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Home My WebLink AboutMiscellaneous - 405 SALEM STREET 4/30/2018 T'Y^� 405 SALEM STREET 210/037.6-0063-0000.0 I 00 R f North Andover Board of Assessors Public Access y Page 1 of 1 5 NORTH � orth Andover Board of Assessors 3r Oe`..•o l�ghOOc ._,_�...... _��,�.��,,N..:i:'9. ., P.,,.:�- »:....�.. ....�"�. "°�""� ,.. , � ,4:� °-„r:-� 9SSACMU`,�t roperty Record Card Parcel ID :210/037.B-0063-0000.0 FY:2012 Community:North Andover - EWE i Click on Sketch to Enlarge Click on Photo to Enlarge i 47 I g — ,t 1' - • 405 SALEM STREET Location: 405 SALEM STREET SULLIVAN REALTY TRUST p Owner Name: SULLIVAN WILLIAM J&BARBARA M Owner Address: 405 SALEM STREET City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 5-5 Land Area: 0.98 acres d Use Code: 101-SNGL-FAM-RES Total Finished Area: 1924 sqft ' 0 Total Value: 400,300 400,300 Building Value: 203,200 203,200 j Land Value: 197,100 197,100 Market Land Value: 197,100 Chapter Land Value: R y Sale Sale Price: 1 12/27/2002 i Date: 4 Arms Length Sale SULLIVAN, f 1' F-NO-CONVNIENT Grantor: Code: WILLIAM Cert Doc: Book: 07395 Page: 0042 http://csc-ma.us/PROPAPP/display.do?linkId=1889610&town=NandoverPubAcc 5/1/2012 Residential Property Record Card PARCEL ID:210/037.B-0063-0000.0 MAP:037.B BLOCK:0063 LOT:0000.0 PARCEL ADDRESS:405 SALEM STREET FY:2012 PARCEL INFORMATION Use-Code: 101 Sale Price: ._1 - Book: 07395 Road Type: T- - Inspect Date 09/22/2006 Owner: Tax-Class: T Sale Date: 12/27/02 Pa e:' 0.042 Rd Condition: P Meas Date: 09/08/2000 - SULLIVAN REALTY TRUST Tot Fin Area: 1924 Sale Type: P Cert/Doc: Traffic: M Entrance: X SULLIVAN WILLIAM J&BARBARA M Tot land Area: 0.98 Sale Valid: F Water: Collect Id: SGC _ _. _ Address: Grantor: SULLIVAN WILLIAM _ Sewer: Inspect Real M SALEM STREET NORTH ANDOVER MA 01845 Exempt-B/L% / Resid-B/L% 100/100 Comm-B/LP/o Indust-B/L% / Open Sp-B/L% / NO RESIDENCE INFORMATION LAND INFORMATION Styleo RN Tot Rooms: 6 Main Fn Area: 1924 Attic: NBHD CODE: 5 NBHD CLASS: 5 ZONE: R3 Story Height: 1G.00 Ful Baths:` 2 Add Fn Area: � Fn Bsmt Area:-1924 3eg -Type _ Code Roof: Method -Sq-Ft ` Acres Influ-Y/N" Value Class - j `- - 1 P 101 S R 42689- 0.980 197,055 Ext Wall: FB Half Baths: Unfn Area:" - Bsmt Grader VALUATION INFORMATION Masonry Trim: - Ext Bath Fix_: 0 Tot Fin Area: 1924 Current Total: 400,300 Bldg: 203,200 Land: 197,100 MktLnd: Foundation: CN Bath Qual: T RCNLD: 203221 197,100 Kitch Qual: T Eff Yr Built: 1980 Mkt Adj: Prior Total: 400,300 Bldg: 203,200 Land: 197,100 MktLnd: 197,100 . Heat Type: HW Ext Kitch: Year Built_: 1975 Sound Value: Fuel Type: G Grade: AG Cost Bldg: 203,200 Fireplace: 1 Bsmt Gar Cap: Condition`. AG Aft Str Val1: Central AC: N Bsm't Gar SF: Pct Complete: Aft Str Va12: Aft Gar SF: 575%Good P/F/E/R: /100/100/83 Porch Type Porch Area Porch Grade Factor W 490 SKETCH PHOTO 14 490 Sq.Ft 14 10 1 24 Sq.Ft z3 575 Sq.F is 43 22 405 SALEM STREET =+ Parcel ID:210/037.6-0063-0000.0 as of 5/1/12 Page 1 of 1 �S�ffLsED_��6- • PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division Certificate of Compliance As of 20tay 2012 This is to certify that a SA`IISE CIORTINSTECTIOX Was completed for the: Installation of a 1500 Galton WonoCthic Tank, and an JT-20 Distri6ution BK for an On Site Wastewater DisposafSystem By: Todd Bateson at: 405 Salem Street Parcel ID :210/037.B-0063-0000.0 5 orthAndover, SIA 01845 The Issuance of this certiftate shaff not 6e construed as a guarantee that the On Site Sewage 1DisposafSystem wifffunction satisfactorily. an Sawyer,,q(E-kS1 (Pu6fic-7feafth Director 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com "ice Of,NO cr 1N 6985 9 • Town of North Andover HEALTH DEPARTMENT �sS�cMust� CHECK#: DATE: " LOCATION: H/O NAME: CONTRACTOR NAME Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ 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) $ ❑ Tit 5 Inspector $ itle 5 Report $ ❑ Other:(Indicate) $ Up Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer s NORTof Th 69U .� L • '... O of��..... �w n Town of North Andover HEALTH DEPARTMENT ,SSwCHU`+tt CHECK#: DATE: LOCATION: H/O NAME: CONTRACTOR NAME-tj V��, 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) $ ❑;1ttle it 5 Inspector $� 5 Report $� ❑ Other(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer a Commonwealth of Massachusettsr lJ( J Title-5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 405 Salem Street Property Address Bradford Hebebrand Owner Owner's Name information is required for North Andover MA 01845 8/20/2014 every 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: A. General Information When filling out forms on the computer,use 1. Inspector: F�R�ECE�I only the tab key to move your Neil J. Bateson cursor-do not use the return Name of Inspector key. Bateson Enterprises Inc. Al ir, _ _ Company Name 111 Argilla Road TOWN OF NORTH ANDOVER Company Address Andover MA 01810 ' City/Town State Zip Code 978-475-4786 SI 15 Telephone Number. License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Ne ds urther Evaluation by the Local Approving Authority 8/20/2014 Insp ctor's digi Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 ' Commonwealth of Massachusetts ID Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments UW405 Salem Street Property Address Bradford Hebebrand Owner Owner's Name information is required for North Andover MA 01845 8/20/2014 everypage. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.-304 exist. Any failure criteria not evaluated are indicated below. Comments: 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 405 Salem Street Property Address Bradford Hebebrand Owner Owner's Name information is required for North Andover MA 01845 8/20/2014 every page. Cityrrown 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): ❑ 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 t5iris-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 i ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary.Assessments 405 Salem Street Property Address Bradford Hebebrand Owner . Owner's Name information is required for North Andover MA 01845 8/20/2014 every page. City/Town 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 arivate water .. p e supply well Method used to determine distance: *x This system asses if the well water analysis, performedD P y p ata E certified laboratory, for fecal Y coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official I=nspection Form Subsurface Sewage Disposal.System.Form-Not for Voluntary Assessments 405 Salem Street Property Address Bradford Hebebrand Owner Owner's.Name information is required for North Andover MA 01845 8/20/2014 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from .a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed,at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface.Sewage Disposal System Form-Not for Voluntary Assessments 405 Salem Street Property Address Bradford Hebebrand Owner Owner's Name information is North Andover MA 01845 8/20/2014 required for every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 400 i t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments •'' 405 Salem Street Property Address Bradford Hebebrand Owner Owner's Name information is required for North Andover MA 01845 8/20/2014 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system?(Include laundry system inspection ort. E] Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes Z. No Water meter readings, if available last 2 ears usa a Yes 9 ( Y 9 �9Pd))� Detail: Sum Y Sump pump??P ® es ❑ No Last date of occupancy: CurrentDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official lns_pection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 405 Salem Street Property Address Bradford Hebebrand Owner Owner's Name information is required for North Andover MA 01845 8/20/2014 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped 2012, owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Measured tank Reason for pumping: Inspect tank&tees 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title .5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 405 Salem Street Property Address Bradford Hebebrand Owner Owners Name information is required for North Andover MA 01845 8/20/2014 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Tank 8t D-Box 2 years old, leach field installed 6/16/1973, final inspection by B.O.H. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4"Cast Iron through wall, 3" PVC in house, no leaks visible. Septic Tank(locate on site plan): Depth below grade: 2 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: 10'x5'x4' Sludge depth: 3" t5ins•3/13 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 405 Salem Street Property Address Bradford Hebebrand Owner Owner's Name information is . North Andover MA 01845 8/20/2014 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 4 Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? Tape Measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Inlet cover has riser 4"deep. 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 t5ins•3/13 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 y< 405 Salem Street Property Address Bradford Hebebrand Owner Owner's Name information is required for North Andover MA 01845 8/20/2014 every page. Citylrown 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: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official l,n spection Form Subsurface.Sewage Disposal System Form-Not for Voluntary Assessments 405 Salem Street Property Address Bradford Hebebrand Owner Owner's Name information is required for North Andover MA 01845 8/20/2014 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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 level 8r distribution equal, has flow levelers. No evidence of leakage. No evidence of carryover. D-box has riser 8'deep. Pump Chamber locate on site plan): ( P ) Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 405 Salem Street Property Address Bradford Hebebrand Owner Owner's Name information is required for North Andover MA 01845 8/20/2014 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 field 20'x 40' ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 405 Salem Street Property Address Bradford Hebebrand Owner owner's Name information is North Andover required wired fo for MA 01845 8/20/2014 every 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 405 Salem Street Property Address Bradford Hebebrand Owner Owner's Name information is required for North Andover MA 01845 8/20/2014 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including.ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately UjG s� � a = L4 a.-a03 'r t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Tit e 5 Official Inspection Form Subsurface Sewage Disposal System Foran--Not for Voluntary Assessments 405 Salem Street Property Address Bradford Hebebrand Owner Owners Name information is required for North Andover MA 01845 8/20/2014 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 4 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 11/18/1972 ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Design plan ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: As per design plan test pit data Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 405 Salem Street Property Address Bradford Hebebrand Owner Owner's Name information is required for North Andover MA 01845 8/20/2014 every page. Citylrown 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 •. N vui 1 11 1 iui mudi m ur ivlassacnuseus City/Town of stem P-im y plin 9 Record Forn1 4 S DEP has provided this form for useby local Boards of Health. Other forms may be used, but the information,must be substantially the same as that provided here. Before using.this form,check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left i h front of house, eft/Right rear of house, Left/right side of house, Left/ Right side of building, Left ig ron o use,, Left/Right rear of building, Under deck Address City/Town State Zip Code 2. System Owner. Name' Address(if different from location) City/Town 1� Telephone Number ; a i B. Pumping Record 1. Date of Pumping g Date 2. Quantity dumped: Gallons . 3. Type of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yews ❑-Mo if.yes, was It cleaned? ❑ Yes ❑ No 5.. Condition of stem: 6. System Pumped By: Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locati a contents were disposed: I-S-0 Lowell Waste Water S194 Haul p t5form4.doc-06/03 System Pumping Record•Page 1 of 1 ............... Town of North Andover Tax Map # 210-037.B-0063-0000.0 Parcel Id 11318 405 SALEM STREET BRAD HEBBEBARD 405 SALEM STREET NORTH ANDOVER MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 0.98 Acres FY 2015 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until BRAD HEBBEBARD Owner 405 SALEM STREET NORTH ANDOVER MA 01845 SULLIVAN,WILLIAM J. Previous Customer Inactive 10/15/2012 405 SALEM STREET N.ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 16077.0-405 SALEM STREET Last Billing Date 7/8/2014 3160118 03 Cycle 03 Active UB Services Maint. Account No.3160118 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 103.75 /1 UB Meter Maintenance Account No.3160118 Serial No Status Location Brand Type Size YTD Cons 29409006 a Active 00 b Badger w Water 0.63 0.63 620 Date Reading Code Consumption Posted Date Variance 6/4/2014 843 a Actual 25 7/16/2014 -4% 3/5/2014 818 aActual 26 4/11/2014 -8% 12/4/2013 792 aActual 28 1/17/2014 17% 9/5/2013 764 a Actual 24 10/15/2013 2% 6/7/2013 740 a Actual 24 7/24/2013 26% 3/7/2013 716 a Actual 19 4/22/2013 -4% 12/5/2012 697 a Actual 11 1/9/2013 741% 10/15/2012 686 f Final Bill 1 10/15/2012 133% 9/6/2012 685 a Actual 1 10/15/2012 -50% 6/7/2012 684 a Actual 2 7/16/2012 -60% 3/8/2012 682 a Actual 5 4/14/2012 -45% 12/8/2011 677 aActual 9 1/17/2012 -88% 9/9/2011 668 a Actual 80 10/13/2011 264% 6/2/2011 588 a Actual 20 7/20/2011 38% 3/4/2011 568 a Actual 14 4/13/2011 -55% 12/7/2010 554 a Actual 34 1/12/2011 -41% 9/3/2010 520 a Actual 56 10/15/2010 185% 6/2/2010 464 a Actual 19 7/15/2010 12% 3/4/2010 445 a Actual 17 4/14/2010 -12% 12/4/2009 428 a Actual 20 1/12%2010 -21% 9/2/2009 408 a Actual 25 10/15/2009 117% 6/2/2009 383 a Actual 11 7/20/2009 -17% 3/6/2009 372 a Actual 14 4/29/2009 -32% 12/3/2008 358 aActual 20 1/20/2009 -72% 9/4/2008 338 a Actual 75 10/10/2008 81% 6/3/2008 263 a Actual 40 7/16/2008 911% Commonwealth of Massachusetts RECEIVE® T Title 5 Official Inspection Form HAY 15 E012 Subsurface Sewage Disposal System Form-Not for Voluntary Assessmen s TOWN OF NORTH ANDOVER 405 Salem Street HEALTH DEPARTMENT Property Address John Sullivan Owner Owner's Name requir�t for is North Andover MA 01845 5/4/2012 required for every age. 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. Imporont: A. General Information When filling,put forms on the computer, use 1. Inspector: only the tab key to move your Neil James Bateson cursor-do not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover MA 01810 �mn Citylrown State Zip Code 978-475-4786 S115 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the 'information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ N edsAFurther Evaluation by the Local Approving Authority 5/4/2012 Insp i ignatur, 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 coi ditiom of use at that time.This inspection does not address how the system will perform in the future uhder the same or different conditions of use. i t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 RECEIVED Commonwealth of Massachusetts v Title 5 Official Inspection Form MAY �# 5 ZU12 Subsurface Sewage Disposal System Form-Not for Voluntary Assessm f)wN OF NORTH ANDOVER HEALTH DEPARTMENT 405 Salem Street Property Address John Sullivan Owner Owner's Name information is required for North Andover MA 01845 5/4/2012 every 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: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: After permit from B.O.H., install new 1500 gallon septic tank&new d-box, inspection from B.O.H., septic system now passes Title 5 Inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts City/Town of System Pumping Record RECEIVID Form 4 " MAY - 8 `1012 DEP has provided this form'for use by local Boards of Health. Other fo s may be used, but the information must be substantially the same as that provided here. Be fo eT kth iyour local Board of Health to determine the form they use.The System Pu fitted to ffi the local Board of Health or other approving authority. A. Facility Information 1. System Location: L /Rio t front of house Left/Right rear of house, Left/right side of house, Left/ Right side of building, Left R-ig-fiFRUM-f-61 building, Left/Right rear of building, Under deck Address City/Town State Zip Code 2. System Owner: Name Address(if different from location) Cityrrown State ip Cod � c r? Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) OSeptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No 5. Conditi of Syste kj, �� 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Loca ' re contents were disposed: G1,S. Lowell Waste Water Sign toe Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 i PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division Cern icate o f Compfiance � e As of JKay 412012 This is to cert that a S 4`IIS F.AC`IORT I-AVSPECTION Was completed for the: Instadation of a 1500 Gadon WonoCthic Tank and an JT-20 Ustri6ution Box for an On Site �Nastezvater�DisposaCSystem By. Todd Bateson at: 405 Sarem Street Parcel ID :210/037.B-0063-0000.0 North.Andover, 91(A 01845 The Issuance of this certificate shaff not be construed as a guarantee that the On Site Sewage 1DisposafSystem wiff function satisfactorify. an : Sawyer,A fS/� Pu6fic,7feafth Director 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division Cenificate of Compliance .As of a 412012 This is to cert that a SATIS E.ACTORT INSIPECTION Was completed for the: Instalration o f a 1500Galron WonoCthic Tank, and an M-20 Oi'stri6ution BK for an On Site Wastewater osaCSystem By. Todd Bateson at: 405 Sairem Street Parcel ID :210/037.B-0063-0000.0 Noi ?th.Andover, jW 01845 The Issuance of this cert cate shaff not be construed as a guarantee that the On Site Sewage Disposaf System wifffunction satisfactorify. FIP�u6fic n Sauyer,,gEbfS/Ifeafth Director 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com g, i i3y"7 a r#�t�r � `i- ��+++4 C 2 f -t r �.�''•r c z - J •r J. s:. ."� a T Y r S xKs 9 �h"'� ` !d U tot zor 114 �� iii• .. , �.. 1.-�� 3'- , ` � , ' . •.. ,' 1. . -�._ .. .. � ,� 4. - . - �c K 7r. t'Ac� 1 Or SOO .. ;.�'stare. b�xrN '`+�C►,Qo•, 4 - ' 00 KUT , _.�. . 4 ,Viol Ik ' QaG f' FAR�t ? t�R,tNbC ►t 4.44 �: '>�4"1�A4��NSF �fr3�i,�.;'y�¢`-f��► s ,. 4.0 -- af3 sI A45OMP E`(ol) AMF=A AZ 's. ;,t o)A •z�sc>. :i.l " 0 , 6064 3,t��" "; OGS, t 0 , p w Town of North Andover HEALTH DEPARTMENT ,SSACM�StS CHECK#: DATE: LOCATION: ) H/O NAME: CONTRAC*7NE: 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) $ ❑ Tit 5Inspector $��] Title 5 Report $ �i✓' �`"' ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer 6064• Gf NOR7:1y �,� .E * Town of North Andover 4 * i ,,,,o.• HEAL, DEPARTMENT ,SSACHHSE� CHECK#: DATE LOCATION: H/O NAME: d ' CONTRACN XME: Type of Permit or License:(Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ i ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC S, stems: ❑ Septic-Soil Testing $ ❑ .Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Ti e 5 Inspector B� Title 5 Report C.f: $ ❑ Other:(Indicate) $ Health Agent Initials i White-Applicant Yellow-Health Pink-Treasurer I� Commonwealth of Massachusetts Title 5 Official Inspection For RECEIVED Subsurface Sewage Disposal System Form-Not for Voluntary Asse smer � K 2 405 Salem Street TOWN OF NORTH Property Address HEALTH DEPARTMENT John Sullivan Owner Owner's Name information is required for 'North Andover MA 01845 4/6/2012 every page. Cityfrown 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: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Neil James Bateson cursor-do,not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover MA 01810 City/Town State Zip Code 978-475-4786 S115 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Nees Further Evaluation by the Local Approving Authority 4/6/2012 Inspector's Signatu Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ***"This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 Official Inspealion Form:Subsurtaoe Sewage Disposal System•Page 1 of 17 I' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a 405 Salem Street Property Address John Sullivan Owner Owner's Name information is required for North Andover MA 01845 4/6/2012 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ® Y ❑ N ❑ ND (Explain below): Tank leaking out t5ins•11/10 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I i I Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 405 Salem Street Property Address John Sullivan Owner Owner's Name information is required for North Andover MA 01845 4/6/2012 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 405 Salem Street Property Address John Sullivan Owner Owner's Name information is required for North Andover MA 01845 4/6/2012 every page. City/Town 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 pi ivate 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: Tank leaking &d-box leaking , both needs to be replaced. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official: Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 405 Salem Street Property Address John Sullivan Owner Owner's Name information is required for North Andover MA 01845 4/6/2012 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. 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. El ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® An portion of a cesspool or privy is less than 100 feet but greater than 50 feet Y P P P vY 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. El Z The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed tinder Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 405 Salem Street Property Address John Sullivan Owner Owner's Name information is required for North Andover MA 01845 4/6/2012 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water,been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 400 t5ins•11/10 Title 5 Oficial Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 405 Salem Street Property Address John Sullivan Owner Owner's Name information is required for North Andover MA 01845 4/6/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Design plan @ B.O.H., no as built plan Number of current residents: 0 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd))� Yes Detail: Sump pump? ® Yes ❑ No Last date of occupancy: October 2011 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallonser day Y(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: l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 405 Salem Street Property Address John Sullivan Owner Owner's Name information is required for North Andover MA 01845 4/6/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Unknown Was system pumped as part of the inspection? ❑ Yes ® 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)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 405 Salem Street Property Address John Sullivan Owner Owner's Name information is required for North Andover MA 01845 4/6/2012 every page. City1rown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 30 years old, 11/18/1972, design plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ® cast iron 40 PVC ❑ other(explain): i Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): 4"Cast iron thru wall to septic tank, 3" PVC in house no leaks visible Septic Tank(locate on site plan): Depth below grade: 2 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: 7"x5'x4' Sludge depth: 4" t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 405 Salem Street Property Address John Sullivan Owner Owner's Name information is required for North Andover MA 01845 4/6/2012 every page. City/Town 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 28" Scum thickness 6" 8.. Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Tape Measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet baffle ok. Outlet baffle corroded on top. Depth of liquid below outlet invert. Evidence of leakage.Tank needs to be replaced. 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 t5ins•11110 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 405 Salem Street ,p Property Address John Sullivan Owner Owner's Name information is required for North Andover MA 01845 4/6/2012 every page. Citylrown 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: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: - ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth A Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 405 Salem Street Property Address John Sullivan Owner Owner's Name information is required for North Andover MA 01845 4/6/2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box cover broken, replaced it. No liquid in d-box, evidence of leakage. Evidence of carryover. D-box 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 405 Salem Street Property Address John Sullivan Owner Owner's Name information is required for North Andover MA 01845 4/6/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 field 20'x 40' ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok.Vegetation ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration i j 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-11/10 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 405 Salem Street Property Address John Sullivan Owner Owners Name information is required for North Andover MA 01845 4/6/2012 every 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 405 Salem Street Property Address John Sullivan Owner Owner's Name information is required for North Andover MA 01845 4/6/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check-one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately o I S,e � D �t �`, l �`� t a ✓��it X�)�� t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 405 Salem Street Property Address John Sullivan Owner Owner's Name information is required for North Andover MA 01845 4/6/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.). Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water. 4 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 11/19/1972 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Design plan info ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: As per design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title_ 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 405 Salem Street Property Address John Sullivan Owner Owners Name information is required for North Andover MA 01845 4/6/2012 every 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 t .l •..S�TT(:ED7�e • RATED A North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS- MAP: LOT: INSTALLER: DESIGNER: ®� PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: r/I/A DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly.abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: E=TANK ❑ Building sewer in continuous grade, on compacted firm base l� 00- ❑ Cleanouts per plan i Bottom of tank hole has 6" stone base ❑ W hole plugged i ❑ _gallon tank has been installed I loading Monolithic tank construction U Watertightness of tank has been achieved by testing Inlet tee installed, centered under accessp ort :s ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of final 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 ❑ gallon Pump Chamber installed ❑ 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 Q 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) Comments: I • *S �?"tiaa Commonwealth of Massachusetts Map-Block-Lot 037.60063 BOARD OF HEALTH ----------------------- PermitNo ,t. BHP-2012-0559 = North Andover ----------------------- tai .4h P.I. FEE F.I. $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd-B-ateson --------------------------------------------------------------------------------------------------- to(Repair-TANK&DISTRIBUTION BOX)an Individual Sewage Disposal System. at No 405 SALEM STREET as shown on the application for Disposal Works Construction Permit No. BHP-2012-055 Dated May O1,2012 ----------------------- ----------------------------- --_---- L -__ Issued On: May-01-2012 BSA D F AL H ---------------------------------------------------------------------------- Commonwealth of Massachusetts Map-Block-Lot . . 037.60063 - BOARD OF HEALTH ----------------------- North Andover CERTIFICATE OF COMPLIANCE THIS IS TO CERTIFY,That the Individual Sewage Disposal System (Repair-TANK&DISTRIBUTI by Todd Bateson ------------------------------------------------------------------------------------------------------------------------------------------------ Installer at No _40-5-SALEM-STREET has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. 13HP-20127055 Dated-- May 01,-2012 ----------------------------------------------------------------- Printed On:May-01-2012 BOARD OF HEALTH O,`NORT: 6 0 'u- 8 Town of North Andover HEALTH DEPARTMENT SACNUSt / CHECK#: �lP DATE: ✓� �� LOCATION: l H/O NAME: CONTRAC4 NAME: ZW zO� 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 91— $ ❑ Septic-Design Approval �� © $ "S tic Disposal Works Constction D ) $ � ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other:(Indicate) $ ea th Agent Initials White-Applicant Yellow-Health Pink-Treasurer 'f Application for Septic pisposal System �OR71, o�,..•• .;ao TODAY'S SATE °AConstruction Permit--T WN OF ORTH ANDOVER 11�IA 01845 $zSO —Full Repair $725.000-Component SgACIW9� Important: Application Is hereby made fora permit to: When filling outConstruct a new on-site sewage disposal system* forms on the computer,use ❑Repair or replace an existing on-site sewage disposal system* only the tab key to move your Mleepair or replace an existing system component—What? taw A- a cursor-do not use the return A. Facility Information �� key. �--� y0.5spr! . Address or Lot# _rte MI City/Town �= 4/� - TOW HEAL2.-*TYPE OF EPTIC SYSTEM*: ❑Pump Wravity(choose one) ***If pump system,attach copy of electrical permit to application*** (Conventional System(pipe and stone system) ❑Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system. ❑Pressure Distribution S.A.S.(No D-Box)(Attach Draft Maintenance Agreement) ❑Pressure Dosed(D-Box Present)S.A.S. 2. _Owner Information a(�� Name /(/� ��a�. S T• , D Address(if different from above) ^ JU9 CRY/Town State Zip Code �( W3 4 l� Telephone Number 3. installer Information J Name Name of CoinON ENTERPRISES,INC. C.4 P4. 111 ARGILLA RnAn Address � 'r ER,f1/IA 01810 Cityrrown state' Zip Code 77fyls—a'bj Telephone Number(Cell Phone#if possible please) 4. Designer Information Name Name of Company Address Cityfrown state Zip Code Telephone Number(Best#to Reach) Application for oisposar System Construction Permit-Page 1 of 2 r� M°RTM Application..for Septic Disposal ystem CTOWN- .Permit - TO - . OF TODAYS DATE ORTH ANDOVER MA 01845 $.250.00-Full Repair CNS $125.00-Component PAGE 2OF2 A. Facility.lnformation continued.... 5. Type-of Building: 56'Residential Dwelling orECommercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation until a Certificate of Compliance has been Issued b his Board of Health. Name Date Application proved By: (Boar of Health Representative) z Name ./� C__. Date rt / . Application Mappro ed for the fof ing reasons: J For Office Use Only: 1 Fee Attached. Yes L11 _ . — No 2. Project Manager Obligation Form Attaehed.� yeS No 3.: P_--SY-8—? Ifso.,Attach conv ofElec&icil Permit`, Yes_ No'-/ 4. Foundation As Built. (new construction ronly). Yes_ No (Same scale as approved plan) n 5, FloorPlans?(new construction only). Yes_ '. I No Awfcation°for ppsposal Sy tem:Construcfion Permit-Page 2 of 2 / Y F , SEPTIC SYSTEM.INSTALh;ER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for'the construction for the septic system.for.the property at For plans by (Address of septic system) (E ' r) Relative to the-application of � `�� And dated (installer's Game) n a ate . Dated I `� With revisions dated o s ate (Last evised date) I understand the following obligations for management of this project: 1. As the installer,I am.obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done• 2. As the installer,.I.miist-call for any and altinspections: If homeowner,contractor,.project manager,or any other person not associated with my,company schedules-an inspection and the system is not ready,then item three-shall.be.applicable. 3.L As the installer,I'am-required to.have.the necessary work completed priaY to the.applicable inspections as indicated below. I titrderstand that requesting an inspection,without completion:of the items in,accordance with Title 5 and the Boatel of Heaitli Ii egulations may result in:a$50 00`fine'bein lv vied against me__and/or a: Bo'tEom of Bed's Generally,this is the`first(1 `j inspection unless.ahere is a'retaining wall,which shouid,be don6Arst. The installer must request xhe inspection but sloes not have to be present. b. Final Construction.Inspection—Engineermust first:do their inspection for elevations;'ties,'etc. As of verb90 K(or a-mail to:h.ealdideptO.townof lorthandover.com):from the engineer must be submitted to.the Board of.Health,after`which:installer.calls for inspection time. Installer must be present for this.inspection, With a pump.&ystem,all electrical-work;miAst be ready and able to j cause putnp.to cdork aiid.alarm.t6 function.. :. . c. Final Grade—installer must request inspection when sill grading is complete. .Installer'does not have to be on-site. 4. As-the installer,'I understand that only I may perform the work(other than Pimple excavation)and lam required to complete the installation of the system identified in the:attached application;for.installation: '.I fiirtlier .understand.that work ]doneothers urilicensed.to-Ins tall septic systems in North Andover can constitute reasons for denial of the system and/or.-revocation or susl ensiori of.my lieense:to operate in the Town.of North Andover, s m'Acant fines to all persons involvezl:are also possible. 5.. ,As the.instiller,,I understand that'I mu§t be'on site during the.perf&mance.of the following construction, steps: a. Detemunatron athat.the proper elevation of the ereatvation has been reached b. Inspeedon oftbe sand and stogie to be used. c. Final inspection by Board ofHealth staffor consultant, d. Installation..oftank,D-Box pipes,stone, vent,primp chamber,retaining walland other components. 6. As the installer,I understand that I:am sblely responsible for the installation.of the system as per the ap roved.lilans No instructions by thehomeowner.general.contractor_or any.other:persons shall absolve meg this obligation. Undersigned Licensed Septic.Installex: (Today's Date) 4 . ame:-fruit� Al — � n w tet'; . �r Summary Record Card generated on 4/3/2012 2:52:33 PM by Karen Hanlon Page -t Town of North Andover Tax Map # 210-037.B-0063-0000.0 r Parcel Id 11318 405 SALEM STREET SULLIVAN, WILLIAM J. 405 SALEM STREET N. ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residentia Zoning2 1 Residential Zoning3 1 Residentia Size Total 0.98 Acres FY 2012 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Unti SULLIVAN,WILLIAM J. Payor 405 SALEM STREET N.ANDOVER,MA 01845 UB Account Maint. Account Noe; Cycle Occupant Name Active/Inactive Bldg Id. 16077.0-405 SALEM STREET Last Billing Date 1/7/2012 3160118 03 Cycle 03 `Active UB Services Maint. Account No.3160118 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 34.20 /1 UB Meter Maintenance Account No.3160118 Serial No Status Location Brand Type Size YTD Cons 29409006 a Active 00 b Badger w Water 0.63 0.63 454 Date. Reading Code Consumption Posted Date Variance 3/8/2012 682 a Actual 5 -450/c 12/8/2011 677 a Actual 9 1/17/2012 -880/( 9/9/2011 668 a Actual 80 10/13/2011 264°/r 6/2/2011 588 a Actual 20 7/20/2011 380/C 3/4/2011 568 a Actual 14 4/13/2011 -550/c 12/7/2010 554 a Actual 34 1/12/2011 -410/( 9/3/2010 520 a Actual 56 10/15/2010 1850/c 6/2/2010 464 a Actual 19 7/15/2010 12% 3/4/2010 445 a Actual 17 4/14/2010 -12% 12/4/2009 428 a Actual 20 1/12/2010 -21 0/c 9/2/2009 408 a Actual 25 10/15/2009 117% 6/2/2009 383 a Actual 11 7/20/2009 -170/( 3/6/2009 372 a Actual 14 4/29/2009 -320/c 12/3/2008 358 a Actual 20 1/20/2009 -72% 9/4/2008 338 a Actual 75 10/10/2008 81 6/3/2008 263 a Actual 40 7/16/2008 911% Trouble Code:13 3/5/2008 223 a Actual 4 4/11/2008 -840/c 12/5/2007 219 a Actual 23 1/22/2008 96% 9/12/2007 196 a Actual 13 10/12/2007 90% 6/11/2007 183 a Actual 7 7/20/2007 128% 3/8/2007 176 a Actual 3 4/16/2007 -98% 12/5/2006 173 a Actual 141 1/19/2007 1196% 9/7/2006 32 'a Actual 11 10/20/2006 93% 6/9/2006 21 a Actual 5 7/10/2006 27% 3/22/2006 16 a Actual 5 4/17/2006 -65% 12/12/2005 11 a Actual 11 1/17/2006 -100% 9/27/2005 0 n New Meter 0 10/14/2005 -100% 9/27/2005 3116 r Replacement 15 10/14/2005 28% 6/8/2005 3101 m Manual estimate 10 7/15/2005 -6% North Andover Board of Assessors Public Access ` Page 1 of 1 NORTH Id�rth Andover Board of Assessors ♦ Dope SACHUSE roperty Record Card Parcel ID :210/037.B-0063-0000.0 FY:2012 Community : North Andover Click on Sketch to Enlarge Click on Photo to Enlarge i i i 405 SALEM STREET Location: _405 SALEM STREET Owner Name: SULLIVAN REALTY TRUST SULLIVAN WILLIAM J&BARBARA M Owner Address: 405 SALEM STREET City NORTH ANDOVER State: MA -Zip 01845 Neighborhood: 5-5 Land Area: 0.98 acres Use Code X 101-SNGL-FAM RES�R!otal Finished Area: !,1924 sgft_ — Total_Value:_ _ #� 400,300 ��_ 400,306— - -1 Building Value: 203,200 203,200 _ Val __._ _{_ Land Value: _1L 197,100 '� ._„ 197,100 - Market Land Value: 197,100 Chapter Land Value: Er E ,Sale Sale Price: ff 1 Date: 12/27/2002 Arms Length Sale F-NO-CONVNIENT Grantor: SULLIVAN, Code: WILLIAM Cert Doc: - !Book 07395 f1Pagert,004 _ http://csc-ma.us/PROPAPP/display.do?linkld=1889610&town=NandoverPubAcc 4/24/2012 A. '. ° ti`} - 04.49 A r.;• 460 PAN 04 f r3. ^ %Y Tia]" "'T. - 3 z lip- �--- ! . - . 00 — a� yy `6 1 qVpco Z 1 C ago 0O klpZ r � 0-6 rT I � 'lAe + .� do, ct - � , o GaL w•- c,r.? ti t A_ k �- t �- '• "i7�'v.' .ter i•i.'; i." .•�,q•.�.�4:ilf�/`T,,..'.f:'�•h, iF.' ;i.�`...�n.f;Ll`.,(t'C7it"v'r'til.i�� !r...• i TOWN U} h'UK I'1y r U �'t ` O 5 Y s'T'�.'M PUMP 1 N Q RF_'C O ALE TH ANDOVER 1ARTMENT �Y5r8M0YINQR � f ��DRESS �'sYSTEM -----.._.._.._.... _ ..... _ __...... L, ,p� � 1.r,`.�•,� � ?�i,ti' .. , ,_ 4*4 a / / DATE OF PVMP1NQ; leo 0 ��/ Q Y •� rVK15 UF' 5eKylce: xUu'rIH. • _ _ bAIGKur!v� Good c do .ION ruu- «1 co �> KZAYY ouA39 8h�'Yl,BJ IN �0'OT3.• L Ei�CKFI El,Q g+�C&981YB PLOODaD SOL CD CA MYO YAR OrNE R X P L,ti I N �'uMM!~NTs. uN I't;N 1'� (X.�Nyy�XK.bU I't