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Miscellaneous - 42 JAY ROAD 4/30/2018 (2)
i 42 JAY ROAD _21=98.A�0004-0000-0 f Commonwealth of Massachusetts ' RECE City/Town of System Pumping-Record Nov I ZU14 Form 4 IOWN OF NORTH ANDOVER HEAL i11 DEPARTMENT DEP has provided this form for use,by local Boards of Health. Other orms may a use , ut 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 LocationL /Right on ofhouse eft/Right rear of house, Left/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. Aitc7P . Name Address(if different from location) cKyrrown state Zip Code Telephone Number B. Pumping Record . 1. Date of Pumping Date 14—;,a 2. antity Pumped: " Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yep No 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 7. Location where contents were disposed: GLL S. Lowell Waste Water S- Signitufe ItHaul Date t5fomu4.d6c-06103 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts IMM M City/Town of System Pumping Record 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: Le / igR ht front of house, eft/Right rear of house, Left/right side of house, Left/ Right side of building, Le Ig ro uilding, Left/Right rear of building, Under deck Address City/Town State Zip Code 2. System Owner Name Address(if different from location) Cityrrown ` State Zig Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic 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 ems,°w =tv Name b Vehicle License Number f Bateson Enterprises Inc �� ��7 Company L L•�d 7. Locatio W Contents Were disposed: TOWN OF NORTH ANDOVER H`ALTH D�PAFtTN ANT CG.., S. Lowell Waste Water F SignAtufe 4 Haule Date t5form4.doc•06/03 System Pumping Record-Page 1 of 1 RE��IV�CC� Commonwealth of Massachusetts City/Town of t ;, 122013 System Pumping Record TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Form 4 lug DEP has provided this form for us&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/ Ight�front Left/Right rear of house, Left/right side of house, Left/ Right side of building, Le ilding, Left/Rightrear of building, Under deck Address Cityrrown State Zip Code 2. System Owner. Name Address(if different from location) City/Town State "��jip Cgde Telephone Number B. Pumping Record 1. Date of PumpingDate 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yeses If yes, was it cleaned? ❑ Yes ❑ No 5. Conditioq of System: LA 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: G�.S. Lowell Waste Water Sig a Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 TOWN OF SYSTEM PUMPING RECORD`-:3 AUG , DATE• "C0 SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example:left front of house) DATE OF PUMPING: _( QUANTITY PUMPED : GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES -�Z- 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: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: l_. TOWN OF NORTH ANDOVE BOARD OF HEALTH � f'� U Location- Permit /� �e �� Permit # Food Service $ Retail Food $ Limited Retail $ Seasonal $ Disposal Works Installers $ Disposal Works ConstructionL--, $ Soil Testing $ _ Design Approval Permit $ j Dumpster Permit $ -- Burial Permit $ Swimming Pool Permit $ 1 Animal Permit $ i Recreational Camp Permit $ 1 Well Construction Permit $ Funeral Directors Permit $ j Massage Establishment License $ Massage Practice License $ Suntanning Establishment $ Offal/Trash Hauler $ i t Other $ t i 7030 Health Agent II s White - Applicant Yellow - Dept. Pink - Treasurer APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: "/3 " O 3 CURRENT INSTALLER'S LICENSE# LOCATION: _/ Cy�_ cs r LICENSED INS A ER: a N ; e,e N 2,oSIGNATURE: ELEPHONE# r!�8-37 0� " y7 CHECK ONE- REPAIR: NEW CONSTRUCTION: IF NEW CONSTRUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. Administrative Use Only 25� / $IM9DO Fee Attached? Yes t1 No Foundation As-built? Yes A "� No Floor plans on file? Yes A *k' No Approval Date: `u,7 I MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza Boston, Massachusetts 02108-1904 (617) 723-3800, Ma Only (800) 392-6108, Fax (617) 557-5675 02/26/03 Form of Notice of Casualty Loss'to Building Under Mass. Gen. Laws, Ch. 139, Sec.313 NORTH ANDOVER HEALTH DEPT. MAR 4 NORTH ANDOVER TOWN HALL �J NORTH ANDOVER MA 01845 Re: Insured: HARBALDEEP SINGH & RAJNI CHITKARA Property Address: 42 JAY RD, NORTH ANDOVER, MA 01845 Policy Number: 0677211 Type Loss: Water Damage Date of Loss: 02/26/03 Claim Number: 197345 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, chapter 139 Section 3 B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. MPIUA Claims Division CMA00021 Insurance Adjustment Service Inc. 531 King Street - Unit 2, Second Floor Littleton, MA 01460 978-952-6966 - Fax 978,-952-2459 Email: iashttleton@netlplus.com Date: 7--� I Board of Health: 7,3, n � � Al rid is�-ca Building Inspector: ' Fire Department: Re: Insured:_ S,`nn A y/ Ck, 1fctr� Locationr Claim Number: /000 /?y Policy Number: I/o 0 Our File Number: Cause of Loss:_ Date of Loss: Dear Sir/Madam: A claim has been made involving loss, damage or destruction of the above captioned property which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6 to be applied. If any notice under Massachusetts General Laws, Chapter 139, Section 36 is appropriate, please direct that information to my attention and include a reference to the captioned insured location,ocation, date of loss and file number.._,..-"� _.- Thank you for your cooperation., __.. Very truly yours, s -- MAR s Scott O'Neil Adjuster Ext. 129 Commonwealth of Massachusetts ' Massachusetts System Pumping Record System Owner System Location a RA Date of Pumping: Quantity Pumped: gallons Cesspool: No [ Yes [] Septic Tank: No [] Yes System Pumped by: Ta4m" License# Contents transferred to: Greater Lawrence Sanitary/ District Date: Inspector: : J STATEMENT c F DANIEL A. GIARD 130A Appleton Street 4-cp y 9 s' NORTH ANDOVER, MA 01845 DATE r Phone 686-7653 i S ...................._..... __.................................._......................_..- -__...__._ . ....._....._...._.......__...._...._....._...__..:.._....._...__....._.. v_. ..._._.._..__......... ........................._._.........._--- .._..__....._....-.. ........ ........... TERMS: PLEASE DETACH AND RETURN WITH YOUR REMITTANCE $ l DATE w .I. INVOICE NUMBER?DESCRIPTION1 yCHARGES rCREDITS va I� BALANCEm BALANCE FORWARD j? .. _ _ -._ __ -..._. _ ..._.._....... _.... - _._...._ ,,,c,... — — _ - - R n J _.... .. .. .._.... ...... -_ r l�¢ _ v4- .._...... _...-_.-'".._ _.._._ ... ...-un -..__— ....._....._ __—....._- ._ _. ..._....-........._..... ....................._...... ............. ... ...... rx ' .........._...........--_--.............................................../...._....._.-.-....._........................— -- — 1 _.............................................................. ....... ..... _. ......... ..... ........ ............. .... ......... _.._._.. _.__ —._...._ 33 d1l 4 PAY LAST AMOUNT DANIEL A. GIARD CC�JJJ IN THIS COLUMN i PRODUCT 100-2 A s Inc,Grolon,Mm 01471.To Or&n PHONE TOLL FREE 1.800-n5,M Rerrdt # 53 Lot 2 Jay Rd Sherwood Hones 2. APPLICATION FOR SEWAGE DISPOSAL INSTALLATION HEALTH DEPARTMENT - NORTH ANDOVER, MASS. I hereby make application for a permit for a sewage disposal installation at Lot 2 Jamar Rd . I will install this system in ac- cordance with all the laws of the Commonwealth of Massachusetts and regulations of the Board of Health of the Town of North Andover. A Further, I will construct the house sewer of bell and spigot pipe, -the minimum diameter being 4 inches, and will maintain a minimum grade of 1/ until 10 feet pre- ceding the septic tank, where the grade shall not exceed 2%. I wri11 install a con- crete septic tank of 1000 in size. A manhole (s) permitting easy cleaning will be provided with co removable ver (s) of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with 4 inch perforated or open jointed pipe and laid in a series of trenches, the bottom of which will pro- vide a minimum of 9nn lineal (square) feet of effective absorption area. ,The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches (dia. ) and the pipes will be surrounded by similar material to a height .of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling the trench, 2 inches of ` -Mvel•or-stone-l/$ -to-1AU-(d a ) will be-placed- over—the course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/ -6- feet. No single tile line will exceed 100 feet in length and in any case, two lines of tile will be installed. A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No part of the installation will be less than 100 feet from any private water supply, 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. I further agree not to cover any portion of this installation until apliroved by the inspection officer, as provided below, and to incorporate any additional requirements that may be attached to the permit. Plot Plans must be submitted with application. DATE 4=1701T 6t, gravel bed beneath leaching field j Jnature of Applicant I hereby issue the above permit f the Board of Health of the Town of North Andover, Massachusetts. DATE ?x/27/70 Signat' o ealth Agent I have inspected the uncovered system indicated above and find everything done as described. f} DATE Signature nspecting Offi .r Percolation Test 7 Y =tee ,Said. Clay Garbage Grindero a-V BOARD OF HEALTH TOWN OF NORTH ANDOVER, MASS. j, r 1 I s—h r ° �o S i n4: 1. NAME_ �� _^� DATE �� ��l� 2. ADDRESS y LOT NO. 3. NO. OF BEDROOMS DEN YES_ w NO 4. GARBAGE GRINDER YES NO 5. SHOW DIMENSIONS OF HOUSE _ ehl 6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES �� 7. SHOW DIMENSIONS OF LOT 8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL 9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM 10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC. 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY. I BOARD OF HEALTH OF NORTH ANDOVER , MASSACHUSETTS SEWAGE DISPOSAL �17-71e7o— NAME DATE OF APPLICANT j LOCATION dd ess of lot no. BUILDING: Dwelling K Other SYSTEM: New K- Repair f, GENERAL DESCRIPTION OF LAND SUBSOIL: Clay?C G vel Sand PERCOLATION TEST 7 minutes per inch. MINIMUM INSTALLATION RECOMMENDATIONS CONCRETE SEPTIC TANK-_gallon capacity. LEACH FIELD lineal feet of drainpipe. � n William J. Dri coli , Engineer Board of Healt 1 �vY � went III v V yp,YiMd �i1i����'4 4W�al Y5 i 4�p _ ueano over �wubdi � F70— VIIPI JF NORTH AYu9..OVER/ BOARD OFHE -71-1 0 PTIC,TANK LEACH FIELD y 11 - _ _ _ EJAN299 Septic Compliance, Inc. E Paul Cardone, Soil Evaluator January 26, 1999 No. Andover Board of Health 27 Charles Street North Andover, MA 01845 Attn: Sandra Starr Re: Sanitary Disposal System Inspection 42 Jay Road- Dr. Chatterjee Dear Ms. Starr: In accordance with the Commonwealth of Massachusetts, Department of Environmental Protection, State Environmental Code (Title V), 310 CMR 15.301, paragraph 7, please find attached a"Subsurface Sewage Disposal System Inspection Form" for your records. If you have any questions regarding this report or any of its contents please do not hesitate to contact this office. We thank you, in advance, for your continued cooperation in these matters. Very truly yours, SEP C MPLIANCE, INC. Paul Cardone Certified Septic Inspector Attachment PC/JMP title5 chattedeemps • TITLE 5 SYSTEM INSPECTORS D.E.P. SOIL EVALUATORS • 447 Boston St, Topsfield, MA 01983 37'h Baremeadow St.,Methuen,MA 01844 Tel (978) 887-8586 Fax(978) 887-3480 (978) 681-0726 • i � y • f—Vefit v `r \ .� tx� ,�CTIG BuK I.E� IElO Y$tEf�i31>L°i TITLE 5 INSPECTIONS DATASHEET Address: Date received 9 Cj Owner: _ � Add. If diff. Inspector's Name: C>~-t aadI o- Date of Insp. ;L 9 9 Inspector's Address: Systems No.bedrooms Garbage Grinder Al Status ass Fail, CP, BOH evaluation) Type of System: Septic tank_2, � D-box Leach field_y�,_ Trenches Leach pits Cesspool_ [� Town water Private well System pumped for inspection?_ jam_ How many gallons? The Sy shall submit a copy of this inspection report to the �g Authority(Board of Health or DEP)within thirty(30)days of for and the stem owner a i flow of 10 000 or ter,the ins system tion. If the stem is a shared em or has design SPd � P� completing pec system system shall submit the report to the appropriate regional office of the Department of Envirormiental Protection. The original should be sent to the System owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND CONBENTS •TITLE 5 SYSTEM INSPECTORS • D.E.P. SOIL EVALUATORS • 447 Boston St.,Topsfield,MA 01983 37'/2 Baremeadow St., Methuen,MA 01844 Tel (978)887-8586 Fax (978) 887.3480 (978) 681-0726 Revised 9/2198 Page 1 of 11 I 1 TITLE 5 INSPECTIONS DATASHEET Address: V2 Date received Owner: Add. If diff. Inspector's Name: gyp_ Date of Insp. q q Inspector's Address: 'Z Systems No.bedrooms Garbage Grinder Al Status ass Fail, CP, BOH evaluation) Type of System: Septic tank _ D-box Leach field�_ Trenches Leach pits Cesspool [ Town water Private well—IAIA System pumped for inspection? Al' How many gallons? it ` Y I .� ,LEACA �1-stile, Septic Comphimee, Inc• F. Paul Cardene, Soil Evaluator COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVgiONMENTAL PROTEMON ONE WINTER STREET,BOSTON MA 02108 (617)292-6600 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Addres:42 Jay Rd-No.Andover,Ma.01845 Name of Owner.Dr Chatterjee Address of Owner.Same Date of inspection:January 20,1999 Name of inspector.(Please Print)Paul Cardone I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name:Septic Compliance,Ine. Mailing Address:447 Boston Rd.Topsfield,Ma.01983 Telephone Number.(978)887.8586 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes X Condition asses Needs r Hon a Local AXpoving Authority Fails Inspector's Signaature: Date r 2 -The Sy shall submit a copy of this inspection report to the ApAuthority(Board of Health or DEP)within thirty(30)days of completing thi pection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the System owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS .TITLE 5 SYSTEM INSPECTORS • D.E.P. SOIL EVALUATORS • 447 Boston SL,Topsfield,MA 01983 37'/2 Baremeadow St., Methuen,MA 01844 Tel (978)887-8586 Fax (978) 887-3480 (978) 681-0726 Revised 9/2/98 Page i of I I I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET,BOSTON MA 02108(617)292-55M X TRUDY CORE Secretary ARGEO PAUL CELLUCCI Governor DAVID B.STRUHS Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address:42 Jay Rd.No.Andover,Ma.01845 1 Name of Owner:Dr.Chattelee Address of Owner:Same Date of Inspection:January 20,1999 Name of Inspector:(Please Print)Paul Cardone I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)Company Name:Mailing Address:Telephone Number. CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X_ Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fail inspector's Signatu i The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Hearth or DEP within thirty(30)days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environments Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM(INSPECTION FORM PART A CERTIFICATION(continued) Property Address:Owner:Date of inspection:Dr.Chatterjee 42 Jay Rd.No.Andover,Ma.01845 INSPECTION SUMMARY:check A,B,C,or D. A.SYSTEM PASSES:Yes 1 have not found any information which indicates that any of the failure conditions described in 310 CMR 16.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: B.SYSTEM CONDITIONALLY PASSES: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. _ The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration, or tank failure is imminent.The system voll pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping-more than four times-a year-due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:42 Jay Rd.No.Andover,Ma.01845 Owner:Dr.Chattedee Date of Inspection:January 20,1999 C.FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _ Conditions e)dst which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH.WILL PROJECT THE PUBLIC HEALTH.AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetlend or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.Method used to determine distance (approArnation not Valid). 3) OTHER revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:42 Jay Rd.No.Andover,Ma.01845 Owner:Date of Inspection:Dr.Chatterjee 42 Jay Rd.No.Andover,Ma.01845 D.SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of-sewage into facility or system component-due to an overloaded 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 dogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to dogged or obstructed pipe(s).Number of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a'cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is-within a Zone I of a public hell. 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 then 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for-coliform bacteria,volatile organic-compounds,ammonia nitrogen-and nitrate nitrogen. E.LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: _ The system servos a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety an, the environment because one or more of the following conditions exist Yes No the system is within 400 feet of a surface drinking water supply the system-is-within 200 feet of a tributary to a surface drinking water supply- the system is located in a nitrogen sensitive area(interim Wellhead Protection Area;IWPA)or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:Owner.Daft at Inspection:Dr.Chattarjee 42 Jay Rd.No.Andover,Me.01845 January 20,1999 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No Y — Pumping information was provided by the.owner,occupant,or Board of Health. —Y None of system components have at least two weeks and has been floor, rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. N/A As built plans have been obtained and examined.Note if they are not available with N/A A The facility or dwelling was inspected for signs of sewage back-up. —Y— The system does not receive non-sanitary or industrial waste flow. _Y_ The site was inspected for signs of breakout. Y— — All system components,excluding the Soil Absorption System,have been located on the site. _Y The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: –N_ Existing information.For example,Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (15.302(3)(b)) Y The facility owner land occupants,if different-owner)were provided information on the proper maintenance f SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 { • i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:42 Jay Rd.No.Andover,Ma.01845 Owner:Dr.Chatterjee Deft of Inspection:January 20,1999 FLOW CONDITIONS RESIDENTIAL: Design flow:110 g.p.d./bedroom. Number of bedrooms(design)._.A._ Number of bedrooms(actual)- _4-Total DESIGN flow_440 Number of current residents:- 4-Garbage grinder(yes or no):_No_ Laundry(separate system)(yes or no):_No_If Yes,separate inspection required Laundry system inspected(yes or no): Seasonal use(yes or no):_No Water meter readings,if available Oast two year's usage(gpd): Sump Pump(yes or no):Yes_ Last date of occupancy:occupied COMMERCILA I INDUSTRIAL: Type of establishment: Design flow: aad(Based on 15-203) Basis of design flow Grease trap present:(yes or no) Industrial Waste Holding Tank present:(yes or no)_ Non-sanitary waste discharged to the Title 5 system:(yes or no)_ Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Lest date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Owner told me they had the tank pumped one or two years ago,I also found a pump slip at the B.O.H.dated 10-24-95. System pumped as part of inspection:(yes or no) No_ If yes,volume pumped:_gallons Reason for pumping: TYPE OF SYSTEM _X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)Of yes,attach previous inspection records,if any) 1/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank_Copy of DEP Approval Other APPROXIMATE AGE of all components,date installed(if known)and source of information: Approx.25 years of age Found some info.At the health dept. Sewage odors detected when arriving at the site:(yes or no)No revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC71ON FORM PART C SYSTEM INFORMATION(continued) Property Address:42 Jay Rd.No.Andover,Ma.01945 Owner:Dr.Chattedee Deft at Inspection:January 20,1999 l BUILDING SEWER: (Locate on site plan) Depth below grade: l Material of construction: cast iron_40 PVC_other(explain) i! } Distance from private water supply well or suction line Diameter_ Comments:(condition of joints,venting,evidence of leakage,etc. SEPTIC TANK Yes (locate on site plan_) Depth below grade:16' Material of construction:_X_concrets_metal_Fiberglass_Polyethylene_other(explain) If tank is metal,list age_Is age confirmed-by Certificate of Compliance_(Yes/No) Dimensions:–diameter 93"height 56'invert 46" Sludge depth_3' Distance from top of sludge to bottom of outlet tee or baffie:_22` Scum thickness:-4' Distance from top of scum to top of outlet tee or baffle: 8. Distance from bottom of scum to bottom of outlet tee or baffte:_12' How dimensions were determined:–septic dip-stick Comments: (recommendation for pumping,condition of inlet and outlet toes or-baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) We recommend tank be pumped once every two to three years,baffles were intact an functioning,liquid levels were good,structural integrity seemed to be good, no apparent leaks in or out of tank. GREASE TRAP: N/A (locate on site plan) _ Depth below grade: Material of construction:-_concrete- metal- Fiberglass Polyethylene other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet too or baffle: Distance from bottom of scum to bottom of outlet tee or baffle:_ Date of last pumping: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) 4 revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:42 Jay Rd.No.Andover,Ma.01845 Owner.Dr.Chattedee Date of Inspection:January 20,1999 TIGHT OR HOLDING TANK:—N/A— (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: Material of construction:_-concrete`-metal_-Fiberglass_-Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes_ No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert_Even-good level Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) _Level and distribution were equal none none none PUMP CHAMBER:NIA (locate on site plan) Pumps in working order:(Yes or No)_ Alarms in working order(Yes or No)_ Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) Revised 9/2/98 Page 8 of 11 z a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:42 Jay Rd.No.Andover, Ma.01845 Owner: Dr.Chattelee Date of Inspection:January 20,1999 SOIL ABSORPTION SYSTEM(SAS):_Yes (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: Type: leaching pits,number.__ leaching chambers,number leaching galleries,number: leaching trenches,number,length: X leaching fields,number,dimensions:1 field 20'x 50' overflow cesspool,number. Alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) nomral none none yes grassy front yard CESSPOOLS: N/A (locate on site plan) Numbed 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(cesspool must be pumped as part of inspection) Comments: (note condition of soil,signs of hydraulic failure,level of pending,condition of vegetation,etc.) PRIVY: NIA_ (locate or_site plan) Materjals of construction: Dimensions: Depth of solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) revised 9/2/98 Page 9 of 11 1 � J 1 revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:42 Jay Rd.No.Andover,Ma.01845 Date of Inspection:January 20,19% NRCS Report name Soil Survey of Essex County Mass.Northern Part Soil Type CbB Canton very stoney fine sandy loam Typical depth to groundwater 6' USGS Date website visited Observation Wells checked Groundwater depth:Shallow Moderate Deep SITE EXAM Slope 3—8% Surface water None Check Cellar Dry Shallow wells Estimated Depth to Groundwater 6' Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record —X Observed Site(Abutting property,observation hole,basement sump etc.) X Determined from local conditions X Checked with local Board of health X Checked FEMA Maps X Checked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) Checked basement(dry)no ponding in field area,all liquid were good,perc rate was 7 min/inch. I dug a small hole in the field area with my backhoe stone looked good. revised 9/2/9 Page 11 of 11 —S'c I 3 d Q o i i I i f � 4 I � I f I I i i 15 Y:5 ojl6e- ,�Jy� I TEL. 682-6483 Exr23 f t COMMONWEALTH OF MASSACHUSETTS in. f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION A F Q OW I � �H Ste TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_42 Jay Road i10 _North Andover Owner's Name:_Mr.Harbaldeep Singh_ �v Owner's Address:_42 Jay Road_ _North Andover,MA 01845_ Date of Inspection:_8/19/2003_ Name of Inspector: Neil J.Bateson Company Name: Bateson Enterprises Inc._ Mailing Address:_111 Argilla Road_ _Andover,Ma.01810_ Telephone Number:_(978)475-4786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X_ Passes — Conditionally Passes Needs Further Evaluation by the Local Approving Authority —c F ' Inspector's Signature: Date: _8/19/2003_ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments:After permit,Stewart Septic installed new d-box,and the Town of North Andover B.O.H.inspected, septic system now passes Title 5 Inspection. ""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. II COMMONWEALTH OF MASSACHUSETTS Z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a d DEPARTMENT OF ENVIRONMENTAL PROTECTION F ytr 5' 9 V�V TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM o PART A r CERTIFICATION V Property Address:_42 Jay Road_ _North Andover_ Owner's Name: Harbaldeep Singh_ Owner's Address: 42 Jay Road_ _North Andover,MA 01845_ 2��3 Date of Inspection:8/11/2003_ `Z Name of Inspector: Neil J.Bateson_ Company Name: Bateson Enterprises Inc._ .- Mailing Address:_111 Argilla Road_ Andover,Ma.01810 Telephone Number:_(978)475-4786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes - X Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fa' Inspector's Signature: Date: 8/11/2003_ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments: ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_42 Jay Road_ _North Andover— Owner:_Singh_ P Date of Inspection:_8/11/2003_ 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 m 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: _X_ 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. D-Box Replacement. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If`not determined"please explain. N The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally uns,ound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: N_ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: N The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 42 Jay Road_ _North Andover— Owner:_Singh_ Date of Inspection:_8/11/2003_ C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance__ "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 42 Jay Road_ North Andover— Owner: Singh_ Date of Inspection:_8/11/2003_ D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ _No_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _No_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _No Liquid depth in cesspool is less than 6"below invert or available volume is less than V2 day flow —No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ _No_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. No Any portion of a cesspool or privy is within a Zone 1 of a public well. _ _No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] _No_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CARR 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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—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. Page 5 of l l OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 42 Jay Road_ _North Andover- Owner:_Singh_ Date of Inspection:_8/11/2003_ Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Yes _ Pumping information was provided by the owner,occupant,or Board of Health _No Were any of the system components pumped out in the previous two weeks? _Yes_ _ Has the system received normal flows in the previous two week period? No Have large volumes of water been introduced to the system recently or as part of this inspection? _N/A _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _Yes — Was the facility or dwelling inspected for signs of sewage back up? Yes _ Was the site inspected for signs of break out? _Yes_ _ Were all system components,excluding the SAS,located on site? _Yes_ _ 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? _Yes_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _Yes_ _ Existing information.Old Title 5 Inspection anc _No Determined in the field(if any of the failure criteria related to Part C is at issue approximation of diste is unacceptable)[3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFI INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS OFFICIAL T O SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 42 Jay Road _North Andover– Owner:_Singh_ Date of Inspection:_8/11/2003_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): N/A Number of bedrooms(actual):_5_ DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):_N/A Number of current residents:_4 Does residence have a garbage grinder(yes or no): Yes_ Is laundry on a separate sewage system(yes or no):_No_ Laundry system inspected(yes or no): Seasonal use:(yes or no): No_ Water meter readings: Yes_ Sump pumps(yes or no): Yes_ Last date of occupancy:— Current-COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:Pumped Jan. this year,owner_ Was system pumped as part of the inspection(yes or no): Yes_ If yes,volume pumped:_1000_gallons--How was quantity pumped determined?_Measured tank_ Reason for pumping:_Inspect tank&tees_ TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe):_ Approximate age of all components,date installed(if known)and source of information: 36 years old,Owner_ Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_42 Jay Road_ _North Andover— Owner:_Singh_ Date of Inspection:_8/11/2003 BUILDING SEWER(locate on site plan)X Depth below grade:_24" Materials of construction:—X—cast iron _40 PVC_ .other Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.):_4"Cast iron thru wall. 3"PVC in house. 3"Cast iron in house.No leaks visible. SEPTIC TANK: X jocate on site plan) Depth below grade:_12" Material of construction:—X—concrete_metal fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 71x 5'x 41 _ Sludge depth —2"_ Distance from top of sludge to bottom of outlet tee or baffle: 2511 _ Scum thickness:_211 _ 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: 19"_ How were dimensions determined:_ Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Pumped septic tank.Inlet tee ok.Outlet tee corroded on top.Depth of liquid at outlet invert.No evidence of leakage._ GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 42 Jay Road_ _ North Andover– Owner:_Singh_ Date of Inspection:_8/11/2003_ TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: --l"— 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& distribution not equal.Evidence of leakage,d-box needs replaced.Evidence of solid carryover._ PUMP CHAMBER:—(locate on site plan) Pump in working order(yes or no): Alarm in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):_ Page 9 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 42 Jay Road_ _North Andover— Owner:_Singh_ Date of Inspection: 8/11/2003_ SOIL ABSORPTION SYSTEM(SAS):_X (locate on site plan,excavation not required) If SAS not located explain why: Type _ leaching pits,number: leaching chambers,number: leaching galleries,number: X leaching trenches,number,length: 4 trenches 50'long_ 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 all leach pipes,no standing liquid in pipes._ I 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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property hAddress:_42 Jay Road _ _North Andover— Owner:_Singh_ Date of Inspection:_8/11/2003_ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. House Water Meter e Gara A g B A to Tank=23'10" A to D-Box=36'6" B to Tank=15'10" B to D-Box=26' Driveway Septic Tank 50' D-Box Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 42 Jay Road_ _North Andover— Owner:_Singh_ Date of Inspection:_8/11/2003_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water_1 to 3_feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) _ Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation ) _X Accessed USGS database-explain: Essex County Soil map_ You must describe how you established the high ground water elevation:_Essex County Soil Map,Sheet#36, Sudbury Soil,Water 1 to 3 Feet Deep. Front yard elevated above water>4' r- � Dell Dell Symantec Acrobat EnZip 3.00 Documents Accessories pcAnywhere Reader 4.0 r - tax collector Microsoft Outlook hlodemTest pdriver.aspc... Citrix Program Windows Install NPinhhruhnnr)} FxnlnrPr .: ,s. r' .' .,,:4::,.� .....i{Y:::Y:tYIx��-•tq;..iit �ilSG-_��5!::'7i °�t 'i7 ,.-... .-�� .a „t ��"?', x Connect Edit Terminal Help V-1 r " WATER BILLING HISTORY 2100684-SINGH, HARBALDEEP METER #1 : 2100684 Copy o Dell Sul ----_ ------------- 42 JAY RD wnload hdl..- # CYCLE SERUICE PRIOR CURRENT USE WATER SEWER FEES TOTAL r� 1 2000-12 08/05/1999 4081 4081 0 0.00 0.00 2 2000-22 12/10/1999 4081 4111 30 81 .90 0.00 0.00 81 .9© n32 Intern- 2 2000-32 03/16/2000 4111 4136 25 68.25 0.00 0-00 b8.25 Explo 4 2000-42 06/06/2000 4136 4214 78 212.94 0.00 0.00 212.94 E--- 5 2001-12 08/10/2000 4214 4244 30 81 .90 0.00 11 .00 92.90 6 2001-22 11/16/2000 4244 4284 40 109.20 0.00 11 .00 120.20 Shortc� 7 2001-32 02/16/2001 4284 4314 30 81 -9D 0.00 11 .00 92.90 Printk 8 2001-42 05/23/2001 4314 4364 50 136.50 0-00 11 .00 147.50 9 2002-22 12/11/2001 0 38 38 114.02 0-00 5-55 119-57 WN 10 2002-32 03/18/2002 38 92 54 166.98 0.00 5.55 172.53 X11 2002-42 05/20/2002 92 112 20 49.40 0.00 5.55 54.95 Outic12 2002-12A 10/02/2001 4364 4434 70 228.90 0.00 5.55 234.45 Q Exprt 13 2002-CRD 10/03/2001 4434 4434 0 -22.40 0.00 0-00 -22.40 : 14 2003-12 08/07/2002 112 149 37 112.20 0.00 5.97 118.17soft C15 2003-22 11/12/2002 149 192 43130.74 0.00 5.97 136.71 rd # ZI16 2003-32 02/05/2003 192 232 40 123.60 0.00 5.97 129-57 Ne17 2003-42 05/08/2003 232 254 22 53.78 0.00 5.97 59.75 Neigf REUIEW CHOICE # or <ENTER> MORE HISTORY: Q cn m 0 Start lnbox - Mt..- Telnet- 1... iD Lexmark O.. 1 My Docum... 3:25 PM 0 as Tel: (978)475-4786 Fax: (978) 475-5451 i BATESON ENTERPRISES, INC. Excavating-Water.& Sewer Lines-Septic Systems&Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 42 Jay Road, North Andover Owner: Singh Date of Inspection: 8/11/2003 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. NI Neil J. Ba on Bateson Enterprises,Inc. MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza Boston, Massachusetts 02108-1904 (617) 723-3800, Ma Only(800) 392-6108, Fax (617) 557-5675 07/01/03 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec.3B TOWN OF NORTH A-NF7T/�/ BOARD OF HEA--,14 NORTH ANDOVER HEALTH DEPT. NORTH ANDOVER TOWN HALL NORTH ANDOVER MA 01845 ' 7 Re: Insured: HARBALDEEP SINGH & RAJNI CHITKARA Property Address: 42 JAY RD, NORTH ANDOVER, MA 0184._5 Policy Number: 0677211 Type Loss: Other Section I losses Date of Loss: 06/23/03 Claim Number: 199889 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, chapter 139, Section 3 B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. MPIUA Claims Division CMA00021 OE t%ORTI{ TOWN OF NORTH ANDOVER ._�•� ti �2 66'x- -A •O OOL HEALTH DEPARTMENT 27 CHARLES STREET ` NORTH ANDOVER,MASSACHUSETTS 01845 SSACHUSE'S Sandra Starr,R.S.,C.H.O. Telephone(978)688-9540 Public Health Director FAX(978)688-9542 FAX To: John DiVincenzo From: Pamela Stewart's Septic Service Fax: 978.373.6611 Pages: 2 978.372.7471 Date: Phone: Disposal Works Construction Permit for CC: Sandra Starr, R.S.,C.H.O. Re: Septic System Health Director ❑ Urgent x For Review ❑Please Comment ❑Please Reply ❑Please Recycle • Comments: Attached a copy of the approved permit for Disposal Works Construction at: Please call 978-688-9540 for assistance with any questions. Thank you. Cc: File-Address Town of North Andover, Massachusetts Form No.3 t NORTH 1 BOARD OF HEALTH j o t•L•D;°•aO � ,r/C�o2OO�9 o � f' 9 DISPOSAL WORKS CONSTRUCTION PERMIT 4 HUS /J /j Applicant 0� /f�� � / �fG7"•/ ��� NAME,/ ADDRESS TELEPHONE Site Location : Permission is hereby granted to Construct ( ) or Repair r an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S. : C IRMAN,BOARD OF HEALTH Fee D D.W.C-. Nor.-, /�j0 Town of North Andover, Massachusetts Form No.3 f NORTH BOARD OF HEALTH appZ. F A 0<etw�<ww-_�q�•' "•,..C��",I DISPOSAL WORKS CONSTRUCTION PERMIT CHU Applicant NAMES,/ ADDRESS TELEPHONE Site Location i• , � is Permission is hereby granted to Construct ( ) or Repair t an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S. r; �• FwAIRMAN,BOARD OF HEALTH 3 Fee , D W.C. No., I. Commonwealth of Massachusetts 4� ® City%Town of System Pumping Record JUN 1 2 2007 Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. �ie-System-PUMP—Iffg—Record must be submitted to the local Board of'Health or other approving authority. . A. Facility Information .Important: When filling out 1. System Location: forms the compute r,use only the tab key Address to move your cursor-do not /Town use thereturn Cit y f State Zip Code .key. 2. System Owner: Name Address(if different from location) CityfTown State Zip Cade' Telephone Number B. Pumping Record 1. Date.of Pumping Date 2. Quantity`Pumped: canons 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: Conditio of System: U' 1: 6. Syste Pu pe By: :—� Name Vehicle License Number Company - 7. Location ere conte wer sposed: 7 Sign re H er Date http://www.mass.gov/dep/water pprovals/t5forms.htm#inspect t5form4.doc•003 System Pumping Record•Page 1 of f Commonwealth of Massachusetts = City/Town of a System Pumping Record RECElVD - Form 4 MAR 19 2010 �M DEP has provided this form for use by local Boards of Health. Other forms ma be u �ttt �iv�R information must be substantially the same as that provided here. Before �, rft-AU th our local Board of Health to determine the form they use. The System Pumpin ed to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left side of house, Right side of hous Left frons of hous ht front of house, Left rear of house, Right rear of house. Left rear of building. zef�fig. Address. 1 r ��. O� City/Town l� `v\ State Zip Code 2. System Owner: Name Address(if different from location) Ci /Town State i Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank I ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No 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 7. Loca ' contents were disposed: .LAS.D Lowell Waste Water g to'eof Haul r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 but the DEP has provided this form far" camel as that Prov ded hrds of ere Beta a us g tlher-forms may hets form,chuck with your information must be substantially 'Pumping Recard must be-submitted'tt� local ljoa' of Health to determine the form they use..The.Systerr►'Pump. g 4 to Me in the korai Baartl of Fitaltfs.or.other ipprovin -authority within 14 days from the p.mp 9' accordance with 310 CMR 15.351 A. Facility -information Important: 1 System Location_ When filling out - rorms on the computer,use address oe ab keY io move your _ /, State Zip Cade cursor•do not C1lyrTown use the return key, 2. System Owner, WM ��.`jl�Iw1I Name �" Address(it dliferent Karri to'caiipn7 .. - � — -- - - , state: Z�p.Cotie Cily/Town Teli;ptSiSrtie NurTiner — $. Pumping Record .2. Quantity Pumped, sa�t Dale 1. Date of Pumping Da e tic Tank `(„] Tight Tank � Grease Trap Cesspgol{s) ,P 3• Type of System: ❑ � Q 'Other(describe): _ Yes No Ikyes,, was cteaned? C1 Yes C3` No 4, Effluent.-fee Fiiter.present. E L� 5. Condition of System: 6, System.PumPetl.By Vehicle License NurT}t Name , company 7. Location where contents were disposed: ' Qate Sigriafure of aider $Inalu gre,of R Ceiving Facility -" Date System pumping Record•Page 15form4.d0c•09!06