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HomeMy WebLinkAboutMiscellaneous - 345 CANDLESTICK ROAD 4/30/2018. -� MAP LOT # ..................... ................. ... ........... ..... __.... ..... � ' PARCEL'' STREET C�,� `_-�������c��,c.��,�.�---�... APPROVAL �� ��� HAS PLAN REVIEW FEE BEEN PAID? NO ^' PLAN APPROVAL: DATE APP. BY -° DESIGNER: PLAN DAT . ' ' CONDITIONS—% '. ~~ � , ` '~ . ^ WATER SUPPLY: WELL .^ ^ WELL PERMIT DRILLER____________ �j.. . WELL TESTS: CHEMICAL DATE APPROVED_______ BACTERIA I DATE UPPRUVEU '`.-' ^, BACTERIA II DAlE FORM U APPROVAL: DATE ISSUED CONDITIONS: FINAL APPROVAL: A NO 1B__ .... .... ....... ALL PERMITS PAID WELL CONSTRUCTION APPROVAL SEPTIC SYSTEM CONSTRUCTION APPROVAL OTHER ANY VARIANCE NEEDED FINAL BOARD OF HEALTH APPROVAL: YES NO YES NO YES NO YES NO YES NO $ERjkCL F L.Lf IS THE INSTALLER LICENSED? TYPE OF CONSTRUCTION:NLW ES NO REPAIR " ik NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YES 140 CONDITIONS OF APPROVAL YES NO (FROM FORM U) ISSUANCE OF DWC PERMIT YES NO LLER: DWC PERMIT NO. 5"41 INSTA ._-Lu -1 q BEGIN INSPECTION YES J0: 0-10,00v NEEDED: ,Ole 11 t.lEXCAVATIONJNSPECTION: /00 0 Wll: w PASSED ah By -7T- _7 CONSTRUCTION INSPECTIONs NEEDED: ........ . AS BUILT PLAN SATISFACTORYc YES: lie Z00110" APPROVAL TO BACKFILL. DATE:—/ BY ... ........ ... FINAL GRADING APPROVAL: DATE FINAL CONSTRUCTION APPROVAL: DATE:___. 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DATE: LOCATION: ,..3 9'�S � " H/O NAME: J-0" 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 $ ❑•'i 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) $ 01 -.Title 5 Inspector $ Qi tid ❑ Title 5 Report $ ❑ Other. (Indicate) $ 17 Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Owner ,— information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. rerun Commpnwealth of Massachusetts Title 5 Official -Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 345 Candlestick Road Property Address John & Debbie Miller Owner's Name North Andover City/Town MA 01845 State Zip Code 6/27/2012 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. A. General Information 1. Inspector: Neil James Bateson Name of Inspector. Bateson Enterprises Inc. Company Name RECEIVED JUL -i 2 2012 TOWN OF NORTH ANDOVER 111 Argilla Road Company Address Andover MA 01810 Citylrown State 978-475-4786 S115 Telephone Number B. Certification License Number Zip Code 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 ❑ Nee s F rther E aluation by the Local Approving Authority / { 6/27/2012 Insp„cto gnature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 345 Candlestick Road Property Address John & Debbie Miller Owner Owner's Name information is required for North Andover MA 01845 6/27/2012 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 345 Candlestick Road Property Address John & Debbie Miller Owner Owner's Name information is required for North Andover MA 01845 6/27/2012 every page. Citylrown 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 • 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 345 Candlestick Road Property Address John & Debbie Miller Owner's Name North Andover MA 01845 6/27/2012 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) p 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y day flow t5ins .11/10 Title 5 Official 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 M 345 Candlestick Road Property Address John & Debbie Miller Owner Owner's Name nformation is required for North Andover MA 01845 6/27/2012 very page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No F1® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: El® Any portion of the SAS, cesspool or privy is below high ground water elevation. El® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El® Any portion of a cesspool or privy is within a Zone 1 of a public well. El® Any portion of a cesspool or privy is within 50 feet of a private water supply well. 1:1® 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.] i e ❑ ® 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. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 ❑ ® 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. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 345 Candlestick Road Property Address John & Debbie Miller Owner's Name North Andover Cityrrown C. Checklist MA 01845 State Zip Code 6/27/2012 Date of Inspection 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: A Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Gnr% Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 345 Candlestick Road Property Address John & Debbie Miller Owner Owner's Name information is required for North Andover MA 01845 6/27/2012 every page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Yes Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins • 11/10 Title 5 Official Inspection form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 345 Candlestick Road Property Address John & Debbie Miller Owner Owner's Name information is required for North Andover MA 01845 6/27/2012 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: Date Pumped 2011, owner 1500 gallons Mesured tank Inspect tank & tees. ® Yes ❑ No ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,. 345 Candlestick Road Property Address John & Debbie Miller Owner information is required for every page. Owners Name North Andover City/Town State Zip Code 6/27/2012 Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 21 years old, 12/2/1991, as built plan Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 16 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" PVC thru wall to tank 3" PVC in house. No leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal .6 feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 10'x 5'x 4' Sludge depth: 1" ❑ Yes ❑ No t5ins • 11/10 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 s345 Candlestick Road Owner information is required for every page. t5ins - 11/10 Property Address John & Debbie Miller Owner's Name North Andover Cityrrown D. System Information (cont.) Septic Tank (cont.) MA 01845 6/27/2012 State Zip Code Date of Inspection Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumped septic tank. Inlet tee ok. Outlet tee ok. Outlet filter partially clogged, clean same. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): 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 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 345 Candlestick Road rropeny Aaaress John & Debbie Miller Owners Name North Andover MA 01845 6/27/2012 Cityrrown 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 El other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins - 11/10 Title 5 Official Inspection Fonn: Subsurface Sewage Disposal System - Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 345 Candlestick Road Property Address John & Debbie Miller Owner's Name North Andover nnn Cityrrown State D. System Information (cont.) 01845 6/27/2012 Zip Code -Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D -box cover broken, replaced it. D -box level & distribution equal. No evidence of leakage. Evidence of carryover, pumped d -box to clean. 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 • 11/10 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Owner information is required for every page. t5ins - 11/10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 345 Candlestick Road Property Address John & Debbie Miller Owner's Name North Andover MA 01845 6/27/2012 Cityrrown State Zip Code -Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 3 trenches 61' long ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 345 Candlestick Road Property Address John & Debbie Miller Owner's Name North Andover City/Town D. System Information (cont.) MA 01845 6/27/2012 State Zip Code Date of Inspection Comments (note condition of soil, signs of hydraulic failure, level of Ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins • 11/10 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 14 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 345 Candlestick Road Property Address John & Debbie Miller Owner Owner's Name information is required for North Andover MA 01845 6/27/2012 every page. Cityrrown State Zip Code -Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately �r� t A '�o to i a=3Lt 3=2atgll 7Jam.SG t �V0 � n 3 ' "7 11 e -ems= L4S'311 k t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 345 Candlestick Road Property Address John & Debbie Miller Owner's Name North Andover MA 01845 6/27/2012 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: '4 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 8/7/1989 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Design plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: As per test pit data on design plan shows water 60". Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 11/10 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 M . 345 Candlestick Road Property Address John & Debbie Miller Owner information is required for every page. Owner's Name North Andover MA 01845 6/27/2012 Cityrrown State Zip Code .Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 Summary Record Card generated on 6/14/2012 11:40:02 AM by Karen Hanlon Town of North Andover Tax Map # 210-106.A-0230-0000.0 Parcel Id 17375 345 CANDLESTICK ROAD MILLER, JOHN & DEBBORA 345 CANDLESTICK RD NORTH ANDOVER, MA 01845 Page 1 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.1 Acres FY 2012 UB Mailina Index Name/Address MILLER, JOHN & DEBBORA 345 CANDLESTICK RD NORTH ANDOVER, MA 01845 UB Account Maint. Type Loan Number Payor Active/Inact. From Account No Cycle Occupant Name Active/Inactive Bldg Id. 17641.0 - 345 CANDLESTICK ROAD Last Billing Date 4/5/2012 3170311 03 Cycle 03 Active UB Services Maint. Account No. 3170311 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1 / WTR WATER 01 ALL METER SIZE 125.18 /1 UB Meter Maintenance Account No. 3170311 Brand Serial No Status YTD Cons 36388115 a Active b Badger Date Reading 3/14/2012 288 12/12/2011 259 9/12/2011 232 6/7/2011 205 3/8/2011 169 12/9/2010 137 9/10/2010 103 6/7/2010 62 3/9/2010 22 1/23/2010 0 1/23/2010 2439 12/8/2009 2441 9/9/2009 2396 MSG 6/8/2009 3/13/2009 MSG 12/9/2008 9/8/2008 6/5/2008 3/7/2008 12/11/2007 9/5/2007 6/18/2007 3/15/2007 12/8/2006 Trouble Code:05 9/12/2006 6/14/2006 MSG BLOCKED Until Location Brand Type Size YTD Cons ERT HH b Badger w Water 0.63 0.63 264 Code Consumption Posted Date Variance a Actual 29 4/14/2012 5% a Actual 27 1/17/2012 7% a Actual 27 10/13/2011 -30% a Actual 36 7/20/2011 10% a Actual 32 4/13/2011 -5% a Actual 34 1/12/2011 -12% a Actual 41 10/15/2010 -3% a Actual 40 7/15/2010 -9% a Actual 22 4/14/2010 0% n New Meter 0 4/14/2010 0% r Replacement -2 4/14/2010 -109% m Manual estimate 45 1/12/2010 0% m Manual estimate 45 10/15/2009 -6% 2351 m Manual estimate 45 7/20/2009 8% 2306 m Manual estimate 45 4/29/2009 -2% 2263 a Actual 43 1/20/2009 14% 2220 m Manual estimate 39 10/10/2008 -5% 2181 a Actual 39 7/16/2008 8% 2142 a Actual 35 4/11/2008 18% 2107 a Actual 33 1/22/2008 8% 2074 a Actual 25 10/12/2007 -43% 2049 a Actual 53 7/20/2007 171% 1996 m Manual estimate 20 4/16/2007 -34% 1976 a Actual 27 1/19/2007 -30% 1949 m Manual estimate 40 10/20/2006 118% 1909 m Manual estimate 20 7/10/2006 -17% Commonwealth of Massachusetts City/Town of ° System Pumping Record w Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping- Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left side of house, Right side of house, Left front of house Ri ront of hous Left rear of house, Right rear of house. Left rear of building. Right rear of building. Address City/Town State Zip Code 2. System Owner: Name Address (if different from location) Cityfrown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): 6 --a ti -1 a, — 2. Quantity Pumped' Ej--Septic Tank Date Cesspool(s) 1500 Gallons ❑ Tight Tank 4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? EJZYes ❑ No 5. Condition of System: !v p b --\ 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: /G. 1 Lowell Waste Water of F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record - Page 1 of 1 w � c \. O o rn rn ;o A oZ 3:4 D D r i rn Q rn Z m m N N • rn c Z Z N � n � C N o < rn rn ;v oo< .N rn z0 a Z �. . • m u Yl w V w V N CD 0> ;-q4 ����oJ c: cn r rn m •• m mv� _ -U cn Co '11 Z m �. C K down D ri� v � D Cl1 , t _ rn CD 0> ;-q4 ����oJ c: cn r rn m •• m mv� _ -U cn Co '11 Z m �. C K down D ri� v � D Cl1 , t rn N_ As- eulcr 7 t mss' f�L1Y� . G�olL4q , SAG, G'o2.8 Com. SErr11L �1;M•Ny 3.3.g .�,`1' %' As - Eo I G -r it VATi Du s ; \ f rkiv, G BcfaC F-�J(aZ�! 1mv, ale �-r �� &1,7zj )kjv. Ill eQ-pox IIoI,D7 „ livv ogreb-Box a=16082 h t, It , 1"v, IucE r' -m*j- 160, S It It ,, it 1 P(,I�j a-)60.172 )60.172 1\ ,. N 1• �� �� Tp�wZ, F -L= 160,ZZ r u7T-o- y CEE77F>/ `7714-7—WE. N VEr IiWlP re774Co"gTpi..?TdA4 c� its t rulAL GP N94 NAS 8mr- .I tk1 Ae, ve)W4icC 7 -Tye 4kS q SPE�r(M:17t u ' Ry 7R-7 9 EF. XJVVE A996--lrA7F—S , 2 � 1 1�k nsT )5o�G . 213 N { p _ gcX C. O.C. N b'r1P A ZZ' AS BUILT- PLAN OF SUBSURFACE DISPOSAL SYSTEM LOCATED IN kia2rf+ AuDoVEEF, MA�s AS PREPARED FOR. -1-OOVIAS GAULAQ I DATE : DEFeQ1� SCALE: MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS 0 PLANNERS: 66 PARK STREET 0 ANDOVER, MASSACHUSETTS 01810 0 TEL. (5a8) 475-3555, 373-5721 a�_ Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. iehm Commonwealth of Massachusetts City/Town of NORTH ANDOVER, System Pumping Record Form 4 MASSACHUSETT DEP has provided this form for use by local Boards of Health. be submitted to the local Board of Health or other approving a A. Facility Information System Location: 3�� Ca�ndle�-�ic•k �� Address N66\-) City/Town 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): RECEIVE® 4YAMO 2008 m P mping Re ord must ��yy JALTH D PARTM ENTER State Zip Code State Zip Code _meq 146- q 40b Telephone Number D` 19-01E, 0g 2. Quantity Pumped: / 50d Gallons Cesspool(s) [v]�Septic Tank ❑ Tight Tank 4. Effluent Tee Filter present? []/yes ❑ No 5. Condition offSystem- G(31 ystem: Glad 6. System Pumped By: jIYY) (2;(a11 ame 1 inG' +iyt( Enyironmeln�a� Company 7. Location where contents were disposed: S' natt)re bf Hfuler http://www.mass.gov/dep/water/app.rovals/t5forms.htm#inspect If yes, was it cleaned? 121"Y'es ❑ No Vehicle License Number 5 fA -(late Date t5form4.doc• 06/03 System Pumping Record - Page 1 of 1 lat I L 1j, WTw, e% nX 1142 TOWN, OF NORTH ANDOVER SYSTEM PUMPING RECORD e-, qj ttttt; Z ili* SYSTEM OWNER &ADDRE997_�` SYSTEM LOCATION (example: left front of house) 1'4 �V jf�i, qz, CAl 0 rh� Z;I 'R �N 'RV h4,�,,�DATEC I QUANTITY PUMPED GALLONS ALLONS OF�P:UMPING: �n in ,v P g ES `,-SEPTIC TANK: NO C ESSPO.O.U', NO" Y >\ YES/ 1 6, OF SERVICE: ROUTINE EMERGENCY T ONS'. -,w,. 1 21 I `GQO 0 I;QNDITION',�` FULL TO COVER ;� HEAVY' GREASE -BAFFLES IN PLACE ROOTS' LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) RIM PUMPER. BY (A ef C M, OF 1, Nu 43RANSFE R—M To 4K R I Owner • �llt Commonwealth of Massachusetss Massachusetts System Pumoira Record Location f'r iR 1r J j. Form 4 -- System Pumping Record + •f+.. . i , :'tom r '1 .� -rt n A, L , i:,t, , Type: Emergency Routine Cesspool: No Yes Date of Pumping: `� (SSI D3 System Pumped By: Wind kwr Envir mnento% LLC Contents transferred to: Contents Disposed at: Date: J�o3 Pumper Signature: Condition of System/Other Comments Dep Approved Form - 12/07/95 r nn!1;1 Septic tank: No =Yes Qua" Pumped: SC) C) Gallons Permit #: FORM - U - LOT RELEASE FORM ��1 �,���►` S �d .`., C. INSTRUCTIONS' This form is used to verify that ail -necessary approval/ permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. APPLICANT � C.coo PHONE q �C ER ASSESSORS MAP NUMB I d (0 LOT NUMBER 3 SUBDIVISION LOT NUMBER STREET CA!vcFei (c �C I 4 STREET NUMBER 3 q .■...■..■...■■rr■■■rrr. r.■■rrr.■....■.■.■■.■■...■.■....rr.......r.■rr....rr■ .. ........................... U�s00a0N L USE ONLY■■..r■.■....r......■......a■. RECOMMENDATIONS OF TOWN AGENTS ..............................won ...... mom .........r.........■.....son ...o DATE APPROVED CONSERVATION AD7STRATOR DATE REJECTED COMMEND DATE APPROVED TOWN PLANNER DATE REJECTED CONS ENTS FOOD INSPECTOR--- HEALTH SEPTIC INSPECTOR - HEALTH •722 PUBLIC WORKS - SEWER / WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT COMMENTS RECEIVED BY BUILDING INSPECTOR DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED e , 14. DATE APPROVED DATE REJECTED .TE NJ DR, E APR 12 2001 BUILDING DEPT. ,421:1994 y 07-29 FRO 14 CoreS ponahue. Ina Job No..�rxo�" This plan was not prepared from an Instrument surrey. Offsets and distances shown should not be used to establish property lines. This plan is intended for mortgage -purposes only. 1 certify that the structure —shown on this Plan - in conformance with the zoning setbacks in effect at the time of construction. I cerilly that the parcel shown ism'--= located within a flood hazard area as dePictcd on FEMA Flood insurance Rate Maps for Community No!.� Po V•J� MORTGAGE LOAN INSPECTION'. LOCATION: SCALE: REGISTRY. TITLE REFERENCE PLAN REFERENCE-,"" coREy & DONP.HUE- 1rn((rcers & sur"7asr ire r,,,nbe{dRs Qawd, wohnrn, WX 01001 FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: Phone LOCATION: Assessor's /Map Number Parcel Subdivision C n, J �t S -i C' l Lots) Street St. Number ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Conservation Administrator Comments Town Planner Comments Food Inspector Health Septic Inspector -Health Comments f5 /3% 17 6,1 yZ Public Works - sewer/water connections - driveway permit Fire Department Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Date ApprovedZL1?,L_YY Date Rejected Received by Building Inspector Date FORM U TOWN OF NORTH ANDOVER LOT RELEASE FO1U1 1` SUBDIVISION ASSESSORS MAP SUBDIVISION LOT(S) PERMANENT ADDRESS (ASSI NED BY D.P.W. STREET�/�,�,�JL [ J 7-e& � APPLICANT M �� 7;'i�E3 PHONE %;7 DATE OF APPLICATION PLANNING_ B TOWN YEANN TOWN USE BELOW THIS LINE V . 11 DATE APPROVED • �-v DATE REJECTED CONSERVATION COMMISSION CONSERVATION ADMIN. BOARD OF HEALTH T rr S KN7 T IZI A.N z rD a4-4 .4 F31 DEPARTMENT OF PUBLIC WORKS DATE APPROVED DATE REJECTED DA'T'E APPROVED 9 -461?✓ DA'Z'E REJEC'T'ED DRIVEWAY PERMIT i SEWER/WATER CONNECTIONS ' TIRE DEPT. RECEIVED BY BUILDING INSPECTION DATE This form shall be signed by the agents of the Planning and Health Boards, the Conservation Commission prior to the issuance of any building permits for the subject lot. This form shall not releive the applicant from the compliance of any applicable Town requirement or Bylaw. NEW_ENGLAN b CLAIMS SERVICE, INN. ReplyTo C] P.O. BOX 345 MANSFIELD, MA 02048 TEL. (508) 337-8058 FAX (508) 339-5835 Reply To C] Reply To: ❑ 100 CONIFER HILL DRIVE, SUITE 308 P.O. BOX 578 . DANVERS, MA 01923 SHREWSBURY, MA 01545, TEL (978) 777-9900 TEL. (508) 842-3995. FAX (978) 774-9296 FAX (508) 842-7510 Ti. j QF t,:ORTH,n..•:. EOARD OF Ft " _T €� Form of Notice of Casualty Loss to Building r .4 Under Mass. Gen. Laws, Ch: 139 Sec 3D i OCT 1 .62002 TO: Building Commissioner or Board of Health or. Inspector of Buildin s Board of Selectmen addresses RE: INSURED PROPERTY ADDRESS - 3 _c "um, s tw POLICY NO.: LOSS OF: _ a i 47— FILE ZFILE OR CLAIM NO.: Claim has been made involving loss, damage or destruction of the above -captioned property which may either exceed $1,000.00 or cause Mass. Gen. Laws Chapter 143 J, Section 6 to be applicable. If any notice under Mass. Gen. Laws Chapter 139 Section 3D is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. TITLE On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. tem owner J t lin Rd t�.7rr..� Nzidc�rr>r, MA, 01845 .n Type: Emergency Cesspool: No Date of Pumping: System Pumped By: Contents transferred to: Contents Disposed at: Commonwealth of Massachusetss Massachusetts System Pumping Record Routine Yes Wind River Envirvmmntoi, LLC Date: . 0(--jq1z) V Condition of System/Other Comments Pumper Signature: :tem Location 1� � ? .iC.c• r�. Hci3i!� 345 k.. Form 4 -- System Pumping Record RECEIVED JUL - 9 2004 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT isc>r.r_t, Anr-tovc^r, kiA, )1h45 i 9 t)S X Dep Approved Form - 12/07/98 Septic tank: w =Yes Quantity Pumped: /,50b Gallons Permit #: Commonwealth of Massachusetts City/Town of�, _ ° System Pumping Record R ® Form 4 ,M JAN 'I "i LU17 DEP has provided this form for use by local Boards of Health. Other rms ma be �se information must be substantially the same as that provided here. Be o c with your local Board of Health to determine the form they use. The System P miffed to the local Board of Health or other approving authority. A. Facility Information <c 1. System Location: Left / Rightjnt of house Left / Right rear of house, Left / right side of house, Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address CityrFown State Zip Code 2. System Owner: Name Address (if different from location) Cityrrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Date Cesspool(s) State 'r�O 6 Zip Code Telephone Number I �'�<Z) 2. Quantity Pumped: Gallons ❑ Tight Tank ❑optic Tank 4. Effluent Tee Filter present? ❑ Yes ©-ig If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: Nj� e, -%-c � Y,,- 4z� �, 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Locatioj3-wh contents were disposed: G.L�S.J�7-Lowell Waste Water F5821 Vehicle License Number Date t5form4.doc• 06103 System Pumping Record • Page 1 of 1 i ' ,1p7 ZZ ,q7 F R,- 9Z -d? _ I:C=11o1,7Z 1) -fox t2,- W,o7� 3o.�dZ D-rm a-10082 i p -BOX TZ w3 Q,= 160-14-7 , IG&o\ZZ k� , v, 14 1 1 t ti�.H�-• � C= �.sy a1r�.zv AS BUILT- PLAN OF SUBSURFACE DISPOSAL SYSTEM LOCATED IN AS PREPARED FOR. THOMAS 1AuA4Q i DATE : j�EJKE'P, Z �4e11 SCALE: MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS: 66 PARK STREET 0 ANDOVER, MASSACHUSETTS 01810 • TEL. (sae) 475-3555, 373.5721