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Home My WebLink AboutMiscellaneous - 310 BERRY STREET 4/30/2018 / 310 BERRY STREET 210l108.0-0052-0000.0 E ^ Lot & Street 9/0 Map/Parcel CONSTRUCTION APPROVAL Hasla p VO Permit# Plan Ap Npproved by: Designf �' 'Ian Date: Condi r/ Water ,' ; ' r Well Pf : Well Te - d d Bacteria II-y Date Approved Plumbing Sign-Off: Wiring Sign-off: Comments: Form "U" Approval: Approval to Issue: YES NO Date Issued By. Conditions: Final Approval: All Permits Paid? YES NO Well Construction Approval? YES NO Septic System Construction Approval? YES NO Certification? YES NO Other? YES NO Any Variance Needed? YES NO FINAL BOARD 9F.HEA H APPROVAL: DATE: 3 l / APPROVED BY: f t r • Lot & Street k 9J0 Map/Parcel CONSTRUCTION APPROVAL Has plan review fee been paid AYES NO Permit# Plan Approval: Date: Approved by: Designer: Plan Date: Conditions: Water Supply: Town Well Well Permit: Driller: Well Tests: Chemical Date Approved Bacteria I Date Approved Bacteria II Date Approved Plumbing Sign-Off: Wiring Sign-off: Comments: Form "U"Approval: Approval to Issue: YES NO Date Issued By: Conditions: Final Approval: All Permits Paid? YES NO Well Construction Approval? YES NO Septic System Construction Approval? YES NO Certification? YES NO Other? YES NO Any Variance Needed? YES NO FINAL BOARD OF,HEALXH APPROVAL: DATE: 3VfT / APPROVED BY: , SEPTIC SYSTEM INSTALLATION CONDITIONS: Is the installer licensed? YES NO Type of Construction: NEW REPAIR New Construction: Certified Plot Plan Review YES NO Floor Plan Review YES NO Conditions of Approval from Form U YES NO Issuance of DWC permit: YES NO DWC Permit Paid? YES NO DWC Permit# Installer: Begin Inspection: YES NO Excavation Inspection: Needed: Passed: By: Construction Inspection: Needed: As Built Plan Satisfactory: YES: Approval of Backfill: Date: By: J� Final Grading Approval: Date: By: Final Construction Approval: Date: By: Certificate of Compliance: Approval: Date: 310 BERRY STREET JS-2004-1044 Proiect Detail Report Printed On:Tue Jun 01,2004 Project Name: GIS#: 8064 Project No: JS-2004-1044 Owner of Record COOPER JR,HARLEY Map: 108.0 Date Submitted: May-13-2004 310 BERRY STREET Block: 0052 Status: Open NORTH ANDOVER,MA 01845 Lot: Work Category: Work Location: 310 BERRY STREET Zoning: Proposed Use: District: land Use: 104 Proposed Use Detail Subdivision Description Septic-Tank Replacement Comments: of Work: Department Status GeoTMS Module: Status File No. Comments: LCDate: Board of Health GREEN FLAG BHJ-2004-0062 5/20/04-COC issued-Tank Replacement. 5/13/04-Susan signed off. Will bring permit with her at Final Grade Inspection out at 984 Turnpike.--p.d. a 5/13/04-John Soucy dropped off application for DWC permit-tank replacement. In Susan's box for sign-off.--p.d. Permit History Type: Permit No: Issue Date Status Work Category Contractor Project No: Description of Work: DWC Component Repair- BHP-2004-0372 May-13-2004 SIGNED OFF JS-2004-1044 Tank Replacement Only 1 GeoTMS®2004 Des Lauriers Municipal Solutions,Inc. Paget oft d Date... ................... t NaRTM 1 TOWN OF NORTH ANDOVER p PERMIT FOR WIRING �SSACMUS� This certifies that ...... :.................... ............... has permission to perform ... .ti -.........�. :-�...�'�:`........................................ wiring in the building of../;(.....: ............................................ ............ � ........................ .North Andover,Mass. Fee`.........`.......... Lic.No.?,Cswl_J ELECTRICAL INSPECTOR Check # 790 3 C/� pJ Official Use Only 'nwtonweaR o f///aajacLetb Permit No. /!7 /000 2epartnwn`o1 j ire servica4 J Occupancy and Fee Checked W� BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave biankl APPLICATION FOR PERMIT-TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC), 527 Ci`'fl; 12,.00 (PLEASE PR:VT 1N INK OR TYPE A4,L IVFORVLzT10:V) Date: /v2 City or Town of: /�/QXi�li Z�Noyef To the Inspector of IPires: By this application the undersigned gives notice of his or h r intention to perform the electrical work described below. Location (Street g Number) Q , - J� 35-2_0?9�-( 8a Owner or t keU>!Y Telephone No.3So2- Owner's Address /AZYS aewz�e_e Is this per in conjunction with a building permit' Yes ❑ No � (Check Appropriate Box) Purpose of Buildin Utility.authorization No. 31 Lt� 70. 1e Overhead ❑ Undard❑ No. of:Meters +* Service1Q0 Amps / Volts Overhead V L"ndard ❑ No.of Meters / Number of Feeders and Ampacity Location and Mature of Proposed Electrical Work:-2q Se_gou kz- S me dlr Corro?etion ofthe,`bho% ;nF table ma,'be waived o: the Irsoec:or cf Fires. No. of Recessed Luminaires No.of Ceil.-Sus (Puddle) Fans No. of Total p' (Transformers KVA No.of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ :No. o mergenc`,- ighnng ernd. grind. Batten•Units No. of Receptacle Outlets Z INo. of Oil Burners FIRE ALARMS (No.of Zones No. of Switches (No. of Gas Burners No. of Detection and ' Initiating Devices COIaI No. of Ranges INo.of Air Cond. Tons �No. of.Alerting Deices IN-o- of Waste Disposers Heat Pump .Number I Tons K« No.of Self Contained I' Totals: I I I Detection/Alerting Devices_ No. of Dishwashers Space/Area Heating KNV Local❑ �lunicipai j 11 Other Connection iNo. of Dryers (Heating .-appliancesK��• Securin• Svstems:' No.of Devices or Equivalent ' INo. of later No. of No �l . of Data irin;: ' Heaters K`� Ballasts Signs No.of Dei ices or Equivalent No. Hydromassage BathtubsINo. of Motors Total HP IT elecommunications �i iring: No.of Devices or Eauivalent OTHER: A:ia:h adcitioral detai:i;desired, or as required c'.'the 1rspec!or of P'ires. Estimated Value of Electrical Work: (When required by municipal police.) Work to Star: Inspections to be requested in accordance with MEC Rule 10. and upon comeletion. INSUR_ NCE COVERAGE: Unless waived by t:le owner,no permit for the performance of electrical work may issue unless the licensee pros'ides proof of liabilir•insurance including"completed operation"coverage or its substantial equivalent. The ur,cersigned ce:roes that such coverage is in force, and has exhibited proof of same to the permit issuing office. . CHECK ONE: ENSURANlCE ❑ BOND ❑ OTHER ❑ (SpeciTy:) G-S 1 cerci,},, under the pains nd penalti s of perj , that the information on this application is true and complete. F1R'M NAME: �'�,y47C, LIC.NO.: t S Licensee G �,� Signature LIC. NO. j L �GG.IC Cie rt e "e..empt"ir, he li rse�ber tine,t .Address: � �'j>�C�%� �'�✓� �Lu1{C$bwry �.�} Z3iQ.�lo Bus. Tel..No.: .alt.Tel..No.: gSs`d"a- M.G.L. c. ?- .s. -;'7-6 1, _-Cl,security wor:.zquires Deparment or-Puollc Sa?-ty 'S" License: Lic. No. 0«NER'S INSURANCE , AIVER: I am aware that the liabdit-'insurance coverage normally sired bV la'.t. By m}'�lonaCUre )$lO�hre,-;,vw lye th15 i'qutrement. l t^e(check on-) own'r ❑owner's agent. O%yneri.Signaturre� �Y.�ielephone PERMIT FEE: �`� � ♦ i R.i 4y f CITY OF SOMERVILLE �'Q� G'✓` C' � . ELECTRICAL FEES INITIAL CHARGE FOR ALL PERMITS_.._.__..................,_..._ 1 Q._-_APPLIANCE_ S COMMERCIAL _._$50.00 RESIDEN FIAL.......$25.00 2.' TEMPORARY SERVICE........................................................................ $65.00 DISHWASHERS OR DISPOSALS........................................... $15.00 3. SERVICES 11. SIGNS (A) ALL ELECTRICAL SERVICES &ALTERATIONS TO EXISTING SERVICES OUTSIDE OR INSIDE.............................................................. $4 .00 OF 100 AMPERES CAPACITY WITH UP TO TWO(2)METERS AND 12. BOND TWO (2) DISTRIBUTION PANELS....................................................... $40.00 SWIMMING POOLS.................................................................. $30.00 (B) ALL ELECTRICAL SERVICES AND ALTERATIONS TO EXISTING 13. TRANSFORMERS SERVICES OF 2.00 AMPERES CAPACITY WITH UP TO TWO 1(2) PER KVA RAFING........................................ ................... .... . $3.00 METERS &TWO(2)DISTRIBUTION PANELS..................................... $60.00 14. MISCELLANEOUS (C) ALL ELECTRICAL SERVICES AND ALTERATIONS TO EXISTING (A) ALL OTHER ELECTRICAL EQUIPMENT NOT LISTED HEREIN WILL SERVICES EXCEEDING 200 AMPERES CAPACITY WITH UP TO ' BASED ON CURRENT CONSUMED PER 1000 WATTS......... $5.00 TWO (2)METERS &TWO(2) DISTRIBUTION PANELS..................... $30.00 (B) OUTDOOR LIGHTING PER 1000 WATTS...........................,.. . $5.00 (D) EACH ADDITIONAL METER& PANEL BEYOND TWO(2)................... $12.00 15,_EMERGENCY LIGI_11 S (E) SUB MAINS 60 AMPS 10 100 AMPS.................................................... $30.00 (A) BATTERY PACK/GEL.CELL ETC............... 1 TO 10...:.......,... $12 50 (F) SUB MAINS 200 AMPS& BEYOND....................................................... $40.00 (B) EACH ADDITIONAL.................................................................. $1.00 4. OUTLETS/BALLAST/FIXTURES/SWITCHES/LIGHTING OUTLETS 16._ SMOKE DETECTORS (A) PTO 10 OUTLETS....... ._...._.. .. .. ..... ......... ... . ...... . .. ............. $12 50 (A) 10 OR LESS ....... .. .. _...... ......... . ...._ ... . .. ..... ..... ... $45.00 (B) EACH ADDITIONAL OU11_ET BEYOND 10........................................... $1.00 (R) EACH ADDITIONAL_DF I ECTOR BEYOND 10 .... .. ........... $1 00 5_HOT TUBS OR IIYDRO MASSAGE-I UBS._..,,_.___.-..... ._.. $2500 1.7.., MAIN I-ENANCI_ PERMI I 6. MOTORS PER CALENDAR YEAR............:.............................................. $200.00 (A) 5 HORSEPOWER OR LESS.................................................................. $15.00 18. EMERGENCY POWER- SYSTEMS (B) 6 TO 10 HORSEPOWER....................................................................... $20.00 (A) 100 KW OR LESS.................. ..... $65.00 ............................................ (C) 11 TO 25 HORSEPOWER. ................................................................... $30.00 (B) OVER 100 KW......................__..................................._........... $130.00 (D) 26 HORSEPOWER &AROVE................................................................ $75.00 1.9.-GROUNDING 7. AIR CONDITIONERS (STA110 RY) COMMUNICATION SYS1-EMS.............................................. $15.00 (A) 5 TONS OR LESS.................................................................................. $35.00 20._VINYL_SIDING (B) 6 TONS OR ABOVE............................................................................... $70.00 REMOVE &REPLACE SERVICE EQUIPMENT................... $40.00 S. HEATING DEVICES 2-1. FIRE ALARM SYSTEM $6500 22. SECURITY SYSTEM $65.00 (A) RANGES UP TO 12 KW........... ......................._._................................. $15.00 23. -IL-LEI'IIONE OUII_LTS&CABLE OUTI_f_IS (B) EACH ADDITIONAL KW BEYOND 12.................................................... $3.00 (A) 1 TO 10.................................................................................. $12.50 (C) DRYERS........................ .. _... ..................................................... $25.00 !Bl EACH ADD!TIO;i L.................. ............................,....., ....... $1.00 (D) OIL BURNERS.............................. ......................................................... $2.5.00 2.4. 'FAILURE TO CALL FOR FINAL INSPECTION WITI IIN TEN (E) GAS BURNERS.......... .......... ..... ........... ............................................. $25.00 (10)WORKING DAYS Al-1 Eft COMPLETION OF WORK. (F) WATER I IEATERS................................................................................. $25.00 9. 'PUBLIC METERS $35.00 CONSULTATION FEE/SITE MEETINGS $50.00 OFF HOUR INSPECTIONS-4 HOUR MINIMUM $200.00 SUNDAYS/HOLIDAYS $300.00 Jan 03 09 12: 46p Charles Gendron 970-950-0662 p�Z r 1 The Commonwealth of Massachusetts y Department of Industrial Accidents Office of Investigations 600 Washing;tort Street Roston,MA 02111 www rnass.gov/dia Workers' Compensation Insurance Affidavit: ]Builders/Contractors/Electricians/Plumbers Applicant Information ' Please Print Legibly Name(BusinesstorganimionM /_( dividual): ( 7 /6[A ('1'f _ Address' C O r : ) vor CitylState/Zip:_- bc rL. Phone-#: 2f) Are-you an employer?Chock the appropriate box: Type of ro ecu r( �aired ', — I am a etlerdl contraotoT and I p J ). 1.�am a employer with�_ 4. ❑ g 6. ❑New construction employees(full andlor part-time).* have hued the sub-conrractors listed on the attached sheet: 7. akfinode 2.�] 1 am a'sole proprietor or partner- * ship and have no eaployees Thcsc soh-contractors have g, barnotition worldnp, for me in any capacity. crnpioyees and have workers' (No workers'comp.insurance comp.insurance. t 9. 0 Built ing.addition required.) 5. We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am it homeowner doin all work officers have exercised their 11. Plumbin s ❑ s repaizs or additions myself [No workers'comp. right of exemption per MGL l 2.0 Roof repairs insurance required.]t e. 152,§1(4), and we have no etttployeea, [No workers' 13.[3 Other comp.insurance required.) "My gsrlieant that cheeks box 91 aunt also fill out the rection below showing their workers'coat =soon pokey information. t Homeo—en who submit this affidavit indicatins they in doing all work and then hire 0hrW6 c6nva;wr5 mun submit a new affidavit indicating such- 'Contractors tors that check this box must arched un additional sheet showing d1c rare of the sul catuaetors ind sate whether ornot thou entitiis have trtwioyes. If the subcontmaors.have employees,they mur provide their workers•comp,policy ntrrnbC. I ant an employer that is providing workers'compensation insurance for my emplopcea. Below is the policy and job site infurmation, Insurance Company Natne: C� Policy#or Self-ins, Lic.#: (� 7f i��t 7_ Exp iratioa Datc: Job Site Address: „City/state/Zip: Attach a copy of the workers'compensation policy declaration pave(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 and/or one-year imprisonment,as well as civil pcnaldes in the form of a STOP WORK ORDER and a fine of up to$250.00 it day against the violator. Be advised that a copy of this statement may be forwarded-to tate Office of _ Invcstieations of the DIA for inctgranec coverage verification. Ido ceitifj Rdcr/the pains•an CJ1ittlliCS of pt rjur,�that the information provided above is true and correct Siatxtre: +', Date: 01103M OffICial use unly. Do not wriw in this area,to be completed by city or town offrciaC City or Town:' Permit/License# Issuing Authority(circle one): 1.Aoard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5,plumbing Inspector 6..Other Contact,Person: Phone#: 4 V 1 / 1 • ti U 3?�• •.� Opp t. t - , Town of North Andover ;'•�,; o:.� HEALTH DEPARTMENT CHECK 4: DATE: LOCATION: , f O NAME: CONTRACTOR NAME: 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) $ ❑ Tit 5 Inspector $ 2:tle 5 Report ❑ Other. (Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer OommonweAth of Massachusettsr "` at Title 5 Official � �� f i I Ins eetion Form ,= - �011 Subsurface Sewage Disposal System Form Not for Voluntary Assessmen s tele- TOWN OF NORTH ANDOVER 310 Berry St. HEALTH DEFARIME - Oroperty Address Kevin Abernathy Owner Owner's Name information is MA 01845 05/11/2011 required for every North Andover — 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 filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not John Soucy use the return Name of Inspector key. Soucy's Sewer Service ran Company Name z 78 N. Broadway - Company Address Salem NH 03079 City/Town State Zip Code 603-898-9339 13397 _ 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 ❑ Neeedsa Further Evaluation by the Local Approving Authority r r 05/16/2011 Inspecior's Signature Date Tie system inspector shall su it a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. on t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 310 Berry St Property Address Kevin Abernathy — Owner Owner's Name information is North Andover MA 01845 05/11/2011 required for every — page. City/Town State Zip Code Date of Inspection 13. 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): t5ins•09/08 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 2 of 17 f' Commonwealth of Massachusetts N =r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 110 Berry St_ — Property Address Kevin Abernathy — Owner Owner's Name information is required for every North Andover MA 01845 05/11/201 1 -_ — page. City/Town State Zip Code Date of Inspection B. Certification (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 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 t Commonwealth of Massachusetts w� Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form Not for Voluntary Assessments 310 Berry St. Oroperty Address Kevin Abernathy — Owner Owner's Name information is MA 01845 05/11/2011 required for every North Andover _ — 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. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® 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 '/2 day flow t5ins•09/08 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 310 Berry St. — Property Address Kevin Abernathy Owner Owner's Name information is MA 01845 05/11/2011 required for every �Jorth Andover — _ _— — page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® 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 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 ❑ ❑ 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. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 t51ns•09108 Commonwealth of Massachusetts -U-4 Title 5 Official Inspection Form !l r" I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 310 Berry St. _ Property Address Kevin Abernathy Owner Owner's Name information is North Andover MA 01845 05/11/2011 required for every — — --- page. City/Town 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): 5 - Number of bedrooms (actual): 5 - DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): .550 t5ins•09108 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts tTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^N 310 Berry St. -- -- Property Address Kevin Abernathy — Owner Owner's Name information is North Andover MA 01845 _ 05/11/2011 required for every — ty/Town State Zip Code Date of Inspection page- C D. System Information Description: 4 Number of current residents: 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 Seasonaluse? ❑ Yes ® No On well water Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ® Yes ❑ No Current Last date of occupancy: 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: Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 t5ins•09/08 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 310 Berry St. _ Property Address Kevin Abernathy Owner Owner's Name information is MA 01845 05/11/2011 required for every North Andover State Zip Code Date of Inspection page. City/Town D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Gauge on truck Reason for pumping: maintenance &4nspection 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•09108 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 V C p C a 310 Berry St. Property Address Kevin Abernathy Owner Owner's Name information is MA 01845 05/11/2011 required for every North Andover page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: House 30 years old _ Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 15" _ Depth below grade: feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >100 to S.A.S.feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" cast iron thru wall 3" PVC in house Septic Tank (locate on site plan): 5" Depth below grade: 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 6'X11' Dimensions: 3" Sludge depth: t5ins•09708 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 a, 310 Berry St. Property Address Kevin Abernathy _ Owner Owner's Name information is North Andover MA 01845 05/11/2011 required for every ._— 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 38" -- - - Scum thickness 2 - - Distance from top of scum to top of outlet tee or baffle 7 — - Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Tape & Sludge tool Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumped septic tank. Pipe comes into tank on side, inlet tee not being used. Inlet too ok, outlet too ok. Depth of liquid at outlet invert. No evidence of leakage. I 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•09/08 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 ^'tee 310 BerrySt. t. — Property Address Kevin Aberna� Owner Owner's Name information is MA 01845 05/11/2011 required for every North Andover 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 i Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: bate Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form Not for Voluntary Assessments "M 310 Ber St. Property Address Kevin Abernathy Owner Owner's Name information is North Andover MA 01845 05/11/2011 required for every _ - page. City/Town 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 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.): Flow checked ok. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts title 5 Official Inspection Form m� j! Subsurface Sewage Disposal System Form Not for Voluntary Assessments ^M 1 310 Bei St. Property Address Kevin Abernathy -- —__— — -- Owner Owner's Name information is MA 01845 05/11/2011 required for every North Andover _ --- State Zip Code Date of Inspection page. City/Town D. System Information (cont.) Type: ❑ leaching pits number: - ❑ leaching chambers number: - ❑ leaching galleries number: - — ® leaching trenches number, length: 3 (40) ❑ 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form I. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 310 Berry St. -- — Property Address Kevin Abernathy — Owner Owner's Name information is North Andover MA 01845 05/11/2011 —_ required for every State Zip Code Date of Inspection page. CitylTown 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 lan):Materials of construction: - -- Dimensions -- Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 J Commonwealth of Massachusetts _ Title 5 Official Inspection Form 1, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 310 Berry St. _- Property Address Kevin Abernathy - -- Owner Owner's Name information is North Andover MA 01845 05/11/2011 required for every State Zip Code Date of Inspection page. City/Town 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 i i Driveway I i House To Weil Garage I, A B I Deck iD- BoX Septic Tank 2 1 I AtoI=381 Ato2=301 A to D-Bog=7161) B to I=311711 B tot=3815" B to D Bog=621 I I Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 t5ins•09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form ISubsurface Sewage Disposal System Form - Not for Voluntary Assessments 310 Berry St. — --- r'roperty Address Kevin Abernathy Owner Owner's Name information is MA 01845 05/11/2011 required for every North Andover _ _ page. City/Town 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: 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: pate ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Dint hole with auger in low drop off area. _ Before filing this Inspection Report, please see Report Completeness Checklist on next page. t51ns•09/08 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 uz X, 310 Berry St. _ Property Address Kevin Abernathy Owner Owner's Name information is North Andover MA 01845 05/11/2011 required for every _ page. City/Town 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts w City/Town of No Andover System Pumping Record Form 4 M fy' 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,thisform check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from h pumping date in accordance with 310 CMR 15.351. No; j IVvr �vrn�rt/-dgl�:�y411 A. Facility Information F cALTH Important:When filling out forms 1. System Location: on the computer, use only the tab '310 rq key to move your Address cursor-do not No Andover Ma use the return key. City/Town State Zip Code r� 2. System Owner: Name 2Gun Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 16 —1 S 2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) �' Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: tn�Ci� 6. System Pumped By: Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Ste 's Pre- tment Plant, 20 So. Mill Bradford, Ma 01835 Lam/-► Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 1: 1 Town of North Andover NORTN ?°6S1lED ne'.'I° Office of the Health Department 3 4.yr Community Development and Services Division " 27 Charles Street - ' North Andover,Massachusetts 01845 9SSACNus�t< Susan Y. Sawyer,REHS/RS 978.688.9540-Phone Public Health Director 978.688.9542-Fax f RTjq7jCAr1'(F OF CO3V1r'.GIA9VM As of: .May 20, 2004 This is to cert that the individualsu6surface disposa[system' repaired(f� — component Only — Tank Rep&cement by ,john Soucy at 310 Berry Street North Andover, JKA 01845 has 6een installed in accordance with the provisions of Ttfe v of the State Sanitary Code and with the North Andover Board ofYfealth regulations. The Issuance of this certificate shall not 6e:construed as a guarantee that the system will function satisfactorily. Susan T Sawyer, RE9TSlgU Bu6Ctc I fealth Director BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 { h Andover /e artment Date: P of &,/eqWORKS CONSTRUCTION PERMIT zcate Address, if Residential,or, ame of Business) r `Check#: ,�` [ZRENT INSTALLER'S LICENSE# Type of Permit or License:(Circle) 051,rUA � ➢ Animal $ ➢ Dumpster $ ➢ Food Service-Type: $ ➢ Funeral Directors $ TELE10NE# ➢ Massage Establishment $ ➢ Massage I3ractice $ ➢ Offal(Septic)Hauler $ CONSTRUCTION: ➢ Recreational Camp $ ➢ SEPTIC PERMITS. ATTACH FOUNDATION AS-BUILT. ❑ Septic-Soil Testing $ ❑ Septi Design Approval $ ' eptic Disposal Works Construction(DWC)$ ttistrative Use Only ❑ Septic Disposal Works Installers(DWI) ' $ ➢ Sun tanning $ No ➢ Swimming Pool $ _ No ➢ Tobacco $ ➢ Trash/Solid Waste Hauler $ No ➢ Well Construction $ Date: l ➢ OTHER:(Indicate) - 055 Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer TOWN OF NORTH ANDOVER of �o DrH qti Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT x 27 CHARLES STREET * x ry �gATlC wP¢y,�j NORTH ANDOVER,MASSACHU ETTS-01845 �SSacH�SEs 978.688.9540-Phone Susan Sawyer,RENS/RS 978.688.9542-FAX Public Health Director healthdept@townofnorthandover.com www.townofnorthandover.coni FAX TO: From: Fax: Pages: 6 le Phone: Date: ' Z410 Re: CC: ❑ Urgent ❑ For Review ❑ Please Comment ❑ Please Reply ❑Please Recycle Please contact the Health Department at the above numbers for further assistance. a r HP Oki i Ali Log for NORTH ANDOVER 9786889542 May 28 2004 2:39pm Last Transaction Time Toe Identification Duration Pages Result M4 �8 2:37pm Fax Sent 819786947274 1:10 3 OK RECEIVED ' Commonwealth of Massachusetts ,; _ . City/Town of NORTH ANDOVER MASS AC U �T ES System Pumping Record TOWN OF NORTH ANDOVER Form 4 HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: forms on the r computer,use / t � only the tab key d ss c move your ) r �1 /K/c cursor-do not Ci /Town V� uu..JJ VV An( use the return State Zip Code key. 2. S stem Owner. �^ , 1/ 1 Name Address(if different from location) Cityrrown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. :Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank "IkO Other(describe): 4. Effluent Tee Filter present? E3 Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Name Vehicle License Number Company 7. Location where contents were disposed: Signature of Hauler Date http://www.mass.gov/deptwater/approvals/t5forms.htm#inspect t5forrn4.doa 06/03 System Pumping Record•Page 1 of 1 �fQ 1✓f h 3 { M , c SS ACHUSETTS i � ' ` l=p..has provided jhts form for uae by local Boards of Health, The System Pumping ba +ubmlt�edyto'the local Board of Hoalth or other approving authority, A;. Facility IntotgatIon 471�pr-WL " 04n tiIJ119 0v1 System Louuon, ' CA?lpUW, l:Sd', �i/o ply 0 ltb k4 Addre') uie tM ntum`:��';;: - ,CIt�lTam Stale 7�n Aly,�J,��wAl'j�1�'/„J'1''.,.'.1;,'•rlid'.),r,,,�,!.•'.., ..:,��, ,. .. / Cooa _. 1.' I1,,�•i;�,2'!r;-$Yvem 0WneP ,,,; •. . , i �. •-,�ji :1 i;..itj�,^;'t�,y�,j]11. .;., 1 ;lw.n '17,�'„1,:; un :i'• Addre+i (II dlKerenl rpm IQUQn) kylT ovrn ._ ... ice O� S tate F ffl U w — 19 Aj SLVA � Telephone Numoer ,i... '.y:;1;;;'Y�:c: '•',��,t>' `�,';',r , � � PPRP \O NcE � Rumpin PIN ' -- •, • ''1, Oal9 of Pumping 2' ry Quant' Pumpedi S� Oa 3 ; -- 3,. `,TyP.9 Pf.ayatam;• ❑ Cesspools) eptic T �,,,, } :�•�. ank ❑ TI9ht Tank .' tfluerit•Tea Fllter pr�•s.ent? ..❑ Yes o . *('rtj 7 If yes, was II cleaned? ❑ Yes r' �” n�r•/,,� '.].'rtn''y1,(f:(ft•J,J' L...,',i.ult 1'JJJ.?di:: '„ __._� ,�. ., ! ;� ...1.lyvr(..••'�:�; �1"' tt��l.�V',��I./ , 1., i,y 1r,,. ..1. Vehlc' U 1 K ' • ., '•�;`,I��:,i�.i�:�;�:r:;��'�fH'��1q �'.(I'I'T.''�y�vy1,1��.'irtti�,'+��'/li��.�.. .. . .. ../, 'r ..r(•('. �., lel 7 I 1^; r(�1„ ��( 1' fir;rl',':';t:1: '- . , t;'�•,;.' :.):T;. Loce on.wh8re'conlenls' ere dl r, S .(Jif':1!•'�• :/'•�--.1]�I�r:.�:. �I 1 �•�.1'I'' '�I• ';•,::.x�,''�; '�:�r�•,',: :.,,Slpnelwe o(H wlef; � �-.Y.•.',,:..I:. .' octe U ' hr.��hvw�i'mass,gov/daphvele�/approvaJa/t6forms,htm.#Inspect i Sy�tam PumpinP Recap %i; TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE 8/24/01 This is to certify that the distribution box constructed ( ) or repaired (X) by John DiVincenzo at 310 Berry Street has been repaired in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations. The Issuance of this certificate shall not be construed as a guarantee that the system_ will function satisfactorily. Board of Health Inspector BOARD OF HEALTH NORTH ANDOVER, MA 01845 978-688-9540 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: o/ CURRENT INSTALLER'S LICENSE# LOCATION:_-?,/0 e/ LICENSED IN TA LER: v v v ,` e�� SIGNATURE: ELEPHONE# 2 9--,3 7,� -2112 J CHECK O REPAIR: NEW CONSTRUCTION: 1b_ bolc IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. Administrative Use Only $4-68 Fee Attached? Yes No Foundation As-Built? Yes No Floor Plans? Yes No I--. Approval_ �}� %/I�� Date: 2s l Form No.3 Town of North Andover, Massachusetts BOARD OF HEALTH �L049/ i pORTM of 1e1M0 - r 3? .!�. •-� of O 9 F DISPOSAL WORKS CONSTRUCTION PERMIT ,SS/ICHUS�� 1 Applicant TELEPHONE NAME ff A ESS 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 � a D.W.C. No. �a �^ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION J F V 6 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_310 Berry Street_ _North Andover_ Owner's Name: Harley Cooper_ Owner's Address: 310 Berry Street North Andover,MA 01845 Date of Inspection 5/1/2004_ Name of Inspector: Neil J Bateson Company Name: Bateson Enterprises Inc._ Mailing Address:_111 Argilla Road_ _Andover,Ma.01810_ Telephone Number:_(978)475-4786_ 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 X Conditionally Passes Needs Further Evaluation by the Local Approving Authority F Rs � I Inspector's Signature: Date: _5/1/2004— The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. 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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 310 Berry Street_ _North Andover Owner: Cooper Date of Inspection:_5/1/2004 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: _X_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.Septic tank leaking,needs replaced. Y 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: N 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 remdved distribution box is leveled or replaced ND explain: _N` The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 310 Berry Street _North Andover — Owner:_Cooper_ Date of Inspection: 5/1/2004_ 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 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. — The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 fat or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 310 Berry Street_ _North Andover — Owner:_Cooper Date of&spection: 5/1/2004 D. System Failure Criteria applicable to all systems: You must indicate"yes"or`n&'to each of the following for all inspections: Yes No _ No Backup of sewage into facility or system component due to overloaded or cloaaed SAS or cesspool _No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _No_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ No Liquid depth in cesspool is less than 6"below invert or available volume is 1/2 day flow. No Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ No Any portion of the SAS,cesspool or privy is below high ground water elevation. No Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ _No Any portion of a cesspool or privy is within a Zone 1 of a public well. _No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis most be attached to this form.] No (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 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 gYoou must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply — _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone H 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. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 310 Berry Street_ _North Andover_ Owner:_Cooper Date of Inspection: 5/1/2004_ Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Yes_ _ Pumping information was provided by the owner,occupant,or Board of Health _No Were any of the system components pumped out in the previous two weeks? No Has the system received normal flows in the previous two week period? Owner away last week No Have large volumes of water been introduced to the system recently or as part of this inspection? N/A _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) Yes_ _ Was the facility or dwelling inspected for signs of sewage back up? Yes _ Was the site inspected for signs of break out? Yes _ Were all system components,excluding the SAS,located on site? _Yes_ _ 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? _Yes_ _ 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 _Yes_ _ Existing information. Old Tide 5 Report _No_ 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)] Page 6 of 11 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 310 Berry Street _North Andover Owner: Cooper Date of Inspection: 5/1/2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_N/A Number of bedrooms(actual):_5_ DESIGN flow basad on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):_N/A_ Number of current residents:_3 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no):_No Laundry system inspected(yes or no):_ Seasonal use:(yes or no): No Water meter readings:_On well water_ Sump pump(yes or no): Yes Last date of occupancy: Current COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(basal on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:_Pumped 2001,owner_ Was system pumped as part of the inspection(yes or no): No If yes,volume pumped:gallons—How was quantity pumped determined?_ Reason for pumping: TYPE OF SYSTEM X_Septic tank,distribution box,soil absorption system T Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval _Other(describe):_ Approximate age of all components,date installed(if known)and source of information: 23 years old,owner Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 310 Berry Street _North Andover_ Owner: Cooper_ Date of Inspection: 5/1/2004_ BUILDING SEWER_X_ (locate on site plan) Depth below grade:_15" Materials of construction X cast iron —X-40 PVC_other Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.):_4"Cast iron thru wa1L 3"PVC in house_ SEPTIC TANK: X_(locate on site plan) Depth below grade: 3"_ Material of construction:—X—concrete metal_fiberglass_polyethylene _other(explain) If tank is metal list age:____ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 10'x 5'x 4'_ Sludge depth 211 _ Distance from top of sludge to bottom of outlet tee or baffle: N/A Sewn thickness:_1"_ Distance from top of scum to top of outlet tee or baffle:_N/A N/A=Tank Leaking Distance from bottom of scum to bottom of outlet tee or baffle:_N/A_ How were dimensions determined: _ Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.):_Pipe enters tank on side,inlet tee not used.Outlet tee corroded on top.Depth of liquid below outlet invert.Evidence of tank leaking out. 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 to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 1 i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_310 Berry Street_ _North Andovcr_ Owner: Cooper Date of Inspection: 5!1/2004 TIGHT or HOLDING TANK: (tank must be pumped at time of inspedion)(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: X (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-boa level& distribution equal No evidence of leakage out of d-box.No evidence of carryover._ PUMP CHAMBER: (locate on site plan) Pump in working order(yes or no):— Alarm in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 310 Berry Street _North Andover Owner._Cooper Date of Inspection: 5/1/2004 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching cumbers,number: leaching galleries,number: _X leaching trenches,number,length: 3 trenches 40'long_ leaching fields,number,dimensions: overflow cesspool,number: innovativelalternative system Typetname 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 inspectionxlocate 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 or no): 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.): Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_310 Berry Street_ _North Andover— Owner: Cooper_ Date of Inspection: 5/l2004 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. Driveway House To Well Garage A B Deck Boz Septic Tank 2 1 Ato1=38' Ato2=30' A to D-Boz=7'6" BtoI=31'7" Bto2=38'5" B to D-Boz=62' Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_310 Berry Street _North Andover_ Owner:Sooper_ Date of Inspection: 5/1/2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water >61 _ 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) X Accessed USGS database-explain: Essex County Soil Map You must describe how you established the high ground water elevation:_Essex County Soil Map,Sheet#40, Canton Soil,Water>6'Deep_ Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating-Water.&Sewer Lines-Septic Systems&Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 310 Berry Street, North Andover Owner: Cooper Date of Inspection: 5/1/2004 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. 4 Neil J. Ba on Bateson Enterprises,Inc. COMMONWEALTH OF MASSACHUSETTS Ro, ' z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS n d DEPARTMENT OF ENVIRONMENTAL PROTECTION w ti ti Y ''fib Svev TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 310 Berry Street_ _North Andover_ Owner's Name:_Benjamin BoBo_ Owner's Address:_310 Berry Street _North Andover,Ma.01845_ Date of Inspection:6/20/2001_ Name of Inspector:_Neil J.Bateson JVI� Company Name: Bateson Enterprises Inc._ 9?�� Mailing Address:_111 Argilla Road_ _Andover,Ma.01810_ Telephone Number:_(978)475-4786 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 _X_ Conditionally Passes Needs Further Evaluation by the Local Approving Authority sAInspector's Signature: �tJDate: _6/20/2001_ The system inspector shall Sulcopy is mspection report to the Approving Authority(Board of Health or DEP)within 30 days of comp g 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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:j10 Berry Street_ _North Andover — Owner: Bobo Date of Inspection:_6/20/2001_ 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: _X_ 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. Needs new D-Bog. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. _N The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: _N_ 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: _N The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 • OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_310 Berry Street _North Andover_ Owner: Bobo Date of Inspection: 6/20/2001 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 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. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_310 Berry Street _North Andover— Owner: Bobo Date of Inspection:_6/20/2001_ D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _No_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _No Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow —No Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped No— Any portion of the SAS,cesspool or privy is below high ground water elevation. No, Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. No Any portion of a cesspool or privy is within a Zone 1 of a public well. _No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] No (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 be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd- You must indicate either"yes"or`no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:_310 Berry Street_ _North Andover_ Owner: Bobo Date of Inspection:_6/202001_ Check if the following have been done.You mast indicate`des"or"no"as to each of the following: Yes No Yes _ Pumping information was provided by the owner,occupant,or Board of Health No Were any of the system components pumped out in the previous two weeks? Yes_ _ Has the system received normal flows in the previous two week period? T No Have large volumes of water been introduced to the system recently or as part of this inspection? N/A Were as built plans of the system obtained and examined?(If they were not available note as N/A) Yes _ Was the facility or dwelling inspected for signs of sewage back up? _Yes_ _ Was the site inspected for signs of break out? Yes _ Were all system components,excluding the SAS,located on site? _Yes_ _ 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? _Yes_ _ 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 N/A _ Existing information.For example,a plan at the Board of Health. _ _No_ 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)] Page 6 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 310 Berry Street_ North Andover— Owner• Bobo Date of Inspection: 6/20/2001_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_N/A_ Number of bedrooms(actual):_5_ DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):_N/A Number of current residents:_4 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no):_No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):—No_ Water meter readings:_On well water_ Sump pump(yes or no):—Yes_ Last date of occupancy:_Current COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:_Pumped seven years ago,owner_ Was system pumped as part of the inspection(yes or no): Yes_ If yes,volume pumped:_1500_gallons--How was quantity pumped determined?_Measured tank_ Reason for pumping:_Inspect tank&tees_ TYPE OF SYSTEM _X_Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: House 20 years old, owner Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 310 Berry Street_ North Andover — Owner: Bobo Date of Inspection: 6!20/2001_ BUILDING SEWER(locate on site plan)X Depth below grade:_15" Materials of construction:—X—cast iron _X_40 PVC other(explain): Distance from private water supply well or suction line:_>100 to S.A.S._ Comments(on condition of joints,venting,evidence of leakage,etc.):_4"cast iron thru wall 3"PVC in house_ SEPTIC TANK: X locate on site plan) Depth below grade:—3"_ Material of construction:—X—concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:_101 x 5'x 4' Sludge depth: 8" Distance from top of sludge to bottom of outlet tee or baffle:_19"_ Scum thickness:_8" 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:_13" How were dimensions determined: Subtract scum&sludge depth to tee length. Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.):_Pumped septic tank Pipe comes into tank on side,inlet tee not being used.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:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 310 Berry Street_ North Andover_ Owner: Bobo Date of Inspection: 6/20/2001_ TIGHT or FOLDING 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._X (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 cover broken&d-boa filled with sand.Camera leach lines no sand in same. D-bog needs replaced.Evidence of leakage.Evidence of carryover._ PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 310 Berry Street North Andover — Owner: Bobo Date of Inspection: 6/20/2001_ SOIL ABSORPTION SYSTEM(SAS):_X (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: X leaching trenches,number,length: 3 trenches 40'long_ leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Typelname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.):_Soil oL Vegetation oL 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 or no): 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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 310 Berry Street North Andover Owner: Bobo Date of Inspection:_6/20/2001_ 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. Driveway O Garage House To Well loolz A B Deck D- Box 3 2 1 Seutic Tank Ato =38' F401] 2 A to 2=33'9" Ato3=30' A to D-Boz=716" Bto1=31'7" Bto2=34'10" Bto3=38'5" B to D-Bog=62' ' Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_310 Berry Street_ _North Andover_ Owner: Bobo Date of Inspection: 6/20/2001_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water >6 feet 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) X Accessed USGS database-explain:_Essex County Soil Map_ You must describe how you established the high ground water elevation:_Essex County Soil Map,Sheet#40, Canton Soil,Water>6'deep _ Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating-Water.& Sewer Lines-Septic Systems&Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 310 Berry Street, North Andover Owner: Bobo Date of Inspection: 6/20/2001 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Neil J. Bateson Bateson Enterprises, Inc. w Town of North Andover of No RTy Office of the Health Department o? Community Development and Services Division �� • �` 27 Charles Street North Andover,Massachusetts 01845 �9SsArwl Susan Y. Sawyer,REHS/RS 978.688.9540-Phone Public Health Director 978.688.9542-Fax CE1��IIFICA�I2 OE CO.�VI�.GA-1 As of: May 20, 2004 This is to certify that the individualsubsurface disposalsystem' repaired(4v' — Component Only — TankReplacement by ,john Soucy at 310 Berry Street North Andover, 911A 01845 has been installed in accordance with the provisions of T fe V of the State Sanitary Code and with the North Andover Board ofYfealth regulations. The Issuance of this certifwate shall not 6e construed as a guarantee that the system will Junction satisfactorify. Susan 2:Sawyer, RUTSIWS P46Ck Ylealth Director BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Commonwealth of Massachusetts Map-Block-Lot 108.C-0052- ----------------------- Board Of Health Permit No 0 North Andover BHP-2004-0372 j B 0----------------------- P.I. FEE F.I. $250.00 1 Disposal Works Construction Permit i Permission is hereby granted John_Soucy----- --- ---------------------------------------------------------------- to ------- - to(Repair)an Individual Sewage Disposal System. i at No 310 BERRY STREET- 6T__-Tank___Replacame_nt_Only--------------- -__---- as shown on the application for Disposal Works Construction Permit No. BHP-20047037 Date May 13,_2004__--__-------- - ---------------------- � Issued On:May-13-2004 Boarf Hea ............................................................................................................................................................................... Commonwealth of Massachusetts Map-Block-Lot 108.C-0052- Board Of Health ----------- North Andover Certificate of Com nce THIS IS TO CERTIFY That the Indiv�l Swage Disposal System (Repair) by John Soucy .. --- -------------------------------------------------------------------------- I Installer ! at No 310 BERRY STREET/ has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Dispo Works Construction Permit No. BHP-20047037 Dated May 13,_2004 ------------------------------------ Printed Om- ay-13-2004 Board Of Health ------------------------------------------ ------------------- J To;,Vn of North Andover Health 'Department Date: Location: v�0 ✓/ i (Indicate Address, if Residential,or kame of Business) Check#: Type of Permit or License:(Circle) ➢ Animal $ ➢ Dumpster $ ➢ Food Service-Type: $ ➢ Funeral Directors $ ➢ Massage Establishment $ ➢ Massage Practice $ ➢ Offal(Septic)Hauler $ ➢ Recreational Camp $ ➢ SEPTIC PERMITS: ❑ Septic-Soil Testing $ ❑ Septic/ -Design Approval $ /� .` m5eptic Disposal Works Construction(DWC)$ - Septic Disposal Works Installers(DWI) $ ➢ Sun tanning $ ➢ Swimming Pool $ ➢ Tobacco $ ➢ TrashlSolid Waste Hauler $ ➢ Well Construction $ ➢ OTHER:(Indicate) y� 055 Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer r APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: �'— ��'I CURRENT INSTALLER'S LICENSE# LOCATION: 310 LICENSED INSTAL SIGNATURE: u TELEP ONE# CHECK ONE: ev REPAIR: W(,K—tfW,7+ NEW CONSTRUCTION: Ent L v IF NEW CONSTRUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. z �`� �' " Administrative Use Only $ 00 Fee Attached? Yes No Foundation As-built? Yes No Floor plans on file - Yes No Approval Date:--5'-/j/ oard of Health SEPTIC SYSTEM ort:? Aric).overzMaes. INSTALLATICK CHECK LIST LOT Z�3E& �, 7 P u—m DATE 5FT–RU ID t 3Z AVATION OF FAIL eammst - OK I. Distance Tot / a. Wetlands b. Drains c. Well 2. Water Line Location 3• No PYC Pipe 4. Septic Tank a. _Tees -_Length & To Clean Ont Covers. b. Cement Pipe to Tank On Both Sides of Tank 5. Distribution Boa a. Covers & Box - No Cracks b. All Lines Flowing dial Amounts C. No Back Flow 6. - Leach Field or Trench a. Dimensions b. Stone Depth c: Capped Eads d. Clean Double Washed Stone 7. Leach Pits a. Dimensions b. Stone/Depth c. Splash Pads d. Tees e. C t Pipe to Pit - Both Sides. f. Olean Double Washed Stone j 8. No Garbage Disposal 9. Final Grading Inspection / 10. Barricading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System c. Location with Regard-to Perc Test d. Elevations e. Water Table TO: NORTH ANDOVER, MASS 19 � BOARD OF HEALTH ✓ FROM: DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at L 96,q9Y -57- North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated 19 MONWEgjTy Reg. njOn r/R -5itarian /V0 0 Tl=- `SED 9��ARiAt �yy 0 u A/D PL I/� Health adover,Mass SUBSURFACE DISPOSAL DESIGN CEBCK LIST LOT ` PPROVED DATE DISAPPROVED DATE_______ rovided: Reasons: 7- //�71 itle FAIL OK eg 2.5 a submitted plan must show as a minimum: the lot to be served-a.rea,dimensions lot #,abutters ation and log deep observation Mes-distance to ties cation and results percolation tests-distance to ties sign calculations & calculations showing required leaching area location and dimensions of system-including reserve area the and proposed contours r' disclaimer-check ation any vat areas vithin 100' of sewage disposal system or wetlands mapping face and subsurface drains within 100' of sewage disposal tem or disclaimer ation any drainage easements within 100' of sewage disposal systtn or disclaimer-Plug Board files (J) known sources of vater supply within 2001 of sewage disposal system or disclaimer location of any proposed well to serve lot-1001 from leaching facility cation of water lines on property-101 from leaching facility location of benchmark driveways o arbage disposals PVC to be used in construction q) profile of system-elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and Other elevations maximum ground water elevation in area sewage disposal system IX'(s) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Reg 6 Septic Tanks v .(a) aap�ties-150 of flog, water table, tees, depth of tees, access, pumping ( cl eanout 10t from cellar wall or inground swimadmg pool d) 251 from subsurface drains Reg 10.2 stribution Boxes s ope greater 0.08 Reg 10.4 b} sump ' P e2 9nbNu�race Desi Check List FAIL CK Leaching Pits Leaching pit /'are preferred mere the installation is possible leg 11.2 a) calculati s ¢f-leaching area-minimam 500 eq ft 11.4 b) spacing 11.10 c snrfaCe�a 2 11.11 d� cove material e) it 'x4l, splash pad f) a at elbow no bends in pipe from d-box to pipe LeachingFields teg 15.1 a) no greater tb 20 minutes/inch area-minim m 900 sq ft 15.4 construction of field 15.8 ) surface drainage 2 % 3.7 e) 20t from cellar van or inground swimming pool Leaching Wenches teg 14.1 &)—calculations or leaching area-min 500 aq ft 14.3 1 b) spacing-4 ft min 6 ft with reserve between 14.4 c) dimensions 14.6 d) construction 14.7 e) stone 14.10 f) surface drainage 2% Downhill $122-! a) slope y/x = (to be shown) b) y/x X 150 - (to be shown) EMS Reg 9.1 a) approval 9.6 b) stand-by power E_57; '61 / 1.21117 1 t to N k Box, ou..T _..._.-'1.3 •32- I f i o. 1 e f I1 l 1 �r r� AN t7 1�540 r� 9 __ OW►JF i2 ' I OWN 5 H 1 I' RSA 1. 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