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Miscellaneous - 36 HAWKINS LANE 4/30/2018 (2)
co 'lop PUBLIC HEALTH DEPARTMENT Town of North Andover Wu" Community and Economic Development Division CERTIFICATE OF COMPLIANCE As of: November 7, 2016 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Tank, D -box and pipe under driveway of an On -Site Sewage Disposal System By: David Maynard — Maynard Construction At: 36 Hawkins Lane Map 106.0 Lot 122 North Andover, MA 01845 Thelance c ificate shall not be construed as a guarantee that the system will function satisfactorily. Bran r of Public Health 120 Main St., North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web www.northandoverma.gov 08/23/2017 Address: 36 Hawkins Lane All North Andover Residents with Septic Systems and Garbage Disposals Please note that due to a recent review of a Title 5 Report, your property has been identified as maintaining a working garbage disposal that is being used in conjunction with a septic system. The Health Department is concerned for the longevity of your septic system. Garbage disposals are never recommended where septic systems are used, but if they are installed, the system must be specifically designed to handle the waste from them; your system can not handle the waste as designed. Please note that continued use of this disposal could quickly cause a pre -mature failure of your septic system, resulting in a large expenditure to replace it. The North Andover Health Department recommends that you remove it from your home as soon as possible. Some information regarding regular maintenance of your septic system is attached. Please call the Health Department at 978.688.9540 if you have any questions, or e-mail your questions to: healthdeptnnorthandoverma. gov. Thank you for taking the time to consider the impact that your current setup has on your septic system and the environment. Sincerely/rasZse,CEIHT friana Director of Public Health 120 Main Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web http://www.northandoverma.gov IV 1 °� NORry qti � m � CO SSACHUS� North Andover Health Department Community and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 36 Hawkins Lane MAP: 106.0 LOT: 0122 INSTALLER: Todd Bateson DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS Tank, D -Box, Pipe under driveway INSPECTION: 11/7/16 DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: SEPTIC TANK X Con tractor_reports any changes to design plan X -.Existing septic tank properly_ abandoned' X Internal plumbing all to one building sewer X Topography not appreciably altered X Building sewer in continuous grade, on compacted firm base X Cleanouts per plan X Bottom of tank hole has 6" stone base ❑ Weep hole plugged X 1500 gallon tank has been installed H-10 loading X Monolithic tank construction X Water tightness of tank has been achieved by visual testing X Inlet tee installed, centered under access port A CONTROLPANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION -BOX (14" under cover) X Installed on stable stone base X H-20 D -Box ❑ Inlet tee (if pumped or >0.08'/foot) X Hydraulic cement around inlet & outlets X Observed even distribution X Speed levelers provided (not required) X Schedule 40 PVC Pipe Comments: speed levelers used, equal distribution V X Outlet tee installed, centered under access port ' (gas baffle/effluent filter) X inch cover to within 6" of finish grade X installed over one access port Hydraulic cement around inlet & outlet Comments-., PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROLPANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION -BOX (14" under cover) X Installed on stable stone base X H-20 D -Box ❑ Inlet tee (if pumped or >0.08'/foot) X Hydraulic cement around inlet & outlets X Observed even distribution X Speed levelers provided (not required) X Schedule 40 PVC Pipe Comments: speed levelers used, equal distribution V Commonwealth of Massachusetts Map -Block -Lot 106.00122 ----------------------- BOARD OF HEALTH Permit No -04 -20 North Andover BHP1664 -----20--04------ P.I. FEE F.I. $175.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd Bateson to (Repair) an Individual Sewage Disposal System. b '� (� 1, , at No 36 HAWKINS LANE 1C� }` ) �1� V--i�V--`--Y y -w - as shown on the application for Disposal Works Construction Permit No BIP? 2-0.1`6,046 Dated Novembe 07, 2016 r zR•,� ) ---- -- ------------ ----------------------------------------------------------------- Issued On: Nov -07-2016 BOARD OF HEALTH - --------------------------------------------------------------------------------- Co_!lApplication for Septic Disposal System TODAY'S DATE ' Construction Permit -TOWN OF NORTH ANDOVER, MA 01845 X001- �ul'Repair ponent Application is hereby made for a permit to: Q Construct a new on-site sewage disposal system' ❑ Repair or replace an existing. on-site sewage disposal system" M epair or replace an existing system component — What? A. Facility Information Address or Lot # C'ty'r°""' RECEIVED�L 2: *TYPE OF SEPTIC SYSTEM*: A ❑ Pump ravity (choose one) NOV U 7016 ""11` pump system, attach copy of electrical permit to application**' ➢ ❑ Conventional System (pipe and stone system) TO ;&&N ANDOVER ➢ [IInfiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to insippjgn.) ➢ ❑ Pressure Distribution S.A.S. (No D -Box) ➢ ❑ Pressure Dosed (D -Box Present) S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No L-� If yes, does plan specify make and model of filter? YES = (no further info. needed) NO = (installer must specify brand of filter before DWC issuance) What is the Make? what is theModef°' 2. Owner Information B h„/ Mame / ``-- 3 Address (if different from above) _ /Vv AlAveA- Cityfrown State Zip Code �'?B' GAS lyyf? Telephone Number 3. Installer Information Name Name of Compan r��r � �A'i'E: ON ENTERPRISES, INC. Address 114 ARG 1 Ebtk ROAD /'y G! V !U i._ ANDOVER, MA 01810 CitylTown N 4. Designer Information Name Address City/Town State Zip Code Telephone Number (Cell Phone # if possible please) Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 Applipation..for Segtic p_posa .sxern ' ' TODAYS DATE Construction Parr-rrit ,. TO'C T OF -RTH ANDOVIER MA 01845 $.250.00 Full Repair 's �C* i $'125.00.- component PAGE 2 OF 2 A. Facility -Information continued.,.. S. Type•of Building: 9 esldentlal,Dwellin or❑Commercial B. Agreement The unders/gned agrees to ensure the construction and maintenance of the afore -described on-s/te sewage disposal system In accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system fn operation unt11 a Certificate of Compliance has been Issued b Is Board of Health. - zz_ • Name Date Applicata Appro : (Board of Health Representative) Name Date Appl tion D approved, for the following reasons: For Office Use Onw• I. Fee Attached? Yes No 2.• ProjectMarlager Obligation Form Attached. Yes M. 3.: B=D Sm=? Ifso) Aaaeb cQ2f P No 4. Fouadatior�As Built.?(hew construction ronly); Yes (Same scale as a ro ed Ian No PP Y P ). • 5. FloorMws? (he.w construction- only); No APplfc�t(bn'tor.p(sppsal 5ystbM 0onstmetloh Pemmft � Pam 2 of 2 SE"IC'S.YSTEM•IN MAS• MA' T&irvB M':PBLiCATIo' m As fb*-Ngt&Andovtrlicmcd isuMa fpg40ietftftgedo for .�aeptic spatggQ•i'M.thelftPa yat; Lwi��tis °[+eptic WOMV) Am plow by Re]ativd to dtapp&adou . le 51:�,n, RAndws 4=0 Abd doped Dated //-17-11, : A whit iievidom dated 4126 revised daft) I nadrratand the foilowiag obligations fat to sagesncut of twS project: 1. As the faod ; I' #p abaazt aIIpes sad Boat+d cf ieacirh appiwed Pial �a nmittg anp. an a lite: I mm hxre dammud." and fimoftko -n m 3. As e iasfalter;.I,twboafmsmy and afl*q=donL. I£ contmmcp p:ojr&= magtt; or my, O*U p=a,, not 04oc€rtted with my compiM �'aa mspac�oat sad theapstem is aotmdp, dtett As soffithem - ," J:Mq, ztd tp i.v�ee �t1c y edprio� to the.�p�pi�bje as iiltnd,ds efndiecem_ u b.*i,�.. j -;_ _-�•ainm Am -at �I'p :tl►esc is ' ' 'j ' aih =Oa A iOut 4cfmjiGt . • •; ...-�ar�ia'�iiap {�' �-tom. arc. • ba �tibirii. ��� �� � �� i� dte esfgfftees must . • . bapte�t fart �•� Arlt �f .. � tune. 'I�afaller iriust CM" tb to ' bei gild able to G k'- e!ctioa etrhei z���P �.�gja eas�Pletect data not 4. As*e kollm-1 tama3� that onlq IMYPI -161 m complete dietstsitit of tit+e sysl�egtid�irrSURM '�ittleaer r I a:t;"iixea and 5.. Ab the ef�•Y t�aatl Ismart d�: p Of � COaStattC ai! a De arlaes mt t. ep rtkv�r arftfie bsa t s -r n rafica - b. Iaspetifo� Qftlie" drmd e7da �e wed �•Prr:l�apcoBon"hp8oa�latttLra�AsB''tttarsaa�llda�. - . d �toflti!]'.g�PAMPbeit+�`�atl$,adtothEir 6. vaad�dsapdc.� P 1 1 G Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. V ISI Commonwealth of Massachusetts RECEIVED Title 5 Official Inspection Form NOV 17 2016 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 36 Hawkins Lane Property Address John Zrebiec Owner's Name North Andover Cityrrown MA 01845 State Zip Code Inspection results must be submitted on this form. Inspection forms way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Neil Bateson Name of Inspector Bateson Enterprises Inc. 11/10/2016 Date of Inspection Company Name ! / 111 Argilla Road 771;E S /:y Company Address v Andover MA 01810 City/Town 978-475-4786 Telephone Number B. Certification State SI -15 License Number Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needg Further Evaluation by the Local Approving Authority 1 11/10/2016 Inspector's Signatu Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent 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.doc • rev. 6116 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 36 Hawkins Lane Property Address John Zrebiec Owner's Name North Andover MA 01845 11/10/2016 CitylTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: After permit from B.O.H.,replaced bad pipe to septic tank, septic tank & d -box, inspection from B.O.H., septic sytem now passes Title 5 Inspection. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Commonwealth of Massachusetts d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Hawkins Lane Property Address John Zrebiec Owner-- -- Owners Name information is required for every North Andover MA 01845 11/10/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately 0 a `3 �9�� S�� =33 r1 11 -� tv� fl t� i© f� h3 =10 '0n\'e U'S/ t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Hawkins Lane Property Address John Zrebiec Owner's Name North Andover Cityrrown MA 01845 State Zip Code 10/18/2016 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: 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 use the return Name of Inspector key. Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover Citylrown 978-475-4786 Telephone Number B. Certification MA State S115 License Number OCT 2 4 2016 T0." M OF 1'ORTH 01810 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Nee F rther Evaluation by the Local Approving Authority 10/18/2016 InsfeWes 8ignati Date The system inspector shall submit z 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 • 3/13 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 36 Hawkins Lane Property Address John Zrebiec Owner's Name North Andover MA 01845 10/18/2016 Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: Z 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): Tank liquid level 3" from outlet invert. t5ins • 3113 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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Hawkins Lane Property Address John Zrebiec Owners Name North Andover Cityfrown B. Certification (cont.) MA 01845 10/18/2016 State Zip Code Date of Inspection ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1- System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Hawkins Lane Property Address John Zrebiec Owner Owner's Name information is required for North Andover MA 01845 10/18/2016 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: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Inlet pipe to septic tank, septic tank & d -box needs to be replaced. 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 • 3/13 Idle 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts upTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Hawkins Lane Property Address John Zrebiec Owner Owner's Name information is required for North Andover MA 01845 10/18/2016 every page. Citylrown 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Hawkins Lane Property Address John Zrebiec Owner's Name North Andover MA 01845 10/18/2016 City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 t5ins - 3/13 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 r 36 Hawkins Lane Property Address John Zrebiec Owner information is required for every page. Owner's Name North Andover MA 01845 10/18/2016 Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: ® Yes ❑ No ❑ Yes ® No ❑ Yes ® No ❑ Yes ® No Yes ® Yes ❑ No Current Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Pap 7 of 17 •� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y< 36 Hawkins Lane Property Address John Zrebiec Owner information is required for every page. Owner's Name North Andover MA 01845 10/18/2016 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Pumped 2011, owner gallons Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 3113. Title 5 Official Inspection Form: Subsurface Selvage Disposal System •Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y< 36 Hawkins Lane Property Address John Zrebiec Owner Owner's Name information is required for North Andover MA 01845 every page. Cityrrown State Zip Code D. System Information (cont.) 10/18/2016 Date of Inspection Approximate age of all components, date installed (if known) and source of information: 27 years old, 1/31/1989, as built plan Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: ® cast iron ® 40 PVC ❑ other (explain): 2 feet ❑ Yes ® No Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" Cast Iron through wall, 3" PVC in house, no leaks visible. Soil pipe to septic tank has a dip in it, needs to be replaced. Septic Tank (locate on site plan): Depth below grade: Material of construction: 1 feet ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 10'x 5'x 4' Sludge depth: PAY ❑ Yes ❑ No t5ins • 3113 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Owner information is required for every page. t5ins • 3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Hawkins Lane Property Address John Zrebiec Owners Name North Andover MA 01845 10/18/2016 CitylTown 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 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 N/A E N/A = Tank leaking N/A How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level 3" below outlet invert, evidence of leakage. inlet tee ok. Outlet tee ok. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass 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: feet ❑ polyethylene ❑ other (explain): Date Tile 5 Official Inspection Form: SubsuAace Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .'� 36 Hawkins Lane 10/18/2016 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 Dimensions: Capacity: Design Flow: Alarm present: Alarm level: ❑ polyethylene ❑ other (explain): 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 - 3113 Title 5 official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 Property Address John Zrebiec Owner owner's Name information is required for North Andover MA 01845 every page. Citylrown State Zip Code 10/18/2016 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 Dimensions: Capacity: Design Flow: Alarm present: Alarm level: ❑ polyethylene ❑ other (explain): 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 - 3113 Title 5 official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 36 Hawkins Lane Property Address John Zrebiec Owner information is required for every page. Owner's Name North Andover MA 01845 10/18/2016 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert -1'1 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Liquid level in d -box 1" below outlet inverts. No evidence of carryover. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 3113 Title 5 Official Inspection Form: Subsurface SewageDisposal sposal System •Pape 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �( 36 Hawkins Lane Property Address John Zrebiec Owner information is required for every page. Owner's Name North Andover MA 01845 10/18/2016 Citylrown 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: ❑ overflow cesspool number: ❑ innovative/alternative system 1 field 20'x 50' 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 - 3113 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 36 Hawkins Lane Property Address John Zrebiec Owner's Name North Andover Cityfrown D. System Information (cont.) MA 01845 State Zip Code 10/18/2016 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 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 36 Hawkins Lane Property Address John Zrebiec Owner's Name North Andover MA 01845 10/18/2016 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 /4 g ()n Ue, wo-j / t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Hawkins Lane Property Address John Zrebiec Owner's Name North Andover City/Town D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar MA 01845 10/18/2016 State Zip Code Date of Inspection ® 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: 4/19/1985 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Design plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: As per test pit data on design plan. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal posal System •Page 16 of 17 •� Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Hawkins Lane Property Address John Zrebiec Owner Owner's Name information is required for North Andover MA 01845 10/18/2016 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 3H3 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Summary Record Card generated on 10/5/2016 2:39:06 PM by Karen Hanlon Page 1 Town of North Andover Tax Map # 210-106.C-0122-0000.0 Parcel Id 17757 36 HAWKINS LANE ZREBIEC, JOHN 36 HAWKINS LANE N. ANDOVER, MA 01845 Class 101 Single Family Zoning2 1 Residential Size Total 1.04 Acres FY 2017 Property Type Zoning3 1 Residential 1 Residential UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until ZREBIEC, JOHN Payor 36 HAWKINS LANE N. ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 17370.0 - 36 HAWKINS LANE Last Billing Date 7/26/2016 3170040 03 Cycle 03 Active UB Services Maint. Account No. 3170040 Service Code Rate Charge Multiplier/Users MISCFEEADMIN FEE 1 1 9.18 1/ WTR WATER 01 ALL METER SIZE 49.40 /1 UB Meter Maintenance Account No. 3170040 Serial No Status Location Brand Type Size YTD Cons 13240314 a Active ERT HH METE METE w Water 1 1 519 Date Reading Code Consumption Posted Date Variance 9/7/2016 983 a Actual 50 285% 6/7/2016 933 a Actual 13 8/2/2016 41% 3/7/2016 920 a Actual 9 4/22/2016 -39% 12/8/2015 911 aActual 15 1/20/2016 -63% 9/8/2015 896 a Actual 41 10/16/2015 84% 6/8/2015 855 a Actual 22 7/24/2015 118% 3/9/2015 833 a Actual 10 4/28/2015 11% 12/9/2014 823 aActual 9 1/15/2015 -77% 9/10/2014 814 a Actual 40 10/15/2014 291% 6/9/2014 774 a Actual 10 7/16/2014 0% 3/10/2014 764 a Actual 10 4/11/2014 -1% 12/9/2013 754 aActual 10 1/17/2014 -62% 9/10/2013 744 a Actual 27 10/15/2013 197% 6/10/2013 717 a Actual 9 7/24/2013 3% 3/11/2013 708 aActual 9 4/22/2013 -18% 12/7/2012 699 a Actual 10 1/9/2013 -71 9/12/2012 689 a Actual 39 10/15/2012 482% 6/8/2012 650 a Actual 6 7/16/2012 -26% 3/14/2012 644 a Actual 9 4/14/2012 18% 12/9/2011 635 aActual 7 1/17/2012 -78% 9/12/2011 628 a Actual 36 10/13/2011 372% 6/6/2011 592 a Actual 7 7/20/2011 -14% 3/8/2011 585 a Actual 8 4/13/2011 -15% 12/10/2010 577 aActual 10 1/12/2011 -80% 9/8/2010 567 a Actual 51 10/15/2010 679% 6/4/2010 516 a Actual 6 7/15/2010 -14% 3/8/2010 510 a Actual 7 4/14/2010 -9% 12/10/2009 503 aActual 8 1/12/2010 -58% 9/9/2009 495 a Actual 20 10/15/2009 116% Of:' "-1R 1 �-1 ,vale -('M AA I-I)v,C; MA y (,����►"{ Sc��y _ wnl ❑ WEc.c_ 5S q1 5E I-Ic Sy s 1L-," I-)Csl6A) PAI��-J(2-7-74F- PLA J Dje5 Gry �IS,QPPRDV�p �j - �Z.- anp S1-0�-e spread V74 F►e5 . i ��ASoNS 0 ifY,(-:7Y,( r -F/30r C.1 Pry S< cl F/OJL �PPi�cwE �i�TC LL -K7 l��l''r<w►ti� �;ui f ORO iy 16W (TIO)JA 1A)5F6 . IOti j �lF Qty) L> 1', -fes T-tv•�- V ot- Di��;�pt'l�UvE1-2 7- F9 IVot ,( cK�� '� XS D,a rC wAru-t (4ivc ro 7,V" r-- c-) lZ�/J50 I ( Gc&5 c-'euve-l-z' RAL APPIZVAL �� NORTH Coleman Mc Donough Mc Donough Construction Corp. 100 Ainsworth Rd. Wilmington, Ma. 01887 postmesterY or fees and i 1 "O Show- to whom d. Ur aoaltional fens the to[iQwing services ere. ,dor additional service(sl' reraiue�ted, _" , � , Donough ' Construct': 0� 1�insworthr,`,Rd: ; I,min ton Ma � , r ��0,._88� t� tura Address to Age tTT _ 3 S P1, Delivery. a :r A. t877,Peb 19$6 ,., Wi 'Certified tx Express M8H Afirvays obtain signature of ad' agentandtDATE DELIVERS[ B.;Addressee'8 Address (OWL) requested and fec patdJ DOMESTIC RETUR November 4, 1988 Your septic system installers license has expired. After the violations that occurred during the construction of lot 2 Old Cart Way inNorthAndover this Board feels it has sufficient cause to refuse to reissue that license. Please bear in mind that before any septic system construction begins a permit must be taken out by a licensed installer. Any system constructed without a license will not be approved and the occupancy permit will be denied. You have the right to appeal this decision in writing within seven days of receipt of this letter. If you request a hearing you will be called before the Board during one of the regularly scheduled mettings, which are attended by reporters and the general public. At the hearing I will desribe to the Board what happened at lot 2 Old Cart Way and you will be allowed to present your excuses. I feel it is unlikely that you will be able to convince the Board to reissue the license over my objections. sincerely, 1.10 Michael Graf R.S. C.H.O. r y . C.P. McDonough Construction Corp. 100 Ainsworth Road Wilmington, MA 01887 Tel. 657-5800 • 657-5801 Certified Mail Board of Health 120 Main Street North Andover, MA 01845 Attn: Michael Graf November 7, 1988 Please consider this correspondence as formal notification that I am requesting a hearing in response to your decision dated November 4, 1988 concerning the status of my Septic System installers license. Sincerely, Coleman McDonough President C.P. McDonough Construction Corp. C. P. McDonough Construction, Corp. 100 Ainsworth Road Wilmington, MA 01887 Tel. (508) 657-5800 • 657-5801 FAX (508) 657-4818 February 2, 1989 Mike Graf Town of North Andover Town Hall 120 Main Street N. Andover, MA 01845 RE: Septic System As-Builts - Lot #2, Hawkins Lane Dear Mike, Please find attached a copy of the interim as -built plan for the subsurface sewage disposal system on Lot #2, Hawkins Lane. Particular attention should be paid to note #2 on the plan relative to the soil pipe not being installed as of the plan date. Once we are notified by the owner that the pipe has been installed, a revision to the plan will be prepared and submitted to your office to document installed invert elevations of same for your use and files. Should you have any questions, please let me know. Sincerely yours, Raymond T. Fraser, II, P.E. Vice President C.P. McDonough Cosntruction Corp. enclosure yt ,.• .. .a OL James Ragonese 419 Main St. Amesbury, Ma. BOARD OF HEALTH 120 MAIN STREET NORTH ANDOVER, MASS. 01845 2-16-89 re: lot 2 Hawkins La. TEL: 682-6483 Ext. 32 or 33 This is to verify that your septic system as installed so far has been approved by the Board of Health. The septic tank and leach field have been installed as described in an as -built plan dated 1-31-89 and a letter dated 2-2-89 by C.P. McDonough Const. As mentioned in the letter, this system is complete except for the pipe from the foundation to the septic tank which cannot be installed at this time. While the completed part of the system is satisfactory, final approval must wait.until the septic tank is connected to the foundation. 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