HomeMy WebLinkAboutMiscellaneous - 41 CEDAR LANE 4/30/2018 (2) 53 CEDAR LANE f
1 210/106.A-0145-0000.0
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r&clusive omP�r sem_
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Che I Tanguay,CRS
Broker-Partner,GRI,ABR,SRES
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978-233-2834 direct&fax
Cheryl@eHomesGrp.com
r- www.ExclusiveHomesGroup.com
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Commonwealth of Massachusetts -- „
City/Town of
System Pumping.Record OCT 0 X014
F Form 4 ur,,uh,,,ANDOVER r
HEALTH PART%MNf--1
DEP has provided this form for use-by local Boards of Health. Other forms may be'used' but-the
information must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of hous khag.,>Left
igh r ar of hous. , Left/right side of house, Left/
Right side of building, Left/Right front of bui /Right rear of building, Under deck
Address p
City/Town ��f State Trp Code
2. System Owner.
Name
Address(d different from location)
Citylrown Stater\ f 4p Code
Telephone Number t
B. Pumping Record
Cd `� ,.
1. Date of Pumping Date 2. Quantity Pumped: Gallons F
3. Type of system: ❑ Cesspool(s) tic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yeas 0-14�0 If yes, was it cleaned? ❑ Yes ❑ No;
" 5. Condition of tem:
6. System Pumped By.
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
ncCompany
7. Location here contents were disposed:
6S. Lowell Waste Water
SignAtufe 9t Haule Date
t51orm4.doc•08103 System Pumping Record•Page 1 of 1
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PRINTED BY: Pamela DelleChiaie-PLEASE LEAVE IN PRINT-OUT TRAY.......THANK YOU.
DelleChiaie, Pamela
From: DelleChiaie, Pamela
Sent: Thursday, January 27, 2011 11:19 AM
To: 'jdebilio@hotmail.com'
Cc: Sawyer, Susan
Subject: FW: I.R. -53 Cedar Lane-Scanned Copy of Health Dept. File
Attachments: 20110125155837095.pdf
Importance: High
Hello,
Below is the confirmation of information regarding the status of your septic system from Susan Sawyer, Health
Director. Please feel free to call our office if you have any further questions regarding your septic system.
Vaal Rjae4,
Pamela DelleChiaie
Departmental Assistant 1 Community Development 1 Health Department
Town of North Andover I
1600 Osgood Street I Bldg 20 1 Suite 2-36
North Andover,MA 01845
2 Office-978-688-9540
R Fax-978-688-8476
O Email-pdellechiaieatownofnorthandover.com
-8 Website hup://www.townoffiorthandover.com/Pages/index
"We can never see the path ofour life ifwe are too busy focusing on the pebbles under our feet."�Anonymous
From: Sawyer, Susan
Sent: Thursday, January 27, 20118:25 AM
To: DelleChiaie, Pamela
Subject: FW: I.R. - 53 Cedar Lane - Scanned Copy of Health Dept. File
Importance: High
I would add that it is automatically good for two years to July 2011.The third year to July 2012 is only granted if the
tank is pumped one time each of those three years.
No matter what,The insp. is good for 2 years from the date of the passing Title V.
S
From: "Sawyer, Susan" <ssMergtownofnorthandover.com>
Date: Wed, 26 Jan 201120:16:54 -0500
To: Susan Sawyer<sysawyerahoo.com>
ReplyTo: "Sawyer, Susan" <ssawyer@townofnorthandover.com>
Subject: Fw: I.R. - 53 Cedar Lane - Scanned Copy of Health Dept. File
Sent on the Sprint®Now Network from my B1ackBerry®
From: "DelleChiaie, Pamela" <pdellech@townofnorthandover.com>
Date: Tue, 25 Jan 2011 16:31:23 -0500
To: 'jdebilio@hotmail.com'<jdebilioghotmail.com>
I IOF2
DelleChiaie,Pamela
PRINTED BY:Pamela DelleChiaie- PLEASE LEAVE IN PRINT-OUT TRAY.......THANK YOU.
Cc: Sawyer, Susan<ssaw�r(a�townofnorthandover.com>
Subject: I.R. - 53 Cedar Lane - Scanned Copy of Health Dept. File
Reference: Julie Debilio-978.208.7945
Dear Julie,
Attached is a scanned copy of your Health Dept.File. I understand that your house is on the market,or will be
soon,and you want to know if the Title 5 work done in July 2009 (Outlet T replaced)is good through 2012 (3
years) if you had it pumped in Oct.
I will copy this to the Health Director,and she will be able to give you the most accurate answer.
SW Rgaada,
Pamela DelleChiaie
Departmental Assistant I Community Development I Health Department
Town of North Andover
i600 Osgood Street I Bldg 20 1 Suite 2-36
North Andover,MA 01845
W Office-978-688-9540
R Fax-978-688-8476
0 Email-pdellechiaiePtownofnorthandover.com
`6 Website hnp://www.townofiiorthandover.com/Pages/index
"We can never see the path of our life if we are too busy focusing on the pebbles under our feet."--Anonymous
Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records.For more
information please refer to:http://www.sec.state.ma.us/pre/preidx.htm.
Please consider the environment before printing this email.
2 2OF2
DelleChiaie,Pamela
IL" Commonwealth of Massachusetts -
City/Town of
System Pumping Record NOV � X010
Form 4
TOWN CIO NONTM ANDOVttA
DEP has provided this form for use by local Boards of Health. Other forms Aw
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 Lo : Left front of house, right front of house, left side of house, right side of hous , e t
aro ht rear of house, left side ofbuildin , ri t tear of building, under deck.
`J
City/Town State Zip Code
2. System Owner:
d�
Name
Address(if different from location)
Cityllbwn State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping —�-U T - 2. Quantity Pumped: - �<
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes VNo If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Location where contents were disposed:
L.$.D
Lowell Waste Water
14?Signature of Hauler Date t d— 2r?—
06rm4.doc•06/03 System Pumping Record•Page 1 of t
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lr ::4:r: :. ':a;' t; - ' :•. . '+ , ' System Pumping Record•Page t of t
TOWN OF NORTH ANDOVER ;
SYSTEM PUMPING RECORD
DATE 6 A
SYSTEM OWNER&ADDRESS '
SYSTEM LOCATION
��• CP'iupOUe� , ���
DATE OF PUMPING 4L �QUANTITY PUMPED b
CESSPOOL NO-ZYES SEPTI ✓
C TANK NO
YES
NATURE OF SERVICE: ROUTINE, EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN LACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLID CARRYOVER OTHER EXPLAIN
SYSTEM PUMPED BY
COMMENTS:
CONTENTS TRANSFERRED TO
i`• ri t�
NOV
' - 4 X11[)
TOWN Or NORTH AND
ovER
S Y ST E M PUMPING R.E C o RD
'0 D'I'EM OWNER & ADDRESS SYSTEM LOCATION —`�� --
j�����7?G�, (example: (eft front of house) •
(71 14 rd-e. oc �xjle-, in
Avga�� �-
a
u %'I'C OF PUMPING: a -! -0'C---- QUANTITY PUMPEr/lez"y CA LLU'�-,
NO IZYES SEPTIC TANK: NO YES
� �TUF2E OF SERVICE: ROUTINE -V�- EMERCENCY
0I1>PRVATIONS:
GOOD CONDITION FULL TO COVER
H[:AVY CREASE _ BAFFLES IN PLACE
ROOTS LEACNFIELD RUNBACK
EXCESSIVE SOLIDS L_ FLOODED
SOLIDS CARRYOVER 01�1-lER (EXPLAIN)
PUMPED RY
� u 11�1 cNTS:
U'�TENTS TRANSFEIMED TO:
i
TOWN OF NORTH ANDOVER °�NORTH A
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
1600 OSGOOD STREET;Building 2-36 ��,
NORTH ANDOVER,MASSACHUSETTS 01845 �4aieHus�tte
Susan Y.Sawyer,REHS/RS 978.688,9540—Phone
Public Health Director 978.688.8476—FAX
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: Jr �, ,r f, MAP: LOT:
INSTALLER: /
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
INSPECTIONS
TANK INSPECTION:
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
❑Existing septic tank properly abandoned
❑Internal plumbing all to one building sewer
[]Topography not appreciably altered ,
Comments:
SEPTIC TANK
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ 1500 gallon tank has been installed
H-10 loading Monolithic construction
❑ Water tightness of tank has been achieved
(Visual or Vacuum Test or Water held for 24hrs)
El Inlet tee Installed, centered under access port
❑ Outlet tee (gas baffle or effluent filter) Installed,
centered under access port
❑ 24" Inch cover to within 6" of final grade installed over
one access port,must be over outlet of tank if effluent
filter is present
❑ Hydraulic cement around inlet & outlet
Wastewater System Documentation•-Feb 2006
.a /r
Pagel of b
oft�;;� Applicr .
#Ion forSeptic Disposal System
• c �
w
Construction Permit-TOWN OF TODAY'S PATE
ORTH ANDOVER, MA 01845 $250.00--Full Repair
„.
--� $125.00-Component
important: Application Is hereby made fora Permit to:
When filling out El Construct a new on-site sewage disposal system*
forms on the
computer,use ❑Re air or replace an existing on-site sewage disposal system*
only the tab key I
to move your Repair or replace an existing system component--What? O�f�� �- —
cursor-do not
use the return A. Facility Information
key. '
QAddress or lot#
,bm cifyrrown 0 y
2.-*TYPE OF SEPTIC SYSTEM*:
❑Pump [3- ra rity(choose one)
""if pump system,attach copy of electrical permit to application*"k
M-150onventional System(pipe and stone system)
❑ Inftitrator 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-Sax Present)S.A.S.
2. Owner Information
�oNlVl� L Co Ao r cy h
Name
Address Of different from above)
�D• /hJ� ._.� ISA - U���iS
City/Town State Zip Code
12k-- 6U—le-3.5
Telephone Number
3. installer Information
Name Name of Company / R
Address
CitylT�own State Trp Code
Telephone Number(Cell Phone#Uposslble please)
4. Desioner information
Name Name of Company
Address
Cityfrown state . Zip Cdde
Telephone Number(Best#to Reach)
Application for Disposal System Construdicn Permit•Page 1 of 2
...,.; o A lica#i,,;n for Septic Disposal`'System r _o
.,t•, ,�,•. °c TODAY'S DATE
COnStrUction Permit ' TO`�UN :OF
`��'' �..,•p+ ORTH ANDOVER MA 01845 $260.
00--Full Repair
sACa„s $926.00-Component
PAGE 2OF2
A. Facility.Information continued...,
5. Type,of Buildingesidential Dwelling or❑commercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore-described
on-site sewage disposal system/n accordance with the provisions of T1116,6 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 by thi and of Health.
CQZ_pC
Name Data
Application proved By: ( and of Health Representative)
7 6/11
Na 8' Date
Application Disapproved for the following reasons:
For Office Use Only:
I Pee Attached? Yes No
2. ProiectManaget Obligation Form Attached, yes v No
3. P__r�S sT tem? If'so,Attach cob ofElectrical Permit Yes No
4. Foundation As Built?(new construction ronly): Yes No
(Same scale as approved plan)
5. Floor Plans?(new construction only): Yes No
i tr: � -
.,>:: Saj �'/, �4.;? �i rtw ;;{�'�'-'aaa •2•.=i;:<:.:::,...,`:''.`'. �.+.':•.
60
pow!Sys irCostlgcxJone
': 'lr :tt• t. y'fxf:"-) ;la,. t ..'V�'4`_ •Yrt... �) 1
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the.septic system for the property at:
(Address of septic system) For plans by
�--- (Engineer)
Relative to the application of r�y �j,�' e Sc�.✓
(Installer's name) And dated
rtgsna date)
Dated �� �--02
-Z'I'o'uay's a e with revisions dated
(Last revised 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 aVVmxed plans and the pc-rmit on sits when any work is
being done.
2. As the installer,I must call for any and all inspections. 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. As the installer,I am required to have the necessary work completed prior to the applicable inspections as
indicated below. I understand that requesting an inspection,without completion of the items in accordance
with Title 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or
my commsm-
a. Bottom of Bed—Generally,this is die.first(I�inspection unless there is a retaining wall,which
should be done fist. The installer must request the inspection but does not have to be present.
b. Final Construction Inspection—Engineer must first do their inspection for elevations, ties,etc.
As-built of verbal OK(or e-mail to:healthdeptna townofnorthandover com. from the engineer must
be submitted to the Board of Health,after which installer calls for an inspection time. Installer must
be present for this inspection. With a pump system,all electrical'work must be ready and able to
cause pump to work and alarm to function.
c. Final Grade—Installer must request inspection when all grading is complete. Installer does not
have to be on-site.
4. As the installer,I understand that only I may perform the work (other than.dmfik excavation)and I am required
to complete the installation of the system identified in the attached application for installation, fu�rth•,�r_
understand that work done by others unlicensed to install septic systems in North Andover can constitute
reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of
North Andover,significant fines to all persons involved are glso possible
5. As the installer, I understand that I must be on-site during the performance of the following construction
steps:
a. Determination that the proper elevation ofthe excavation has been reached.
b. Inspection of the sand and stone to be used.
c. Final inspection by Board ofHealth staffor consultant.
d Installation of tank,D-Box,pipes, stone, veno pump chamber,retaining wall and other
components.
b. As the installer,I understand that I am solely responsible for the installation of the system as per the
approved plans No ins=ctions by the homeowners,general contractor,or any other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer: oda s Date
8
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Commonwealth of Massachusetts
Title 5 Official Inspection Fo ��I� �l4k
Subsurface Sewage Disposal System Form-Not for Voluntary ssessments Q
r 53 Cedar Lane JUN 1.5 � �9� t �
Property Address
Donna McConaghy TOWN OF NORTH AN 0V R
Owner OwneIF:ATM g£rs Name
Information is
required for North Andover MA 01845 6/5/2009
every page. Citylrown state Zip Code Date of Inspection
Inspection results must be submitted on this form.Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.
Important:
When filling out A General Information
forms on the
computer,use 1. Inspector:
only the tab key
to move your _Neil J. Bateson
cursor-do not Name of Inspector
use the return
key. Bateson Enterprises Inc.
Company Name
VQ 111 Argilla Road
Company Address
Andover Ma_ 01810
City/rown 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 6(310 CMR 15.000).The system:
❑ Passes ❑ Conditionally Passes ❑ Fails
', �n�
® Needs Further Evaluation by the Local Approving Authority rQ,�''I /
� � O
- 6/5/2009
Insp rs ignature 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 DER.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.
Who'09108 Me 6 OM91 MspecOm Fow MsWace Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
53 Cedar Lane
Property Address
Donna McConaghy
Owner Owners Name
Information is North Andover MA 01845 6/6/2009
required for
every page. cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E I 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:
13) System Conditionally Passes:
One or more stem components " "
❑ yas 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):
thins•09109 We 6 ORidal inspedlon Foam Subsufaca Sewage Disposal System•Page 2 d 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form RECEIVED
Subsurface Sewage Disposal System Form-Not for Voluntary A sessments
53 Cedar Lane JUL 16 2009
Property Address TOWN OF NORTH ANDOVER
Donna McConaghy HEALTH DEPARTMENT
Owner Owners Name _
Information is
required for North Andover MA 01845 7/9/20009
every page. Cityrrown 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 and of the form.
Important:
When tilling out A. General Information
forms on the
computer,use 1. Inspector:
only the tab key
to move your Neil J. Bateson
cursor-do not Name of Inspector
use the return
key. Bateson Enterprises Inc.
Company Name -
111 Argilla Road
Company Address
Andover Ma 01810
X01 Cityrrown State - Zip Code
978-475-4786 SI15
Telephone Number license Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
Information reported below is true, accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system Inspector pursuant to Section 15.340 of
Title 6(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
7/9/2009
lnspectoi'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.
****T)tis 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.
LNM.OM Tdie 6 Olridel laspWIM FomG&6udam Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
53 Cedar Lane
Property Address
Donna McConaghy
Owner Owners Name
information is North Andover
required for MA 01845 7/9/20009
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or In 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
After permit from B.O.H., install new outlet tee in septic tank&well water tested by lab, 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):
tbina•oemE
'Fills 5 Officsial InsPedion Farrtc S~ace 8evrege t)lsposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
53 Cedar Lane
Property Address
Donna McConaghy
Owner Owner's Name
Information Is
required for North Andover MA 01845 8/5/2009
every page. Citylrown 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
thins•o9= Title 6 OWwW Inspection Form Substxfeoe Sewspe Disposal System•Page 3 of 17
� Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
53 Cedar Lane
Property Address "m
Donna McConaghy
Owner Owner's Name
Information is
required for North Andover MA 01845 6/5/2009
every page. cityrrown state Zip Code Date of Inspection
B. Certification (cont.)
2. System will fall 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: Tape Measure,well to tank 65'to pit#1 58', to pit#2 81'.
**This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.
3. Other:
Outlet tee replacement also
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 1/day flow _
t5ins'09= Title 6 OMdal Inspection Fomc Subs,xface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
UVSubsurface Sewage Disposal System Form-Not for Voluntary Assessments
53 Cedar Lane _
Property Address
Donna McConaghy
Owner Owner's Name
Information is
required for North Andover MA 01845 6/5/2009
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.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributaryto 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 collform 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 falls.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—1WPA)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.
16ins•09!'08 Title 6 Official Inspection Fomr S~am Sewage Disposal System•Pepe 6 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
b 53 Cedar Lane
Property Address
Donna McConaghy
Owner owner's Name
information is
required for North Andover MA 01845 6/5!2009
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate"yes"or°no°as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant,or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
Inspected for the condition of the baffles or tees, material of construction,
dimensions,depth of liquid,depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner)provided with
Information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example,a plan at the Board of Health.
® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440
Una•MM title 5 O11dal k"ectlon Fom Stftdace Sewage Disposal System•Page 6 or 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
53 Cedar lane
Property Address
Donna McConaghy
Owner Owner's Name
information is
required for North Andover MA 01845 6/5/2009
every page. Cityrrown state Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d On well water
9 ( Y g (gP ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
Dat®
Commerciallindustrial 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:
t5lm•om Title 6 OWal fnspectbn Form:61 b aw Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
53 Cedar Lane
Property Address
Donna McConaghy
Owner Owner's Name
information is
required for North Andover MA 09845 6/5/2009
every page. Cityrrown State tip 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 last year, owner
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):
t6he-09= We 5 Of lel lnspeWw Form:Wwxface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
53 Cedar Lane
PropertyAddress
Donna McCona h
Owner Owner's Name
Information Is
required for North Andover MA 01845 8/5/2009
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:
35 years old,9/25/1974,final inspection info
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.8
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 thru wall, no leaks visible
Septic Tank(locate on site plan):
Depth below grade: 'S
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: Tx 5'x 4'
Sludge depth: 2
t5ins'09108 Title 6 Official inspection Forth:StftWeoe Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
53 Cedar Lane
Property Address
Donna McConaghy
Owner Owner's Name
Information is
required for North Andover MA 01845 6/5/2009
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
28"
Scum thickness
2"
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
16"
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. Outletbaffle badly corroded, needs to be replaced with tee. Depth of liquid at outlet
invert. No evidence of leakage.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle --
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
151na•09M We 6 OffWal Inspection Forth:Subsurface Sewage Disposal System•Page 10 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
53 Cedar Lane
Property Address
Donna McConaghy
Owner Owner's Name
information Is
required for North Andover MA 01845 6/5/2009
every page. Cityfrown State Zip Code bate 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: pate
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
/Sins•OM Tike 5 OMat Inspection Form:Suhsurfaoe sewage Olsposal system•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
53 Cedar Lane
Properly Address
Donna McCona h
Owner Owner's Name
Information is
required for North Andover MA 09845 615!2009
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&distibution equal. No evidence of carryover. Evidence of light carryover.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
Soll Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located,explain why:
Wins•02!08 TIUe b O(fidat 1
nspealon Form:Subsurface Sewage Disposal System•Page 42 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Fon-Not for Voluntary Assessments
53 Cedar Lane
Property Address
Donna McConaghy
Owner Owner's Name
Information is
required for North Andover MA 01845 _ 6/5/2009
every page. CiWrown State Zip Code Date of Inspection
D. System information (cont.)
Type:
® leaching pits number: 2
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil ok.Vegetation ok. No sign of ponding to surface. Camera inside of pits thru outlet in d-box. No
liquid to inverts of pits.
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
Wins09= T30e 5 offidaf Insp$cUon Form;Subsurface Sewage Disposal System•Pepe 13 of 17
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal'System Form-Noffor Voluntary Assessments
53 Cedar Lane
Property Address
Donna McConaghy
Owner Owners Name
information is North Andover MA
required for 01845 6/5/2009
every page. City/To" 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 ane of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
Dt;u C.
IX
/k
qR i awl
;_)40 .alt
Lfts•om 'Me S Offl"kapedinrt Fam StftWaw Sewage piVMW system Page 16 or V
.1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
53 Cedar Lane
Property Address
Donna McConaghy
Owner Ownees Name
Information is
required for North Andover MA 01845 _ 6/5/2009
every page. Cityrrown State Zip Cods 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
tuns•090) Title 5 official Inspection Fara Subsurface Sewage Disposal System•Paye 11 or 17
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Form No.4
R . '
Town of North Andover, Massachusetts
BOARD OF HEALTH i
19
CERTIFICATE OF COMPLIANCE
This is to certify that
the Individual Soil Absorption Sewage Disposal System constructed ( ) or repaired ( )
by
INSTALLER t
at- `,.s�--` -env L 15 .
SITE LOCATION
has been installed in accordance with Board of Health Regulations as described in the Design
Approval Site System Permit No, dated 19
The issuance of this certificate shall not be' construed as a guarantee that the system will
function satisfactorily,
�L c.:
BOARD OFHEALTH-ENGINEER
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
' SYSTEM OWNER&ADDRESS SYSTEM L-0- CATION
//C1 Comet AC, (example: left front of house)
: DATE OF PUMPING: �v
QUANTITY PUMPED,��GALLONS
CESSPOOL: c/
NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE; ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS
LEACHFIELD RUNBACK
EXCESSIVE SOLIDS �� FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: e c
w;
:.:.' ,�ONTENTS TRANSFERRED TO:
i
�//o U:U .., 4 2001
pORTh q
O��tLto !bY NO
l` a
OR COC
1Itl(KIMK. 1+ T
��SSacHuS����
PUBLIC HEALTH DEPARTMENT
Community Development Division
CFr� rc.A� o� Co ��rAN
As of.-
July
f:July 8, 2009
2hiis is to certify that the individua(su6surface dtsposa[system received a
SA`I'ISTF,AC70RTINSMC 0jYof the:
ft&cement of Outfet Tee of
Septic Usposa[System
By,
Todd Bateson
53 CedarLane
9Wap — 106.A; Farrel= 145
North-Andover, MA 0.1845
The Issuance of this certificate shaft not 6e construed as a guarantee that the system wilt
function satisfactorify.
Aan er
T'uOc Zealth(Director
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8416 Web www.townofnorthandover.com
Commonwealth of Massachusetts
City/Town of
System Pumping Record LRJ
Form 4
DEP has provided this form for use b local Boards of Health. Ot r fp e he
information must be substantially the same as that provided here Befk with your
local Board of Health to determine the form they use.The Syste tPdtubmitted to
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location: Left fror KIePe , left sid of hou . Right front, right rear, right side of house.
forms on the
computer,use
only the tab key Address
to move your
cursor- not Cityrrown State Zi Code
use the return P
key. 2. System Owner:
Name
Address(if different from location)
Citylrown Stat Zip Code
2 -C!�)
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Ilona
3. Type of system: Cesspools) ept1c Tank ® Tight Tank
® Other(describe):
4. Effluent Tee Filter present? [j Yes No If yes,was it cleaned? Yes ® No
5. Condition of System:�
v �
6. System Pumped By:
Nell Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca' here contents were disposed:
.L.S.D Lowell Waste Water
7n-o�--Y- A - 7 -9
Igna ure of H u r Date
t5form4.doc•06103 System Pumping Record-Page 1 of 1
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4
PRINTED BY:Pamela DelleChiaie-PLEASE LEAVE IN PRINT-OUT TRAY.......THANK YOU.
DelleChiaie, Pamela
From: Sawyer, Susan
Sent: Thursday, January 27, 20112:48 PM
To: 'julie debilio'; DelleChiaie, Pamela
Subject: RE: I.R. -53 Cedar Lane-Scanned Copy of Health Dept. File
Julie,
We are just providing you the information about the state code.There is no extension required in this case. Please find
below the applicable section of the MA DEP CMR 310.000. Basically you will provide proof at your time of sale that you
meet this criteria.The mortgage company will likely be the entity looking for the proof.
Susan Sawyer
Health Director
15.301: System Inspection
(1)Inspection at Time of Transfer. Except as provided in 310 CMR 15.301(2), 15.301(3), and 15.301(4), a system
shall be inspected at or within two years prior to the time of transfer of title to the facility served by the system.An
inspection conducted up to three years before the time of transfer may be used if the inspection report is
accompanied by system pumping records demonstrating that the system has been pumped at least once a year during
that time. If weather conditions preclude inspection at the time of transfer,the inspection may be completed as soon
as weather permits, but in no event later than six months after the transfer,provided that the seller notifies the buyer
in writing of the requirements of 310 CMR 15.300 through 15.305. A copy of the complete inspection report shall be
submitted to the buyer or other person acquiring title to the facility served by the system.
From:julie debilio [mailto:jdebilio@hotmail.com]
Sent: Thursday, January 27, 20111:21 PM
To: DelleChiaie, Pamela
Cc: Sawyer, Susan
Subject: RE: I.R. - 53 Cedar Lane - Scanned Copy of Health Dept. File
Thank you so much for getting back to me about the title V
If I could provide dates when the septic was pumped each year since the Title V, would we be able to have the extension
until 7/2012?
We are hoping we can sell the house before this July, but given the way the market is, it would be very helpful to know
we have another year and that it is one less thing we would need to worry about.
Thank you for your time
Julie
From: pdellech@townofnorthandover.com
To:jdebilio@hotmail.com
CC: ssawyer@townofnorthandover.com
Date: Thu, 27 Jan 2011 11:19:15 -0500
Subject: FW: I.R. - 53 Cedar Lane - Scanned Copy of Health Dept. File
I IOF3
DelleChiaie,Pamela
PRINTED BY: Pamela DelleChiaie-PLEASE LEAVE IN PRINT-BUT TRAY.......THANK YOU.
Hello,
Below is the confirmation of information regarding the status of your septic system from Susan Sawyer, Health Director.
Please feel free to call our office if you have any further questions regarding your septic system.
haat Rganala,
Pamela DelleChiaie
Departmental Assistant I Community Development I Health Department
Town of North Andover
1600 Osgood Street I Bldg 20 1 Suite 2-36
North Andover,MA o1845
2 Office-978-688-9540
R Fax-978-688-8476
0 Email-pdellechiaie@townofnorthandover.com
-16 Website http://www.townofnorthandover.com/Pages/index
"We can never see the path of our life if we are too busy focusing on the pebbles under our feet."��Anonymous
From: Sawyer, Susan
Sent: Thursday, January 27, 20118:25 AM
To: DelleChiaie, Pamela
Subject: FW: I.R. - 53 Cedar Lane- Scanned Copy of Health Dept. File
Importance: High
I would add that it is automatically good for two years to July 2011.The third year to July 2012 is only granted if the tank is pumped
one time each of those three years.
No matter what,The insp. is good for 2 years from the date of the passing Title V.
S
From: "Sawyer, Susan" <ssawyer@townofnorthandover.com>
Date: Wed, 26 Jan 201120:16:54 -0500
To: Susan Sawyer<sysawyer@yahoo.com>
ReplyTo: "Sawyer, Susan" <ssawyer@townofnorthandover.com>
Subject: Fw: I.R. - 53 Cedar Lane - Scanned Copy of Health Dept. File
Sent on the Sprint@ Now Network from my BlackBerry@
From: "DelleChiaie, Pamela" <pdellech@townofnorthandover.com>
Date: Tue, 25 Jan 2011 16:31:23 -0500
To: 'jdebilio@hotmail.com'<jdebilio@hotmail.com>
Cc: Sawyer, Susan<ssawyer@townofnorthandover.com>
Subject: I.R. - 53 Cedar Lane - Scanned Copy of Health Dept. File
Reference: 3ulie Debilio—978.208.7945
Dear Julie,
Attached is a scanned copy of your Health Dept. File. I understand that your house is on the market, or will be soon, and
you want to know if the Title 5 work done in July 2009 (Outlet T replaced) is good through 2012 (3 years) if you had it
pumped in Oct.
I will copy this to the Health Director, and she will be able to give you the most accurate answer.
Ve49 Roqae4,
Pamela DelleChiaie
Departmental Assistant I Community Development I Health Department
Town of North Andover
1600 Osgood Street I Bldg 20 1 Suite 2-36
North Andover,MA o1845
2 Office-978-688-9540
R Fax-978-688-8476
0 Email-pdellechiaie@townofnorthandover.com
'18 Website http://www.townofiiorthandover.com/Pages/index
We can never see the path of our life if we are too busy focusing on the pebbles under our feet."--Anonymous
2 2OF3
DelleChiaie,Pamela
T
PRINTED BY:Pamela DelleChiaie- PLEASE LEAVE IN PRINT-OUT TRAY.......THANK YOU.
Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records.For more
information please refer to:http://www.sec.state.ma.us/pre/preidx.htm.
Please consider the environment before printing this email.
3 3OF3
DelleChiaie,Pamela
PRINTED BY:Pamela DelleChiaie- PLEASE LEAVE IN PRINT-OUT TRAY.......THANK YOU.
DelleChiaie, Pamela
From: Sawyer, Susan
Sent: Thursday, January 27, 20112:48 PM
To: 'julie debilio'; DelleChiaie, Pamela
Subject: RE: I.R. -53 Cedar Lane-Scanned Copy of Health Dept. File
Julie,
We are just providing you the information about the state code.There is no extension required in this case. Please find
below the applicable section of the MA DEP CMR 310.000. Basically you will provide proof at your time of sale that you
meet this criteria.The mortgage company will likely be the entity looking for the proof.
Susan Sawyer
Health Director
15.301: System Inspection
(1) Inspection at Time of Transfer. Except as provided in 310 CMR 15.301(2), 15.301(3), and 15.301(4), a system
shall be inspected at or within two years prior to the time of transfer of title to the facility served by the system. An
inspection conducted up to three years before the time of transfer may be used if the inspection report is
accompanied by system pumping records demonstrating that the system has been pumped at least once a year during
that time. If weather conditions preclude inspection at the time of transfer,the inspection may be completed as soon
as weather permits, but in no event later than six months after the transfer,provided that the seller notifies the buyer
in writing of the requirements of 310 CMR 15.300 through 15.305. A copy of the complete inspection report shall be
submitted to the buyer or other person acquiring title to the facility served by the system.
From:julie debilio [mailto:jdebilio@hotmail.com]
Sent: Thursday,January 27, 2011 1:21 PM
To: DelleChiaie, Pamela
Cc: Sawyer, Susan
Subject: RE: I.R. - 53 Cedar Lane - Scanned Copy of Health Dept. File
Thank you so much for getting back to me about the title V
If I could provide dates when the septic was pumped each year since the Title V, would we be able to have the extension
until 7/2012?
We are hoping we can sell the house before this July, but given the way the market is, it would be very helpful to know
we have another year and that it is one less thing we would need to worry about.
Thank you for your time
Julie
From: pdellech@townofnorthandover.com
To: jdebilio@hotmail.com
CC: ssawyer@townofnorthandover.com
Date: Thu, 27 Jan 2011 11:19:15 -0500
Subject: FW: I.R. - 53 Cedar Lane - Scanned Copy of Health Dept. File
I IOF3
DelleChiaie,Pamela
PRINTED BY:Pamela DelleChiaie-PLEASE LEAVE IN PRINT-OUT TRAY.......THANK YOU.
Hello,
Below is the confirmation of information regarding the status of your septic system from Susan Sawyer, Health Director.
Please feel free to call our office if you have any further questions regarding your septic system.
fiat Ref 404,
Pamela DelleChiaie
Departmental Assistant I Community Development I Health Department
Town of North Andover
1600 Osgood Street I Bldg 20 1 Suite 2-36
North Andover,MA o1845
2 Office-978-688-9540
2 Fax-978-688-8476
0 Email-pdellechiaie@townofnorthandover.com
-?� Website http://www.townofnorthandover.com/Pages/index
"We can never see the hath of our life if we are too busy focusing on thepebbles under our feet."—Anonymous
From: Sawyer, Susan
Sent: Thursday, January 27, 20118:25 AM
To: DelleChiaie, Pamela
Subject: FW: I.R. - 53 Cedar Lane - Scanned Copy of Health Dept. File
Importance: High
I would add that it is automatically good for two years to July 2011.The third year to July 2012 is only granted if the tank is pumped
one time each of those three years.
No matter what,The insp. is good for 2 years from the date of the passing Title V.
S
From: "Sawyer, Susan" <ssawyer@townofnorthandover.com>
Date: Wed, 26 Jan 201120:16:54 -0500
To: Susan Sawyer<sysawyer@yahoo.com>
ReplyTo: "Sawyer, Susan" <ssawyer@townofnorthandover.com>
Subject: Fw: I.R. - 53 Cedar Lane- Scanned Copy of Health Dept. File
Sent on the Sprint@ Now Network from my BlackBerry@
From: "DelleChiaie, Pamela" <pdellech@townofnorthandover.com>
Date: Tue, 25 Jan 2011 16:31:23 -0500
To: 'jdebilio@hotmail.com'<jdebilio@hotmail.com>
Cc: Sawyer, Susan<ssawyer@townofnorthandover.com>
Subject: I.R. - 53 Cedar Lane- Scanned Copy of Health Dept. File
Reference: Julie Debilio—978.208.7945
Dear Julie,
Attached is a scanned copy of your Health Dept. File. I understand that your house is on the market, or will be soon, and
you want to know if the Title 5 work done in July 2009 (Outlet T replaced) is good through 2012 (3 years) if you had it
pumped in Oct.
I will copy this to the Health Director, and she will be able to give you the most accurate answer.
aw RVs,
Pamela DelleChiaie
Departmental Assistant I Community Development I Health Department
Town of North Andover
1600 Osgood Street I Bldg 20 1 Suite 2-36
North Andover,MA o1845
9 Office-978-688-9540
2 Fax-978-688-8476
0 Email-pdellechiaie@townofnorthandover.com
-11� Website http://www.townofnorthandover.com/Pages/index
"We can never see the path of our life if we are too busy focusing on the pebbles under our feet"--Anonymous
2 2OF3
DelleChiaie,Pamela
I
37
01
4AORTN 1h
. O
3+.tr ' .• oc
o s
Town of North Andover
JV
�.,s ..�� HEALTH DEPARTM
SCHUSE
CHECK#: 7/4 1,0
LOCATION.
H/O NAME: t9��lli
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 $
❑ Se�ftc
tic Design Approval $
isposal s ks Con 470__, Iw
e $
❑ Septic Disposal or�Installers
(DWI) $
❑ Title 5 Inspector $
❑ Title 5 Report $
❑ Other. (Indicate) $
f
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer
Commonwealth of Massachusetts Map-Block-Lot
106.A0145
0 Board of Health PermtNo
BHP-2009-0630
North Andover -__---._---.-___-_____
r
` °• +•• ' ' P.I. FEE
F.I. $125.00
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Todd-Bateson
to(Repair-OUTLET TEE ONLY)an Individual Sewage Disposal System.
at No 53 CEDAR LANE
----------------------------------------------------------------------------------------------------------------------------------------------------------
as shown on the application for Disposal Works Construction Permit No. BHP-2009-063 Dated July_06,2009--_
------------- C0-PY--------------
Issued On:Jul-06-2009 of Health
f " qW" Commonwealth of Massachusetts Map-Block-Lot
r'0 d'``° ''•¢oda 106.A0145
L Board of Health -----------------------
• North Andover
� Ts �q CERTIFICATE OF COMPLIANCE
Arm
THIS IS TO CERTIFY That the Individual Sewage Disposal System (Repair-OUTLET TEE ONLY)
byTodd Bateson
-----------------------------------------------------------------
------- -- --------------- ------------------- ------------------ -
Installer
at No 53 CEDAR LANE
-------------------------------------------------------------------------------------------------------------------------------------------------------
has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the
application for Disposal Works Construction Permit No. - ---
BHP-2009-063 Dated July 062 2009........
---------------------- ----
-----------------------------------------------------------------
Printed On: Jul-06-2009 Board of Health
Application fer_Septic Disposal System �? - �--o Ct
3:•�'. %' °c TODAY'S DATE
pConstruction Permit -TOWN OF
-°' F; ORTH AND OVER, MA 01845 $250.00-Full Repair
$925.00-Component
�c«us
Important: Application is hereby made for a permit to:
When filling out ❑ Construct a new on-site sewage disposal system*
forms on the
computer,use ❑ Re air or replace an existing on-site sewage disposal system*
only the tab key
to move your Repair or replace an existing system component-What? �u c
cursor-do not
use the return A. Facility Information
key.
3 C2 cls 2 I-iV .
Ir--v Address or Lot#
ILEI CftyfTown ple Y
2.-*TYPE OF SEPTIC SYSTEM*:
❑Pump [g-Girravity(choose one)
***If pump system,attach copy of electrical permit to application***
onventional 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-Bax)(Attach Draft Maintenance Agreement)
❑Pressure Dosed(D-Box Present)S.A.S.
2. Owner Information
�oA�NA /'IL h
Name ,
_� '?j 4-/2.
Address(if different from above
lya10-1,4
Cityfrown State Zip Code
17 3' 6"- o3s
Telephone Number
3. Installer Infonnation
�1(�-CQ Y'�r4-/�-S Gti u '�9 �-� dam✓ ,&/ -T"C—
Name Name of Company
/I/ fel-�`�i�ala- f�r9. �l / /�rye`/�•t' `�
Address
�a--LSA !V,4 6. e5p 8'/v
City/Town State Zip Code
Telephone Number(Cell Phone#if possible please)
4. Designer Information
Name Name of Company
Address
Cityrrown State . Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
a
"O"T"�, Application for Septic Disposal System
pConstruction Permit — TOWN .OF TODAYS DATE
:, ORTH AND OVER. A IA ' 01845 $250.00-Full Repair
S"„C,;,,s� . $125.00-Component
PAGE 2OF2
A. Facility.information continued..
5. Type of Building: Residential Dwelling or OCommercial
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 by thi and of Health.
Name Date
Application proved By: ( and of Health Representative)
-7 Ah
Na a Date
Application Disapproved for the following reasons:
For Office Use Only:
I Fee Attached. Yes�/ No
2. Project Manager Obligation Form Attached. Yes v No
I Pump S_ stem? If so,Attach copy of Electdcgj Permit Yes No
4. Foundation As-Built. (new construction ronly). Yes No
(Same scale as approved plan)
5. Floor Plans?(new construction only). Yes No
• i
P j
APPr for Disposal System Construction Permit-.Page 2 of 2
'3 My�a x 1
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
Cid•4 z A-A., .
(Address of septic system) For plans by
�,( (Engineer)
Relative to the application of /d J ��4/ e
(Installer's name) And dated
ngui ate
Dated '7— a---d
I o3ray's ate With revisions dated
(Last revised 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 must call for any and all inspections. 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. As the installer, I am required to have the necessary work completed prior to the applicable inspections as
indicated below. I understand that requesting an inspection,without completion of the items in accordance
with Title 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or
MY company.
a. Bottom of Bed—Generally,this is the.first(1s) inspection unless there is a retaining wall,which
should be done first. The installer must request the inspection but does not have to be present.
b. Final Construction Inspection—Engineer must first do their inspection for elevations, ties,etc.
As-built of verbal OK(or e-mail to: healthdept@townofnorthandover.com) from the engineer must
be submitted to the Board of Health,after which installer calls for an inspection time. Installer must
be present for this inspection. With a pump system,all electrical work must be ready and able to
cause pump to work and alarm to function.
c. Final Grade—Installer must request inspection when all grading is complete. Installer does not
have to be on-site.
4. As the installer, I understand that only I may perform the work (other than simple excavation)and I am required
to complete the installation of the system identified in the attached application for installation. I further
understand that work done by others unlicensed to install septic systems in North Andover can constitute
reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of
North Andover. significant fines to all persons involved are also possible.
5. As the installer, I understand that I must be on-site during the performance of the following construction
steps:
a. Determination that the proper elevation of the excavation has been reached
b. Inspection of the sand and stone to be used.
c. Final inspection by Board ofHealth staff or consultant.
d. Installation of tank,D-Box,pipes, stone, vent,pump chamber,retaining wall and other
components.
6. As the installer,I understand that I am solely responsible for the installation of the system as per the
approved plans. No instructions by the homeowner,general contractor,or any other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer: (Today's Date) --o
ame— rint ame- ,rgn
I
cf'LTH
Nov 4 2002
TOWN OF NORTH ANDOVER La_�„��
SYSTEM PUMPING RECORD
, 0. STEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
in
A(A
U \"I E OF PUMPING: /g`/ '�� QUANTITY PUMPCQ07111!�' -A LLUV >
I)SPOOL: NO LZYES SEPTIC TANK : NO YES
`, ATURE OF SERVICE: ROUTINE (/ EMERGENCY
uHi ,RV:MONS:
GOOD CONDITION FULL TO COVER
HEAVY CREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RI-NIBACK .
EXCESSIVE SOLIDS �� FLOODED
SOLIDS CARRYOVER OjtHER (EXPLAIN)
l
>o )TLM PUMPED BY /l/:' �`lri Y� 1211
U�' I I:N I'J TRANSFERREDTO:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
//,�d Com A� (example: left front of house)
� %✓�clove✓
DATE OF PUMPING: QUANTITY PUMPED GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES c
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS: ,
. .CONTENTS TRANSFERRED TO:
/���0 CC( 42001
NORTH
Y OF 1LE0 ,
by6 O
O 1e
O mcwu wew.c« 1
SAO101
�9SSAC HUS���y
PUBLIC HEALTH DEPARTMENT
Community Development Division
C2RTI FIC,A,I'E O F CO�VI��J-1/—L
As of:
July 8, 2009
9his is to cert that the individuaCsu6surface disposal system received a
SAMITAC` ORTIAVSTECTIONof the:
ft&cewnt of Outlet Tee of
dept Disrovars IF sten
By
Todd Bateson
At:
53 Cedar Gane
JKap — 106.A; Farrel— 145
North Andover, w q 01845
'The Issuance of this certificate shall not 6e construed as a guarantee that the system will
function satisfactorily.
ZIS an T Sawyer
(Pu6CZc Ylealth Director
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 918.688.9540 fax 918.688.8416 Web www.townofnorthandover.com
TOWN OF NORTH ANDOVER OORTN
pf�z4a°ry6q,�,
Office of COMMUNITY DEVELOPMENT AND SERVICES o� °0�
HEALTH.DEPARTMENT A
1600 OSGOOD STREET;Building 2-36
NORTH ANDOVER MASSACHUSETTS 01845c
SgHus I
Susan Y. Sawyer,REHS/RS 978.688.9540—Phone
Public Health Director 978.688.8476—FAX
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: Jr— ��, �,r- __MAP: LOT:
INSTALLER: ��—
DESIGNER: a /�-
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
INSPECTIONS
TANK INSPECTION:
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
❑Existing septic tank properly abandoned
❑Internal plumbing all to one building sewer
❑Topography not appreciably altered
Comments:
SEPTIC TANK
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ 1500 gallon tank has been installed
H-10 loading Monolithic construction
❑ Water tightness of tank has been achieved
(Visual or Vacuum Test or Water held for 24hrs)
El Inlet tee installed, centered under access port
❑ Outlet tee (gas baffle or effluent filter) installed,
centered under access port
❑ 24" inch cover to within 6" of final grade installed over
one access port,-must be over outlet of tank if effluent
filter is present
❑ Hydraulic cement around inlet & outlet
Wastewater System Documentation—Feb 2006
Page 1 of 6
12J
FROM FAX N0. :9784B63319 Jun. 18 2009 03:47PM Pl
Mduh0ba
_t A�S4 LLC Tak 97"gri-1114 FAX:978-186-3319 WpNurnbsr: M 107.378
29 ting Sunni,Litddan MA 014bo WdMite:bttp:#www NwkW,4ndyticza.xoi thx'tlrie nnmlxt with an
Clkmk ROWO ts: aH8f2009
Donna McConaghy
53 Cedar Lane
North Andover,MA 0184S
Gerfficate of ANWis
Paraalcter Method Rmlt KMl MRL Date of Aa*ds Aeltlyat
53 Cedar Lane, Nath Andover.MA,l0k hen Tap
Sm"d an1/YaDtJD ft.30.,00 AMby QWW _ f
Total Cordarm BachWk MOOML MF-SM9222B Absent OlAbwnt Absent' 6M 1/2000 J 115:00 AM M-MA1118
Ammonia,MOIL SM 4tir>aftW ND Not Spee 0.1 W2009 M4"1118
Nitrate as N.MG/L EPA 300.0 ND 10 0.05 em irZ009 m m1118
Nitrite as N,MGA. EPA 300.0 NO 1 '0.01 w1112009 FA AA1118
t
i
MCL=Maximum Contaminant Lewl(EPA Limn),MRL-MMmen Repw"LOM
SoMkim buidekhes-Mess 20.EPA 250. d=Reeuk Eneeds Limit or GukMne
ND=None Defected(WRL), •■Background Bacula Noted
Massachlmft Co Med David L.:Knowkon
LaboraksrytllMAt'118 " L.abora*Dkector
Commonwealth of Massachusetts
a Title 5 Official Inspection Fo m RECEIVED
1
Subsurface Sewage Disposal System Form-Not for Voluntary A 3sessments
' M
53 Cedar Lane JUL 16 2009
Property Address TOWN OF NORTH ANDOVER
Donna McConaghy IEALTH DEPARTMENT
Owner Owner's Name
information is
required for North Andover MA 01845 7/9/20009
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:
When filling out A. General Information
When
forms on the
computer,use 1. Inspector:
only the tab key
to move your Neil J. Bateson
cursor-do not
use the return Name of Inspector
key. Bateson Enterprises Inc.
Company Name
Q 111 Argilla Road
Company Address
Andover Ma 01810
I IMW City/Town State Zip Code
978-475-4786 SI15
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and-experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
` 7/9/2009
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•09/08 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
53 Cedar Lane
Property Address
Donna McConaghy
Owner Owner's Name
information is
required for North Andover MA 01845 7/9/20009
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:
After permit from B.O.H., install new outlet tee in septic tank&well water tested by lab, 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
City/Town of
a` System Pumping Record RECEIVED
Form 4
DEP has provided this form for use by local Boards of Health. Ot er forJU6Jy OeQ, bu the
information must be substantially the same as that provided here Before using this for ck with your
local Board of Health to determine the form they use. The Syste PU "e ubmitted to
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location: Left fro , le , left sid of hoe . Right front, right rear, right side of house.
forms on the
computer,use
only the tab key Address
to move your
cursor- not
use the return City/Town State Zip Code
key. 2 System Owner:
Name
Address(if different from location)
City/Town States-�, �vZip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: aeons
3. Type of system: L] Cesspool(s) Septic Tank ' 0 Tight Tank
Other(describe):
4. Effluent Tee Filter present? Yes y No If yes, was it cleaned? 0 Yes L] No
5. Condition of otV/yvf�� �� 1
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati here contents were disposed:
L.S.D Lowell Waste Water
-7 ``9 e--)
o�J— Jigna ere of H Or Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Town of North Andover
` `'HEALTH DEPARTMENT
,SSACMUStt q
z, CHECK#: � DATE: / Ul
LOCATION: ezt
H/O NAME: ,11— , � Q
CONTRACTOR NAME:c'�l � ��""
Type of Permit or License: (Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type: $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice i $
❑ 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 $
Za Title 5 Report $ �0
❑ Other. (Indicate) $
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer
Commonwealth of Massachusetts
Title 5 Official Inspection Fo 7/6 0
p ECEIVE
Subsurface Sewage Disposal System Form-Not for Voluntary Issessments
J 1
U
53 Cedar Lane N 5
2
Property Address
TOWN
Donna McCona hOF NORTH AND
Owner Owner's Name ENT
OVER
information is
required for North Andover MA 01845 6/5/2009
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:
only the tab key
to move your Neil J. Bateson
cursor-do not Name of Inspector
use the return
key. Bateson Enterprises Inc.
Company Name
111 Argilla Road
Company Address
Andover Ma 01810
II I+ City/Town State Zip Code
978-475-4786 SI15
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
❑ Passes ❑ Conditionally Passes ❑ Fails
I '�' "r
® Needs Further Evaluatiomby the Local Approving AuthorityJ1 ��JL
.,.I,)-
6/5/2009
InSpI Date
The system inspector shall submit a copy of this inspection report to the Aporoving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Foran-Not for Voluntary Assessments
M 53 Cedar Lane
Property Address
Donna McConaghy
Owner Owner's Name
information is
required for North Andover MA 01845 6/5/2009
every page. Citylrown 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:
E
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
' M
53 Cedar Lane
Property Address
Donna McConaghy
Owner Owner's Name
information is
required for North Andover MA 01845 6/5/2009
every page. City/Town 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,
L )l ) Y 9
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-09/08 Title 5 Official Inspection 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
wM 53 Cedar Lane
Property Address
Donna McConaghy
Owner Owner's Name
information is
required for North Andover MA 01845 6/5/2009
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
® The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance: Tape Measure,well to tank 65'to pit#1 58', to pit#2 81'.
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.
3. Other:
Outlet tee replacement also
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 '/2 day flow
t5ins-09108 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 4 of 17
s Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 53 Cedar Lane
Property Address
Donna McConaghy
Owner Owner's Name
information is
required for North Andover MA 01845 6/5/2009
every page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 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 Foran-Not for Voluntary Assessments
M 53 Cedar Lane
Property Address
Donna McConaghy
Owner Owner's Name
information is
required for North Andover MA 01845 6/5/2009
every page. City/town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
I
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
•
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
53 Cedar Lane
Property Address
Donna McConaghy
Owner Owner's Name
information is
required for North Andover MA 01845 6/5/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d On well water
9 ( Y 9 (gP ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
Date
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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 53 Cedar Lane
Property Address
Donna McConaghy
Owner Owner's Name
information is
required for North Andover MA 01845 6/5/2009
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 last year, owner
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
El Shared system (Yes or no) (if yes, attachprevious 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
o- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
53 Cedar Lane
Property Address
Donna McConaghy
Owner Owner's Name
information is
required for North Andover MA 01845 6/5/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
35 years old, 9/25/1974, final inspection info
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.8feet
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 thru wall, no leaks visible
Septic Tank(locate on site plan):
Depth below grade: .6feet
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: Tx 5'x 4'
Sludge depth: 2
t5ins•09/08 Title 5 Oficial 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
I
M 53 Cedar Lane
Property Address
Donna McConaghy
Owner Owner's Name
information is
required for North Andover MA 01845 6/5/2009
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
28"
Scum thickness
2"
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
16" �
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. Outietbaffle badly corroded, needs to be replaced with tee. Depth of liquid at outlet
invert. No evidence of leakage.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•09/08 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
53 Cedar Lane
Property Address
Donna McConaghy
Owner Owner's Name
information is
required for North Andover MA 01845 6/5/2009
every page. Cityrrown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i
53 Cedar Lane
Property Address
Donna McConaghy
Owner Owner's Name
information is
required for North Andover MA 01845 6/5/2009
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.):
I
D-box level &distibution equal. No evidence of carryover. Evidence of light carryover.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 53 Cedar Lane
Property Address
Donna McConaghy
Owner Owner's Name
information is
required for North Andover MA 01845 6/5/2009
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
2
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil ok. Vegetation ok. No sign of ponding to surface. Camera inside of pits thru outlet in d-box. No
liquid to inverts of pits.
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
I
i
Dimensions of cesspool
Materials of construction
Indication of groundwater Inflow ❑ Yes ❑ No
15ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealthof Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
I
53 Cedar Lane
Property Address
Donna McConaghy
Owner Owner's Name
information is
required for North Andover MA 01845 6/5/2009
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
t
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
53 Cedar Lane
Property address
Donna McConaghy
Owner Owner's Name
information is North Andover MA 01845 6/5/2009
required for
every page. Cityrrown State Zip Code Date of Inspection
D. System Information leont.)
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 wellsm" 100 feet: Locate.
where public water supply enters the building.Check one of the boxes below:
hand-sRetch in-the area below
f] drawing.attached separately
%1U&
vS�-
f
qR
4
-4- = 4
_q3oI`
t5fns-09M Tdle 5 Olfiaal kmpedion fame S1ubmufam Sewage Disposai Mein-page 15 of 17
v
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
wM 53 Cedar Lane
Property Address
Donna McConaghy
Owner Owner's Name
information is
required for North Andover MA 01845 6/5/2009
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: 5/24/1974
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
As per design plan test pit data, no water found 10'deep
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
r
Commonwealth of Massachusetts
H Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M
53 Cedar Lane
Property Address
Donna McConaghy
Owner Owner's Name
information is
required for North Andover MA 01845 6/5/2009
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
I
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
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�`� {Yt@ ► Pump�ng:Record
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be submitted to the locai'Board of Health or other approving authority,
JUN — 4 2007
A: Facility Information
>> URPoottant. <' TOtn. NORTH ANDOVER
HEALTh DEPARTMENT
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;.for On th0
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only the tab key Address
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Gallons
Type of system ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑'Other(descrlba)
4 Effluent Tea Filter Present?.❑ Ye
No If yes, was It cleaned? ❑ Yes []' No
" tion of Systgm;'"
6 Sy Pumped By
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httpJ/www.mas's.gov/dep/water/approvals/t5forms,htm#inspect
tSfortM.doc�08103 System Pumping Record•Page 1 of 1
TOWN OF NORTH ANDOVER r "
SYSTEM PUMPING RECORD
r
DATE 104
SYSTEM OWNER&ADDRESS SYSTEM LOCATION
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DATE OF PUMPING I QUANTITY PUMPED
CESSPOOL NO /YES SEPTIC TAN f
K NO YES
NATURE OF SERVICE: ROUTINE V EMERGENCY
OBSERVATIONS: /
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN LACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLID CARRYOVER OTHER EXPLAIN
SYSTEM PUMPED BY A
COMMENTS:
f
CONTENTS TRANSFERRED TO ✓//.�/
Commonwealth of Massachusetts
City/Town of
System Pumping Record � � 010
Form 4
TOWN OF NOMYN ANOweR
DEP has provided this form for use by local Boards of Health. Other forms
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 Lo : Left front of house, right front of house, left side of house, right side of hous eft
ear o ght rear of house, left side of'building, rigpt tear of building, under deck.
5--::�
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Dat U 12. Quantity Pumped: Gallo 1
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes LSJ' No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Location where contents were disposed:
L.S.D. Lowell Waste Water
Signature of Hauler Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
.-a
,.� T 0: 11..r T i At,1 -V rpt, 1 A SS.
30nRD C i+ ti�',ALTH
Re: Sub Surface Disposal
[V': rSI!=3 IKIGINFM System Inspection
"hi n _ -c — r-d f' ,h 3t I have inspected the construction of the sub surface
No.Andov--.rjMass.
'.'he ar-i ,r ,4 e:-)ns+r 1.&Aon are qs specified in r7 plans •and -pecifirritionn
eg.P - ,; neer •.3)tni
Form No.4
Town of North Andover, Massachusetts
BOARD OF HEALTH
19,k^r CERTIFICATE OF COMPLIANCE
y ^` This is to certify that
f'm , the Individual Soil Absorption Sewage Disposal System constructed ( ) or repaired ( )
by INSTALLER
` at
4-CLV' L Cxsti.._$,
SITE LOCATION
has been installed in accordance with Board of Health Regulations as described in the Design
F
Approval Site System Permit No. dated 19
The issuance of this certificate shall not be construed as a guarantee that the system will
function satisfactorily.
C"
ep:::
BOARD OF HEALTH ENGINEER.
.`w
IN
17
24 MAY-14
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R EIVED
-C-\ Commonwealth of Massachusetts
u,pCity/Town of OCT 16 2012
System Pumping n Record TOWN OF NORTH ANDOVER
Y P g HEALTH DEPARTMENT
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house Le Rig rear of hous , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address �`..J �o
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State -- Code
Lc�-EG[ -� 76 '7
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2• Quanti umped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Con ition of System: lf
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio here contents were disposed:
/G.LS.p I Lowell Waste Water
Sign aHauIe Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
i •
Commonwealth of Massachusetts
City/Town of
ED
System Pumping-Record
Form 4 „ J , 6-Jill. �t
DEP has provided this form for use-by local Boards of Health. Other forms mayI&�sedhbtit�:'Ii�VFR
information-must be substantially the same as that provided here. Before using.this form, chithY our
local Board of Health to determine the forltm they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Information
I. System Location: Left/Right front of house, E / o house eft/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Cityfrown State Zip Code
2. System Owner.
Name
Address(d different from location)
Cityfrown • Stater-�„
Telephone Number t
.B. Pumping ,Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons y
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
ncCompany
7. Location re contents-were disposed:
C�,.L S'. Lowell Waste Wafer
SignjAV
eHaul Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1