address Gary Colello Owner Owner's Name information is required for every North Andover MA 01845 3/6/2017 page. City1rown State Zip Code Date of Inspection B. Certification (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 a surface water supply. tributary to pp .y ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El Elthe 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.doc•rev.6116 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 5 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 Sugarcane Lane Property Address Gary Colello Owner Owner's Name information is North Andover MA 01845 3/6/2017 required for every page. CityrFown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ 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? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ 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)] D. 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): 660 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Sugarcane Lane Property Address Gary Colello Owner Owner's Name information is North Andover MA 01845 3/6/2017 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Yes Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/industrial Flow Conditions: Type of Establishment: 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 Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 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 r 31 Sugarcane Lane Property Address Gary Colello Owner Owner's Name information is required for every North Andover MA 01845 3/6/2017 page. Cityfrown 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: Pumped two years ago, owner Was system pumped as part of the inspection? ❑ Yes ® 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 C Commonwealth of Massachusetts y . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 31 Sugarcane Lane 9 Property Address Gary Colello Owner Owner's Name information is North Andover MA 01845 3/6/2017 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 24 years old, 5/7/1993, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 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, 3" PVC in house, no leaks. Septic Tank(locate on site Ian): Depth below grade: 2 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'x5'x4' 2" Sludge depth: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 31 Sugarcane Lane Property Address Gary Colello Owner Owner's Name information is required for every North Andover MA 01845 3/6/2017 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle N/A Scum thickness 2" Distance from top of scum to top of outlet tee or baffle N/A=Tank leaking 6"from invert Distance from bottom of scum to bottom of outlet tee or baffle N/A 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 below outlet invert six inches, evidence of tank leaking. Center cover has riser two inches deep. Grease Trap(locate on site plan): Depth below grade: feet 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: Date t5ins.doc-rev.6116 Title 5 Official Inspection Form:.Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 Sugarcane Lane Property Address Gary Colello Owner Owner's Name information is North Andover MA 01845 3/6/2017 required for every page. City/Town 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: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ 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.doc•rev.6/16 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 31 Sugarcane Lane Property Address Gary Colello Owner Owner's Name information is North Andover MA 01845 3/6/2017 required for every page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert -1" 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 not equal. Evidence of leakage has corrosion holes. Evidence of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments rt 31 Sugarcane Lane Property Address Gary Colello Owner Owner's Name information is North Andover MA 01845 3/6/2017 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: E leaching pits number: 3 ❑ leaching chambers number: ❑ leaching galleries number: leaching trenches number, length: ❑ 9 9 ❑ 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. Vegetaion ok. No sign of ponding to surface. Camera inside of pits through outlets in d-box, no liquid to inverts of pits. 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 • Commonwealth of Massachusetts Titre 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 31 Sugarcane Lane Property Address Gary Colello Owner Owners Name information is required for every North Andover MA 01845 3/6/2017 page. Cityrrown 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.doc•rev.6116 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 31 Sugarcane Lane Property Address Gary Colello Owner Owner's Name information is required for every North Andover MA 01845 3/6/2017 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 ❑ drawing attached separately 1 O. ..-qtr; �t?lcuhO-� p60 C] T _ Y t "t 0 t5ins.doc•rev.6/16 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 31 Sugarcane Lane Property Address Gary Colello Owner Owner's Name information is required for every North Andover MA 01845 3/6/2017 .page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® 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: 4/14/1992 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: Design plan ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: As per test pit data on design plan. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 ' Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 31 Sugarcane Lane Property Address Gary Colello Owner Owner's Name information is required for every North Andover MA 01845 3/6/2017 page. Cityrrown 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 t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Summary Record Card generated on 217/2017 9:06:36 AM by Tare Hurley rage 1 Town of North Andover Tax Map # 210-106.A-0242-0000.0 Parcel Id 17387 31 SUGARCANE LANE COLELLO, GARY M Since Jan 2003 CHRISTINE M COLELLO 31 SUGARCANE LANE NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1 Acres FY 2017 UB.Mailing.1ndex Name/Address Type Loan Number Active/Inact. From Until COLELLO,GARY Payor 31 SUGARCANE LANE N.ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 17650.0-31 SUGARCANE LANE Last Billing Date 1/13/2017 3170320 03 Cycle 03 Active UB Services Maint. Account No. 3170320 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 34.20 /1 UB Meter-Maintenance Account No.3170320 Serial No Status Location Brand Type Size YTD Cons 36348663 a Active ERT HH b Badger w Water 0.63 0.63 1168 Date Reading Code Consumption Posted Date Variance 12/9/2016 1127 aActual 9 1/23/2017 -27% 9/9/2016 1118 a Actual 12 10/24/2016 -52%0 6/13/2016 1106 a Actual 27 8/2/2016 153% 3/9/2016 1079 a Actual 10 4/22/2016 -65% 12/10/2015. 1069 a Actual 29 1/20/2016 -51% 9/9/2015 1040 a Actual 59 10/16/2015 44% 6/10/2015 981 a Actual 41 7/24/2015 305% 3/11/2015 940 aActual 10 4/28/2015 -84% 12/11/2014 930 aActual 62 1/15/2015 -58% 9/11/2014 868 aActual 151 10/15/2014 122% 6/11/2014 717 aActual 68 7/16/2014 348% 3/11/2014 649 aActual 15 4/11/2014 13% 12/10/2013 634 a Actual 13 1/17/2014 -21% 9/12%2013 621 a Actual 17 10/15/2013 40% 6/12/2013 604 a Actual 12 7/24/2013 -19% 3/13/2013 592 a Actual 15 4/22/2013 -70% 12/11/2012. 577 aActual 49 1/9/2013 83% 9/13/2012 528 a Actual 28 10/15/2012 -13% 6/12/2012 500 a Actual 31 7/16/2012 69% 3/14/2012 469 a Actual 19 4/14/2012 -7% 12/12/2011 450 aActual 20 1/17/2012 -80% 9/12/2011 430 a Actual 104 10/13/2011 117% 6/7/2011. 326 a Actual 45 7/20/2011 145% 3/8/2011 281 a Actual 18 4/13/2011 14% 12/9/2010 263 a Actual 16 1/12/2011 -91% 9/10/2010 247 a Actual 186 10/15/2010 389% 6/7/2010 61 a Actual 36 7/15/2010 82% 3/9/2010 25 a Actual 20 4/14/2010 14% IORTAI 7786 4 � Town of North Andover HEALTH DEPARTMENT SSC NUSf CHECK#: DATE: 3 /d .ZO/7 LOCATION: 3 SC_I Qa r C- 1-1/0 NAME: _Garc.l © �.- �!O s CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ 3, ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ r' ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ y ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco. $ ❑ Trash/Solid Waste Hauler $ 4 ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ sr ❑ Title 5 Inspector $ Title 5 Report - / $ 5/0" -�,nS,,DeG7�/D/J - COlk�r�✓o/)c�/`!�' 1. 53' ❑ Other:(Indicate) $ W—th Agent Initials White-Applicant Yellow-Health Pink-Treasurer Residential Property Record Card#1 of 1 Parcel Year:2018 PARCEL ID: 210/106.A-0242-0000.0 MAP 106.A BLOCK 0242 LOT 0000.0 PARCEL ADDRESS: 31 SUGARCANE LANE as of:3/13/2017 PARCEL INFORMATION Use-Code: 101 Sale Price: 494000 Book: 05135 Tax Class: T Sale Date: 8/4/1998 Page: 0315 Tot Fin Area: 3446 Sale Type: P Cert/Doc: Tot Land Area: 1 Sale Valid: Y Owner#1: COLELLO,GARY M Grantor: MARTIN PERRY Owner#2: CHRISTINE M COLELLO Address#1: 31 SUGARCANE LANE Inspect Date: 3/21/2012 Road Type: T Exempt-B/L%: 0/0 Address#2: Meas Date: 3/21/2012 Rd Condition: P Resid-B/L%: 100/100 NORTH ANDOVER MA 01845 Entrance: C Traffic: M Comm-B/L%: 0/0 Collect ID: RRC Water: Indust-B/L%: 0/0 Inspect Reas: C Sewer: Open Sp-B/L%: 0/0 RESIDENCE#1 INFORMATION LAND INFORMATION NBHD CODE: 8 NBHD CLASS: 8 ZONE: R1 Style: CL Tot Rooms: 8 Main Fn Area: 1790 Attic: Y Seg Type Code Method Sq-Ft Acres Influ-1/2/3 Value Class Story Height: 2 Bedrooms: 4 Up Fn Area: 1656 Bsmt Area: 1992 Roof: H Full Baths: 2 Add Fn Area: Fn Bsmt Area: 600 1 P 101 S 43560 1 N 230868 Ext Wall: FB Half Baths: 1 Unfin Area: Bsmt Grade: A Masonry Trim: 18 Ext Bath Fix: 1 Tot Fin Area: 3446 Foundation: CN Bath Qual: M RCNLD: 521632 Kitch Qual: M Eff Yr Built: 1996 Mkt Adj: Heat Type: FA Ext Kitch: Year Built: 1993 Sound Value: Fuel Type: G Grade: V Cost Bldg: 521600 Fireplace: 1 Bsmt Gar Cap: 3 Condition: A Att Str Val1: DETACHED STRUCTURE INFORMATION Central AC: Y Bsmt Gar SF: Pct Complete: Att Str Va12: Str Unit Msr-1 Msr-2 E-YR-BIt Grade Cond %Good P/F/E/R Cost Class Att Gar SF: %Good P/F/E/R: ///91 Porch Type Porch Area Porch Grade Factor E 216 W 300 VALUATION INFORMATION SKETCH Current Total: 752500 Bldg: 521600 Land: 230900 MktLnd: 230900 Prior Tot: 790400 Bldg: 559500 Land: 230900 MktLnd: 230900 18 30 E/B W PHOTO 12 216 Sq.Ft. 10 300 Sq.Ft. 1016 F$1 214 .Ft' 30 44 18 FU*0.75 FM/13 FU 528 Sq.Ft. 1776 Sq.Ft. 1260 Sq.Ft. 24 28 22 2 15 24--- 242 15 31 SUGARCANE LANE u -t;-,ou A MDoye V- M,�A. ScA L-e--- x A— L7A-r�r�: ��IQ3 LOT 35 8 • l I NCBytrlt=Y TG1AT S NAVE_INSP�GT� _Tl•t6 , l.DttSTKuC'flo►.1 c�1�_R'IS- 3g� , •„ POSH,- SLtS'C'EtA ANS T&JAT Tke 641 sTRUYGT1at4 APED VI L- r� ' f.RADtu4. W�5 BSN II.1 Pte- t✓KIsT. �htD, � . . oP.�.�iCE i.�t'['t-t'C�II✓ QES- � y N tG�:S�R'S;11�►�-hr'C �l1.ID.�tI�T .� � ,raw�sz,� , Caut;c,vlN-ro -rge?L4*t `m - AS BUIL-T•.tai(.. ` c-t G kCAT145 AW�3L G.c R-. I►JY.4trc N56,=149.%7- IN 4832IN !WK- 147.80 �aJ .� Wt'TPdlK< t4'1�62 . 5 19 3 ttt Box = 141.15 � � • aJt�1�= 14�o.g8�3 pJ PIT= 146•SG 131 At.1H �. � rt G=�.af tis c..-,-ter•-�G�i_.l ='?"_t(--r G'��� � _yc�.N v�c�. . :. - _ ... `� 0 5 � c k rr-r� -�'t.tE.. c.�.cx►_:'r�:�� L-:+�`t''���c_ti..•�,:>.. c. .' ,r_�•_� r�. F- �_... �_., _ L � P—M r T y �'k _ s !. w, r r. L,res o \A-1 u Gu c I►a -T e.c�� ;, gdr - TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM WNER & ADDRESS SYSTEM LOCATION (example: left front of house) k_1z tC DATE OF PUMPING:��`�' r QUANTITY PUMPED GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: COMMENTS: CONTENTS TRANSFERRED TO: Town of North Andover, Massachusetts Form No. 1 NORTp BOARD OF HEALTH ply i 19y 320 t�eo b16 -0 ! ! lM" l 1 C/ APPLICATION FOR SITE TESTING/INSPECTION 7 QDRATED �SSACHUSE� Applicant I1C.q NAME ADDRESS TELEPHONE Site Location Engineer ' NAME 9 RES TELEPHONE Test/Inspection Date and Time j CHAIRMAN,BOARD OF HEALTH Fee jJ Test No. � S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of Nortk,Andover, Massachusetts Form No. 1 NORTH BOARD.,O.F HEALTH �[ [�j�y�/j{p���(�( J^' OSS LED /b��O ! �.+v9 FF, • �� 19 ou APPLICATION FOR SITE TESTING/INSPECTION 7.9 ADRATED SSACHUS� Applicant Lko NAME- (j fp! ADDRESS TELEPHONE Site Location 1 ,iri t* Engineer NAME ARDRESSJ 1 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. C CCC .v, 951MM- w� . 4 iiaE SUL= i Eiii iiiiiiLIMi iiiiiiii iiiiii iiiiiii mm mm i�7i�►iiiiiiiii iiiiii iM—IPO i:iiEZiiii INmm i��aiia iiii �imiimiiii�sii t r' Commonwealth of Massachusetts Executive-Office. of Environmental Affairs Departmtnf of E041rohm .. . ail , Pfttoction Wllllam F.Weld Govemor Trudy Coxe Secretary,EOEA David B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A - CERTIFICATION n �i`? / lt? Ct✓ Property Address: Address of Owner r Date of Inspection: d��S (If different) Name of Inspector: c�1,/�t id Company Name, Address and Telephone Number: / elf 15P A 4e7 j2,4f tjZ� .)f t#fi�'v'j?"<l K00(1 P' 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 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: sse5. - .. Conditionally .Passes Needs Further Evaluation By the Local Approving Authority Fails, Inspector's Signature: Date: .- . The System Inspe ,rctor shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing air's inspection If the,system is a shared system or has a design flo" 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 !e the ,vstem owner and copies sent to the buyer, if applicable and the approving autholit�. INSPECTION SUMMARY: Check A, B, C, or D A] -,SYSTEM PASSES: #� I have not found any!kinformation which indicates that the system violates any of the failure criteria as defined in 310 CMR 45.303. Any failure criteria not evaluated are indicated below. B] 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 imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) 1 One Winter Street • Boston,Massachusetts 02108 • FAX(61/)556-1049 • Telephone(611)292-5500 40 Pnnted on Recycled Paper - s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A - CERTIFICATION (continued) 1i° Property Address: v ✓.0 ! Owner: i{ Date of Inspection: " V ?- z 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 t C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _ Conditior s 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. I 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER t. 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. t — s 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: 1 he system nas a septic tank ano soil absorption system.and is witlm, 100 feet`iv a surface water supply or tributary to a surface water supply =_; -'�7he ssStena;ha .a'sept�c tank_ad So�l;absorptio ,system-and is_within..a Zone I of a public-.,water supply well. m - — The systehas a septic tank and soil absorption system and is within'50 feet of a private water supply well. The system, hay a septicank 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 welFis free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm D] SYSTEM FAILS: ` 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. (revised 6/15/95) .2 f � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART A CERTIFICATION (continued) } Property Address:. U, 1c/ Gnat+e �+°7 ' ��(/. � i Owner: i Date of inspection: 1 V✓`�. 3•") r Q 'rj - - D] SYSTEM FAILS:(continued): 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 pipes) —5 ' - tims' u - �r .�NumbeLd - .. 7F x Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. _ Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a.cesspool or privy'is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. } _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no } acceptable water quality analysis. If.the well has been analyzed to be acceptable, attach copy of well water analysis for 4 "coliform bacteria, volatile.organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design•flov, of system is 10,0.00 gpd or greater (Large System) and the system is a significant threat to public health and safety a 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 surface drinking water supply,"* -,.M..F -r «.^-..: r..r_ � �. F:.,�a.•n+- r.._._ r s...$,`.q- ,�-��>« �.... -�..rw: .. rvw. ...•.a-...,,,, �-.,,,-�.. �"".•:.,. `�`.. _ the system is located r a nitrogen sensitive are(interim Wellhead Protection Area•(IWPA) or a mapped Zone lI of a i public water supply well, # ti 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. A (revised 8/15/95) 3 ' 4N- • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t: PART1 : B CHECKLIST Property Address: Owner: Date of Inspection: PC V Check if the following have been done: �'�` Piyfii'�p4ing iriforirsafion i asprequested offthe own4er; occupant;>and Board f Health,,-,, . l None of the system components have.been pumped for at least two weeks and the system has been receiving normal flow rates wring that period. Large volumes of water have not been introduced into.the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. • The facility or dwelling was inspected for signs of sewage back-up. a• —j' f he'system does notreceive non-sanitary or industrial waste,flow, t he site was inspected for signs of breakout. `•' _)Aystem components, excluding the Soil Absorption System, have been located on the site. Thi septic tank 'manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or, t es, material of construction, dimensions, depth of liquid; depth of sludge, depth of scum. w The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. The facility o.:c cr (and occupants, if,different from owner? were provided with information on the proper maintenance of Sub- + Surface Disposal System.Or �. fry. xsrc �s (revised 8/15/95) 4 r , . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION,FORM PART C SYSTEM INFORMATION Property Address:.21 y` Owner: , Dete of.lnspection: �+/'✓`j FLOW CONDITIONS RESIDENTIAL: ' Design flow' rta to s Number of bedrooms: Numberof current residents Garbage grinder (yes or no)�:96 � q Laundry connected to system (yes'or no): Seasonal use (yesorno) Water meter reamgs; if available 94 Last date of occupancy: C"f� e COMMERCIAUINDUSTRIAL• ( rj Type of establishment: l`tIJ Design flow:_gallons/day 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; t Last'date of occupancy: t OTHER: (Describe) is Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information:/ 2 IS ,System pumped as partof inspection: (yes or.no) k s. :lff es, voFurne uripped- 1, � allon4= y p �{ ',h"f'-d�-4--'AA a`^°- ."f r. :, .• "`'1hY a'!�rc ,,_ Jr' - Reason for pumping. t ` TYPE: 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) Other (explain) APPROXIMATE AGE of all.components, date installed (if known)and source of info'emation: Sewage odors detected when arriving.at the site: (yes or no) �, (revised 8/15/95) 5 ' f a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C t SYSTEM.INFORMATION (,conntinued) ¢ Property Address: ' Owner: Date of Inspection: VV SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP—other(explain) 3 f f Dimensions:.. . + .� x15 Sludge depth: " r Distance from top'of sludge to bottom of outlet tee or baffler 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:L6LL 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.) A:'�/ ? 4- 0u74- ? 66 b CA 14A1.7`/.d A.- m y 1-4 k-T, GREASE TRAP:_ (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 n urn t;bottom of outlet tee or battle orn entS p _'p P"(recommendation for pumping! condition of inlet and outlet tees or.baffles,depth of liquid level t relation to outlet itt4ert; structural integrity,-evidence of leakaei:"', et C) (revised.8/15/95) 6 h SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION:(continued) t Property Address: —7j",Coll,c- !�"� /-' '� 004 ' Owner:.' Date of`Inspection; ... 0 TIGHT OR HOLDING TANK:_ •. (locate on site plan) Depth below.grade: Material of construction: concrete metal _FRP other(explain) 4. Dimensions: S Capacity: 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: �aJ Comments: (note if le,c! and d.;tril,:.. cr,•.;' evidence of 59h+. ca.—vovs r, Pvid--nce of leakage into or out of hox, etc) . NO C 4141 o u et,- Rot, t9 P col-ta -710444: A/y 4'P-Vr1„f' s w'a.'+,.+eMwt^..wo.,wU..r++.e+.wew+p� �y..ry ...n�"", .,. r . r • (w.,, `s4i :.t".-} �+•:�`>}7 t,.�:�„ 1`-= ta ..:wt_ g ._j' �s f •� {•w ` 'a°':, x .' »�� I `` ..' ; - ,. PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) r s I (revised 8/15/95) v' 4 M1jfe .. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.0 SYSTEM INFORMATION (continued) Property Address: t! ✓ Cam e Owner: * Date of Inspection: PIP SOIL ABSORPTION SYSTEM (SAS):_ (locate on site pian, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type t k . t g'. i y ' t.-: } two 00 leaching pits, number._ ( 9 leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: `Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) CESSPOOLS: (locate on site plan) ° ` fi 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 pumped as part of inspection) �, �•• ' YAVs .. ! ,.w.,� {,.1 2 1-}.?`��if f.-..:, d t j.:<<I '{dF.a�`--.t�,1�$ �'- � ..V � •=i�� .., �` c%�' � -:.� ! 41'" Corn rents: (note condition of soil, signs of hydraulic failure, le v I of ponding, condition of vege�ati�dn, etc.) PRIVY• M• (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 8/15/95) ti V SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` PART C .SYSTEM INFORMATION (continued) Property Address:, cJ. 7 Y y t -A01 Qev Owner: Date of Inspection: SKETCH,OF SEWAGE DISPOSAL'SYSTEM: „- include ties to at least two permanent references landmarks or benchmarks locate all wells w'b t-jjQA,.,. '�'S =�s, k.. '� - _ rwT+r++r�!n'�.N%..a�.ef .. Kr�'wm.+nnh wu,ow�"•. 7�F'' _ �,• may.. DEPTH TO GROUNDWATER Depth to groundwater: 'feet { method of determination or approximation: G � V' f3 )f O Ak('yt l (revised 8/15/95) 9 /r ORTf1 oTwn of Noft! , And O !r »_ cn No. 5 5 ^L A E Ori ° dover, Mass., 19A& COCHICHE-ICK �ADRATED N BOARD OF HEALTH Food/Kitchen PERMIT TSeptic System 6 ,15W BUILDING INSPECTOR THIS CERTIFIES THAT. ... 104J0.4.4po ..ot 'nap .......A.••u•T�••• Foundation has permission to erect.wQ.O .. uildings on . .. �/�►./ ../ 1i�. RoughW W0. 3 w�= � orc. W c•a to be occupied as.,s�> � ��. •k� I �• •••••• imney 3 . .... .. ...... ..... provided that the person accepting this permit shall in eve respect conform to the terms of the app'T ca ion on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration anCst uc i of Buildings in the Town of North Andover. ruUMM PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. MIX=BY NK IRS& BSC. Rough PERMIT EMPIRES IN 6 M.C✓T Tj � ' Final UNLESS CONSTRUCTION STARTS ' U v ELECTRICAL INSPECTOR Rough PERMIT FOR FRAME/BUILDING . .... ,..... .. ..... ... .. Service..... .......................... BUILDING INSPECTOR Final )ATE: FEE 1D&_ -o o, VCCi,(.�janc-\' I E'.1"1nit R'.C�LGG7'C'GL �0 �cc-upy Bitild ul� GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough l No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner ONC13 PLANNING FINAL l i CONSERVATION FINAL Street No. _,l �s; Smoke Det. CMAICo /%AIATCQ �inini nRIVFWAY FNTRY PERMIT _— PLAN REVIEW CHECKLIST ADDRESS-,/ , ENGINEER /1/ed�- GENERAL 3 COPIES STAMP LOCUS C/ NORTH ARROW SCALE I CONTOURS L/ PROFILE L---' SECTIONC, BENCHMARK SOIL & PERC INFO ELEVATIONS WETS. DISCLAIMER_L_==- WELLS & WETLANDS WATERSHED? 1410 DRIVEWAY-"---- (Elev) WATER LINE Li FDN DRAIN Li SCH401�� TESTS CURRENT? SEPTIC TANK MIN 1500G. . 17 INVERT DROP �� GARB. GRINDER //( (+200% EDF) 25' TO CELLAR L,,- MANHOLE TO GRADE ELEV GW D-BOX ^� - SIZE U 8', # LINES c3 FIRST 2' LEVEL STATEMENT INLET/,16 ,/,3 OUTLET /4! --,73 = •Z (2" OR . 17 FT) TEE REQ'D? AIJ LEACHING RESERVE AREAL/ 4' FROM PRIMARY? "1� 100"TO WETLANDS' 2% SLOPE 100' TO WELLSi/ 35' TO FND & INTRCPTR DRAINS / 4' TO S.H.GW 325' TO SURFACE H2O SUPP C/" 4' PERM. SOIL BELOW FACILITYo<-- MIN 12" COVER _FILL? (25' if above natural elev• 10' ' below) BREAKOUT MET? �- TRENCHES MIN 660 gpd SLOPE (min . 005 or 6"/1001 ) >3' COVER? - VENT SIDEWALL DIST. 2X EFF. W OR D (MIN 61 ) IS RESERVE BETWEEN TRENCHES? IN FILL? MUST BE 10' MIN. 4" PEA STONE? BOT X LDNG + SIDE X LDNG = TOT (L x W x #) (G/ft2) (DxLx2x#) PITS MIN 660 LEACHING GW MIN 4' BELOW BOTTOM MANHOLE/PIT EXCAV 2x EFF W OR D 12"-48" STONE SURROUNDING BOT + SIDE x LOAD = TOTAL (L x W x #) (2 x (L+W) x D x #) CHAMBERS MIN 660 LEACHING GW MIN 4" BELOW COVER >3 FT - VENT 64 MANHOLES 12"-48" STONE L--- SPLASH PADS SLOPE .005 BED/TRENCH- (Bed max. 60' X 601 ) BOT X532 - 3 3-�- + SIDE A60 3 Z 5 X LOAD = TOTAL 6�0� (L x W x #) (2 x (L+W) x D x #) FIELDS MIN 900 ft2 LEACHING PERC RATE FASTER THAN 20M/IN GW MIN 4' BELOW BOTTOM OF FIELD PIPE ENDS JOINED W/NON-PERF. PIPE? 4" PEA STONE? DIST LINE SLOPE . 005? >3 ' COVER - VENT SCH 40 MIN 12" COVER L x W = T x LDNG > DESIGN FLOW? DOSING TANKS AND PUMPS DIMENSIONS X X = PUMP CAPACITY gpm L W D Vol. DISCHARGE SIZE DISCHARGE RATE DISCHARGE TIME gpm MANHOLES TO GRADE ALARM SEP,. CIRC. GW (Min. 1' below inlet) HWL LWL CHECK VALVE BLEEDER HOLE MANUAL OP. SWITCH DATE `�/ q �7, Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER / SUBSURFACE DISPOSAL DESIGN REVIEW FEE C) - PERMIT # ���_ DATE RECEIVED—/6/e/5?7 APPLICANT� - V,4A1QSZ ASSESSOR'S MAP ADDRESS PARCEL # LOT # ENGINEER 7' Nz VE- STREET ADDRESS PLAN DATE 1017119,Z, REVISION DATE CONDITIONS OF APPROVAL: APPROVED v� DISAPPROVED Town of North Andover, Massachusetts No,Of tMc°Th Form N 2 ?:_r. BOARD OF HEALTH ti0 O� w � A 7 �- ACNU54t ACHU�ry DESIGN APPROVAL FOR SAIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant Site LocationTest No. 35 Reference Plans and Specs. ENGINEER Permission is granted for an individual soil absor DESIGN DATE ption se in accordance with regulations of Board of Healthwage disposal system to be installed CHAIRMAN,BOARD OF HEALTH Fe Site System Permit No. FORM U - IAT RETFASE FORK INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: Phone LOCATION: Assessor' s Map Number 10("4 Parcel Subdivis ionTy/e-'D Lot(s) 3 %� Street �CfG'. C /�� St. Number ************************Official Use Only************************ RECONX=ATIONS OF TOWN AGENTS: Date Approved Conservation Administrator Date Rejected Comments i Date Approved �— ToPlan er Date Rejected Comments Date Approved Health Agent Date Rejected Comments Public Warks - saw•er/water connectio Mr �` �/P� ,� l� l2" U✓ i driveway permit ktSved 6'A not ,IPt Aco(-u0eA Fire Department Received by Building Inspector Date 1 e Town of North Andover, Massachusetts Form No.3 a : AORTH BOARD OF HEALTH (/ Ot t,�ao d°1'1'O L . O 9 s''°•,,,o.�^`� DISPOSAL WORKS CONSTRUCTION PERMIT • ,SgACHUSEt Applicant I I /dl L"V -- NAME ADDRESS TELEPHONE Site Location Permission is hereby granted to Construct X 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. 407- AS-BUILT CHECK LIST and FINAL INSPECTION Proposed Elevations As-Built Elevation House Tank IN Tank OUT .4 / 7- D-box IN /T D-box OUT Trench Inverts Line 1 Line 2 Line 3 Line 4 Bottom of Exc. 143, 166 Stone OK? D-box checked? Pipes cemented? T t7.0�r��riiCttrltll 11{j ' •t `/ h�setts r� , ORTH�A�IDOVERt �MASSACHUSETTS SVs. e u, Record . • _ tamplt�' �c k , ,r . POT r f'OTn,•'' ?/ J,•yA' ..PIi l,r'?l:"!' ® 7 5 200 ..;,l:�;lr!fi'r.: •r'�•;:Kl�.'sl,,,,:, .,r.;�;!'.�,,, ;q �i�i• NOV DEP,has provided this form for use by local soarda of Health. The Systema umping Record m s: be submitted to the local'Soard of Health or other"a'r'i"'`\'` �•- r ;;:.,: .,,. ( PPQy1n9 authority �r A, .Facl.11ty Infori tlon ;: Un rtanG,: 'srYfn�.out' .1:. System Location •� ;i�s:tarp,.; r use y '.ony the tab key� Address _ to move your:; �. ,.cur:or-do Dot � .. uie the rotum.;r„' CItY/Town $fat kpy'u,,: �';:;..,;., ZJpCode �2;. .S stem Owner,•, Name Address(If different from location) state zi Telephone Number �Pumpl�g:Re�ord �J:.f��Jrlwrie, jlii.;i.a1(:1��tfT`li.f'•. /JI r . ' 1 'M I:J `� '',/ '•';•,:%}\�,,'hY,� ' �T 1, jr, �T� ,•� 1 `Date of Pumping: ,Dat 2' Quantity Pumped: —l ”C�711_1 Gallons !F :TYPa Pf system::.... ❑ Cesspools) Septic Tank f� t. ❑ Tight Tank !Other(describe); Effluent Tee 11 El❑ Yes ❑ If yes, was It cleaned? ❑ YeS E No • ,=;h`,�'r" �'t�-•6,-� C.ondltJon'ot'.Syst mr`y•'•• AX >r,J y Pumped Sy,�' ��';. ... •'S';,ia •.�r�,rt,1,�^j17. ;�,. , l j'.:>,;� ,;.. `S�, VehlCle Ucen#e Number „. Y a'•J,k, :�:: . .�. �;><a,a.' :7;-ln.�ii•.;. wt'+,, '�ftlri•y. f,,�� t~,' .,�,::: J 'i`, t`r•'Y"YP 1 i '. r, ��pi v..t y; �`•{i�. %�!1.;�Irtj�l.,.... ,.i�, .�y�.Y{%•,��fi•r,...,•4.e'•a.H'rpgJ �ta,.0,J'.t:�:r::�1,�' I'�'•r::r.Va('::' {:7;,: L n.wtiere contents Were'dl;posed: • 't.ri:. •`:i�•.,,:�”. •'... L�:�.::;Y=.<'":c, �f ,;i b,,•., •,•;r:. J r:4.>.:•.'•��' .. i �j •f.;.:'.:;.SIGr1{torso(Hauls(;;Ni;.,,.;;.a..,,.:,..1'....: Date ,t. :ht#pJ/uhvw:mass.goWdeawafer/apprCva)slt5forms,htm#Inspect t5fwm4,doa�06/Q3 . System Pumping Record Pale ! or TOWN O.F N O R T H 'A N D O Vy E R ,u.,,F-'Y"° 'F 7--1 SYSTEM P'UMPIN ;.- P. JU�a - 3 2003 a 1'EM OWNER & ADDRESS SYSTEM LO'CAT-I'0-N (example; left front of house) Sc ar C�h A? , y /vQ .n aove4l z. L) OF OF PUMPING: ,5-5` �J (QUANTITY PUMPCD C !...SPOOL: NO YES SEPTIC TANK: NO YES � ATUKE OF SERVICE: ROUTINE EMERCENCY I MhFRVATIONS, COOD CONDITION. hULLTU CUYCIz HrAYY CREASE BAFFLES IN PL.ACL'. ROOTS LEACHFIELD RUNBACK . CXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER O�HER (EXPLAIN) M.P.0 D, BY: UM'vl FLATS: UN , 1:'.N r TRANSFERRED TO: TOWN OF NORTH ANDOVER; 0!" SYSTEM PUMPING RECORD 01 FEB.t 2 20 DATE: yo r s• . SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example: left front of house) 1 ' arca n NO a�e DATE OF PUMPING: ) 476 L QUANTITY PUMPED 1560 GALLONS CESSPOOL: NO_X YES SEPTIC TANK: NO YES X NATURE OF SERVICE: ROUTINE_5 EMERGENCY OBSERVATIONS: GOOD CONDITION X FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Ravi rlaj Ar"�Ga COMMENTS: is CONTENTS TRANSFERRED TO: 36 1 t �vvt