Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Miscellaneous - 345 R. T Lane
06/28/2017 01:31PM 9783831097 To: Mchelle ECONOMIC ENVIRO TEC Economic EnviroTechs, Inc. 38 Intervale Road Fitchburg, MA 01420 p.978.348.1118 f.978.383.1097 www.9coenvirotech.net COMPANY: North Andover Board of Health rAX; (978) 688-9542 mONE NUMBER: 'TRANSMITTAL DOCUMENT FROM: Rhonda DATE: 06/28/17 TOTAL NO. OF PAGES INCLUDING COVER: 7 SENDF,R'S DEFERENCE NUMBER; RE: YOUR DEFERENCE NUMI RR-* 345 Raleigh 'Z ivem Lane Good Afternoon Michelle, Following are copies of the paperwork fox the completed work at 345 Raleigh Tavem Lane, North Andover, MA. 'hanks so j ueh, Rhonda a"-;"be6�'> R���� PAGE 01/07 06/28/2017 01:31PM 9783831097 ECONOMIC ENVIRO TEC SERVICE TRANSPORT GROUP, 3' PYLES LANE, NEW CASTLE, DE 18720 N? 484528 1 I . gi S'e a aVe� _ W z W WASTE SHIPMENT RECORD Economic Enviro Techs, Inc 38 Intervale Road Fitchburg, MA 01420 3. ReWEpj INJOIDWY Name/Address 1 Congress Street, Suite 1100 Boston, MA 02114 5, Description of Materials Specify Friable or Non -Friable PAGE 02/07 PHONE: (877) 999-9559 S.T.G. # fterato P # (978) 348-1118 Contact: Henry Moses 4. US DOT Class - FRIABLE ASBESTOS ONLY M NA2212, Asbestos, 9, PG III, RQ Type Total IF Friablo (enter required information) IF Non-Frlable (check one): it Category I 0 Category II 6. Special Handling Instructions 24-hour emergency spill response no. 80Q-424-9300 7. Generator Certification: P proper condition for transport highway This Is to certify that the above named materials are property classified, described, packaged. marked ePd labeled and are In rope P � 9 y ny ratata to the best of my knoto the wledge. n heble tons'of the waste shipment is not ae Ient ra aced, I amp th RETURN of theeCOMP government� LOAD to the getneratfy thatthe tor's seNw location atis true and �orrect the gsnerator's expense. Printed/Typed Name &Title Slgnatur Dat Henry A Moses, owner- �_77 bi 6� 12 8. Trans orter 1 ckno .. em nt of Receipt of Materi Is If ank, see Transporter 2 or 3 below. ' CorrfjA4fft�tABd ,Inc. Signature: Up a No. W 38 Intervale Road Fitchburg, MA 01420 Printed Name: Dat . 1. � ee Title: 9. Transporter 2 (Acknowledgement of Receipt of Materfals) If Transporter 1 & 2 are blank, Transporter $ servers effi sole tran s o Company Name & Address Signature: Telephone No. Z a Printed Name: Date: H Title: 10. Trans rte(Acknowlecloiamentof Receipt of Materials Company Name & Address Signature: Telephone No. 877-999-9559 Service Transport Group, Inc. Printed Name: Date: W 58 Pyles Lane E. New Castle, DE 19720 Title: 11. Discrepancy Indication Space: 12. Waste Disposal Site Owner or Operator's Certification (Receipt of above Waste except as noted in 11) H Waste Disposal Site (Check One) STG NI_Y Date: Signature: O Sanitary Landfill Minerva Landfill n V% 901 Tyrol Blvd. 8955 Minerva tad. Printed Name: Belle Vernon. PA 15012 Waynesburg, OH 44688 724-929-7694 Ext. 14 330-866-3435 Title: Permit No. 100977 Permit No. PO4 WHIT -Generator -GREEN-6,TG.-YELLOWCOnitaclor - PINK-Lsneful -GOLD-Pick Up Receipt 06/28/2017 01:31PM 9783831097 ECONOMIC ENVIRO TEC PAGE 03/07 Environmental Sampling and Testing 54 Water Street Ashburnham, MA 01430 978.827.1169 envfrosarnPIe y9d;pna9 CHAIN OF CUSTODY diient: EETI 38 Intervale Street Fitchburg MA Date: June 23, 2017 Job Number: 6930 bite: 345 F.alei h Tavern Lane North Andover MA Locetion of Work: 11 Floor Hallway and Stairway Type of Material: Joint Compound & Drywall Type of Containment- Full Containment with 2000 CFM HEPA filter/Negative Pressure Enclosure (NPE) Visual Inspection Determination: PASS Sample Location Flow Duration Volume Concentration 001 Blank -Open Lab QC 002 Blank -Closed Cassette QC 003 Inside Containment After 16 75 1200 <0.005 Asbestos Abatement and Visual LPM Min Liters F/CC Inspectipn :..e Huai.. iu•.iu:�-:_�. .�:.:.n.•�. ..��•... !:i1 _•.moi'.: •.:.: e. ...�`A�.i.!":::!. i•.l.. .. .. _. .::.ff.::d..• ',;' ..:.._�., r.� .. �!'"'"��'4:STA;yr:i.:.';i-".il'.•.:1"el"{., r��i'�� ivy ri. . �:il .. .., i'�::i�....iq . inl�:..1?1, IAj1�:. ��ii�:�; jA+j�?'!�d'1:i't'N !' '. 1..._ "G�' •.�.i Vii. ::�if �.� 06/28/2017 01:31PM 9783831097 ECONOMIC ENVIRO TEC PAGE 04/07 Instructions 1. All sections ofthls form must be completed in order to comply with MassDEP notification requirements of 310 CMR 7.15 and Department of Labor Standards (DLS) notification requirements of 453 CMR 6.12 MassDEP Use only Massachusetts DepartmerLt of Environmental Protection10026_.._.-...6644 - BWP AQ 04 (,ANF -001) ' Asbestos Project; Asbestos Notification Form j )project Revision Project Cancellation A. Asbestos Abatement Description 1. Facility Location: 345 RALEIGH TAVERN LANE a. Name of Facility NORTH ANDOVER 345 RALEIGH TAVERN LANE b, Street Address MA 01845 6038360499 G, City/Town d. State e- Zip Code f. Telephone JEN VNitrAKER OW VIER REPRESENTATNE g. Facility Contact Person Name h. Facifib Contact Person Tile Worksite Location: MUDROOM, GARAGE i. Building Name, Wng, Floor, Room, etc. 2. Is the facility occupied? Pa. Yes 17b. No 3. Is this a fee exempt notification (city, town, district, municipal housing authority, state facility, or owner -occupied residential property of four units or less)? rl a. Yes r, b. No Revised: 11/13/2013 Page 1 of 4 4. Blanket Permit Project Approval, if applicable: Date Received Approval ID # 5. Non -Traditional Asbestos Abatement Work Practice Approval, 2, Submit Original if applicable: Approval ID # Form To: commonwealth of Massachusetts 6. Asbestos Contractor: P.O. Box 4062 Boston, MA 02211 EcONOMICeMROTECHS 381NTERVALEROAD EL Name b. Address FMq tBURG MA 01420 9784233999 c. Citylrown d. State e. Zap Code f. Telephone h. Contract Type, W 1. Written. 2- Verbal AC000459 g, DLS License # HENRYMOSES AS031082 7. a. Name of Contractors onsite supeTvlsor/Foreman b. DLS CerOcatlon # RAY BRESNAHAN AM900294 6. a. Name of Project Monitor b. DLS CertifioatJon # ENVIRONMENTALSAMPUNGANDTE$MNG LTD AA000132 9. a. Name of Asbestos Analytical Lab b. DLS Certification # 10. 6/22/2017 6/23/2017 a. Project Start Data (MM/DD/YYY`n b. End Date (MM/DDNYYY) 7A -5P N/A c- Work Hours - Monday Through Friday d. Work Hours - Saturday & Sunday 11, What type of project is this? a. Demolition r b. Reaovation ri c. Repair 17 d. Other - Please Specify: Revised: 11/13/2013 Page 1 of 4 06/28/2017 01:31PM 9783831097 ECONOMIC ENVIRO TEC PAGE 05/07 Massachusetts Department of Environmental Protection BWP AQ 04 (ANF -001) Asbestos Notification Forma i A. Asbestos ,abatement Description: (cont.) 100266644 .Asbestos PlroJect ## r Project Revision rl project Cancellation 12. Abatement procedures (check all that apply): j a. Glove Bag l~ b. )encapsulation $� c. Enclosure(—... d. Disposal Only l- e. Cleanup r f. Full Containment r, g. Other- Please Specify: 13. Job is being conducted:V a. Indoors b. Outdoors 14 a. Total amount of each type of asbestos Containing materials (ACM) to be removed, enclosed, or encapsulated: 300 1. Linear Feet (Lin. Ft) 2. Square Feet (Sq. Ft.) b. Boiler, Breaching, Duct, c. Transite Pipe Tank Surface Coatings 1. Lin. FL Z Sq. Ft d. Pipe Insulation . e. Transite Shingles f Spray -On Fireproofing h. Cloths, Woven Fabrics j. Insulating Cement 1. Lin. Ft 2. Sq. Ft. 1, Lin. Ft 2. Sq. Ft. 1. Lin, Ft. Z Sq. Ft 1, Lin, FL Z Sq. Ft. 15. Describe the decontamination systems) to be used: 3 Ci1AMBER g. Transito Panels i. Other - Please Speeify- 1, Lin. Ft 2. Sq. Ft. 1, Lin. Ft 2. Sq. Ft. 1. Lin. Ft 2. Sq. Ft JOINTCOMPOUNDAMMCOAT 30D 1. Lin. Ft 2. Sq. Ft 16. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (g), (2) 6 -MIL BAGS WETTED 17. For Emergency Asbestos Operations, the MassDEP and DLS officials who evaluated the emergency - a. Name of MeaaDEP Official c, Deta of Authorization (MM/DD/YYYY) b. Tide of MassDEP official d. Waiver # e_ Name of DLS Oficial f. Title of DLS Of dal g. Date of Authorization (MM/DD/YYYY) h. Walver# 18_ Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A—F apply to this 17 a. Yes P b. No project? Revised: 11/13/2013 page 2 of 4 06/28/2017 01:31PM 9783831097 ECONOMIC ENVIRO TEC PAGE 06/07 Massachusetts Department of Environmental Protection 10026664 BWP AQ 04 (ANF -001) Asbestos Project # Asbestos Notification Form �", Project Revision j" Project Cancellation B. Facility Description 1. Currept or prior use of facility: RESIDENTIAL 2. Is the facility owner -occupied residential with 4 units or less? r a. Yes C_`- b_ No MARCIA LANE 345 RALaGH TAVERN LANE 3 a Facility Owner Name b. Address NORTH ANDOVER to City/Town .IEN WHIMAiIFR 4.a. Name of Facility owner's On -Site Manager SAME a City/rown MA 01845 9786094345 d. Stat® e. Zip Code t Telephone SAME b. Address MA 01845 6038360499 d. State e. Zip Code f. Telephone 5 ECONOMIC ENMRO TECHS, INC. 3e INTERVALE ROAD a. Name of General Contractor b. Address FITCHBURG MA 01420 9783481118 c. Cityrrown d. State e, Zip Code f. Telephone BERKLEY SPECIALTY UNDERWRITING MANAGERS g. Contractor's Worker's Compensation Insurer WCA165205 3/27/2018 h. Policy # 1. Ekpirefion Date (MM/DD/YYYI) 1932 2 6. What is the size of this facility? a. Square Feet b. # of Floors C. ,Asbestos Transportation & Disposal 1. Transporter of asbestos -containing waste material from site of generation: a. Directly to Landfill or b. To Temporary Storage Location/Transfer Station ECONOMIC ENMRO TECHS, INC, 38 INTERVALE ROAD G Name of Transporter d. Address Note: Temporary F ITCHBURG MA 01420 9783481116 storage of Asbestoe containing waste e_ Cityfrown f. State g. Zip Code h. Telephone material Is only allowed at the place or business of a DLS 2, If a temporary storage location/transfer station is used, list name of transporter of asbestos containing Ilcanaed Asbestos ante material from temporary waste storage location/transfer station to final disposal site' or a transfer station that is permitted by SERMCETRANSPORTGROUP r38 PYLES LANE MassDEp and a. Name of Transporter b, Address operated in compliance with Solid NEWCASTLE M 19720 3027781394 Waste Regulations G Cidlfown d. State e. Zip Code f. Telephone 310 CMR 18.000 Revised: 11/13/2013 Page 3 of 06/28/2017 01:31PM 9783831097 ECONOMIC ENVIRO TEC PAGE 07/07 Massachusetts Department of Environmental Protection 100266644 BWP AQ O4 (A -001 Asbestos )Project # Asbestos Notification Form �, Project Revision (- Project Cancellation C. Asbestos Transportation & Disposal; (01111 ) 3 _ Name and address of temporary storage location/transfer station for the asbestos containing waste material- FIORE TRUCMG RECYCLUDISPOSAL 158 AIRPORT ROAD a Temporary storage Location Name b. Address FI CHBURG MA 01420 9783533192 c. Cityrrown d. State e. zip Code f, Telephone 4. Name and location of final disposal site (asbestos lan.dfill): MINERVA ENTERPRISES INC. MINERVAETIT7:RPRLSESINC. a. Final Disposal Site Name b, Final Disposal Site Owner Name 8955 MINFRVAROAD c. Address WAYNESBURG OH 44688 d. City/town s. State f. Zip Code A Certification HENRY MOSES "I certify that I have personally examined the foregoing and am familiar with the information Note: Contractor muat contained in this document and s)gn thio form for DLs 6,11 attachments and that, based notifir.ation purposes on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the Information is true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including posalble fines and imprisonment. The undersigned hereby states that 1 have read the Commonwealth of Massachusetts regulations governing asbestos abatement (453 CMR 6.00 promulgated by the Department of Labor Standards and 310 CMR 7.15 promulgated by the Department of Environmental Protection), and that 1 am aware that this permit application or notification shall not be deemed valid unless payment of the applicable fee Is made" 1. Name PRERI)ENr 3. position/rile 9784233999 5. Telephone 38 INTERVALE ROAD 7. Address MA 9. State 3308663435 g, Telephone 2, Authorized Signature 4, Date (MM/DD/YYYY) ECONOMIC ENV1RO TECHS,INC. 6, Representing FIT"URG 8. Cityrrown 01420 10. Zip Code Revised: 1.1/13/2013 Page 4 of 4 06/09/2017 12:35PM 9783831097 0014 S140% 10 o 101 ECONOMIC ENVIRO TEC Economic EnviroTechs, Inc. 38 Intervale Road Fitchburg, MA 01420 p.978.348.1118 f.978.383.1097 0000 www.ecoenvirotech.net TRANSMITTAL DOCUMENT TO: FROM: Michelle Rhonda COMPANY: DATE: North Andover Board of Health 06/09/17 PAX: TOTAL NO. OP PAGES INCLUDING COVER: (978) 688-9542 5 PHONE. NUMBER: sENDEWS REFERENCE NUMBER: YOUR RLPERENCE NUMBER: 345 Raleigh Tavem Lane PAGE 01/05 Good Afternoon Michelle, . Following please find a copy of the DEP/DOS notification form for the asbestos abatement at 345 Raleigh Taverp. Lane. The project is scheduled for June 22, through June 23, 2017. Copies of the paperwork will be fazed to you once all documents are completed. Please contact Henry Moses (978) 423-3999 or myself if you have any questions. Tb=ks so much, Rhonda 06/09/2017 12:35PM 9783831097 ECONOMIC ENVIRO TEC PAGE 02/05 Massachusetts Department of EnvironmentsProtection - 100266644 BWP AQ 04 (ANF -001) Asbestos )Project # Asbestos Notification Form � Project Revision f" Project Cancellation Instructions 1. All sections of this form must be completed In order to comply with MessDEP notificabon requirements of 310 CMR 7.15 and Department of Labor Standards (DLS) notification requirements of 453 CMR 6,12 MassDEP Use only Date Received 2. Submit Original Form To: Commonwealth of Massachusetts P.O. Box 4062 Boston, MA 02211 A. Asbestos Abatement ]Description 1. Facility Location: 345 RALEIGH TAVERN LANE a. Name of Facility NORTH ANDOVER a City/Town JEN WHITAKER g. Facility Contact Person Name Worksite Location: 345 RALEIGH TAVERN LANE b. Street Addrees MA 01845 d. State C. Zip code 6038360499 f. Telephone OWNER REPRESENTATIVE h. Facility Contact Person Title MUDROOM,GARAGE i. Building Name, Wing, Floor, Room, etc, 2. Is the facility occupied? 17. a. Yes Ci b. No 3. Is this a fee exempt notification (city, town, district, municipal housing authority, state facility, or owner -occupied residential property of four units or less)? 911 a. Yes 171 b. No 4.131anket Permit Project Approval, if applicable: Approval ID '# 5. Non -Traditional Asbestos Abatement Work Practice Approval, if applicable_ Approval ID # 6. Asbestos Contractor: ECONOMIC ENVIRO TECHS 38 INTERVALE ROAD a. Name b. Address FITCHBURG G, City/Town AC000469 g. DLS Lioense # MA 01420 9784233899 d. State 7 Zip Code f, Telephone h_ Contract Type: F 1. Written r 2. Verbal 7. HENRY MOSES AS031082 a. Name of Contractor's On -Site Supervisor/Foreman b. DLS Certification # RAY BRESNAHAN AM900294 $ a. Name of Project Monitor b. DLS Certification # 9 EWRONMENTALSAMPLINGAND TESTING LTD AA000132 a. Name of Asbestos Analytical Lab b. DLS Certification # 10. 6/22/2017 6/23/2017 a, project Start Date (MM/DD/YYYY) b. End Date (MM/DDNYYY) 7A -5P N/A c, Work Hours - Monday Through Friday d. Work Hours - Saturday & Sunday 11. What type of project is this? r- a. Demolition W b. Renovation 17: c. Repair F d. Other - Please Specify: Revised: 11/13/2013 Page l of 4 06/09/2017 12:35PM 9783831097 ECONOMIC ENVIRO TEC 1V[assacbusetts Department of Environmental Protection BWP AQ 04 (ANF -001) Asbestos Notification Form A. Asbestos Abatement Desclrlption: (cont.) PAGE 03/05 100266644 Asbestos Project # r Project Revision j Project Cancellation 12. Abatement procedures (check all that apply). r a. Glove 13ag r b. Encapsulation 17.1 c. Enclosure 1-' d. Disposal Only e. Cleanup r f. bull Containment [! g. Other - Please Specify: 13. Job is being conducted: 1✓i a. Indoors 17 b. Outdoors 14 a. Total amount of each type of asbestos Containing materials (ACM) to be removed, enclosed, or encapsulated: 1. Linear Feet (Lin, Ft) b. Boiler, Breaching, Duct, Tank Surface Coatings d. Pipe Insulation f. Spray -On Fireproofing h. Cloths, Woven Fabrics j. Insulating Cement 1, Lin, FL 2. Sq. Ft 1, Lin, Ft 2. Sq. Ft. 1, Lin. Ft 2. Sq. Ft. 1. Lin. FL 2. Sq. Ft 1. Lin, Ft 2. Sq. FL 15. Describe the decontamination systems) to be used: 3 CHAMBER 300 2 Square Feet (Sq. Ft) c. Transite Pipe 1. Lin. Ft 2. Sq. Ft. e. Transite Shingles 1. Lin. Ft. 2. Sq. Ft S. Transite Panels 1. Lin. Ft 2. Sq. Ft. i. Other - Please Specify: .IoINTcomPotJND,Sf4MCOAT 300 1. Lin. Ft 2. Sq. Ft. 16. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (8), (2) EMIL BAGS WETTED 17. For Emergency Asbestos Operations, the MassDEP and IDLS officials who evaluated the emergency*. a. Name of MessDEP Official b. Title of MassDEP Official c. Date of Authorization (MM/DD/YYYY) d. Waiver# e. Name of DLS Official f. TIVe of DLS Official g. Date of Authorization (MM/DD/YYYY) h. Waiver# 18. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27,A—F apply to this !M a. Xes r b. No project? Revised; 11/13/2013 Page 2 of 4 06/09/2017 12:35PM 9783831097 ECONOMIC ENVIRO TEC ,1 Massacbusetts Department of Environmental Protection BWP AQ .04 (ANF -001) ` Asbestos Notification) Form D. Facility Description 1. Current or prior use of facility: RESIDENTIAL PAGE 04/05 100266644 Asbestos Project # ("'°. Project Revision 1, i Project Cancellation 2. Is the facility owner -occupied residential with 4 units or less? R a. Yes C b. No 3 MARCIALANE a Facility Owner Name NORTH ANDOVER a City/Town 345 RALEIGH TAVERN LANE b. Addre9s MA 01845 d. State e. Zip Code 4. JEN VNITAKER SAME a. Name of Facility Owner's On -Site Manager b. Address c. City/Town MA 01845 d. State e. Zip Code 9786o94345 t Telephone 6038360499 f. Telephone ECONOMIC ENAROTECHS, INC. 381NTERVALE ROAD 5 a. Name of General Contractor b. Address FiTCH)3URG MA 01420 9783481118 c, City/town d. State e. Zip Code f. Telephone 6ER14.EY SPECIALTY UNDERWRITING MANAGERS g. Contractor's Workers Compansation Insurer WCA165205 3/27/2018 h. Policy # i. Expiration Date (MM/DD/YYYY) 6. What is the size of this facility? 1932 2 a. Square Feet b, 4 of Floors C. Asbestos. Transportation & Disposal 1, Transporter of asbestos -containing waste material from site of generation: r. a. Directly to Landfill or W b. To Temporary Storage Location/Transfcr Station Revised: 11/13/2013 Page 3 of 4 ECONOMIC r-WROTECHS, INC. 38 INTERNALE ROAD c. Name of Transporter d. Address porary Nota: Asbestos storagea of A9bealoe Of FITCHBURG MA 01420 9783481116 containing waste e. City/rown f. State g. Zip Code h. Telephone materlal Is only allowed at the place of business of a DL8 7. if a temporary storage location/transfer station is used, list name of transporter of asbestos containing licensed Asbestos waste material from temporary storage location/transfer station to final disposal site: contractor or a transfer station that Is permitted by SERMCE TRANSPORT GROUP 55PYLESIANE MassDEP and a. Name of Transporter b. Address operated in compliance with Solid NEWCASTLE CE 19720 3027781394 waste Regulations c. City/Town d, State e. Zip Code f. Telephone 310 CMR 19,000 Revised: 11/13/2013 Page 3 of 4 06/09/2017 12:35PM 9783831097 ECONOMIC ENVIRO TEC PAGE 05/05 Asbestos Notification Form r: Project Revision Massachusetts Department of F-rivironmental Protection 100266644 ' BWP AQ 04 (ANF -001) Asbestos Project # r Project Cancellation Note: Contractor must sign this form for DLS notirleation purposes C. Asbestos Transportation & Risposal: (cont.) 3. Name and address of temporary storage location/transfer station for the asbestos containing waste material; FIORETRUCIdNG RECYCLE&DISPOSAL 158 AIRPORT ROAD a. Temporary Storage Location Name b. Address FITCHBURG MA 01420 9783533192 c, City/Town d. State e. zip Code t Telephone 4. Name and location of Enal disposal site (asbestos landfill): MINERVA ENTIIZPRSES INC. MINERVA ENTE.RPPOSS INC. a. Final Disposal Site Name b. Final Disposal Site Owner Name 8955 MINERVA ROAD c. Address WAYNESBURG OH 44688 3308663435 d, Cdyfrown e. State •f. ZIP Code g. Telephone D. Certification HENRYMOSES 9 certify that I have personally examined the foregoing and am familiar with the Information contained In this document and all attachments and that, based on my Inquiry of those Individuals Immediately responsible for obtaining the information, I believe that the Information is true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including possible flnes and Imprisonment. The undersigned hereby states that I have read the Commonwealth of Massachusetts regulations governing asbestos abatement (453 CMR 6.00 promulgated by the Department of Labor Standards and 310 CMR 7.15 promulgated by the Department of Environmental Protection), and that I am aware that this permit application or notification shall not be deemed valid unless payment of the applicable fee is made" 1. Name PRESIDENT 3, Posi ionrntle 9784233999 5. Telephone 38 INTERVALE ROAD 7. Address MA 9. state 2. Authorized signature 4, Date (MMIDDIY1'YY) ECONOMIC ENVIRO TECHS,INC. 6. Representing FITCHBURG 8. Cityrrown 01420 10. Zip Code Revised: 11/13/2013 Page 4 of 4 SEPTIC Sustems: ❑ Septic - Soil Testing Of NORT .,h ❑ � 9 Town of North Andover $ ❑ Septic Disposal Works Construction (DWC) HEALTH DEPARTMENT cHustt ❑ CHECK #: DATE: $ LOCATION: Tittle 5 Inspector 00 f H/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 $ ❑ Recteational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ TrashlSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Tittle 5 Inspector 00 $ } Q.fl itle 5 Report �" �oO $ . ❑ Other: (Indicate) $ .-? /1 Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer GUS C> �- i �tE,�- Please Copy Need — Copies Copies To: Original: ❑ Return to: _ ❑ File under: _ I11 Post•it'" copy request pad 7670 Owner information is required for every page. Comms onwealth of Massachusetts Title S Official Inspection Fo Subsurface Sewage Disposal System Form - Not for Voluntary RECEIVED o5 � DEC 2 2 2008 ;ments TOWN OF NORTH ANDOVER 345 Raleigh Tavern Lane HEALTH DEPARTMENT Property Address i < a Dennis Wade Owner's Name North Andover Cityrrown MA 01845 12/16/2008 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 forge. Important: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your Neil J. Bateson cursor - do not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name UQ 111 Argilla Road Company Address Andover Ma 0 Cityfrown State Zipp Code 978-475-4786 SI15 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 ❑ e ds Further Evaluation by the Local Approving Authority 12/16/2008 Ins ecto s Signature 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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 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 Raleigh Tavern Lane Property Address Dennis Wade Owners Name North Andover MA 01845 12/16/2008 City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® 1 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 • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 345 Raleigh Tavern Lane Property Address Dennis Wade Owner's Name North Andover MA 01845 12/16/2008 Cityrrown 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 obstruction is removed distribution box is leveled or replaced ❑ Y ❑ Y ❑ Y ❑ N ❑ N ❑ N ❑ ❑ ❑ ND (Explain below): ND (Explain below): 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 Foran: Subsurface Sewage Disposal System • Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments rr 345 Raleigh Tavern Lane Property Address Dennis Wade Owner owner's Name information is North Andover MA 01845 12/16/2008 required for every page. Cityrrown 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: U ❑ 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 ❑ ® 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 % day flow t5ins • 09108 Title 5 Of kxW lrepection Form: Subsurface Sewage Disposal System • Page 4 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 Commonwealth of Massachusetts . Title 5 Official Inspection Form the system is within 400 feet of a surface drinking water supply Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 345 Raleigh Tavern Lane ❑ Property Address Dennis Wade Owner Owner's Name information is required for North Andover MA 01845 12/16/2008 every page. Cityrrown 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. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form • a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM , 345 Raleigh Tavern Lane Property Address Dennis Wade Owner Owner's Name information is required for North Andover MA 01845 12/16/2008 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 information on the proper maintenance of subsurface sewage disposal systems? this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not Existing information. For example, a plan at the Board of Health. ® ❑ 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): N/A Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): N/A t5ins • 09/08 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 M 345 Raleigh Tavern Lane Property Address Dennis Wade Owner Owner's Name information is required for North Andover MA 01845 12/16/2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 9 ( y 9 (gPd))� Yes Detail: Sump pump? Last date of occupancy: Commerciallindustrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Gallons per day (gpd) ❑ Yes ® No Current Date 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 - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Y 345 Raleigh Tavern Lane Property Address Dennis Wade Owner's Name North Andover Cityrrown D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: un nwnwr- General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Date 12/16/2008 Date of Inspection Pumped last year,owner 1000 gallons Measured tank Inspect tank, baffles & tee Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ® Yes ❑ No ❑ 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 UA 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 Owner information is required for every page. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 345 Raleigh Tavern Lane Property Address Dennis Wade Owner's Name North Andover Cityrrown D. System Information (cont.) 12/16/2008 Date of Inspection Approximate age of all components, date installed (if known) and source of information: 35 years old, tank & field 5/28/1973,d -box was replaced five years ago, info @ Board of Health Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 14"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 in house no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 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: 7' x 5' x4' Sludge depth: 3" ❑ Yes ❑ No t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts F w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 345 Raleigh Tavern Lane Property Address Dennis Wade Owner Owner's Name information is required for North Andover MA 01845 12/16/2008 every page. Cityrrown 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 24" Scum thickness 3" 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 18" 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 baffle ok. Outlet baffle 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 Dimensions: Scum thickness ❑ fiberglass Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: t5ins - 09/08 feet ❑ polyethylene ❑ other (explain): Date 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 M 345 Raleigh Tavern Lane Property Address Dennis Wade Owner Owner's Name information is required for North Andover MA 01845 12/16/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ No 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 • 09/08 Title 5 Oficial Inspection Form: 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 Raleigh Tavern Lane Property Address Dennis Wade Owner's Name North Andover Cityrrown D. System Information (cont.) MA 01845 State Zip Code Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 12/16/2008 Date of Inspection Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D -box level & distribution equal, has flow levelers. No evidence of leakage. Evidence of carryover, pumped d -box to clean. D -box was replaced five years ago. 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 - 09/08 Title 5 official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , ' 345 Raleigh Tavern Lane Property Address Dennis Wade Owner information is required for every page. Owners Name North Andover MA 01845 12/16/2008 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: ® leaching fields number, dimensions: 1 field 20'x 40' ❑ 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 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 Raleigh Tavern Lane Property Address Dennis Wade Owner's Name North Andover MA 01845 12/16/2008 CitylTown D. System Information (cont.) 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 - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 345 Raleigh Tavern Lane Property Address Dennis Wade Owner Owner's Name information is required for North Andover MA 01845 12/1612008 every page. Citylrown 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 i4o"sQ_ 0 Tv 3 t5ins • 09/08 Title 5 Official Inspection Form: SubsuAece Sewage Disposal System •Page 15 of 17 t5 14 It �} , "t 16 It i4o"sQ_ 0 Tv 3 t5ins • 09/08 Title 5 Official Inspection Form: SubsuAece 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 Raleigh Tavern Lane Property Address Dennis Wade Owner's Name North Andover MA 01845 12/16/2008 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: >6 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ 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: Essex County Soil Map. You must describe how you established the high ground water elevation: Essex County Soil Map, Sheet # 36, Chariton Soil, Water > 6' deep Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 09/08 Title 5 official inspection Form: Subsurface Sewage Disposal System - Page 16 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 345 Raleigh Tavern Lane Property Address Dennis Wade Owner information is required for every page. Owner's Name North Andover Cityrrown State Zip Code E. Report Completeness Checklist 12/16/2008 Date of Inspection ® 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 - 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 Summary Record Card generated on 12/16/20081:55:28 PM by Karen Hanlon Town of North Andover Page 1 Tax Map # 210-107.A-0124-0000.0 Parcel Id 17951 345 RALEIGH TAVERN LANE WADE, NORMA & DENNIS 345 RALEIGH TAVERN LANE NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 1.01 Acres FY 2009 UB Mailing Index Name/Address Type Loan Number Active/lnact From Until WADE, NORMA & DENNIS Payor 345 RALEIGH TAVERN LANE NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Activelinactive Bldg Id. 14115.0 - 345 RALEIGH TAVERN LANE Last Billing Date 12/1/2008 2100096 02 Cycle 02 Active UB Services Maint. Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE /1 UB Meter Maintenance Serial No Status Location Brand Type Size YTD Cons 0021255003 a Active ENC F.RT. w Water 0.63 0.63 169 Date Reading Code Consumption Posted Date Variance 11/3/2008 4430 a Actual 89 12/10/2008 9% 8/1/2008 4341 m Manual estimate 80 9/12/2008 180% MSG 5/1/2008 4261 a Actual 27 6/18/2008 -20% 2/4/2008 4234 a Actual 37 3/14/2008 -45% 11/1/2007 4197 aActual 65 1/15/2008 -25% 8/2/2007 4132 a Actual 87 9/14/2007 91% 5/3/2007 4045 a Actual 32 6/26/2007 55% 2/28/2007 4013 m Manual estimate 38 3/23/2007 -78% 11/2/2006 3975 a Actual 106 12/22/2006 8% Trouble Code:03 8/21/2006 3869 a Actual 146 9/13/2006 118% Trouble Code:03 5/4/2006 3723 a Actual 56 6/20/2006 49% Trouble Code:03 2/2/2006 3667 a Actual 38 3/13/2006 -2% 11/2/2005 3629 aActual 35 12/14/2005 -24% 8/11/2005 3594 a Actual 52 9/12/2005 37% 5/9/2005 3542 a Actual 34 6/8/2005 4% 2/14/2005 3508 a Actual 35 3/15/2005 -11% 11/16/2004 3473 a Actual 43 12/17/2004 -7% 8/10/2004 3430 a Actual 40 9/20/2004 6% 5/17/2004 3390 a Actual 40 6/14/2004 14% 2/17/2004 3350 a Actual 40 4/16/2004 0% 11/6/2003 3310 n New Meter 0 11/6/2003 0% 11 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. �a Commonwealth of Massachusetts City/Town of System Pumping Record 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 front, left rear, left side of house. Right front, right rear, right side of house. �a11 ���Q1Js2 L-aM e Address Citytrown 2_ System Owner. Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: p Other (describe): Date M State Trp Code StateS ` 1-4— 01 VR Zip Telephone Number — Z. Quantity Pumped: Gallons Cesspools)Septic Tank Q Tight Tank 4. Effluent Tee Filter present? g Yes _ No if yes, was it cleaned? p Yes [ No 5. Condition of System: 6. System Pumped By: Neil Bateson t5form4.doc- 06/03 Name Bateson Enterprises Inc Company 7. Location where contents were disposed: f G. L.S D � Lowell Waste Water tet. F 5821 Vehicle License Number Date System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts Map -Block -Lot 107.A- 0124 - Board Of Health - Pemrit ------- No - ------------- North AndoverBHP-2003--0 ---- ------------------ P.I. FEE F.I. $250.00 ----------------------- Disposal Works Construction Permit Permission is hereby gra kted Todd -Bateson_______ --------------------------------------------------------------------------------- to (Construct) an Individual Sewage Disposal System. at No 345 RALEIGH TAVERN LANE ---------------- ------------------------------------------------------------------------------------------------------------------------------------- ----- as shown on the application for Disposal Works Construction Permit No. BHP -2003-026 Dated August 25, 2003 ------------------------------------------------------ Issued On: Aug-25-2003 ---------------------------------------------------------------------------- Board Of Health •...............................................................i.............................................................................................................. Commonwealth of Massachusetts Map -Block -Lot 107.A- 0124 - Board Of Health -- -- North Andover Certificate of Compliance THIS IS TO CERTIPY,That the Individual Sewage Disposal System (Construct) byTodd Bateson -------------------- ---------------------------------------------------------- ------------------------------------------------------------------------ Installer at No 345 RALEIGH TAVERN LANE ---------------------------------------------------------------------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No.-BHR2003-026 - Dated --- August_25,-2003 ---- Printed On: Sep -12-2003 - --------------------------------------------------- Board Of Health I.......................................................................................................................................................................... 0. Commonwealth of Massachusetts Map -Block -Lot 107.A- 0124 - Board Of Health ----------------------- Permit No North Andover BH- --------0 -0264 --- P-20----------- FEE $250.00 ----------------------- Disposal Works Construction Permit Permission is hereby granted Todd -Bate -son ---------------------------------------------------------------------------------------------------- to (Construct) an Individual Sewage Disposal System. at No 345 RALEIGH TAVERN LANE ----------------------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP -2003-026 Dated August 25, 2003 ------------------------ ------------------------------ ----------------------------------------------------------------- Issued On: Aug -25-2003 Board Of Health F Town of North Andover, Massachusetts Form No. 3 HORTN BOARD OF HEALTH F 9 '�•,:,;:�`� DISPOSAL WORKS CONSTRUCTION PERMIT ,SS^CHUs�t AP plicant N AIM Ems/ ADDRES % TELEPHONE Site Location & / �5- Permission is hereby granted to, -Construct ( ) or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S o. AIRMAN, BOAR 0 OF HEALTH Feee D.W.C. No. KeC;rea Well Construction Permit $ Funeral Directors Permit $ Massage Establishment License $ Massage Practice License Suntanning Establishment $ Offal/Trash Hauler $ Other Health Agent White - Applicant Yellow - Dept. Pink - Treasurer No No No Date: �� d J ' h TOWN OF NORTH ANDOVER BOARD OF HEALTH Location Permit # Food Service Retail Food $ Limited Retail $ Seasonal $ Disposal Works Installers $ Disposal Works Construction &1-1 Soil Testing $ Design Approval Permit $ Dumpster Permit $ Burial Permit $ Swimming Pool Permit $ Animal Permit $ Recreational Camp Permit $ Well Construction Permit $ Funeral Directors Permit $ Massage Establishment License $ i Massage Practice License $ I Suntanning Establishment $ Offal/Trash Hauler $ i Other $ 7G 39 ' Health Agent White - Applicant Yellow - Dept. Pink - Treasurer APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: 9—d5- 5- 0 �3 CURRENT INSTALLER'S LICENSE# LOCATION: 3JI5. /_/ /V ` LICENSED INSTA14,ER: SIGNATURE: CHECK ONE: TELEPHONE# REPAIR: NEW CONSTRUCTION: Zco x /(2- 6.4 /e7F P,G-I-IF NEW CONSTRUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. Admini Iative Use Only 2--�-Z> 1T95-- Fee Attached? Yes No Foundation As -built? Yes '' No Floor plaWAon, Yes No_ Approval '(' ��e� °1I 46 l v� i � a1(__ Date: g �� INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North. Andover licensed installer for the construction of the septic system for the property at relative to the application of 1 S� ted r'01 -f for plans by �� and dated with revisions dated I understand the following obligations for management of this project: 1. As the installer I am obligated to call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item two shall be applicable. 2. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection,. without completion of the items in accordance with Tile 5 and the Board of Health Regulations may result in a $50.00 fine being levied against my company. a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As -built or verbal OK from engineer must be submitted to Board of Health, after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade — Installer must request inspection when all grading is complete. Does not have to be on site. 3. As the installer I understand that persons or companies not associated with my company may not perform the work required by my company to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the, system, and/or revocation or suspension of my license in the Town of North Andover plus significant fines to all persons involved. 4. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached. b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff. d) Installation of tank, D -box, pipes, stone, vent, pump chamber, retaining wall and other components. 5. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. ?11dxlcensed Septic Installer /G� E Date: -0 3 Disposal Works Construction Permit # DelleChiaie Fwm: "Brian Lagrasse"<blagrass@townofnorthandover.com> To: "'Pamela DelleChiaie"'<pdellechiaie@townofnorthandover.com> Sent: Tuesday, August'26, 200310:19 AM Subject: RE: 345 Raleigh Tavern Ln. - Request for DWC Permit - D -Box & Outlet Pipe approved -----Original Message ----- From: Pamela DelleChiaie[mailto:pdellechiaie@townofnorthandover.com] Sent: Monday, August 25, 2003 6:07 PM To: Brian LaGrasse Cc: Pamela DelleChiaie; Heidi Griffin Subject: 345 Raleigh Tavern Ln. - Request for DWC Permit - D -Box & Outlet Pipe Page 1 of 1 8/27/2003 APPLICATION FOR SEWAGE DISPOSAL INSTALLATION HEALTH DEPARTMENT - NORTH ANDOVER, MASS. I hereby make app cation for a permit for a sewage disposal installation at a t/S'" . I will install this system in ac- cordance with all the laws of the Commonwealth of Massachusetts and regulations of the Board of Health of the Town of North Andover. Further, I will construct the house sewer of bell and spigot pipe, the minimum diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre- ceding the septic tank, where the grade shall not exceed 2%. I will install a con- crete septic tank of / in size. A manhole (s) permitting easy cleaning will be provided with removable cover (s) of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with 4 inch perforated or open jointed pipe and laid in a series of trenches, the bottom of which will pro- vide a minimum of lineal (square) feet of effective absorption area. The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling the trench, 2 inches of gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single tile line will exceed 100 feet in length and in any case, two lines of tile will be installed. A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No part of the installation will be less than 100 feet from any private water supply, 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. I further agree not to cover any portion of this installation until approved by the inspection officer, as provided below, and to incorporate any additional requirements that may be attached to the permit. Plot Plans must be submitted with application. DATE Sig ure of Applicant I hereby issue the above permit for the Board of Health of the Town of North Andover, Massachusetts. DATE /G -/i- Signature of Health Agent I have inspected the uncovered system indicated above and find everything done as described. DATE tC ! Signature o nspecting Officer Percolation Test G` Garbage Grinder l BOARD OF HEALTH TOWN OF NORTH ANDOVER, MASS. S ® .Sri ti .1.- 1. NAME �c�ii� -' i/ ��� DATE 2. ADDRESS LOT NO. TEL. 3. NO. OF BEDROOMS DEN YES NO 4. GARBAGE GRINDER YES NO 5. SHOW DIMENSIONS OF HOUSE 6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES 7. SHOW DIMENSIONS OF LOT 8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL q. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM 10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC. 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY. BOARD OF HEALTH OF NORTH ANDOVER, MASSACHUSETTS NAME OF APPLICAN LOCATION SEWAGE DISPOSAL DATE D L� BUILDING: Dwelling utner SYSTEM: New Repair GENERAL DESCRIP`T'ION OF LAND 4L/l SUBSOIL: Clay Gr vel Sand PERCOLATION TEST lA minutes per inch. MINIMUM INSTALLATION RECOMMENDATIONS CONCRETE SEPTIC TANK-�vco gallon capacity. LEACH FIELD 20-0 lineal feet of drain pipe. R William J. DriNcoll, Engine. Board of Healt / �6, -40 �'O''r3,7 95: as /* fzAjc.,Clb List PIPE WV A->W4D4413'vG, RA LE I G t� TAV cl L.O J -o I % i �•k A7� �- aa sr\4_— 4 r.+ 91 mo a .-- T t � �'� �Q �'� �R � �L1 av s L iT Ylrr p � d �'� .112 ICJ Inv o!`. (7AEli�'� l'rf �'� .,Sr . +'�.f r • `' • °� ar ... K . 5f L>157- A3OJe �S'_ o0 0 • i,ve-e r . A ` e t-1 ll' 3 -r.4 a l< 1 'S' 1mr Q .1;8 ��7 ��� � i,� �� �� id/ �.� Commonwealth of Massachusetts City/Town of System Pumping Record ��: ?0 Form 4 TOWN OF NORTH AN HEALTH DEPART DEP has provided this form for use=by local Boards of Health. Other forms maRECEIVED]t the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/ Right front of house, 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 <� l' /' "— Cityrrown "W State �J ` Zip Code 2. System Owner. Name Address (if different from location) t5form4.doc• 06103 System Pumping Record • Page 1 of 1 City/Town State C�a/n`C—ode Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 8'No ' If yes, was it cleaned? ❑ Yes ❑ No. 5. Condtion of System: I _ /) Vo 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Lo here contents were disposed: GL. Lowell Waste Water D ( ? SigWHaulej Date t5form4.doc• 06103 System Pumping Record • Page 1 of 1 �LN Commonwealth of Massachusetts rctCEIVL=® C ity/Town of r �� g 1 z System Pumping Record VER LHEALTHW"DFNORr�+AND0 Form 4 DEPARTMENT 4�M 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. Syste cation: Left front of house, right front of house, left side of house, right side of housCLeV rear of hous , right rear of house, left side of building, right rear of building, under deck. "3 Lf v(\ -- P--e�-A CitylTown State Zip Code 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ Date Cesspool(s) ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No 5. Conditio/ of PCte 6. System Pumped By: Neil J. Bateson Name Bateson Enterprises Inc. Company 7. Location where contents were disposed: L.S:Dgv�ell Waste V�atey� 70// / StIC2�?-43(4 Zip�ade _ Telephone Number — 2. Quantity Pumped: EPS -e -p -tic Tank Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts�6� = City/Town of System Pumping- Record L 61 2 0 2014 FGi'Iri14 rNUN I H ANDOVERH DEPARTMENT DEP has provided this form for use=by local Boards of Health. Other forms may be use but -the information must be substantially the same as that provided here. Before using -this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1 System Location: Left / Right front of hous , e Rig r�ho Left / right side of house, LeftRight side of building, Left / Right front of b Ing, Left / Igbuilding, Under deck City/Town 2. System Owner Name S,, Lip t;oae Address (if different from location) City/Town statep de Telephone Number B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ 4. Date Cesspool(s) ❑ Other (describe): Effluent Tee Filter present? ❑ Yes No 5. Condition of stem: v 6. System Pumped By - 7 t5form4.doo- 06/03 Neil. Bateson Name i Bateson Enterprises Inc- Company ncCompany where contents were disposed: — 2. Quantity Pumped Septic Tank Gallons al-❑ Tight Tank If yes, was It cleaned? ❑ Yes ❑ No (ZC�_a � 4A- 4�n� F5821 Vehicle License Number System Pumping Recons • Page 1 of 1 0 TOWN OF N • J} m ren SYSTEM PUMPIN DATE:i-l�-nl SYSTEM OWNER & ADDRESS RECEIVED CORD OCT 19 2004 SYSTEM LOCATION (example: left front of house) t(�- � CA- C-� 0 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DATE OF PUMPING: _ S-ftq QUANTITY PUMPED: ( 0 Q & GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. CONTENTS TRANSFERRED TO: G.L.S.D \/ Lowell Waste Town of North Andover Office of the Health Department Community Development and Services Division t 27 Charles Street North Andover, Massachusetts 01845 'Ss,cMus�` Heidi Griffin Telephone (978) 688-9540 Acting Health Director Fax (978) 688-9542 TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE 9/12/03 This is to certify that the D -Box & Outlet Connection Pipe constructed O or repaired (X) by Todd Bateson At 345 Raleigh Tavern Lane has been installed 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 he construed as a guarantee that the system will function satisfactorily. J. LaJGrasse Board of Health Inspector BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 TOWN OF /U - SYSTEM PUMPING RECORD DATE: q 3 SYSTEM OWNER & ADDRESS FOLl A OF MOR 5 2003 _.., STEM LOCATION example: left front of house) e DATE OF PUMPING: ✓[ �� QUANTITY PUMPED: /"GALLONS CESSPOOL: NO 'YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACMULD RUNBACK FLOODED OTBER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS. (---A ,7A A&A.AJjam. CONTENTS TRANSFERRED TO: - " TOWN OF SYSTEM PUMPING RECORD RECEIVED DATE: JAN Y 3 2005 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT SYSTEM�I AO'WNE & ADDRESS SYSTEM LOCATION (example: left front of house) Kai DATE OF PUMPING: QUANTITY PUMPED: /e-;;:--e-5-:1--/GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACIIFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. \\ Commonwealth of Massachusetts City/Town of ;' System Pumping Record OCT 1 5 2007 Form 4 TOWN Ct NC,,t' a At f)-01, ER HEAL -Ti C.'�.vT DEP has provided this form for use by local Boards of Health. Other foRns 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 Locatiory;A- � _ 0 �— n I -eA-- Address 'r3 L4 Ste- Citylrown 2. System Owner: Name (if different from location) Citylrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): CA 01 state Zip Code state Zi Code co Telephone Number 162-1► ,07 Date 2. Quantity Pumped: Gallons Cesspool(s) Septic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes Erl;Z— If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped �^ C T-- f Name Vehicle License Number Company 7. Location vore contents were Isposed: L. R77% % Date t5form4.doc• 06103 System Pumping Record • Page 1 of 1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION . TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION cam' Property Address: _345 Raleigh Tavern Lane _ North Andover_ Owner's Name: _George Lavoie _ Owner's Address: 345 Raleigh Tavern Lane_ North Andover, MA 01845_ Date of Inspection 9/11/2003_ 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: Inspector's Signature: X Passes _ Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails A /-) _ Date: 9/11/2003 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: After permit from B.O.H., installing outlet tee, pipe from tank to d -box & d -box, inspection from B.O.H., septic system now passes Title 5 Inspection. ****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. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 345 Raleigh Tavern Lane- - North ane_ _North Andover_ Owner's Name: _George Lavoie fl O Owner's Address: _345 Raleigh Tavern Lane_ _ North Andover, MA 01845_ Date of Inspection: 8/7/2003_ 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 /yAFai Inspector's Signature: Date: _8/7/2003_ 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: 345 Raleigh Tavern Lane- - North ane__North Andover_ Owner: _Lavoie_ Date of Inspection: _8/7/2003_ 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. Outlet pipe To D -Box & D -Box Replacement. 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: 345 Raleigh Tavern Lane- - North Andover— Owner: _Lavoie_ Date of Inspection: 8n12003_ 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: 345 Raleigh Tavern Lane _ _ North Andover— Owner: _Lavoie _ Date of Inspection: _8/7/2003_ D. System Failure Criteria applicable to all systems: You must indicate "yes" or `5io" 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 V2 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 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. Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 345 Raleigh Tavern lane- - North Andover— Owner: _Lavoie_ Date of Inspection: _8/7/2003_ 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? Yes_ _ Has the system received normal flows in the previous two week period? _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. 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: 345 Raleigh Tavern Lane_ _ North Andover — Owner: _Lavoie_ Date of Inspection: _8/7/2003_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): _N/A_ Number of bedrooms (actual): _3_ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): _N/A Number of current residents: Does residence have a garbage grinder (yes or no): Yes_ 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: Yes_ Sump pump (yes or no): No Last date of occupancy: _Current CONEVIERCIAL/INDUSTRIAL 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: Never pumped, owner_ Was system pumped as part of the inspection (yes or no): Yes_ If yes, volume pumped: _1000_gallons -- How was quantity pumped determined? _Measured tank_ Reason for pumping: _Never pumped, & inspect tank, & baffles._ 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: 30 years old, 5/28/1973, Info at Board of Health _ 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: _345 Raleigh Tavern Lane_ _ North Andover_ Owner: _Lavoie_ Date of Inspection: _8f7/2003_ BUILDING SEWER (locate on site plan) X Depth below grade: _14"_ Materials of construction: —X—cast iron _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 wall. 3" PVC in house, no leaks visible. SEPTIC TANK: X locate on site plan) Depth below grade: _2"_ 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: Tx 5' x 4' Sludge depth 12"_ Distance from top of sludge to bottom of outlet tee or baffle: 20"_ Scum thickness: _24" Distance from top of scum to top of outlet tee or baffle: — -2" Distance from bottom of scum to bottom of outlet tee or baffle: 0"_ 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.): Pumped septic tank. Inlet baffle ok. Outlet baffle corroded on top. Depth of liquid at outlet invert. No evidence of leakage. Septic tank is located under stairs for porch._ 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: _345 Raleigh Tavern Lane_ _ North Andover— Owner: _Lavoie_ Date of Inspection: _8/7/2003 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: _X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: --1/2"— 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 -boxes level & distribution not equal. Evidence of carryover. Evidence of leakage. Liquid level below outlet invert._ PUMP CHAMBER: (locate on site plan) Pump 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: 345 Raleigh Tavern Lane- - North Andover— Owner: _Lavoie_ Date of Inspection: _8/7/2003_ SOIL ABSORPTION SYSTEM (SAS): _X (locate on site plan, excavation not required) If SAS not located explain why: Tyle leaching pits, number: _ leaching chambers, number: leaching galleries, number: _ leaching trenches, number, length: X leaching fields, number, dimensions: _1 field 20' x 451 _ 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 oL Vegetation oL No sign of ponding to surface. Camera all leach fines, no standing liquid in pipes._ 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 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _345 Raleigh Tavern Lane _ —North Andover— Owner: _Lavoie_ Date of Inspection: _8/1/2003_ 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. A to 1 = 20'3" Ato2=17'9" Ato3=15'4" A to D -Boz = 31'10" Bto1=3'10" Bto2=5'6" Bto3=7'10" B to D -Boz =16'6" Septic tank is located under stairs for porch. Collapsed Pipe 20' Driveway Water Meter House A Septic Tank Porch 3 2 1 B D -Boz 45' Deck Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 345 Raleigh Tavern Lane _ _ North Andover Owner: _Lavoie_ Date of Inspection: _8/7/2003_ 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 # 36, Charlton Soil, Water > 6 feet deep. Rug.11 03 10:34a C1� co J N J N J .47 V 04r'0J',1 VO•W vV1 VvIr CO J N tvlw f7.JJ ,rJJvo © a V9 J d b O. ,O O. w O• w kO •o N -C VI ViJVN vvovvvvovvvovvvv vvv©000v©©o©©ovv v v v v o a ©v ©v o ©v v© v N m c m S J J J J V1 V1 V1 V1 V1 V1 VI V1 J J J J ©© � 'Tl �o�o�o�ovlinininvv©©©vvv m 4 Vi V1 V1V7OOvvvvvp m H Go J N -i -1 V7 V1 v J V W N J V1 " J©© O VI Vn J V v V1 V9 N v V •O V W 'o •D N -1 •0:::. W J V7�rIh1J 6466.JNv r 4 o ba --4 W V1 w -+ 00 •O V VI J v N O O Do m M z 15: p.l cn 0 N ra vi ,�, a y. i i 'U 0 tii 1 O II rn N 77a CDCc, m o.k wNJoom-4oO Vn wN-+ �-+ NNNNNNNNNNNNNNNN C7 I �.� �•--; rm vvvvvvvvvvvvvvvv -C 1 m n -• ye vvvDOD©vvvvvvvvv G7 170 cnD p: wwwWNNNNJJJJovvv ,. S w N J J k CJ N W N J W N J I rn ,may tt- O NNNNNNNNNNNNNNNN I r J4 h •-• a I r g' m v©-©©©v►�00-+vvvJv I = V1 NJ mmV1wJV9NJwV1wNw N I 0; � � .. � y' O ©©©©©J N J J DOJ ©©© V'1 W VlNNO. •O -412, 12 ti r 11V9Oti V N �';;a"f;=? � NNNNNNNNNNNNNNJJ l7 I -{ ri ►*� v v v v v v© v ©O v v v v o• o m I I O ��x:' vvvvvovvvvv©vv�o�o W WNN.+NN-+JJvv ©©'O.O I { w `t3 M -o rn D -_ -j W W W w W w W co W w W W w W W N O ii _ ©_ N N N N J N N J .� O .L & N v Vl © © tel V1 jrgr N J J 'V •O O 004.1 V1;r•O�©WND.W•ONNCO b m o`; x Vf W W W W W W w W W W W W W W W w cwr SNC 35 {TI l R' ti J. N N J . 1& J J J v m O W O ���N V©©vV7Vl� WNJ►�l =77� o x o�W.WVIw.;"*Z No..W�NoNN � z G -c �. IT C r. L7 co J N J N J .47 V 04r'0J',1 VO•W vV1 VvIr CO J N tvlw f7.JJ ,rJJvo © a V9 J d b O. ,O O. w O• w kO •o N -C VI ViJVN vvovvvvovvvovvvv vvv©000v©©o©©ovv v v v v o a ©v ©v o ©v v© v N m c m S J J J J V1 V1 V1 V1 V1 V1 VI V1 J J J J ©© � 'Tl �o�o�o�ovlinininvv©©©vvv m 4 Vi V1 V1V7OOvvvvvp m H Go J N -i -1 V7 V1 v J V W N J V1 " J©© O VI Vn J V v V1 V9 N v V •O V W 'o •D N -1 •0:::. W J V7�rIh1J 6466.JNv r 4 o ba --4 W V1 w -+ 00 •O V VI J v N O O Do m M z 15: p.l