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Home My WebLink AboutMiscellaneous - 37 SULLIVAN STREET 4/30/2018ri 0 K) Q co WATER SUPPLY: TOWN WEL WELL PERMIT DRILLER.__._._.___.__.__._...__.._...__ WELL TESTS: CHEMICAL UP I E APPRUVED-_ BACTERIA I DA I E ()PPRUVED BACTERIA II DATE APPROVED COMMENTS: FORM U APPROVAL: APPROVAL 1*0 ISSUE YES NO DATE ISSUED BY 7AA1 CONDITIONS: FINAL APPROVAL: - ALL PERMITS PAID WELL CONSTRUCTION APPROVAL SEPTIC SYSTEM CONSTRUCTION APPROVAL OTHER ANY VARIANCE NEEDED FINAL BOARD OF HEALTH APPROVAL: YES YES YES YES NO NO NO NO YES NO DA I'E:.Jl-e BY:.. -4e '•-,•,-� s,^.y^-.;s-' n-•..:•-� .,F ... ;. � a, � ~<""""t'- ; '"ar :.+ �"" #., r,`" -'v -� , ",.� K i '"`.'�•'�-""' - --".e, ^'-- �-..`n.. - ;;tt', '*.r tE- L--=: k y >r j r 1`^+ i -e iJ"'"i,a .r i,,, Y S}t"",bSr...f X .. y }'} .L,._ _ .1..r R ;r „ "i' . r•}. tr .,• 4 *} x , j jer rt J 4 i •,.1� ! Vf:. }!. O, 4 l r !f n t ..�1 } •• 4 , f 5 y i"_ :' ! t.'.h •�t i V' �• h iJ 1 z. M1t �„ jY'6•. :7 t ' + t b.'� ,,. t !. Z.eo- • ^'fr � i f �.y 4•s `;} 1� i'., ` �' .,. 'r ,_..'. a ,'' � .K c� A.�j ci4 -X if' " ht .�, N1..1. � � t n.[•AY-, ry,' -y: '� f ,R..:Y!';.+•;•1"'?K-,� # \ 1'q !iw.ti �'_'�`:=+:+��`a'. i. Z• •' ', }• i THE INSTALLER LICENSED? �y;'_;.': r,��_ r x YES NO :<• :`.,: i•11, .'(�•i' .ti •$r:a _-'-i�e'�: :i. _ ... . Jni - .'t. .S _- •:. t ;; - OF ONS RUCT• YPE C T IO 'REPAIR"..r.' :, ; • ::T 1V . NEW .REPA VY -....'NEW CONSTRUCTION: ,.:_,. CERTIFIED PLOT -PLAN REVIEW_yFS— NO CONDITIONS OF:. APPROVAL YES NO FROM FORM U) �` .c. AM1 } ;�'•'•t l: �:� 1' i' •i }.' , tial. • ,. s,ISSUANCE OF DWC ` YES NO PERMIT ; DWC PERMIT; N0. ° ,: / INSTALLER:m /��G>,i�t/ ' ;:. iii.?`.. -. t�: ._"'�'+�:��+:' •• •. ''. • BEGIN INSPECTION YES N0. -.,_ EXCAVATION INSPECTION: _ ;NEEDED: i .,rt ... •r•:. zt .alt . •r's:. PASSED 'BY-:* ' CONSTRUCTION INSPECTIONS NEEDED: = AS -BUILT PLAN SATISFACTORY: YES APPROVAL TO BACKFILL: DATE: HY ' " F3NAL.GRADING APPROVAL: DATE BY : " :..FINAL CONSTRUCTION APPROVAL: DATE. ccS Z� BY i NORTy O 4 ACHUSE� North Andover Health Department Community and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 37 Sullivan Street MAP: 107.13 LOT: 0100 INSTALLER: Todd Bateson — Bateson Enterprises DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: D -Box Repair INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: 9/22/2017 DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: SEPTIC TANK ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ® Topography not appreciably altered ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Watertightness of tank has been achieved by visual testing F ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) .'��jl� ^� ❑ inch cover to within 6" of finish grade installed over one access port T,¢,a • ; ❑ 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 ® Installed on stable stone base ® H-20 D -Box ❑ Inlet tee (if pumped or >0.08'/foot) ® Hydraulic cement around inlet & outlets ® Observed even distribution ® Speed levelers provided (not required) ® Schedule 40 PVC Pipe Comments: 9/22/2017 All Set. Brian LaGrasse SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder / concrete / timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel -less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = FINAL GRADE ❑ Loamed ❑ Seeded ❑ Cover per plan Comments: DOCUMENTS NEEDED ❑ Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer ❑ As -Built Plan BM = HR = HI = SYSTEM ELEVATIONS ROD ELEVATION AS -BLT INVERT DESIGN INVERT ELEV ELEV Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 TOP Lateral 1 INVERT Lateral 2 TOP Lateral 2 INVERT Lateral 3 TOP Lateral 3 INVERT Lateral 4 TOP Lateral 4 INVERT Lateral 5 TOP Lateral 5 INVERT Lateral 6 TOP Lateral 6 INVERT Top of Chamber Bottom of Bed/Chamber SKETCH PLAN M CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- Waterline 10 10 101 ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh, Inland / Coastal Banka 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib. to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot. Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 ® Drains (Other) Foundation 10 (5) 20 (10) ® Drywells 20 25 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws North Andover Health Department Community and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 37 Sullivan Street INSTALLER: t DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: MAP: 107.13 LOT: 0100 INSPECTIONS TANK INSPECTION: ' p— DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: f DATE OF FINAL GRADE INSPECTION: �W— SITE CONDITIONS Comments: SEPTIC TANK ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑^/ Internal plumbing all to one building sewer L/' Topography not appreciably altered ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Watertightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION -BOX Installed on stable stone base H-20 D -Box �j Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets []/Observed even distribution Speed levelers provided (not required) Schedule 40 PVC Pipe Comments: ,. G SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder / concrete / timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel -less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = FINAL GRADE ❑ Loamed ❑ Seeded ❑ Cover per plan Comments: DOCUMENTS NEEDED ❑ Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer ❑ As -Built Plan BM = HR= HI = SYSTEM ELEVATIONS ROD AS -BLT INVERT DESIGN INVERT ELEVATION ELEV ELEV Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 TOP Lateral 1 INVERT Lateral 2 TOP Lateral 2 INVERT Lateral 3 TOP Lateral 3 INVERT Lateral 4 TOP Lateral 4 INVERT Lateral 5 TOP Lateral 5 INVERT Lateral 6 TOP Lateral 6 INVERT Top of Chamber Bottom of Bed/Chamber SKETCH PLAN j, ti CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- Waterline 10 10 101 ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh, Inland / Coastal Banka 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib. to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot. Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 ® Drains (Other) Foundation 10 (5) 20 (10) ® Drywells 20 25 ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws •. • C PUBLIC HEALTH DEPARTMENT 01 D Town of North Andover q L6 c.ol� Community and Economic Development Division CERTIFICATE OF COMPLIANCE As of: September 22, 2017 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: D -Box Repair of On -Site Sewage Disposal System By: Todd Bateson Bateson Enterprises, Inc. At: 37 Sullivan Street Map 107.B Lot 100 Brian Direr asse, CEHT blic Health er, MA 01845 a guarantee that the system will function satisfactorily. 120 Main St., North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web www.northandoverma.gov Commonwealth of Massachusetts RECEIVED u W Title 5 Official Inspection Form SEP 2 5 201 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments OF NORTH ANDO 37 SULLIVAN STREET THEALTH DEPARTMENTER SIM Syey`w Property Address STEPHEN JASKELA Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 8/23/17 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. 10 rm A. General Information Inspector: JAMES H. CURRIER II Name of Inspector J'S SEPTIC & DRAIN Company Name 131 FOREST STREET Company Address MIDDLETON City/Town 978-774-6685 Telephone Number B. Certification MA State S12327 License Number �6�D 01949 r0 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 ❑ Needs Further Evaluation by the Local Approving Authority 8/23/17 Inspector'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 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. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 37 SULLIVAN STREET Property Address STEPHEN JASKELA Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 8/23/17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ❑ 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.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 &N- Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 SULLIVAN STREET Property Address STEPHEN JASKELA Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 8/23/17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): DBOX NEEDS TO BE REPLACED. ❑ 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.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments aM 37 SULLIVAN STREET Property Address STEPHEN JASKELA Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 8/23/17 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: k 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 ❑J \ Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 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 37 SULLIVAN STREET Property Address STEPHEN JASKELA Owner's Name NORTH ANDOVER Cityrrown B. Certification (cont.) Yes No MA 01845 State Zip Code 8/23/17 Date of Inspection ❑ ® 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. ❑ ❑O' Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ❑44�N 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 withi 00 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.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 wE Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 SULLIVAN STREET Property Address STEPHEN JASKELA Owner Owner's Name information is NORTH ANDOVER required for every page. Cityfrown C. Checklist MA 01845 State Zip Code 8/23/17 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example..- a gpd x # of bedrooms): 660 GPD �(6 t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GM , 37 SULLIVAN STREET Property Address STEPHEN JASKELA Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 8/23/17 page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Yes 2 No ❑ Yes ❑ No ❑ Yes residence have a garbage grinder? ElYes ® No PIPDoes Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 9 ( Y 9 (gP ))� WELL Detail: Sump pump? ® Yes ❑ No CURRENT Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): 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: Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 SULLIVAN STREET Property Address STEPHEN JASKELA Owner Owner's Name information is NORTH ANDOVER required for every page. Cityrrown D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: MA 01845 8/23/17 State Zip Code Date of Inspection Date General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: LPD - 8/15/12- B.O.H. RECORDS 1000 GALLONS gallons TRUCK GAUGE INSPECTION & MAINTENANCE Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 SULLIVAN STREET Property Address STEPHEN JASKELA Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 8/23/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: AS BUILT DATED 5/13/94 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): 6" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: 24 feet Comments (on condition of joints, venting, evidence of leakage, etc.): PIPES IN GOOD CONDITION„ NO EVIDENCE OF LEAKAGE. Septic Tank (locate on site plan): Depth below grade: 25"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 9'6" X 68" X 4'8" Sludge depth: 7" t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 37 SULLIVAN STREET Property Address STEPHEN JASKELA Owner information is required for every page. Owner's Name NORTH ANDOVER MA 01845 8/23/17 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 Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? RE • 2" 16" 14" SLUDGE JUDGE & TAPE Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK IN GOOD CONDITION, OUTLET BAFFLE NEEDS TO BE REPLACED. LIQUID LEVEL CORRECT, NO EVIDENCE OF LEAKAGE. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet t e or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 SULLIVAN STREET Property Address STEPHEN JASKELA Owner Owners Name information is NORTH ANDOVER required for every page. City/Town MA 01845 8/23/17 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: gallons gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 SULLIVAN STREET Property Address STEPHEN JASKELA Owner Owner's Name information is NORTH ANDOVER required for every page. Cityrrown D. System Information (cont.) MA 01845 State Zip Code 8/23/17 Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D BOX IS DETIORATED AND NEEDS TO BE REPLACED. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 37 SULLIVAN STREET Property Address STEPHEN JASKELA Owner Owner's Name information is NORTH ANDOVER required for every page. Cityrrown D. System Information (cont.) Type: ❑ leaching pits State Zip Code number: 8/23/17 Date of Inspection ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: (3) 47' ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SOILS DRY, NO SIGNS OF HYDRAULIC FAILURE, VEGETATION NORMAL. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 37 SULLIVAN STREET Property Address STEPHEN JASKELA Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 8/23/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 og Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 SULLIVAN STREET Property Address STEPHEN JASKELA Owners Name NORTH ANDOVER MA 01845 8/23/17 City/Town 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 t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 owl Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 SULLIVAN STREET Property Address STEPHEN JASKELA Owner Owner's Name information is NORTH ANDOVER required for every page. Cityrrown D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells MA 01845 8/23/17 State Zip Code Date of Inspection Estimated depth to high ground water: 108" feet Please indicate all methods used to determine the high ground water elevation: // Obtained from system design plans on record If h kddt fd 1 d' 1992 c ec e, a e o eslgn pan reviewe 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: You must describe how you established the high ground water elevation: TEST PIT DATA ON FILE WITH B.O.H. - TEST PITS PERFORMED ON 4/12/90. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 37 SULLIVAN STREET Property Address STEPHEN JASKELA Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 8/23/17 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 A� a � ��ak Obi\ VX / y- No TE : $ EN -G N MA e K 70P FCVtJPAi78N = 1647-51 P 2 CvN iR7A c TO 2 Ec CV47-10N AT... .(TOP OFSTONE) _ a EZEWT/ON QT ......... 2E'QU/2E0 F/cL = ................................................... . �ICLEI/.�IT/ONS o�sl�N qs aUicT �L/T OF,�/OUSE 1�6,G o VTO T4NA- 9UT OF TANK 5,83 1(,6.05 INTO D. BOX. OUT OF D. 430)(/(,5.59 165-76 -"LoT SUB-SU�PFOCE D/ SYSTEM /N .f NO oTN , 8033 $ ❑ Town of North Andover $ '+�'••,,,,o .:,' HEALTH DEPARTMENT ,SSACMOst� Septic Disposal Works Construction (DWC) CHECK #: DATE: - S- QP LOCATION: 3S-�- Septic Disposal Works Installers (DWI) H/O NAME: Z5&s ❑ CONTRACTOR NAME: Jctm¢,S Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ _ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ Title 5 Report C©n $ s0 '- ❑ Other: (Indicate) $ h Agent Initials White - Applicant Yellow - Health Fink - Treasurer ' Commonwealth of Massachusetts Map -Block -Lot ua, • 107.60100 ----------------------- BOARD OF HEALTH Permit No LoomNorth Andover BHP -2017-0544 P.I. FEE F.I. $175.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Bateson Ent to (Construct) an Individual Sewage Disposal System. at No 37SU_LLIVAN STREET as shown on the application for Disposal Works Construction Permit No. BHP-2017-0�4TDate e¢i�Yhbll, 2017 DL �.� >f---------- Issued On: Sep -11-2017 BOARD OF HEALTH ,� -------------- --------------------------------------------------------------- Commonwealth of Massachusetts Map -Block -Lot 107.60100 r, BOARD OF HEALTH --------- Permitmit No North Andover BHP -2017-0544 --------------- -- - P.I. FEE F.I. $175.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Bateson - --- Ent ------------------------------------------------------------------------------------------------ to (Construct) an Individual Sewage Disposal System. at No 37 SULLIVAN STREET ---------------------------------------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. 1311P-2017-054 Dated September 11, 2017 ----------------------------------------------------------------- Issued On: Sep -11-2017 BOARD OF HEALTH r - Application for Septic Disposal System • _I Construction Permit —TOWN OF NORTH ANDOVER, MA 01845 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. I� Application is hereby made for a permit to: F1 Construct a new on-site sewage disposal system* TODAY'S DATE $ 250:00' -full Repair $125.00 - Component ❑ Repair or replace an existing on-site sewage disposal' system* tepair or replace an existing system component - What? b— o,X A. Facility Information Address or Lot # Ale - /V_jQ_ P111* r tr 2.- *TYPE F SEPT STEM*: �no Pp�E� 2. TYPE O N� ➢ ❑ Pump ravity (choose one) ***!f pump sy , attach copy of electrical permit to application*** ➢ &Conventional System (pipe and stone system) ➢ ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your cenyfrcation to install this type of system) ➢ ❑ Pressure Distribution S.A.S. (No D -Box) ➢ ❑ Pressure Dosed (D -Box Present) S.A.S. ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES = (no further info. needed) NO = (installer must specify brand of inter before DWC issuance) What is the Make? [What is the Models' 2. "Owner Information S,1t P �A-Skk_I A- flame r 37 5,, /1 Address (if different from above) City/Town State Zip Code `7Y1-- Telephone Number 3. Installer Information Name Address / A Cityrrown 4. Designer Information Name Address City/Town Name of Company 111 ARGlLLA ROAD C. ^ -- o/r/r) 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 — /7 • TODAY'S DATE $:250.00 -Full Repair 3`125.00;- Compon'ent PAGE 20.F2. A. .adfilty- informa#ion continued,,,, S. Type pf Building: esidentlal-Dwelling or OCommerciai B. Agreement The undersigned agrees to ensure: the construction and maintenance of the afore:described on-site sewage disposal system,ln accordance w/th the. provisions of Title 3 of the EnVlronn7ental Code, as. well. as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place. the system fn operation unt!% a Certlflcate of Compliance has been Issue this Board of Health. Name Date Application Approved By: (Board of Health Representat/ve) Name Date Application Disapproved. for the following reasons: 0 For Office Use Only: 1 -Fee Fee Attached?:�• Yes, 2.• ProjcetMartager Obligation Form Attached. _ No 3.: �riin System? Ifso� Attach co,Rp� ..Y��r';.• IPermrt'.; �'es ' No t/ . 4. FoundottoVAs Built.? (hew constructfot) ron!}r): Y . (Same scale ass to ed laa ° PP Y p ) • S. Floor mws? (hew corisfruction only): Yes No Applfegtlon'iorpisposat SystbM%06MstMCVC1 Nnnft - Race 2 rir :0 .C14 �7I a1 •�. ' VMMi1[ *BLlmnm As fiWNqlth AnduvarZmset#33ianlleY fr/sF Ee fiats c f theaeptia ay�te } fob the'ptQpes�YA Ll (Ad*rtotsq* ggtesa) P'Clzpim= bS 4htl" to d"#of d 1y �S�i✓ Abd dstnd Dstrd 1-7 _ us -W with revidof I Tindcrataftd tht foltoWlag bffligauvim for pmagc cut of=s projcct: i. As the festaltezi I am.obltgated to obu& Plpemift aad'BomA alIealth �ppwvedP ' 'P h - 3. As lhi iiwbw -.I.Mbkr da -fos =7 =d ttftT cd=& Uhe>tne w' nto :prajectmat>Ager, ar Anp other pemcm fiat tuOchftd vhh mycmupky mieduitem tium"Im • ! t C tCtil !d n6tz dy, thciz 3.* Asp 1tIL2 �4� • mO0tecl i74m• 40 �e 9 ��•prio�#o i1�e`.aplptlts�bk u�: sts miffiout . � �.�I`�•�p�d�ou-a:then � �ut�ning•c�, �iiclr ... �t:�sgecdos� �t �qea-notbane to b�presait:• . - .6. 6' • . _ •: ��it�c-_�rr•Fclo•t�ap far thw,,i�a�t�, ct�c• .. o vt OIfi (os ell 111i ba ttibaiittied trtc Boatel ofHa, anti'fi the erEgiaeea gust taeir�r for �,Rln4n�tasn.tit+ae. Iasmlter ititisr b ;Xuw tte j►�able to , gat�•tb�of3c smti to •• - . .• - e. must WPM aq== abe�'ijpdf nX j cmplttt. Ipsta a does s�or bkva to ba +o� ' 4. lres the iaatsltes;'I d thatcidy Fti>:y gt u c'�et�a,t6c�r ; baa coMPie.the�aata titin oth�c spi%skti atzi tired M . 'f�taotaa fnr denial �f thts-a�yat�rat a�dle�nt,��ea;i• �''''�-• �.�e i . 5.. _ th`einanlllerl.r tmderaa: or mwhre:d t pix �f t cmikpcfm. k Iaspet�a� Qftlre`es�ad>:adaaexo he uaea C. FivadAw, zi d ofd p-�P=P lea tvs:ltta�aGf ether 6. O` NOFTM 1M 8002 Town of North Andover �';'•,'+ HEALTH DEPARTMENT CHECK #: J/ `/(o DATE: LOCATION: 3 7 56/ 1h "11 L I) `V H/0 NAME: 5 /�. 0 �a,S)&& CONTRACTOR NAME: /60,*''on Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic -Design Approval �-boy, $ xSeptic Disposal Works Construction (DWC) ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) $ Heal ent Initials White - Applicant Yellow - Health Pink - Treasurer w 0 J k 0 ci 0. /�/oTF: $ENGN MASK 7bP FcvjtJ,9A- IvN = 169.51 PE 2 Coll TRA c TO R. .SLOPS ........................... DES/CN 6-LEI/,47-ION 47 .........(TOP OF STONE) _ . _ _ EX/5T/1V6 6ZEVdr1ON 47 ......... REQUIRED R4L - FZ&V..dT/O/V.5 VV, PIPE OUT OF yOUSE /i✓V PIPE INTO T4Nf( 1/VV PIPE OUT OF 7,4NK //VV. PIPE INTO D. BOX IiVV PIPE OUT OF D. BOX INV END OF PIPE a .o �tiv: at -FRENCH •n GVaTE2 EL E'I/,4 TION ,411 VER,4 E STONE D67P7-1-/ 4T ACOBE /1'OTF W15 _ PLAN /S NOT ,4 91,,41Pie41VTY OF 7,4'E' SYSTEM BUT ,4 tl-6-12%FIC,4T/O/V Of TqE LOC4TION OF TWE EX 3TI 57'W(f TU2E5 . .5o.;rT t 91 SYSTEM /N A1oZTH ANDoV E Ii l"IA55. FD/2 TAM E5 6R- F0141 D4 TE: NrA Y 10 CU15/5TIANSEN SE)9GI, INC. /600 SUMMER STREET HAVERq/LL , MASS. PLAN REVIEW CHECKLIST ADDRESS Z,:3- ENGINEER A V,' GENERAL 3 COPIES STAMP LOCUS '-� NORTH ARROW SCALE CONTOURS /" PROFILE `� SECTION `'' BENCHMARK :s SOIL & PERC INFO ✓ ELEVATIONS WETS. DISCLAIMER WELLS & WETLANDS ✓ WATERSHED?/V/0 DRIVEWAY-, (Eley) WATER LINE -� FDN DRAIN SCH40 X TESTS CURRENT? SEPTIC TANK MIN 1500G .17 INVERT DROP �� GARB. GRINDER/t�> (+200% EDF) 25' TO CELLAR ✓ MANHOLE TO GRADE ELEV GW D -BOX SIZE INLET LEACHING - OUTLET # LINES 3 FIRST 2' LEVEL STATEMENT (2" OR .17 FT) TEE REQ'D? MIN 660 GPD? RESERVE AREA 4' FROM PRIMARY?,k 2% SLOPE_ 100' TO WETLANDS 100' TO WELLS 4' TO S.H.GW 35' TO FND & INTRCPTR DRAINS 1 325' TO SURFACE H2O SUPP tl 4' PERM. SOIL BELOW FACILITY MIN 12" COVER FILL? (25' if above natural elev; 101if below) BREAKOUT MET? TRENCHES MIN 660 gpd SLOPE (min .005 or 6"/1001) >3 'COVER? -VENT SIDEWALL DIST. 2X EFF. W OR D (MIN 6') IS RESERVE BETWEEN TRENCHES? ✓ IN FILL? MUST BE 10' MIN. �' 4" PEA STONE? Lf Goa 3� z Z �� Za BOTS X LDNG !,1t'5 + SIDE S�� X LDNG ' %Z = TOT 7e,c!` (L x W x #) (G/ft2) (DxLx2x#) (G/ft2) G Copyright GD 1993 by S.L. Starr SkJ LINGS & SONS IL DATE TO Attention FAX: 16034653512 May -13-94 Fri 14:12 PAGE: 01 ARTESIAN WELLS, PUMP$,4ND FILTERS 269 PROCTOR HILL ROAD HOLL!S, NH 03049 PHONE (603) 889-5009 1 (800) 4411-6281 FAX (603) 465-3512 Numbn of co.pies includling ccvei, sheet: Doi FROM: GFILLINGS & SONS 05/13/94 FAX: 16034553512 Mar -13-94 Fri 14:12 a ARTESIAN WELLS, PUMPS AND FILTERS 289 PROCTOR HILL ROAD HOLLIS, NH 03049 PHONE (803) 889.5009 1 (800) 441-6281 FAX (603) 465.3512 WHITE BIRCH CONSTRl1('TION 380 ESSEX STREET, ST'E 1 LAWRENCE, MA 01841 RE` Lot 5 Su,.t,Lvan- Road Non -#.h. An -d. o v e<n. , MA. To whom it m(.y conte r� PAGE: 02 —._. "N i`h.e. pump zy.-6te4p Zn:3ta- ted at tke. above addyte.-t J, _�-6 a. !HTI 7Cor'M Eag-e.c yeni e.�-3u,bme � h2e pu.rnp rza.de_ W.Ah. No,'tCtZ pko=a.ti.c.. TILL PUMI) !ai4ou�.d. no-�CC. 1Lo p,,GGbt.w to the. Zea.d. con-tc-n.t- conce,ia. 14 a.n.y d ou.bt , a, wate.ij, ,�t.e� t �h ot4-P d. t e �o►t��-d.e�ecC . Tha.ntz. You, S coat. E. UJti4 f t n-3 pump Sy'6'.em.6 Matw-ge-L I' 7haedtewew Xaaeaeoepr, Ayc. 66 LITTLETON ROAD WESTF'ORD, MA 01886 (508) 6928395 FAX (508) 692.0023 1.800 -649 -'GEST Report Number: C-aks-12151 Report.Datet May 26, 1994 client: Sample Taken At: Mr. Roger Skillings White Birch constr. skillings and sono Lot 5 Sullivan Rd. 269 Proctor Hill Rd. N.Andovertmana. Mollis NH 03049 Sample Taken By: SKS staff on: May 25,2994 cEnirxchn or ANA.L,Y64s TEST PARAMETER: LPA Max "SOLTS U14ITS Total CO:iiforM (P) 0 0 Per 100mi calcium No Limit 37t2 mg/L copper (8) 1.3 <0.02 mg/L Iran (S) 0.3 # 1.6 mg/L magnesium No Limit 6.6 r,,911, Manganese (9) 0.05 # 0.27 mg/L Sodium 20 134.7 mg/L Potassium (a) NO Limit 1.6 mg/L Alkalinity (s) NO Limit 68 mg/L Ammonia No Limit <0.03 mg/L chloride (S) 250 65.5 mg/L Chlorine (total) 0.7 <0.02 mg/i, color (S) 15 # 40 CPU conductivity No Limit 359 u:mhos/cm Hardness NO Limit 12Q mg/L Nitrates(as N)(F) 10 0,78 mg/L Nitrites(as 14) 1 50.01 Mg/L pH ( a ) 6.58.5 6.9 tau odor (a) 3 0 TON sulphates (a3) 250 37.7 mg/L Turbidity 5 4.8 NTV Sediment Poo/rieg nog NT&Not Tested, f=V&lue Exceeds . ZPA STD, t'NTCOTOO Numer ou9 Co Count -Background bacteria Noted, "*EPA Adviaory biviit .*Exceeds EPA Advisory Limit (P) -Primary EPA Standard, (s)ngecondary EPA standard (may affoot aesthetics of drinking water i.e. taste, color, etc.) Thiaa water sample, as tested, is considered SAFE to drink according to EPA guidelines, however, Ono or more of the parameters exceeds EPA secondary standardB as indicated by the (#) sign. Mass aohuasotts State certified HOW VP/CO�Xson , dor Testing Laboratory #MA048 Thorstensen Laboratory Ino. f y Vl� 1.1 a W � W Cc m -� m - C O) E C \ L a O) C0 Q L U y� O) •> �p 0C m m O) C Q 11 O Y C O m m m V lL LL 1.1 a Lo m W, An E O E 09 Z r O L CL H" c ♦.r to C W cm Oa.w= �. 41k m CL c = o a e N EM4, W G,. � � � C Z s� LLJ �. �� ti W y ` d +L'' E ; ++ fZ LL (A * •� _ 3 {y+' a: r d O aL ..0 < L&A �p C) CL 0 oc C W a a°, T W) W o Lij O l Z c0 �lw ;�tiP�rc; f��t►ia!'#J++�1'{�6 t 5�?��riv"R�;��.�.'iYf�"j��A,�,p�Q�_�T,�:�'�`1,�.:}f r r;'%� M1 r s : ..:_� _ �_ -';�.. '•t � Town of North Andover, Massachusetts Form No. 3 of NoRTN BOARD OF HEALTH .< •.•+o A 19�_ DISPOSAL WORKS CONSTRUCTION PERMIT SACHUSE Applicant , 'k rV-1 NAME Site Location_ 1 —* t l/1 A Permission is hereby granted to Construct or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHgIRMAN, BOARD OF HEALTH Fee D.W.C. No. _ 2 i� COA1�i0NWEALTH OF MASSACHUSETTS 2 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET; BOSTON NIA 02108 (617) 292-5500 ARGEO PAUL CELLUCCI TRUDY CORE 3 Secretary DAVID B. STRUHS Governor Comnussioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION r1,If OwL � Property Address: v11 vd,I� / N � "Name of Owner !� Address of Owner` Date of Inspection: 'i/ i— Name of Inspector: (Please Print) - 1�15 1 am a DEP approved system insect or rsuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: X0 0 Mang Address: Telephone 'Numbers: CERTIFICATION STATEMENT I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes _ Needs Fur et Evaluation By the Local Approving Authority _ Fails Inspector's Signature: z Date:2—,? r / The System Inspector shal�ubmit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. . NOTES AND COMMENTS revised 9/2/98 Page 1 of 11 Prinled or Recycled Paper P ti t LAUG10 199!9 _ J I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A / CERTIFICATION (continued) 'roperty Address: %J v h TAU Alol t� Jwner: Date of Inspection: 1 e " ! V ,sow INSPECTION SUMMARY: Check A, 8, C, or D: f A.' SYSTEM PASSES: " `r _V:6—6- I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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 corhpletion of the replacement or repair asA pro;yed;by,the-Bpard of Health, =will`.pass T , Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revised 9/2/98 f Page 2 of 11 r e r � . f . fw� . 0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: q7 a3 V L L ty Al W,0 A1,D ©Y e— owner: e ' if S D �✓ Date of Inspection. 7-- C. FURTHER EVALUATION IS REQ IRED 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 the public.health, safety and 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. _ _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the 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. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3of11 w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 4. CERTIFICATION (continued) Property Address:„'3 So L ✓ 41t9 - I/(= /a— Owner: Date of Inspection: r? ti D. SYSTEM FAILS: You st indicate either "Yes” or "No" to each of the following: have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No _ Backup of sewage into facility or system component due'to an overloaded orclogged 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 leyel in the distribution. box above outlet invert due to an 'overloaded,o clogged SAS it cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 dayiflow., 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. _ Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any sucfasystem shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Pagc4of11 N ( �# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM {. PART B CHECKLIST Property Address: 3 V j) L L( V j /I/4„/pe ./� 0 �+/�mr fQ Date of Inspection: ii GusrY 19 Check Check if the following have been done: You must indicate either "Yes” or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and -the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. w ¢ The facility or dwelling"was inspected for signs of sewage back-up. _ The system does not receive non -sanitary or industrial waste flow. The site was inspected for signs of breakout. J All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ Existing information. For example, Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)1 The facility owner (and occupants, if different from owner) were provided with information on the proper. maintanaac's-of SubSurface Disposal Systems. 0 ^+ y'. ,► til rt. revised 9/2/98 Pagc5of11 -W P- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Iroperty Address: Owner i >1 Aw � . a. Date o/ Inspection: . • Its. �•,' *- FLOW CONDITIONS RESIDENTIAL: t Design flow:g.p.d./bedro Number of bedrooms (designl: Number of bedrooms (actual): Total DESIGN flow / Number of current residents:—,f,—�{-- Garbage grinder (yes or no): Laundry (separate system) (yes or no),�L ; If yes, separate.inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):�i- / Water meter readings, if available (last two year's usage (gpd): Well Sump Pump (yes or no): --Ho Lest dfied-of occupancy: COMMERCIAL%INDUSTRIAL: Type of establishment: Design flow: 9pd ( Based on 15.203) Basis of design flow 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: OTHER: (Describe) Last date.of occupancy: t GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)440S If yes, volume pumped: gallons Reason for pumping: f l/e-,q T -A/// _- TYPE OF YSTEM 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) I/A Technology etc. Attach copy of�up to date operation and maintenance contract Tight Tank ' Copy of bEP 4provaF`' Other APPROXIMATE AGE of all components, date installed (if known) and source of information: - Sewage odors detected when arriving at the site: (yes or no)() f .r revised 9/2/98 Page 6of11 r- r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION lcontiinued) i f� 'roperty Address: L [.. ! Y A// i'Q ' fT AA10D y j C + Owner: Date of Inspection: if S "' A BUILDING SEWER: ! (Locate on site plan) Depth below grader Material of construction: — cast iron '- 40 PVC _ other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, -etc.) SEPTIC TANK:_,PS g (locate on she jfplan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Wage confirmed by Certificate of Compliance _ (Yes/No) // �^ r. Dimensions: /U 'S '( r� Sludge. depth:_. el 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: la How dimensions were determined:% 'omments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) r`G-E'S 4-- Z'.i1 4C -,,i 40 0 C 0r-! flr T/o <-i -'::.w e!zC'.z 1d t�v i'4r .t -'- GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum tNrickness:` .' r ya 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: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) revised 9/2/98 Page 7of11 .•ori SUBSURFACE SEWAGE DISPOSAL SYSTEM -INSPECTION FORM PART C SYSTEM INFORMATION (continued) "roperty Address: 137 IS10/ 4 j Owner: r'.J Q y Date of Inspection: le g TIGHT OR HOLDING TANK:'(Tank must be pumped: prior to, or at time of, inspection) (locate on site. plant Depth below grade:_ Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarmlevel:, Alarm in working order: }}Yes r No 4. Date of reuiou�n rpt k. 4 r. t t1, P P {� 9 Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) GoU `l -r SCJ tT// A-!Gc►�f PUMP CHAMBER: (locate on site plan) Pumps in working order: (Yes or No) Alarms, in working order (Yes or No) Comments: (note condition of pump chamber, condition of pump's and appurtenances, etc.) 4 revised 9/2/98 Page 8 of 11 0_4� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 4operty Address: 7 U j ✓ rY ©. n/ Z ,D owner: Date of Inspection: 7-;z3 �. 9 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, location may be approximated by non -intrusive methods) If not located, explain: Type: leaching pits, number leaching chambers, number:_ leaching galleries, number:_ / leaching trenches, number, length: -3 C� a 7At/o leaching fields, number, dimensions: overf)bw pesspbol, numbef::_ t �' Alternative system: (. 'y , # Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) r/ 5/�.C/ Gf /?OHd/W 0010414.14. t ,t CESSPOOLS: _ (locate on site plan) j f Number and configuration: Depth -top of liquid to inlet invert: Depth of solids layer: )epth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) 4, ' PRIVY-: locate on site plan) { 7+ F y r .r i Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9 of 11 J? e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C • SYSTEM INFORMATION (continued) 'roperty Address: .�d fA N 0 V A Date of Irupection:7-0so /V 2— «,. SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) it it f. 4 ♦ 1 t 361 revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r r PART C SYSTEM INFORMATION (continued) opertyAddress: � �,t./1� L i' IV, �i/ t j !! l►� © W �j Owner: �, /(J r>n e !V Date of Inspection: _w i ' Soil Type_` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r r PART C SYSTEM INFORMATION (continued) opertyAddress: � �,t./1� L i' IV, �i/ t j !! l►� © W �j Owner: �, /(J r>n e !V Date of Inspection: NRCS Report name ' Soil Type_` Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep r SITE EXAM Slope Surface water Check Cellar y r� 6hallow wells S. s Estimated Depth to Groundwater _.Feet r ,k Please indicate all the methods used to determine High- Groundwater Elevation: i -o"'�'Olbtained from Design Plans on record 06served Site (Abutting property, observation hole, basement sump etc.) L+/�'Determined from local conditions Checked with local Board of health - Checked FEMA Maps Checked pumping records Checked local excavators, installers :r Used USGS Data Describe ,how you established the High Groundwater Elevation. (Must be completed) t revised 9/2/98 Page ttoftt NEW ENGLAND ENGINEERING SERVICES INC `l T;, OF t:C)RI'H ANE M.—R/ J, _ �y 1 7 200? L�� May 13, 2002 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT: 37 Sullivan Street, North Andover, MA Dear Sirs: Enclosed is a copy of the Title V report for the above referenced property. The system PASSED our inspection. If there are any questions please call me at my office, 686-1768. Sincerely 1-2 Benjamih C. Osgood, T. 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 a Lu OW r y Q w , J cri y V � � M C0 O `3 a� c O L a=i � w ►O.i d O O � L E a c G R O `3 a� c O L ca v � V � w ►O.i d O O O `3 19 r al rn cQ) a 0 c m .Ch Ml -i I LO °' F- C:) vi o E p d CDE� 0 d o H c a� O 0 o^ z z z o ,0 0 'o N = a � N Q C O c o m y o a 10. p y a o 0 3 jLL rL O m m E a� c r o a a m a w H z z z J 19 r al rn cQ) a 0 c m .Ch Ml -i I LO °' F- C:) vi o E p d CDE� 0 d o H c c O o^ z z z o ,0 0 'o N = a � c = as o m y o a p y a o 0 3 jLL rL O m m is a� c r o a a 19 r al rn cQ) a 0 c m .Ch Ml -i I LO °' F- C:) vi o E p d CDE� 0 d o H c S i � S Ot HONTM 1� _ Town of North Andover "+�'•�,,,,o : HEALTH DEPARTMENT �ss�cNustt '' CHECK #:% DATE: LOCATION: H/O NAME: CONTRACTOR NAME: T_Yye of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing ❑ Septic - Design Approval ❑ Septic Disposal Works Construction (DWC) ❑ Septic Disposal Works Installers (DWI) ❑ Title, 5 Inspector .Ca le 5 Report . ❑ Other. (Indicate) $ Health Agent Initials, White - Applicant Yellow - Health Pink - Treasurer COT." O 1NWEALTH OF MASSACHUSETTS / EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS �✓ DEPARTMENT OF ENVIRONMENTAL PROTECTION �-/L7h kv--a SS L�) TITLE 5 v OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: �IIIILIAAVI -57 a RECEIVE® Owner's Name: Al A4 Owner's Address: NJ�_ Date of Inspectioi Name of Inspecto Company Name: Mailing Address: Telephone Numb CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal syste below is true, accurate and complete as of the time of the inspectic training and experience in the proper function and maintenance of approved system inspector pursuant to Section 15.340 of Title _Z--P--asses Conditionally Passes -�eeds Further Evaluati( l e- e s SL7 T Inspector's Signate: Date: The system inspector shal mit opy 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. Title 5 Inspection Form 6/15/2000 page 1 COD, "D NV EALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 v� OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: S !&- 0 Owner's Name: Owner's Address: f2A A&_ Date of Inspectioi Name of Inspecto Company Name: Mailing Address: Telephone Numb JUN 2 5 2007 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 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: <asses Conditionally Passes ----Iyeeds Further Evaluation by the Local Approving Authority Inspector's Signate:04— e Date: The system inspector shal mit opy 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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ,j� Sc.dA(Ql Owner: Date of Inspection: Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: 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. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank f 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: 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: 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: Owner: Date of Inspection: 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 i failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more frortl 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: .d Owner: Date of Inspection:2 D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes No ackup 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''/2 day flow 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. --V—/Any Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface /Water supply. V 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 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.] (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 rge 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 — MTA) 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 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:�,� l liki� Owner: Anlr,., Date of Inspection: 0(0=w Check if the following have been done. You must indicate `yes" or "no" as to each of the following: Yes No A' _ Pumping information was provided by the owner, occupant, or Board of Health Zwere 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 ? Z_ Were as built plans of the system obtained and examined? (If they were not available note as N/A) jz_ 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<thb—affles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? V_ 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 AzExisting 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) [3 10 CMR 15.302(3)(b)) Page 6 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: J u /If Owner: _ _ Date of Inspection: Osa L9 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): __it— Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): (al nA(-j Number of current residents: Does residence have a garbage grinder (yes or no): Is laundry on a separate sewage system (yes or no): [if yes separate inspection required] Laundry system inspected( es or no): Seasonal use: (yes or no): 7 Water meter readings, if av rlable (last 2 years usage (gpd)): Sump pump (yes or no): Last date of occupancy: COMM ERCIAIANDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): and 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: �Q25 ,ow EG�CL1�. Was system pumped as part of the inspection (yes or no): _ If yes, volume pumped: gallons -- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank, distribution box, soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) _ Tight tank _ Attach a copy of the DEP approval _ Other (describe): age of all compdr�ents, date installed (if known) and source of information: Were sewage odors detected when arriving at the site (yes or no): Gl Page 7 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner:c Date of nspection: BUILDING SEWER (locate on site plan) Depth below grade:11 Materials of construction:- _cast iron Z40 PVC other (explain): _ Distance from private water supply well or suction line_: —1— Compents ion condition of j,9ints,ti eniting, evidence of leakage, etc.): SEPTIC TANK: _ (locate on site plan) Depth below grade: ;t.5 Material of construction: Zoncrete _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) n Dimensions: I'IQ�O S Sludge depth: , 221/ Distance from top of sludge to bottom of outlet tee or baffle:_ Scum thickness:-, 3// Distance from top of scum to top of outlet tee or baffle: 1--(,0// Distance from bottom of scum to bottom f outlet tee or baffle: How were dimensions determined: Comments (on i)umvinQ recommendations, inlet and outlet tee of baffTe c dition, structural integrity, liquid levels 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: 'uhWIJ Owner: 1 Date of Inspection: p 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:(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0_// Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of PUMP CHAMBER: (locate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propertydress: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: _leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, CESSPOOLS: A (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth — top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 14 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3'-- SJlL1r/1%r1 Owner: r�e_ Date of Insp ce tion:_aD_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water (o.E; feet Please indicate (check) all methods used to determine the high ground water elevation: ei 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) Accessed USGS database -explain: You must scribe hphY\w you established the high grownf� w t elev tion: �.�nT.,, Y6JN/�llvn/i Iif)' t Ol D_ /1. n11,) v��i�t1 R t,�L4C� } je�1 �'Vj. t� R-rd„rrr�� It Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: as Ill�N Owner: _ 2 Date of Inspection: 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 ptt�lic watgr supply enters the building. I051t 7A—dy-- lut 4 ;A or LG H A #t a Trsrs-�� Real estate -Prudential Howe & Doherty Real Page 1 of 2 wz .; �;, C t:�s atl§ 6 �t� the Ah, tea lrh t V'al( j Listing Agent Information Michael Sibulesky Prudential Howe & Doherty 76 Main St • Andover, MA 01810 Direct: 978-475-5100 Property Listing North Andover, MA 01 List Price: Type: Type of Single -Family: Status: No. Bedrooms: Master Bath: No. Full Baths: No. Rooms: No. Half Baths: Style: Year Built: MLS #: Approx. GLA: GLA Source: Additional Photos: Click on th Click Here to see more than th Description: Delightful, completely remodeled Colonial in 2006 located on a level country acre lot. Feature! Improvements include recessed lights in every room, granite counters in kitchen & baths. New tile in kitcher room. Hardwood floors & stairs on 1st floor, new carpet on 2nd floor. All ducts vacuumed for zero residual d car garage, a lot of privacy. Easy access to major highways. Can..tact. Mortgage Calculator S.....c....h....edule aShowing I P,ri.i Interior Details: Exterior Details: Tax Infc ---•--- Basement: No Acres: 1.03 Assessed: Cooling: Window AC Lot Size: 44,866 Taxes: Heating: Forced Air, Oil Lot Description: Wooded, Paved Drive Tax Year: Heating Zones: 2 Waterfront: 0 Book/Page Foundation: Poured Concrete Garage Parking: Under Zoning: Foundation Size: 0 Garage Spaces: 2 UFFI: Flooring: Wood, Tile, Wall to Parking Spaces: 4 Lead Paint: None Utility: for Electric Range Fire Places: 0 Roof Material: Asphalt/Fiberglass Insulation Features: Full Shingles Hot Water: Electric Exterior: Masonite Construction: Frame Sewer/Water: Private Water, Private Sewerage Road Type: Paved Additional Features: Interior Features: Security System, Walk-up Attic Exterior Features: Deck http://www.andoverliving.comldetail.asp?listingID=705 50827&agentid=G0002415&searc... 6/14/2007 Real estate -Prudential Howe & Doherty Real Page 2 of 2 Appliances: Range, Dishwasher, Refrigerator, Washer, Dryer Disclosures: N Room Levels, Dimensions and Features: Room: Level: Size: Features: Room: Level: Size: Fe Master Bedroom 2 17X12 Bedroom 2 2 13X12 Bedroom 3 2 13X13 Bedroom 4 2 9X11 Dining Room 1 11X11 Family Room 1 16X12 Kitchen 1 11X17 Living Room 1 13X13 If you would like more information on this property or would like to Schedule a Shc Michael Sibulesky call: 978-269-2247 or email: msibulesky@andoverlving.c( The listing office is Prudential Howe & Doherty Realtors and the listing agent is Micha The information in this listing was gathered from third party resources including the seller and public records. M and its subscribers disclaim any and all representations or warranties as to the accuracy of this information. Pru be pleased to show you this or any other property. Prudential Howe & Doherty Realtors 12 Bartlet & 76 Main St • Andover, MA 01810 Phone: 978 475-5100 Toll Free; Fax: 978-475-5101 Email: int Prudential Howe & Doherty REALTORS® is an independently owned and operated member of Prudential R *Rankings based on total sides for single-family homes from information provided by MLSPIN for 1 PfrudenUal is a service mark of'The Prudential Insurance Company of America. Equal Housing @ppa http://www.andoverliving.comldetail.asp?listingID=70550827&agentid=G0002415&searc... 6/14/2007 JUN -17-2007 23:22 FROM:SSH 3RD FL COPY RM 314 765 9484 IU:'-J1b1 (..S (11ba4 N: 1,5' 1J i 'FQ4 K 5 1RVEY "M*W"96 ♦ FmcB -A MORTGAWR. ! " 3elat„Q i[AsJG ; - r ! REF: M ADDRESS OF PRMNOPLF BUIUdlllt3 PLANIREF_ My i J? 5P1L.I u4�1.3 GATE lop winafloN aw Iy i star:. s t ., 3 O• j S , i 0 06RrtFICA110M TO,,M—JA ift ria t : Woolon the "6018 Thh Mgfllspe P l01 Plan a oa p�eparad ddfitzilly tar d molt91ga pffpO "atb it b old -I-- ar '"R, *, tiriw !v Ah ft k cd xwit * by0aws in eNect oprrg�ucted lmbea ptqmft ihacwkr4sv".Th'splan lbs to Lound t dao�lsa Tsom awc�on toEe4lMA aW d the properly des far oy No argon Mmdar Most 6.L Tfpe Mi. AW, Se-- 7_ TMS oau)Wm Is bond an tell, 1 0, a d tlwvey i3lli ed WOft Is in �F'lvW Mond pSa of dl+ta,r. Flaad J08! JAN -8-2002 TUE 21:55 TEL:916173711604 once 13Cm3SUI dH WdEb $ fr 6000 11 Znd NAME:TOXIC REDUCTION CONTROL P. 13 W W � •� � a EO .� N 7p 4) U a •14-14 e ° 4. 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Water I Real-time United States Resources System: Web Interface i. i_ Go Warning! Notice! http://water.usgs.gov/ will be briefly down for maintenance (less than 20 min) on Tuesday, June 19 between 9-10PM EDT. USGS 01101500 IPSWICH RIVER AT SOUTH MIDDLETON, MA PROVISIONAL DATA SUBJECT TO REVISION Available data for this site Time -series: Real-time data l„ GO LOCATION.--Lat 42° 34'10", long 71° 01'39", Essex County, Hydrologic Unit 01090001, on right bank in Peabody, 700 ft downstream from Boston Street Bridge at South Middleton, 1.3 mi downstream from Wills Brook, and 2 mi south of Middleton. DRAINAGE AREA. --44.5 mit. PERIOD OF RECORD. --Discharge: June 1938 to current year. Water -quality records: Water years 1957, 1959, 1999. REVISED RECORDS.--WSP 1301:1942(M). WSP 1621: 1938-58 (monthly runoff). WDR MA -RI -84-1: Drainage area. GAGE.--Water-stage recorder with satellite telemeter. Datum of gage is 44.97 ft above sea level (Massachusetts Geodetic Survey benchmark.) REMARKS. --Diversions upstream for municipal supply of Reading, Lynn, and Peabody. Occasional regulation by mill upstream. COOPERATION BY.-- Massachusetts Department of Conservation and Recreation Office of Water Resources and Department of Environmental Protection, Office of Watershed Management. NOTE: Precipitation data are for informational purposes only. Data do not necessarily conform to standards used by the National Weather Service. Summary of additional data for this site Discharge, cubic feet per second http://waterdata.usgs.gov/nwis/uv?01101500 6/20/2007 Available Parameters Output format © Graph G Graph w/ stats 0Graph w/o stats OTable 0 Tab-separated11 Days 7 (1-31) GO E] All 2 Available Parameters for this site R 00060 Discharge 00065 Gage height Summary of additional data for this site Discharge, cubic feet per second http://waterdata.usgs.gov/nwis/uv?01101500 6/20/2007 • Page I of I USGS 01101500 IPSWICH RIVER AT SOUTH MIDDLETON, MA :1.80 1.60 ---, 1 7- 1.48 "H 1.20 0.80 Jun 13 Jun 14 Jun 15 Jun 16 Jun 17 Jun 18 Jun 19 Jun 20 ---- Provisional Data Subject to Revision ---- http://waterdata.usgs.gov/nwis/uv/?dd—cd=03-00065&format--img_default&site—no=O I 10... 6/20/2007 USGS Real -Time Water Data for USGS 01 1,01500 IPSWICH RIVER AT SOUTH MIDD... Page 2 of 3 Most recent instantaneous value: 31 06-20-2007 05:44 70 60 0 as H 50 L 0 CL a(5 40 20 USGS 81101500 IPSWICH RIVER RT SOUTH MIDDLETON, MR A __--__. + i � i i Instantaneous u 20% Median Value Mean 80% Max (1998) I I A II Jun 13 Jun 14 Jun 15 Jun 16 Jun 17 Jun 18 Jun 19 Jun 20 ---- Provisional Data Subject to Revision ---- A Median daily statistic (69 years) — Discharge Create presentation -quality graph Parameter 00060; DD 01 Daily discharge statistics, in cfs, for Jun 20 based on 69 years of record more 0.79 JL9.9 24i 31 41 611 372 Gage height, feet Most recent instantaneous value: 0.94 06-20-2007 05:44 http://waterdata.usgs.gov/nwis/uv?O 1101500 6/20/2007 Most Recent Instantaneous Min (1999) 20% Median Value Mean 80% Max (1998) 0.79 JL9.9 24i 31 41 611 372 Gage height, feet Most recent instantaneous value: 0.94 06-20-2007 05:44 http://waterdata.usgs.gov/nwis/uv?O 1101500 6/20/2007 ,4 USGS Re -al -Time Water Data for USGS 01101500 IPSWICH RIVER AT SOUTH MIDD... Page 3 of 3 1.80 1.66 1.00 0.80 USGS 01101500 IPSWICH RIVER AT SOUTH MIDDLETON, MR Jun 13 Jun 14 Jun 15 Jun 16 Jun 17 Jun 18 Jun 19 Jun 20 ---- Provisional Data Subject to Revision ---- Create presentation-qualityLagh Parameter 00065: DD 03 Questions about sites/data? Top Feedback on this web site Explanation of terms USGS Real -Time Water Data for the Nation http://waterdata.usgs.gov/nwis/uv? Retrieved on 2007-06-20 07:36:13 EDT Department of the Interior, U.S. Geological Survey Privacy Statement 11 Disclaimer 11 Accessibility 11 FOIA 11 News 11 Automated Retrievals 2.73 2.52 va02 http://waterdata.usgs.gov/nwis/uv?01101500 6/20/2007 r Jun 13 Jun 14 Jun 15 Jun 16 Jun 17 Jun 18 Jun 19 Jun 20 ---- Provisional Data Subject to Revision ---- Create presentation-qualityLagh Parameter 00065: DD 03 Questions about sites/data? Top Feedback on this web site Explanation of terms USGS Real -Time Water Data for the Nation http://waterdata.usgs.gov/nwis/uv? Retrieved on 2007-06-20 07:36:13 EDT Department of the Interior, U.S. Geological Survey Privacy Statement 11 Disclaimer 11 Accessibility 11 FOIA 11 News 11 Automated Retrievals 2.73 2.52 va02 http://waterdata.usgs.gov/nwis/uv?01101500 6/20/2007 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 PropertyAddress: Owner's Name: Colleen Anne l.co►,1 g Owner's Address: -7_ , , L, u ti „& ST A)o (LZ( A A) ;, c) , Date of Inspection: N Z-1 o?, Name of Inspector: (please print) C- J)I- Company Name: )O r` -t, iIsC,,t W x' Mailing Address: 6 u g g-&- e H V o xT1e A ryo )� 4, Oi 8 '-lam Telephone Number: `3 7p -- 6,%-/7G b[ 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 emerience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15340 of Title 5(310 CMR 15.000). The system: _L/ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Rj ;., r. 0, ) 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. 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:. 37 SULLIVAN STREET NORTH ANDOVER, MA Owner: COLEEN LAMBERT Date of Inspection: 4/26/02 Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: V/ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR .15:304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired The system, upon completion: of the'replaoement or repair, as approved by the Board of Health, will pass. Answer yes, no or n determined (Y,N,ND) in the for the following sta e ts. If "not determined" please explain. / The septic tank is metal an ver 20 years old* or the septi (whether metal or not) is structurally unsound, exhibits substantial infiltrate or exfiltration or tank dare is imminent. System will pass inspection if the existing tank is.replaced with a complyin tic tank as ap cued by the Board of Health. *A metal septic tank will pass inspection if it structiu lly sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old ' lable. ND explain: Observation of sewage backup or/6reak out or high water level in the distribution box due to broken or obstructed pipe(s) or due to a broken,ttled or uneven distributi x. System will pass inspection if (with approval of Board of Health): , broken pipe(s) are replaced ,f obstruction is removed % distribution box is leveled or replaced ND explain: / The sy$tem required pumping more than 4 times a year due to broken or obstructed piers). The system will pass inspoon 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: _ 37 SULUVAN STREET NORTH ANDOVER, MA Owner: COLEEN LAMBERT Date of Inspection: _ 4/26/02 C. Farther Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine ' e system is failing to protect public health, safety or the environment. System will pass;anless Board of Health determines in accordance with 310 C 1&303(l)(b) that the tem is not functioning in a manner which will protect public health, safe and the environment: spool or privy is within 50 feet of a surface water 1 or privy is within 50 feet of a bordering vegetated wet or a salt marsh 2. System will fail unless the Boa of Health (and Be Water Supplier, if any) determines that the system is functioning in a manner the rotects th abhc health, safety and environment: The system has a septic tank and soil tion system (SAS) and the SAS is within 100 feet of a Surface water supply or tributary to a sur ce er supply. The system has a septic tank d SAS and the S is within a Zone 1 of a public water supply. The system has aseptic and SAS and the SAS is S0 feet of a private wets supply well. The system has a tic tank and SAS and the SAS is less m 100 feet but 50 feet or more from a private water supply ell**. Method used to determine distance "This system asses if the well water analysis, performed at a DEP ce ti laboratory, for coliform bacteria an olatile:organic compounds indicates that the well is free from ution from that facility and the pr of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 p , provided that no other failure. teria are triggered. A copy of the analysis must be attached to this form. I Other: Page 4 of i 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address; _ Owner: Date of Inspection: 37 SULLIVAN STREET NORTH ANDOVER, MA COLEEN LAMBERT 4/26/02 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 V2 day flow 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. — _Z 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 watts 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 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.] A 0 (YesJNo) 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. barge Systems: To be considered a.large system the system must serve a facility with a design flow of 101000 gpd to 15,000 gpd. You must indicate either `W or "no" to each of the following: (The followigg cteria apply to large systems in addition to the criteria above) yes no — _ the system is within 400 a surface drinking supply _ — the system is within 200 feet of a to surface drinking water supply _ the system is located in ogee sensitive area (Int ellhead Protection Area — IWPA) or a mapped Zone II of a publ' ter supply well If you have an ed "yes" to any question in Section E the system is considered a s' ficant threat, or answered "yes" in on D above the large system has failed. The owner or operator of any large system considered a signi t threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15. 04. 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: _ 37 SULLIVAN STREET _ NORTH ANDOVER, MA Owner: COLEEN LAMBERT Date of Inspection: 4/26/02 Check if the following have been done. You must indicate `jres" or `nor as to each of the following: Yes No -Z _ 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 ? V- _ 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 br tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of sctun ? 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 Existing information. For example, a plan at the Board of Health. _ ZDetermined 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: _ 37 SULLIVAN STREET NORTH ANDOVER, MA Owner: COLEEN LAMBERT Date of Inspection: 4/26/02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): __�_ Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): &&0 Number of current residents: 'j Does residence have a garbage grinder (yes or no): -NO Is laundry on a separate sewage system (yes or no): hM [if yes separate inspection required] Laundry system inspected (yes or no): Seasonal use: (yes or no): Water meter readings, if available (last 2 years usage (gpd)): ., Sump pump (yam or no): Lro Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): and Basis of design flow (seats/pe sons/sgketo,.): 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 Primping Records Source of information: _/ qyy F e2 130 (-i V-116 LDS Was system pumped as part of the inspection (yes or no): ,,j c) If yes, volume pumped: ----.gallons — How was quantity pumped determined? Reason for pumping TYPE OF SYSTEM. Septic tank, distribution box, soil absorption system — Single cesspool _ Overflow cesspool — Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a Copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank _ Attach a copy of the DEP approval Other (describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site (yes or no):N Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: — 37 SULLIVAN STREET — NORTH ANDOVER, MA Owner: COLEEN LAMBERT Date of Inspection: 4/26/02 BUHDING SEWER (locate on site plan) Depth below grade: I Z Materials of construction: cast iron _,/40 PVC _other (explain): Distance from private water supply well or suction line: 3y� Comments (on condition of joints, venting, evidence of leakage, etc.) - S2 e- tc.):O2 c o/kS ferry:) INL SEPTIC TANK: _ (locate on site plan) Depth below grade: 3 Material of construction: e/concxete metal _fiberglass _polyethylene othcr(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance (yes or no): _(attach a copy of certificate) Dimensions: 1S" o Sludge depth: 3 Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 2", Distance from top of scum to top of outlet tee or baffle: (o Distance from bottom of scum to bottom of outlet tee or baffle: / 5" How were dimensions determined: rs.a a C s ; I C 14 Comments (on pumping recommendattons, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): GREASE TRAP:NL(locate on site plan) Depth below grade: _ Material of construction: concrete metal _fiberglass _polyethylene other (explain): Dimensions: Salm 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 �t OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 37 SULLIVAN STREET NORTH ANDOVER, MA Owner. COLEEN LAMBERT Date of Inspection: 4/26/02 TIGHT or HOLDING TANK: A& (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: --ons Design Flow: aallons/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.): DWI RMIMON BOX: (if present must be openWocate on site plan) Depth of liquid level above outlet invert: CJ '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.): 1r, Cars �. l (N C fl. PIC i7�5iK(A" a)Ai-.) C- Q, N7 Vr9GNCC (7% PUMP CHAMBER: N* (locate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 37 SULLIVAN STREET NORTH ANDOVER, MA Owner: COLEEN LAMBERT Date of Inspection: 4/26/02 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why. Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: ,/leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number: innovative(alteanative system TYpe/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): �4- eA. CESSPOOLSWLl (cesspool must be pumped as part of inspectionxlocate on site plan) Number and configuration: Depth — top of liquid to inlet invest: . 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: Aliq (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: Owner. Date of Inspection. 37 SULLIVAN STREET NORTH ANDOVER, MA COLEEN LAMBERT 4/26/02 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. M Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:. 37 SULLIVAN STREET NORTH ANDOVER, MA Owner: COLEEN LAMBERT Date of Inspection: 4/26/02 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water � 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) Accessed USGS database -explain: You must describe how you established the high ground water elevation: 4- ��cuz €v�rin ar �� 'i" br.l� _ �,l�i Czro.�.� }>j4i'r,Y�+�1 lj �'.j �{I;; +.�4'ir ...:•'. ..:Y .. � .. '. SYSTEM OWNER & ADDRESS SYSTEM LOCATION A (example: left front of house) Ao`�il�'`{tYatlh7 �r1F�� l�6t ,! • � .... .... _. .� .. .. Kr y r DATE OF PUMPING: - la -�� QUANTITY PUMPED ' `= U GALLONS CESSPOOLS NO _ YES ,_ SEPTIC TANK: NOYES t/ , "NATURE OF SERVICE: ROUTINE ,EMERGENCY J9,, l4 rMe �.`+.}1+ IIG •- .. .. #SERVATIONS: •� GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE _ { ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED i SOLIDS CARRYOVER OTHER (EXPLAIN) IrSYSTEM PUMPED BY: 046il OF TC ovN �I» 9 2001 _• „ it ... .... .. � .. _..�_. CONTENTS,TRANSFERRED TO: f TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD x, � r 9 DAA; �_ f _ -` }>j4i'r,Y�+�1 lj �'.j �{I;; +.�4'ir ...:•'. ..:Y .. � .. '. SYSTEM OWNER & ADDRESS SYSTEM LOCATION A (example: left front of house) Ao`�il�'`{tYatlh7 �r1F�� l�6t ,! • � .... .... _. .� .. .. Kr y r DATE OF PUMPING: - la -�� QUANTITY PUMPED ' `= U GALLONS CESSPOOLS NO _ YES ,_ SEPTIC TANK: NOYES t/ , "NATURE OF SERVICE: ROUTINE ,EMERGENCY J9,, l4 rMe �.`+.}1+ IIG •- .. .. #SERVATIONS: •� GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE _ { ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED i SOLIDS CARRYOVER OTHER (EXPLAIN) IrSYSTEM PUMPED BY: 046il OF TC ovN �I» 9 2001 _• „ it ... .... .. � .. _..�_. CONTENTS,TRANSFERRED TO: f w a 0 0 0 Z Z Z O o z z z C) ,0 O 'O N '00 � c a h (1)'0 o 0 3 � w �L r02O � Gni O d i0 01 �► t C C 0 c m O An a m �1 a LO F- a C a� c "o E o o 0 Lo V N V N d o H y 0 a� m m IL O O w a 0 0 0 Z Z Z O o z z z C) ,0 O 'O N '00 � c a h (1)'0 o 0 3 � w �L r02O � Gni O d i0 01 �► t C C 0 c m O An a m �1 a LO F- a C a� c "o E o o 0 Lo V N V N d o H y 0 a� m m IL Z V y $ a G I w i w � � d .0 G a� 0 R y $ a I w w a� 0 R IC z z z G O o c�0 z z z C) N a ch G j O m y o a O h a o 0 3 w r L O 16 m m a1 on o a a w = V Ip y G = Cl)C7 v a p Ic► � U` Lll 0 H cc A d 0 y $ a I = a a IC z z z G O o c�0 z z z C) N a ch G j O m y o a O h a o 0 3 w r L O 16 m m a1 on o a a w = V Ip y G = Cl)C7 v a p Ic► � U` Lll 0 H cc A d 0 Owner information is required for every past. Important: When ftlting out forms on the computer, use only the tab key to move your cursor - do not use the return key. p6 Commonwealth of Massachusetts Title 5 Official Inspection FormRECdVED Subsurface Sewage Disposal System Form - Not for Voluntary Assessments JUL 0 6 2007 PropertyAddres�11?4 TOWN OF NORTH ANDOVER �1 , HEALTH DEPARTw=-w - Owner's Name �� ec Citylrown State Zip C_ _e Date of insbectiOn Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information Cityfrown C6 Telephcind Number B. Certification ,A1 '— � I� .Ta3 State Zip Code License Number 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 16.340 of Title 6 (310 CMR 16.000). The system: 2- asses ❑ Conditionally Passes ❑t=ails Evaluation by the Local Approving Authority D �d Date TKe 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. tfiinep.doc • 09106 Title 5 Official inspection Form: Subsurface Sewage Disposal system • Page 1 of 15 COmmomwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property /Ad re / Owner Owner's Fla W Aa information is required for every page. citylrown B. Certification (cont.) State 41 _ _ e pate of Ins _ecb_ n Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: 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. Answer yes, no or not determined (Y, N, ND) in the ❑ 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. ND Explain: ❑ 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 t5insp.doc • 08106 Title 6 Oifidal Inspection Forth: Subsurtace Sewage Oisposel System • Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. Cityfrown B. Certification (cant.) 1I�� Mate lap?apC Date ofInnspe&i _n 08) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ 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: 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. t6insp.doa • 08106 Title 5 Olfidal Inspection Form: Subsurfam Sewage Disposal System • Page 3 of 15 Owner information is required for every page. Commonwealth of MmachuseM Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 I _ Nm!�-,� 6(0110( Ini Stag Z pZ p �Cooe Pate-ofirls.PecoWh B. Certification (cont.) ,,JeC) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 El�/ Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow ❑ �/ 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. t5insp.doc • 01106 Title 5 Official Inspec lion Fonn: Subsurface Sewage Disposal System - Page 4 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments q Sta a Zip C_ _e Date o 1 sp_ _ io B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No No ❑ Ej"" 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 Area — IWPA) or a mapped Zone 11 of a public water supply well 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 falls. 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 11 of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5insp.doc - 08/06 Title 5 ORdal Inspection Form: Subsurface Sewage Disposal System • Page 5 of 15 MAE Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments N Owner Owner's Neme information is required for every page. Cityrrown t5lnsp.doc • 08106 C. Checklist 1� 6 State Zip Coda pate of In pe.. _ n 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? Q- ❑ Was the site inspected for signs of break out? E�-' ❑ 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)] We 5 Official Inspedlon Form: Subsurface Sewage Disposal System - Page 6 of 15 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Owner information is required for every page. Jar` ��j#+.)— (0 1/ e /0:;� State Zip Code Date 0. pe+aioh 1 D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): 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 tc.):Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Last date of occupancy/use: Other (describe): Gallons per day Date ❑ Yes [—W Q--Y-e_s ❑ No P -les ❑ No ❑ Yes Ei �o ❑ Yes 91--Iq'o o� o Dat ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5insp.doc - 06106 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 6W& III(ItAl a , State Zip code Date of 16$000 D. System Information (cont.) 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: gallons Type of System: ❑--' Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Yes [moo ❑ 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: Were sewage odors detected when arriving at the site? ❑ Yes U-145" t5insp.doc • 08106 Tide 5 Official Inspection Form: Subsurface Sewage Disposal System • Pages of 15 Owner information is required for every page. t5insp.doc - 08106 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments State Zip coa_e pate o Ins _e_'on D. System Information (cont.) Building Sewer (locate on site plan): Depth below grade: 12 a Material of construction: ❑ cast iron @140 PVC ❑ other (explain): Distance from private water supply well or suction line: feet feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: feet Material of construction: ncrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: 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 ri 'L &// /5// Distance from bottom of scum to bottom of outlet tee or baffle x y 14ow were dimensions determined? Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 15 Commonwealth of Massachusetts ffig Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Prope"d � s Owner Ownersame information is � t p required for Y-� every page. City. own Sate I Code Date of tspeArt D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidepce of leakage, etc.): f51� 00�r Grease Trap (locate on site plan): 40 Depth below grade: Material of construction: ❑ concrete [7 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 feet ❑ polyethylene ❑ other (explain): Date of last pumping: Date 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): t5insp.doc . 08106 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M (/ Property _ d / Owner Owners arae information is required for every page. Oityi,Town $tae Zip C_ _ Date D. System Information (cont.) 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: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of veaetation. etc.): t5lnsp.doc • 0806 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 12 of 16 Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑l leaching trenches number, length:Z ❑ leaching fields number, dimensions: El 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 veaetation. etc.): t5lnsp.doc • 0806 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �a S) ��IyC1tis , 7 Property Address Owner Owner's Name information is t / required for � - � oil eir every page. Cityfrown state Zip a Date o ns _ cti .n U. System Information (cont.) 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 2 No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): (/J Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc • 08106 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 15 Owner Information is required for every page. Commonwealth of !Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Addre s own –kA-- i State Zip codoDate of Ins0Qr17 %— D. System Information (cont.) 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 X4 'q;j or W- H ea �esca�llaa. l.v�-�N I-4KPoQ- t TCeN SST" Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Owner Owner's information is required for every page. CityrrpA D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells $tate Zip _otie Date of Ins _ctio Estimated depth to ground water: feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: Date [ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) (( Accessed USGS database - explain: Yo must describe how you established the high ground w ter elevation: * 'f a BOJ t5insp.doc • 08/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 15 TOWN OF`NO$TH DOER SYSTEM PUMPING DATE—/L � 3 SYSTEM OWNER & ADDRESS 3 ;7 SYSTEM LOCAL tun . K3 QUANTITY PUMPED I �� DATE OF PUWlNG (, SEPTIC TANK NO YE CESSPOOL N0S `. NATURE OF SERVICE; ;.RQU'rLX-- ENSERGENCY OBSERVATIONS: FULL TO COVER ----- GOOD CONDITION BAFFLES IN LACE B]�AVY GREASE LEACHFIELD RUNBACK ROOD' -- FLOODED EXCESSIVE SOLIDS____... OVEREXPLAIN - -- SOLID CARRYOVER— S ARRYOVER — SYSTEM PUMPED BY COMMENTS: CONTENTS TRANSFERRED TO < `' N Commonwealth of Massachusetts N City/Town of NO. ANDOVER a System Pumping Record Form 4 �M DEP has provided this form for use by local Boards of Hey information must be substantially the same as that provide local Board of Health to determine the form they use. The the local Board of Health or other approving authority. A. Facility Information Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. rab 1�1 1. System Location: 37 SULLIVAN ST. Address NO.ANDOVER Citylrown 2. System Owner: STEVE JASKELA Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 5/20/10 Date 3. Type of system: ❑ Cesspool(s) ❑ Other (describe): 4. Effluent Tee Filter present? ❑ YesNo 5. Condition of System: 6. System Pumped By: James H. Currier Name J's Septic & Drain Company 7. Location where contents were disposed: GLSD Z� Signature of MA State _ J t� Oth'je � mJ M' qy"' %e ,re. Before usina this but the check with your be submitted to 01845 Zip Code State Zip Code Telephone Number —2 uantity Pumped: 1000 Gallons Septic Tank ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No H79 406 Vehicle License Number 5/20/10 Date t5form4.doc- 06/03 System Pumping Record - Page 1 of 1 ,CN Commonwealth of Massachusetts City/Town of NO. ANDOVERery System Pumping Record Form 4 SEP - zoll �M TOWN OF N RTHM(withyour DEP has provided this form for use by local Boards of Health. Other fol�gmft, information must be substantially the same as that provided here. Before usl 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. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. re6 �n E A. Facility Information 1. System Location: 37 SULLIVAN ST. Address NO. ANDOVER MA 01845 CityrFown State Zip Code 2. System Owner: Name STEVE JASKELA Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 8/17/11 Date 3. Type of system: U Cesspool(s) ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No 5. Condition of System: 6. System Pumped By: James H. Currier Name J's Septic & Drain Company 7. Location where contents were disposed: GLSD Signature of• . tale' State Telephone Number Zip Code — 2. Quantity Pumped: 1000Gallons [Septic Tank ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No H79 406 Vehicle License Number 8/17/11 Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 R �rjt' Commonwealth of Massachusetts SEP 1 1JD City/Town of NO. ANDOVER TOWN OFNORTN System Pumping Record hEALTH�EPAR Form 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 within 14 days from the pumping date in accordance with 310 CMR 15.351. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. rab ream A. Facility Information 1. System Location: 37 SULLIVAN ST. Address NO.ANDOVER City/ rown 2. System Owner: STEVE JASKELA Name Address (if different from location) City/Town MA State State Telephone Number B. Pumping Record 1. Date of Pumping 8/15/12 2. Quantity Pumped: Date 3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ® No 5. Condition of System: 6. System Pumped By: 01845 Zip Code Zip Code 1000 Gallons ❑ Grease Trap If yes, was it cleaned? ❑ Yes ❑ No JAMES H. CURRIER H79 406 Name Vehicle License Number J's SEPTIC & DRAIN Company 7. Location where contents were disposed: GLSD eO7 - Signature Signature of Receiving Facility 8/15/12 Date Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 Real estate -Prudential Howe & Doherty Real Page 1 of 2 Property Listing North Andover, MA 01 List Price: Type: Type of Single -Family: Status: No. Bedrooms: Master Bath: No. Full Baths: No. Rooms: No. Half Baths: Style: Year Built: MLS #: Approx. GLA: GLA Source: Additional Photos: Click on th Click Here to see more than th Description: Delightful, completely remodeled Colonial in 2006 located on a level country acre lot. Feature! Improvements include recessed lights in every room, granite counters in kitchen & baths. New tile in kitchei room. Hardwood floors & stairs on 1st floor, new carpet on 2nd floor. All ducts vacuumed for zero residual d car garage, a lot of privacy. Easy access to major highways. ContactI _Mortgage Calculator I Schedule a_Sho_w_.ing I Prii Interior Details: _ Exterior Details: Tax In Basement: No Acres: 1.03 Assessed: Cooling: Window AC Lot Size: 44,866 Taxes: Heating: Forced Air, Oil Lot Description: Wooded, Paved Drive Tax Year: Heating Zones: 2 Waterfront: 0 Book/Page Foundation: Poured Concrete Garage Parking: Under Zoning: Foundation Size: 0 Garage Spaces: 2 UFFI: Flooring: Wood, Tile, Wall to Parking Spaces: 4 Lead Paint: None Utility: for Electric Range Fire Places: 0 Roof Material: Asphalt/Fiberglass Insulation Features: Full Shingles Hot Water: Electric Exterior: Masonite Construction: Frame Sewer/Water: Private Water, Private Sewerage Road Type: Paved Additional Features. Interior Features: Security System, Walk-up Attic Exterior Features: Deck http://www.andoverliving.comldetail.asp?listingID=70550827&a-entid=G0002415&searc... 6/14/2007 ' Real estate -Prudential Howe & Doherty Real Page 2 of 2 Appliances: Range, Dishwasher, Refrigerator, Washer, Dryer Disclosures: N Room Levels, Dimensions and Features: Room: Level: Size: Features: Room: Level: Size: Fe Master Bedroom 2 17X12 Bedroom 2 2 13X12 Bedroom 3 2 13X13 Bedroom 4 2 9X11 Dining Room 1 11X11 Family Room 1 16X12 Kitchen 1 11X17 Living Room 1 13X13 If you would like more information on this property or would like to Schedule a Shc Michael Sibulesky call: 978-269-2247 or email: msibulesky(d)andoverlving.cc The listing office is Prudential Howe & Doherty Realtors and the listing agent is Micha The information in this listing was gathered from third party resources including the seller and public records. M and its subscribers disclaim any and all representations or warranties as to the accuracy of this information. Pru be pleased to show you this or any other property. Prudential Howe & Doherty Realtors Phone: 978 475-5100 Toll Free 12 Bartlet & 76 Main St • Andover, MA 01810 Fax: 978-475-5101 Email: inl Prudential Howe & Doherty REALTORS® is an independently owned and operated member of Prudential R `Rankings based on total sides for single-family homes from information provided by MLSPIN for 1 VPrudential is a service mark of The Prudential Insurance Company of America. Equal dousing @ppo http://www. andoverliving.comldetail.asp?listingID=70550827&agentid=G0002415&searc... 6/14/2007 JUN-1(-1_uuf CJ•CC rmuri-JJr7 -nw rL cul-, i,-- - ice- - 0 ►M 0 I E -K -SURVEY INCi MA i�YA87&�798b � F�c�TB-A��16� Q K&A opo! 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Ser- 7., I JOB M I . t i -a DbZB 13Ctl3SUI dH Wd6b$* 6002 Ti Z^d JAN -8-2002 TUE 21:55 TEL:916173711604 NAME:TOXIC REDUCTION CONTROL P. 13 a4-4 ° M C) ozm W E a).o 0 cn ® •z ON W ENO 00--q� W CIS�W.c � w� o tu Ub 3 U� —15 0-� Wct ° ct r� W ct C7 I I �I�IO� C 00 i i cz U_I i I i co LO to(0 ;.......-_�._._.1.. _-�........:......... _-...---�--�-- CLI co CN C) �� O ,ice �I LI UO -�—_-- — — -- ` (D I W L O WN(D,' ,I , 3OIo �•�, a) 0 100 1 y i l0I ' S .0 w r m � v r�lrn I OI ' N con N - � I y � � a aUi S >, F- M CD o ' rn co Lon x I a� ca ! a� U) l 3 0) LCO)1 ' N U) �? o.lN,rnl 3 rIo' 100�di LO N � M��v 01 ��UI �o I C co N I1- 0 co 3i0 N NIO� w 'C a LO 00 0 3�0� T a (`-i(D I� M Ci N �: (0 I Na coCO�oO ` o :: O N (L , � y O I O i o N y 3 o Y c_; o (O O E 3 co , C N r- 00 t N prn N ISI n 3 I "coMi i i coE MN O L L 3 o (n o > V r- (C) W ' I ' rn N cn U) Lm o o a a YP3 j�0 y. L L F(u ti I MINI ' _ L (6 If U) U �I00 c) I C OOIN� (� 43) n C 43 i U X ca -- -a C, Q1 I 3 O I C O r -- Ir- 1- , I ' 13 �j04 o Q o c Lie 1 ( > (nj ONO "t ' I ' i C 0)INI i ' U) _ co Q) >j _ - N � �� ;�I0) ,' CSN , CD U)ti �IV ' I C 0 �y CB Co (n m C) /) r r _ 4 Q r- 0 - M f m r - M n M Ml M a a r - Q M m ti M Q } o 0 Cp Q VT ao H N C V) J d v m o co (D O Q o y 00 Q) .0 b J U 0 to 0 O a� r O O7 J u a O 4 0 U CL ch O 0 0 0 v u' a 00 0 a } o 0 Cp Q VT ao H y 00 (9 U J u a O 4 0 U ch OD v a 0 o a z o LL a� W I.l_ USGS Real -Time Water Data for USGS 01101500 IPSWICH RIVER AT SOUTH MIDD... Page 1 of 3 Water National Water Information Data Category: Geographic Area: Resources System: Web Interface Real-time United States GO 0 Warning! Notice! http://water.usgs.gov/ will be briefly down for maintenance (less than 20 min) on Tuesday, June 19 between 9-10PM EDT, USGS 01101500 IPSWICH RIVER AT SOUTH MIDDLETON, MA PROVISIONAL DATA SUBJECT TO REVISION Available data for this site Time -series: Real-time data GO LOCATION.--Lat 42° 34'10", long 71' 01'39", Essex County, Hydrologic Unit 01090001, on right bank in Peabody, 700 ft downstream from Boston -Street Bridge at South Middleton, 1.3 mi downstream from Wills Brook, and 2 mi south of Middleton. DRAINAGE AREA. --44.5 mi2. PERIOD OF RECORD. --Discharge: June 1938 to current year. Water -quality records: Water years 1957, 1959, 1999. REVISED RECORDS.--WSP 1301:1942(M). WSP 1621:1938-58 (monthly runoff). WDR MA -RI -84-1: Drainage area. GAGE.--Water-stage recorder with satellite telemeter. Datum of gage is 44.97 ft above sea level (Massachusetts Geodetic Survey benchmark.) REMARKS. --Diversions upstream for municipal supply of Reading, Lynn, and Peabody. Occasional regulation by mill upstream. COOPERATION BY.— Massachusetts Department of Conservation and Recreation, Office of Water Resources and Department of Environmental Protection, Office of Watershed Management. NOTE: Precipitation data are for informational purposes only. Data do not necessarily conform to standards used by the National Weather Service. Summary of additional data for this site Discharge, cubic feet per second http://waterdata.usgs.gov/nwis/uv?01101500 6/20/2007 Output format *Graph 0Graph w/ stats G Graph w/o stats 0Table 0 Tab -separated Days 7 (1-31) GO Available Parameters [] All 2 Available Parameters for this site �� 00060 Discharge 00065 Gage height Summary of additional data for this site Discharge, cubic feet per second http://waterdata.usgs.gov/nwis/uv?01101500 6/20/2007 1.80 1.60 1.40 d ao �o c� 1.00 0.80 USGS 01101500 IPSWICH RIFER AT SOUTH MIDDLETON, MA Jun 13 Jun 14 Jun 15 Jun 16 Jun 17 Jun 18 Jun 19 Jun 20 ---- Provisional Data Subject to Revision ---- Page 1 of 1 http://waterdata.usgs.gov/nwis/uv/?dd_cd=03_00065&format=img_default&site_no=0110... 6/20/2007 USGS Real -Time Water Data for USGS 01101500 IPSWICH RIVER AT SOUTH MIDD... Page 2 of 3 Most recent instantaneous value: 31 06-20-2007 05:44 USGS 01181508 IPSHICH RIVER AT SOUTH MIDDLETON, MR 76 60 0 a� y 50 L d CL 5 40 20 Jun 13 Jun 14 Jun 15 Jun 16 Jun 17 Jun 18 Jun 19 Jun 20 ---- Provisional Data Subject to Revision ---- Median daily statistic {69 years} — Discharge Create presentation -quality graRh Parameter 00060; DD 01 Daily discharge statistics, in cfs, for Jun 20 based on 69 years of record more 0.79 9.9 24 31 1[::R::]611 372 Gage height, feet Most recent instantaneous value: 0.94 06-20-2007 05:44 http://waterdata.usgs.gov/nwis/uv?Ol 101500 6/20/2007 Most Recent Instantaneous Min (1999) 20% Median Value Mean 80% Max (1998) 0.79 9.9 24 31 1[::R::]611 372 Gage height, feet Most recent instantaneous value: 0.94 06-20-2007 05:44 http://waterdata.usgs.gov/nwis/uv?Ol 101500 6/20/2007 USGS Real -Time Water Data for USGS 01101500 IPSWICH RIVER AT SOUTH MIDD... Page 3 of 3 1.88 1.68 y 1,48 USGS 81101588 IPSHIGH RIVER AT SOUTH MIDDLETON, MR 1.08 8.80 Jun 13 Jun 14 Jun 15 Jun 16 Jun 17 Jun 18 Jun 19 Jun 20 ---- Provisional Data Subject to Revision ---- Create presentation-cluality graph Parameter 00065; DD 03 Questions about sites/data? Top Feedback on this web site Explanation of terms USGS Real -Time Water Data for the Nation http://waterdata.usgs.gov/nwis/uv? Retrieved on 2007-06-20 07:36:13 EDT Department of the Interior, U.S. Geological Survey Privacy Statement 11 Disclaimer 11 Accessibility 11 FOIA 11 News 11 Automated Retrievals 2.73 2.52 va02 http://waterdata.usgs.gov/nwis/uv?Ol 101500 6/20/2007