HomeMy WebLinkAboutMiscellaneous - 40 MOODY STREET 4/30/2018 40 MOODY STREET
210/081.0-0017-0000.0
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North Andover hoard of Assessors Public Accessi Page 1 of 1
Parcel ID: 210/081.0-0017-0000.0 Community: North Andover
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Location: 40 MOODY STREET
Owner Name: TOMZAK,JULIA LT
JUDITH A & DAWN SIMCHES
Owner Address: 40 MOODY STREET
City: NORTH ANDOVER State: MA ZIP: 01845
Neighborhood: 5 - 5 Land Area: 0.46 acres
Use Code: 101 - SNCL-FAM-RES Total Finished Area: 1729 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 341,600 318,600
Building Value: 175,700 165,000
Land Value: 165,900 153,600
Market Land Value: 165,900
Chapter Land Value:
LATEST SALE
Sale Price: 1 Sale Date: 08/27/2000
Arms Length Sale Code: F-NO-CONVNIENT Grantor: JULIA TOMZAK
Cert Doc: Book: 05844 Page: 0133
http://csc-ma.us/NandoverPubAcc/jsp/Home jsp?Page=3&Linkld=806210 8/4/2006
Residential Property Record Card
PARCEL_ID:210/081.0-0017-0000.0 MAP:081.0 BLOCK:0017 LOT:0000.0 PARCEL ADDRESSAO MOODY STREET
PARCEL INFORMATION Use-Code: 101 Sale Price: 1 Book: 05844 Road Type: T Inspect Date: 03/01/1999
Tax Class: T Sale Date: 08/27/2000 Page: 0133 Rd Condition: P Meas Date: 03/01/1999
Owner: Tot Fin Area: 1729 Sale Type: P Cert/Doc: Traffic: M Entrance: C
TOMZAK,JULIA LT Tot Land Area: 0.46 Sale Valid: F Water: Collect Id: JBS
JUDITH A&DAWN SIMCHES Grantor: JULIA TOMZAK Sewer: Inspect Reas: R
Address:
40 MOODY STREET Exempt-B/L% / Resid-B/L% 100/100 Comm-B/LeW Indust-B/L% 0/0 Open Sp-B/L% 0/0
NORTH ANDOVER MA 01845
RESIDENCE INFORMATION LAND INFORMATION
Style: CP Tot Rooms: 6 Main Fn Area: 988 Attic: NBHD CODE: 5 NBHD CLASS: 5 ZONE: R4
Story Height: 1.75 Bedrooms: 3 Up Fn Area: 741 Bsmt Area: 988 Seg Type Code Method Sq-Ft Acres Influ-Y/N Value Class
Roof: G Full Baths: 1 Add Fn Area: Fn Bsmt Area: 374 1 P 101 S 19900 0.46 165,864
Ext Wall: AV Half Baths: 1 Unfin Area: Bsmt Grade: VALUATION INFORMATION
Masonry Trim: 10 Ext Bath Fix: Tot Fin Area: 1729 Current Total: 341,600 Bldg: 175,700 Land: 165,900 MktLnd: 165,900
Foundation: CN Bath Qual: T RCNLD: 146414 Prior Total: 318,600 Bldg: 165,000 Land: 153,600 MktLnd: 153,600
Kitch Qual: T Eff Yr Built: 1965 Mkt Adj: 1.2
Heat Type: HW Ext Kitch: Year Built: 1956 Sound Value:
Fuel Type: G Grade: A Cost Bldg: 175,700
Fireplace: 1 Bsmt Gar Cap: Condition: A Att Str Vail:
Central AC: N Bsmt Gar SF: 240 Pct Complete: Att Str Va12:
Att Gar SF: %Good P/F/E/R: /100/100/77
Porch Tvoe Porch Area Porch Grade Factor
E 244
W 120
SKETCH PHOTO
W E Picture
10 120 Sq.R. 10 200 Sq.R. 10
18 12 38 20
F07Q15 4 1able
988 Sq.R. Ava
26 26
12 118 26
4 44 S 4
Parcel ID:210/081.0-0017-0000.0 as of 8/4/06 Page 1 of 1
"_ECEIVED
Commonwealth of Massachusetts JAN 0
City/Town of I 2 2006
System Pumping Record TOWN OF NORTH ANDOVER
UV
HEALTH DEPARTMENT
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority. .
A. Facility Information
Important:
When ruing out 1. Systematiorye _
forms on the y
computer,use
only the tab key Address
to move your V
cursor-do not V
use the return City/Town State Zip Code
key.
2. System Owner:
Pl�asv : U c7kex-��.
Name
Address(i(different from location)
Cityfrown StateZip Code
Telephone Number
B. Pumping R edoid --
1. .Date of Pump..i
9\ < "Datet 2 Quantity Pumped:
J Gallons /
3_ Type of system. ❑ Cesspoo)(s) _ ❑ Septic Tank- ❑ Tight.Tank
❑ Other(describe}
4. Effluent Tee Filter present? ❑ Yes ❑. No If yes, was it cleaned? E] Yes:❑ No
5. Conditio of System:
6. System Primped BYr
Name Vehicle License Number —
Company
7. Locati here cont s wer Isposed::
Ca r
Sign ' r o Hauler Date
http://www.mass.govidep/water/apptovalt/tSforms.htm#inspect
t5form4.doc•06103
Systeml limping Record•Page 1 of 1
SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
■ Complete items 1,2,and 5.Also complete atur
item 4 if Restricted Delivery is desired. gent
■ Print your name and address on the reverse U ❑Addressee
so that we can return the card to you. ecei Vd by(P' ed Name C. Date of Delivery
■ Attach this card to the back of the mailpiece, �EP 3 20�
or on the front if space permits. UU
D. Is d e a dress different from item 1? ❑Yes
1. Article Addressed to: If YE dal below: ❑No
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3. NOR7H ANDOVER
❑ Registered ❑Return Receipt for Merchandise
❑ Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number
(rransferfrom service labeo 7003 2260 0006 8627 2081
PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540
UNITED STATES POSTAL SERVICE First-Class Mail
Postage&Fees Paid
USPS
Permit No.G-10
• Sender: Please print your name, address, and ZIP+4 in this box •
NORTH ANDOVER HEALTH DEPT.
1600 Osgood Street
Building 20, Suite 2-36
North Andover, MA 01845
Postal
ra
CERTIFIED MAILT. RECEIPT
D (Domestic Mail Only;
fu
For delivery information visit our wel,>site at viWw.usps.comq
ro Postage $
O Certified Fee ,Y10
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(Endorsement Required) BJ Here
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Certified Mail Provides: (8sqarea)zooz eunr'008E-0d Sd
■ A mailing receipt
■ A unique identifier for your mailpiece
■ A record of delivery kept by the Postal Service for two years
Important Reminders:'
■ Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®.
■ Certified Mail is not available for any class of intemational mail.
■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For
valuables,please consider Insured or Registered Mail.
■ For an additional fee,a Return Receipt may be requested to provide proof of
delivery.To obtain Return Receipt seance,please complete and attach a Return
Receipt(PS Form 3811)to the article and add applicable postage to cover the
fee.Endorse mailpieoe"Return Receipt Requested".To receive a fee waiver for
a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is
required.
■ For an additional fee, delivery may be restricted to the addressee or
addressee's authorized agent.Advise the clerk or mark the mailpiece with the
endorsement"ResMcted-DDelivery'.
■ If a postmark on the Certified Mail receipt is desired,please present the arti-
cle at the post office for postmarking. If a postmark on the Certified Mail
receipt is not needed,detach and affix label with postage and mail.
IMPORTANT:Save this receipt and present it when making an inquiry.
Internet access to delivery information is not available on mall
addressed to APOs and FPOs.
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PUBLIC HEALTH DEPARTMENT
Community Development Division
Julia Tonzak LT
Judith A&Dawn Simches
40 Moody Street
North Andover, MA 01845
September 6, 2006
Re: 40 Moody Street
Dear Homeowners,
The Health Department has received your Title V Subsurface Sewage Disposal System
Inspection Report as preformed by Robert Kimball, dated August 26, 2006. The inspection had a
conditional pass and identified a system component in need of repair. Upon review of the
inspection form, it was discovered that your property at 40 Moody Street has had municipal
sewer available for some time.
The North Andover Board of Health has a regulation that requires immediate hook up into the
town sewer system when available. Obviously, this property was not previously identified to
have a hook-up. For this reason, you are required to hook up to the municipal sewer within 30
days of this order letter. Any requests for extension must be in writing. Once connected to town
sewer, the 40+year-old septic system must be properly abandoned. Proper abandonment
includes the crushing of the septic tank and filling the void with sand.
The Health Department does not license pipe layers, however for more information on
connecting to town sewer regarding fees etc. please contact the Department of Public Works at
978 685-0950. If you have any questions regarding this Order Letter please contact the Health
Office. If you feel that you are aggrieved by this order, you have the right to request a hearing
before the Board of Health if you feel this order should be modified or withdrawn. A request for
said hearing must be made in writing and received by the Health Department within seven (7)
days from the receipt of this order. At said hearing you will be given an opportunity to be heard
and to present witnesses and documentary evidence as to why this order should be modified or
withdrawn.
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 fax 978.688.8476 Web www.townofnorthandover.com
If you fail to comply with this Order Letter, you will be requested to attend the next regularly
scheduled Board of Health meeting. Thank you for this very important matter of public health.
Thank you,
4usan Sawyer, REHSIRS'
Public Health Director
Cc: Robert Kimball, Septic Inspector
Encl: Sewer Tie-In Regulation
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.coni
Septic System Information
40 MOODY STREET
Printed On:Monday, September 11,20
System ID: BHS-2004-0073
General System Information Latest Permit Information
Calcaluted Design Flow: Test Pits Septic Tank Disposal Trench
Design Flow: One Two Capacity: Number:
Design Flow Provided: Minutes per inch: Width: Width:
Total Flow: Depth: Length: Length:
Seasonal: No No Depth to Water: Diameter: Leaching: dog,
Grinder: No No Soil Type: Depth:
Laundry: No No
Hauling/Pumping Listing Quantity
Type System Type Pumped Pumped By Transferred To Disposed At Date Pumped allons
Routine Septic Tank Andover Septic 07/16/2004 1000
Routine Septic Tank Andover Septic 20 So.Mill Street,Bradford 08/03/2006 250
Inspections:
Inspected: Expires: Inspector: Status:
08/26/2006 Robert E. Kimball Conditionally Passes
Comments: Title 5(Septic Tank Replacement needed)
GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Page 1 of 1
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Com _
m nlvealth of Massachusetts
?� Qty/Town of NORTH ANDOVER MASSAC US REM,
- System 1Pumping Record
• Form 4 SEP - 6 2006
TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. The 1t EALTH DEPARTMENT
be submitted to the local Board of Health or other approving authority, cor mug
A. Facility Information
Important:
When fining out 1. System Location:
forms on the -
computer, use „ f
only the tab key Addres
to move youra /� ,�'�,
cursor•do not �/Z �-�/v �__'_ ����Z-!�'---•---•
use the return City/Town State --""---- -"
key.
Zip Code
2. System Owner:
m
Name
Address(if different from location) - -------------------____.__...__..__
City/Town —__ ------- -.._.__------ State ---_ ---- - --- -
Zi Code
_._9 -�p - —-----._..-
Telephone Number
B. Pumping Record -
1. Date of Pumping
Date 2. Quantity Pumped: ------.--_.
Gallons
Type of system: ❑ Cesspool(s) L_1 Septic Tank
❑ Tight Tank
❑ Other(describe): ------ -------- -- -- —.—...- -- . -- —-- __-
4. Effluent Tee Filter present? [D Yes [!T o If yes, was it cleaned? ❑ Yes E] No
5. Condition of System:
6. kame .
ped By:
-
Vehicle License Number --"--"
Company
7. Location where contents were disposed: /
Aw
Si ature of Hau Date ------ - -- -
http://www.mas$.govl/dep/water/ provais/t5forms.htm#inspect
t5form4.doa 06/03
System Pumping Record •Page 1 of
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Septic System Information }.
40 MOODY STREET 1. -
Printed On: Tuesday, September 05, 2 '•
System ID: BHS-2004-0073
i
General System Information Latest Permit Information
4 �
Calcaluted Design Flow: Test Pits Septic Tank Disposal Trench
Design Flow: One Two Capacity: Number:
Design Flow Provided: Minutes per inch: Width: Width:
Total Flow: Depth: Length: Length:
Seasonal: No No Depth to Water: Diameter: Leaching:
Grinder: No No Soil Type: Depth:
Laundry: No No
Haulin-glPumping Listing Quantity
Type System Type Pumped Pumped By Transferred To Disposed At Date Pumped (gallons) a
Routine Septic Tank Andover Septic 07/16/2004 1000
Inspections:
Inspected: Expires: Inspector: Status:
08/26/2006 Robert E. Kimball Conditionally Passes
Comments: Title 5(Septic Tank Replacement needed)
GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Page 1 of 1
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Town of North Andover
:; HEALTH DEPARTMENT
S�CHUsf l
CHECK#: A01a
LOCATION: Me 4�PV S1~
H/O NAME: X74/,�/¢ /2t,
CONTRACTOR NAME: ,fi Ol�/C//J1�i ✓
Type of Permit or License: (Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type. $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
0
/Tit`le 5 Inspector $
Zr Title 5 Report $ 0
❑ Other. (Indicate) $
`� AV
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer
f '
Commonwealth of Massachusetts RECEI L-
luTitle 5 Official Inspection Fo m SEP - 5 2006
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form T°HEALTIS DEPART�ME=NT�R
Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated
611512000. Inspection forms may not be altered in any way.
A. Certification
Important:
When filling out 1. Property Information:
forms on the
computer,use 40 Moody St.
only the tab key Property Address
to move your Julia Tonzak
cursor-do not Owners Name
use the return
key. 40 Moody St.
Owner's Address
N.Andover ma 01845
Cityrrown State Zip Code
Date of Inspection: 08-26-06
Date
2. Inspector:
Robert Kimball
Name of Inspector
R. Kimball Excavation LLC
21 Clifton Ave
Company Address
Salem NH 03079
City/Town State Zip Code
978-375-1011
Telephone Number
Certification Statement:
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
❑ Passes ® Conditionally Passes ❑ Fails
❑ N F rther Ev ua ' n b ocal Approving Authority
08-26-06
Insp ors Signat n3 Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
Title 5 Inspection Forms julia tonzac n.andover.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 1 of 16
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
° Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
40 Moody St.
Property Address
N. Andover MA 01845
Cityrrown State Zip Code
Julia Tonzak 08-26-06
Owner's Name Date of Inspection
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
® One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
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:
Title 5 Inspection Forms John Good n.andover.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 2 of 16
CoMmonweaM of Massachusetts
_ Title 5 Official Inspection Form
Not for Voluntary Assessments
>` Subsurface Sewage Disposal System Form
A. Certification (cont.)
40 Moody St.
Property Address
N. Andover MA 01845
City/rown State Zip Code
Julia Tonzak 08-26-06
Owner's Name Date of Inspection
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
® distribution box is leveled or replaced
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
16.303(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
Title 5 Inspection Forms John Good n.andover.doc•11/2004 Title 5 Official Inspection Form;Subsurface Sewage Disposal System
Page 3 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
° Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
40 Moody St.
Property Address
N. Andover MA 01845
Cityrrown State Zip Code
Julia Tonzak 08-26-06
Owner's Name Date of Inspection
C) Further Evaluation is Required by the Board of Health(cont.):
2. System will fail unless the Board of Health(and Public Water Supplier,if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for
coliform bacteria and volatile organic compounds indicates that the well is free from pollution from
9 P p
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:
Title 5 Inspection Forms John Good n.andover.doc,11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 4 of 16
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
° Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
40 Moody St.
Property Address
N.Andover MA 01845
Cityrrown State ZipCode
Julia Tonzak 08-26-06
Owner's Name Date of Inspection
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 Y2 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.
El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for 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.
Title 5 Inspection Forms John Good n.andover.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 5 of 16
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
40 Moody St.
Property Address
N. Andover MA 01845
City/Town State Zip Code
Julia Tonzak 08-26-06
Owner's Name Date of Inspection
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
YES NO
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
Title 5 Inspection Forms John Good n.andover.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-
Page 6 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
° Not for Voluntary Assessments
` Subsurface Sewage Disposal System Form
M
B. Checklist
40 Moody St.
Property Address
N. Andover MA 01845
Cityrrown State Zip Code
Julia Tonzak 08-26-06
Owner's Name 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(3)(b)]
Title 5 Inspection Forms John Good n.andover.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 7 of 16
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information
40 Moody St.
Property Address
N. Andover MA 01845
Citylrown State Zip Code
Julia Tonzak 08-26-06
Owner's Name Date of Inspection
Residential Flow Conditions:
Number of bedrooms(design): 2 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220
1
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump? ❑ Yes ® No
ocuLast date of occupancy: Date: Date d
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
Title 5 Inspection Forms John Good n.andover.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 8 of 16
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
40 Moody St.
Property Address
N. Andover MA 01845
City/Town State Zip Code
Julia Tonzak 08-26-06
Owner's Name Date of Inspection
Building Sewer(locate on site plan):
Depth below grade: 5'feet
Material of construction:
®cast iron ❑40 PVC ❑other(explain):
Distance from private water supply well or suction line: city
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 5'
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 ❑ Yes ❑ No
certificate)
Dimensions: 1000 gal-round
Sludge depth:
6"
Distance from top of sludge to bottom of outlet tee or baffle
48"
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle
1"
Distance from bottom of scum to bottom of outlet tee or baffle
18"
How were dimensions determined?
field observation
Title 5 Inspection Forms John Good n.andover.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 10 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
` Subsurface Sewage Disposal System Form
5
C. System Information (cont.)
40 Moody St. _
Property Address
N. Andover MA 01845
City/Town State Zip Code
Julia Tonzak 08-26-06
Owner's Name Date of Inspection
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
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 pu ed at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Title 5 Inspection Forms John Good n.andover.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 11 of 16
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M 5 y
C. System Information (cont.)
40 Moody St.
Property Address
N. Andover MA 01845
City/Town State Zip Code
Julia Tonzak 08-26-06
Owners Name Date of Inspection
Tight or Holding Tank(cont.)
Dimensions:
Capacity:
N gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
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.):
Distribution Box was deteriorated
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order. ❑ Yes ❑ No
Title 5 Inspection Forms John Good n.andover.doc•11/2004 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System
Page 12 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
40 Moody St.
Property Address
N. Andover MA 01845
Cityrrown State Zip Code
Julia Tonzak 08-26-06
Owner's Name Date of Inspection
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
I
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: 2-35'
❑ 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.):
Title 5 Inspection Forms John Good n.andover.doc-1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-
Page 13 of 16
Commonwealth of Massachusetts
-Title 5 Official Inspection Form
Not for Voluntary Assessments
` Subsurface Sewage Disposal System Form
M
C. System Information (cont.)
40 Moody St.
Property Address
N. Andover MA 01845
City/Town State Zip Code
Julia Tonzak 08-26-06
Owner's Name 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 public water supply enters the building.
S4.
A c� I"
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Title 5 Inspection Forms John Good n.andover.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 15 of 16
• �`�• � orf ; • . .
11 17.
Wx
T-W
0F. 01 --�11 .1
Robert E.'' 'Xhn�aill St,
.13as 'satisfied;the Depar4pqnt's .iia 'g lfiicatxoxs. as required and ishereby
au thori nd 't:6 use. the I tl a
CERTEFIED TOLE 5' INSPECTOR
ovided . •• • rid. Sec ' * '
ect'*' 13 0� �h�p�cr �Ias x . 310 N , 'X :3A�0 '"a A" of:the"
General Laws.. llssued by 'r'��e De r�vi�o 1 I' '
rt it �f nni—a ro ection
Am 12, 1995
Direcior of the
'1611
p YI�'Stei�fi1 Ct�301 cOc1iCo'
Mrs. Julia(Duda
� Moody Ut.
APPLICATION FOR SEWAGE DISPOSAL INSTALLATION
HEALTH DEPARTMENT--N«RTH ANDOVER, MASS.
I hereby make application for a. permit for a sewage disposal
installation at mood St. I will 4 nstall this
system in accordance with all the ws of the Commonwealth of
%sbachusetts and regulations of the Hoard of Health of the Town
$f Worth Andover, Permit granted only on condition that Town Water connections
be made.
Further, I will construct the house sewer of bell and spigot
pipe, the minimum diameter being 4 inches, and will maintain a
minimtiurz grade of 1% until la feet preceding the septic tank, where
the grade shall. not exceed 2%. I will install a concrete septic
tank of 600gal. in size. A manhole (s) permitting easy clean-
i.nc; w'sll' be prow ed with removable cover (s) of iron or concrete
witbi.ri 12 Inches of the ground surface. I will provide subsurface
disposal field with open jointed bell and spigot Ackronpipe at
.Least 4 inches in diameter and laid in a series of trenches, the
bottom of wb iell will provide a. minimum of ibo Lineal
( zwxe) feet of effective absorption area.�a pipes will be laid
cin a G inch layer of washed gravel or crushed stone ranging in
aize from 3/4 to 1 1/2 inches (dia. ) and the pipes will be
surroimd ed by similar material to a height of 2 inches above the
crown of the pipe. The joints of these pipes will be protected
fr.-.ra cl,oggirg, and before filling the trench, 2 inches of gravel
of, Stone 1./8" to 1/4" (do. ) will. be placers over the course gravel
or tltorie. The d#sposal, field will be installed at a grade of 4
to 6 i.nc:ies/300 .feet. No single the line will exceed 100 feet
ir, length and in any case, two lines of the will be installed,,
A rii.rzimum of 6 feet will be maintained between the center lines of
the disposal field trenches and the average depth of trench shall
not exceed 36 inches. No part of the installation will be less
tliar. 100 feat from any private water supply, 25 feet from any
streamv 20 feet from any dwelling or 10 feet from any property
tine. 'I further agree not to cover an portion of this installation
ult i l ajrsrov,e`R'r" y tFie ins ect3 o�f�r, as provTd`eeTo—w7a
u
o=neorporate any a dit one' requrre�ments that may be attached to
the perm t. Plot Plans must be submitted with application.
Si
gna re o App cant
I hereby issue the above permit for the Board of Health of the
'down sof Worth Andover, Massachusetts.
Date
X5/-2
gna urs o `ea t z Agent
I have inspected the uncovered system indicated above and find
everything done as described.
Date / l n S
" iggna�f-UF o nspect ng Officer
i;ercolation 'rest
Garbage Grinder .._....
Ao
f �4
x
� 0
r
LOT R _. ..=�u L?'��
f40 0
H0vV QrsTF1
OF
SHOW
rs s- ... "' ....- ✓� /��`'�'I f4�r F•1IC' C3 °w+ 6"" yw# 1��SIt
s rC` c� � �,f.,��3tt�t1 �;t1� ,�e� T'i�r '�� �. t��,{� �3 r'l,�ur•'b .aEir�El�H�� � �:�-���"�
MorMort..
t:
.
C:wf?c� �+�•,•t>t - Jam . i�Jr r o
�A KaV-Q i0 a
�s
Miss Mary Sheridan R.N. June 1531.956
Health Agent
Board of Health
North Andover, Massachusetts
Dear Miss Sheridan:
An examination was made relative to the
suitability of the soil for the sub-surface disposal
of sewage on the proposed Street building site of
Mrs . Julia Duda. ( '�)
A three minute percolation test was con-
ducted and the soil in the area consisted of clay.
It is recommended that a 600 gallon septic
tank be installed with 150 lineal feet of drain pipe.
Very truly yours,&I
Q
Ernest F. Romano
TOWN GFJQRTk�I ANDOVER
SYSTEM P AJ[PlN4i RECORD
DA CE
SYSTEM OWNER.& ADDRESSAUG 0 9 2004
SYSTEM LOCATION
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
JVo m OeVy ST.
IUD• C1/V,do ve/C, a
i,
DATE OF PLJMPIN(3:_ _ :/ D __.____OLJANTiTY PUMPED:
Q.
CLSSPOOL: NU YES Sdpcic Tank: NO YES
NATURE OF SERVICE: ROIJTIN ' .__EMERGENC)'
O13SE RVA'CIONS:
GOOD CONDI'T'ION FULL TO COVER
HEAVY GREASE - BAFFLES IN PLACE.
ROOT$ _� LEACEiF1ELD RUNBACK .___-...
EXCESSIVE SOLIDS FLOODED _-
SOLID CARRYC! Rµ OTHER EXPLAIN -
Syntera Pwnpcd by
COMME=NTS.
CVNTE3N I'S FKANSFERRED TO D