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HomeMy WebLinkAboutMiscellaneous - 43 WINTERGREEN DRIVE 4/30/2018 (2)Cl`�U I `74v� r7gl (,-v�elk v�t,���� Ron ���4 -e C( T V, � t, bC4 i --�r° Com' ccn����-T-v�,���`` Owner information is required for every page. Important: When filling out fors on the computer, use only the tab key to move your cursor - do not use the return key. VQ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments 43 Wintergreen Drive north Andover Ma. 01845 Property Address Nancy & Anil Kumar Owner's Name 48 Plymouth Ma. 02360 City/Town State Zip Code 6/29/17 CANNA 1 Date of Inspection 641,c 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. RECEIVE® A. General Information JUL 2 4 2017 1. Inspector: Ron Jenkins Name of Inspector R. Jenkins & Sons Company Name 58 Pleasant Street Company Address Rowley City/Town 978-314-0503 Telephone Number B. Certification Ma. State S14268 License Number TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 01969 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 2 11 I49i,h Ins ectol's Signature Date The system inspect shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc . rev. 6116 Tttle 5 Official Inspection Form: Subsurface Sewage Disposal System . Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Wintergreen Drive north Andover Ma. 01845 Property Address Nancy & Anil Kumar 48 Kensington Owners Name Plymouth Ma. 02360 City, town State Zip Code B. Certification (cont.) 6/29/17 Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined." please explain_ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 43 Wintergreen Drive north Andover Ma 01845 Property Address Nancy & Anil Kumar 48 Kensington Owner Owner's Name information is required for every Plymouth Ma. 02360 6/29/17 page. Cltyrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc . rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Wintergreen Drive north Andover Ma. 01845 Property Address Nancy & Anil Kumar 48 Kensington Owner's Name Plymouth Ma. 02360 CitylTown State Zip Code B. Certification (cont.) 6/2.9/17 Date of Inspection 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 or 17 Commonwealth of Massachusetts Title 5 official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Wintergreen Drive north Andover Ma. 01845 Property Address Nancy & Anil Kumar 48 Kensington Owner information is Owner's Name required for every Plymouth Ma. 02360 6/29/17 page. City/Town 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.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments „ 43 Wintergreen Drive north Andover Ma. 01845 Property Address Nancy & Anil Kumar 48 Kensington Owner Owner's Name information is Plymouth required for every y Ma. 02360 6/29/17 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes” or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):..600 g.p.d. t5ins.doc - rev. 6/16 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �,M ,••~''� 43 Wintergreen Drive north Andover Ma 01845 Property Address Nancy & Anil Kumar 48 Kensington Owner Owner's Name information is required for every Plymouth Ma. 02360 6/29/17 page. City/Town State Zip Code Date of Inspection D. System Information Description: 4 bedrooms x 150 gallons per day = 600 total gallons per da Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) El Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 95,744 total Detail: 95,744 total gallons / 730 = 131.15 galfons�er day Sump pump? ® Yes ® No Last date of occupancy: April Date 2017 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? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins.doc - rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Wintergreen Drive north Andover Ma 01845 Property Address Nancy & Anil Kumar 48 Kensington Owner Owner's Name information is required for every Plymouth Ma. 02360 6/29/17 page. C4mown 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: last pumped 9/14112 info. from home 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): t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 43 Wintergreen Drive north Andover Ma. 01845 Property Address Nancy & Anil Kumar 48 Kensington Owner Owner's Name information is required for every Plymouth Ma. 02360 6/29/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Septic Tank and Leach system 30 years old installed in 1987, Distribution Box is 2 years old, info. from home owner Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 14"feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: n/a feet Comments (on condition of joints, venting, evidence of leakage, etc.): condition of joints good, proper venting, no evidence of leakage Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal If tank is metal, list age: 6" feet ❑ fiberglass ❑ polyethylene ❑ other (explain) years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x5'x5'dp. Sludge depth: t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'r 43 Wintergreen Drive north Andover Ma 01845 Property Address Nancy & Anil Kumar 48 Kensington Owner information is Owner's Name required for every Plymouth Ma. 02360 6/29/17 page. City/Town State Zip Code Date of inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? measuring stick & ruler 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 is missing,outlet tee good, structural integrity good, liquid was level to bottom of outlet invert, no evidence of leakage. Tank does not need pumping at this time.Tank is a heavy duty H2O tank 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: t5ins.doc • rev. 6/16 Date 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 43 Wintergreen Drive north Andover Ma 01845 Property Address Nancy & Anil Kumar 48 Kensington Owner Owner's Name information is required for every Plymouth Ma. 02360 6/29/17 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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.doc . rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Wintergreen Drive north Andover Ma. 01845 Property Address Nancy & Anil Kumar 48 Kensington Owner's Name Plymouth Ma. 02360 Cityfrown State Zip Code D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert a 6/29/17 Date of Inspection 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.): Box was level and distribution was equal, no evidence of solids carryover, no evidence of leakage into or out of box Heavy duty H2O type box 19" below grade, size of box is 17'x17"x15"dp Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc • rev. 6/16 TdIe 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 43 Wintergreen Drive north Andover Ma 01845 Property Address Nancy & Anil Kumar 48 Kensington Owner Owner's Name information is required for every Plymouth Ma. 02360 6/29/17 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number. ❑ leaching chambers number. ❑ leaching galleries number: leaching trenches number, length: 3 @ 72 ❑ 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.): dry loamy/gravel soil, no signs of hydraulic failure, no ponding, leach trenches are located in left front yard under mowed grass Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Wintergreen Drive north Andover Ma. 01845 Property Address Nancy & Anil Kumar 48 Kensington Owner's Name Plymouth Ma. 02360 City/Town State Zip Code D. System Information (cont.) 6/29/17 Date of Inspection Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc . rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M >•''� 43 Wintergreen Drive north Andover Ma 01845 Property Address -- Nancy & Anil Kumar 48 Kensington Owner Owner's Name information is required for every Plymouth Ma. 02360 6/29/17 page. Cltylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below u arawing pttacnea separately S 434; us fs T-,,) 14 omw Z i 9 13 14 m �, R6'0 -Afe ? -Z.E 4 C 14 CIS t5ins.doc - rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Wintergreen Drive north Andover Ma. 01845 Property Address Nancy & Anil Kumar 48 Kensington Owner's Name Plymouth Ma. 02360 6/29/17 City/rown 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' between bottom of S.A.S and Groundwater 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: 7/11/86 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: info. from last title 5 reoort ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Date of soil test 3/25/85 & 5/15/84 Test performed by Dan O'Connell & Steve Durso witnessed by Mike Graf & Mike Rosati Groundwater Elevations = 128.00 -138.00 Elevation of bottom of leach trenches = 132.00 Info. was from last Title 5 report dated 5/27/15 Report states Info taken from System Design Plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc . rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System . Page 16 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Wintergreen Drive north Andover Ma 01845 Property Address Nancy & Anil Kumar 48 Kensington Owner's Name Plymouth Ma. 02360 City/Town State Zip Code t. Keport Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked 6/29/17 Date of Inspection ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc - rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 • . , Summary Record Card generated on 612912017 12;32:07 PM by Karen Hanlon Town of North Andover Tax Map # 210-1043-0203-0000.0 Parcel Id 16527 43 WINTERGREEN DRIVE KUMAR, ANIL & NANCY 43 WINTERGREEN DRIVE NORTH ANDOVER, MA 01845 Page 1 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.28 Acres FY 2017 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until KUMAR, ANIL & NANCY Owner 43 WINTERGREEN DRIVE NORTH ANDOVER, MA 01845 HIDETOSHI & MIDORI ONO Previous Customer Inactive 10/26/2016 43 WINTERGREEN DRIVE NORTH ANDOVER MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 18042.0 - 43 WINTERGREEN DRIVE Last Billing Date 4/6/2017 3180071 03 Cycle 03 Active UB Services Maint. Account No. 3180071 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE /1 UB Meter Maintenance Account No. 3180071 Serial No Status Location Brand Type Size YTD Cons 32945227 a Active 00 b Badger w Water 0.63 0.63 665 Date Reading Code Consumption Posted Date Variance 6/13/2017 828 a Actual 0 -100%e 3/10/2017 828 a Actual 0 4/12/2017 -100% 12/12/2016 828 aActual 1 1/23/2017 -100% 9/12/2016 827 a Actual 0 10/24/2016 -100% 7/11/2016 827 f Final Bill 36 7/25/2016 72% 3/14/2016 791 a Actual 16 4/22/2016 -21% 12/14/2015 775 aActual 21 1/20/2016 -44% 9/11/2015 754 a Actual 37 10/16/2015 101% 6/11/2015 717 aActual 17 7/24/2015 16% 3/18/2015 700 a Actual 16 4/28/2015 -9% 12/15/2014 684 a Actual 17 1/15/2015 -43% 9/16/2014 667 a Actual 32 10/15/2014 88% 6/12/2014 635 a Actual 16 7/16/2014 -8% 3/14/2014 619 aActual 17 4/11/2014 13% 12/16/2013 602 a Actual 16 1/17/2014 -9% 9/13/2013 586 aActual 17 10/15/2013 0% 6/14/2013 569 a Actual 16 7/24/2013 0% 3/20/2013 553 a Actual 18 4/22/2013 13% 12/13/2012 535 aActual 14 1/9/2013 -30% 9/19/2012 521 a Actual 22 10/15/2012 -15% 6/18/2012 499 a Actual 25 7/16/2012 6% 3/20/2012 474 a Actual 24 4/14/2012 11% 12/19/2011 450 a Actual 22 1/17/2012 -23% 9/16/2011 428 a Actual 29 10/13/2011 72% 6/13/2011 399 a Actual 16 7/20/2011 14% t UAV � ��� � c�.onS 61- )00 { _ .. Ot aQRTI1y 7958 ❑ Animal • Town of North Andover `+�'•°,,,,°:;. ,SSACHUSE� HEALTH DEPARTMENT ' CHECK #: DATE: 7 ` ?Y .24 %7 LOCATION: i i� %?o hl H/ O NAME: 1 CrU MO- % CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ Title 5 Report �o,,'55 $ J"o ❑ Other: (Indicate) $ He Ii Agent Initials White - Applicant Yellow - Health Pink - Treasurer 6/19/2017 Town of North Andover Mail - Re: 43 Wintergreen Drive NOR 'AN; Massachuss _ _ . Michele Grant <mgrant@northandoverma.gov> Re: 43 Wintergreen Drive 1 message Michele Grant <mgrant@northandoverma.gov> Mon, Jun 19, 2017 at 11:22 AM To: "Ken Mazonson Esq." <kenmazonsonesq@aol.com> Cc: christine@mercuriolaw.com, doug@mercuriolaw.com Hi Ken, The Health Department will certify that on September 1, 2015 an inspection was done on the Distribution Box at 43 Wintergreen Drive, North Andover, MA. and met the criteria of the inspection. You will have to reach out to Jonathon Granz, the Title 5 inspector for verification as to why he has not re -inspected. Sincerely, Michele E. Grant Public Health Agent Town of North Andover 120 Main Street North Andover, MA 01845 Phone 978.688.9540 Fax 978.688.9542 Email mgrant@northandoverma.gov Web www.NorthAndoverma.gov On Mon, Jun 19, 2017 at 11:06 AM, Ken Mazonson Esq. <kenmazonsonesq@aol.com> wrote: Michele: It was a pleasure to talk to you this morning. I am following up from our conversation with a request for you to reply with an email that your certification of September 1, 20015 was strictly for the satisfactory inspection of the distribution box and not for the whole system. In fact, you indicated that the current owners were supposed to have this remedial work done within 30 days of the inspection of the entire system by Jonathan Granz on June 15, 2015 but failed to do so. Furthermore, you have indicated that the seller must have the whole system re -inspected either by Mr. Granz or another inspector to be in compliance with Title V requirements. I will share this information with the seller's attorney and ask that you "reply all" to corroborate my statements. Ken Mazonson 640 Main Street Malden, MA 02148 Tel. (781)-324-4420 Fax (781)-322-1851 kenmazonsonesq@aol.com https:Hm ai l.google.com/mai I/calul0/?ui=2&ik=d4458df3dg&view=pt&search=sent&th= l5ccOf2536dea57f&si m l=15ccOf2536dea57f 1/1 I-Vl '� __ y3 �ii� ��.e.� 1 �Ca� n-e�a.�,� �m�cl ��2cL C'o� ���� �� ��� PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As o£ 9/1/15 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Repair of D -box By: Peter Breen At: 43 Wintergreen Drive Map 104.B Lot 0203 North Andover, MA 01845 of es certifia e\shall�et beonstrued as a guarantee that the system will function satisfactorily. Michele Grant Public Health Agent 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. VQ mnen Commonwealth of Massachusetts I v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Winterareen Drive Property Address Anil & Nancy Kumar Owner's Name North Andover City/Town MA 01845 State Zip Code L, .11 `f % ppf j` 5/27/15 V 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. RECEIVED A. General Information JUN 15 2015 1. Inspector: TOWN! OF NORTH ANDOVER Jonathan Granz HEALTH DEPARTMENT Name of Inspector Preventative Septic and Drain L.L.C. Company Name 327 Asbury Street Company Address South Hamilton MA 01982 City/Town 978-468-9001 Telephone Number B. Certification State Zip Code S113405 License Number I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: 0�- jo K. ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6/9/15 Date Th&4stem 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 j Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Winterareen Drive Property Address Anil & Nancy Kumar Owner's Name North Andover MA 01845 5/27/15 City/Town B. Certification (cont.) State Zip Code Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ® N ❑ ND (Explain below): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Winterareen Drive Property Address Anil & Nancy Kumar Owner's Name North Andover MA 01845 5/27/15 City/Town B. Certification (cont.) State Zip Code Date of Inspection ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ® Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): Distribution box is in very poor condition, corroded, cracked, structually un -sound and needs to be The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 43 Wintergreen Drive Property Address Anil & Nancy Kumar Owner Owner's Name nformation is required for North Andover MA 01845 5/27/15 for every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 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 ❑ i Liquid depth in cesspool is less than 6" below invert or available volume is less than'/2 day flow t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Wintergreen Drive Property Address Anil & Nancy Kumar Owner Owner's Name nformation is North Andover MA 01845 5/27/15 required for every page. City/Town 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 fee from a private water supply well with no acceptable water quality analysis. [Th 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 analys and chain of custody must be attached to this form.] El® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. 11® 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 i t is is 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 •� Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Wintergreen Drive Owner information is required for every page. Property Address Anil & Nancy Kumar Owner's Name North Andover MA 01845 5/27/15 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): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 600 per plan t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Owner information is required. for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Wintergreen Drive Property Address Anil & Nancy Kumar Owner's Name North Andover City/Town MA 01845 State Zip Code 5/27/15 Date of Inspection D. System Information Description: System is composed of 1500 Gallon septic tank, distribution box and three 72' leaching trenches. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 151.03 GPD 9 ( Y 9 (gP ))� Detail: Water meter readings were provided by the North Andover water department, usage was averaged from 3/20/13-3/18/15, 728 days (see attached copy). Sump pump? Last date of occupancy: CommerciaIII ndustrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes ® No Current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °H 43 Wintergreen Drive Property Address Anil & Nancy Kumar Owner Owner's Name information is required for North Andover MA 01845 5/27/15 every page. City/Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: State Zip Code General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Date Date of Inspection Last pumped 9/14/12, per BOH records. gallons 111111111=111�/EM Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Owner information is required for every page. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Wintergreen Drive Property Address Anil & Nancy Kumar Owner's Name North Andover City/Town D. System Information (cont.) State Zip Code 5/27/15 Date of Inspection Approximate age of all components, date installed (if known) and source of information: The as -built is dated 7/30/87, per BOH records. Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan) Depth below grade: 14"feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: n/a feet Comments (on condition of joints, venting, evidence of leakage, etc.): Building sewer is in good condition with no signs of leakage, backup or any other problems. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 21 feet ❑ 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: 101 x 5'W x 4'D effective Sludge depth: 5" t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 43 Wintergreen Drive Owner information is required for every page. l5ins • 3113 Property Address Anil & Nancy Kumar Owner's Name North Andover City/Town D. System Information (cont.) State Zip Code Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 31" 6" 14" 5/27/15 Date of Inspection How were dimensions determined? SludgeJudge/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.): Tank is in good conditon, structually sound, no signs of leakage or infiltration, liquid at outlet invert. Inlet has a concrete baffle in good condition, outlet has a PVC T in good condition. "this tank does not require pumpinq at this time** Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness ❑ fiberglass 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: feet ❑ polyethylene ❑ other (explain): Date 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 43 Wintergreen Drive Property Address Anil & Nancy Kumar Owner Owner's Name information is required for North Andover MA 01845 5/27/15 every page. CitylTown 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 Dimensions: Capacity: Design Flow: Alarm present: Alarm level: ❑ fiberglass ❑ polyethylene ❑ other (explain): gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 =_= Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Winterareen Drive Property Address Anil & Nancy Kumar Owner's Name North Andover MA 01845 5/27/15 City/Town D. System Information (cont.) State Zip Code Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0"— Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The distribution box is in poor condition, cracked, corroded and is in need of replacement. Liquid level is at the outlet inverts, no solids carryover. D -box is 23" below grade, outlet inverts are 32" below arade. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Wintergreen Drive Property Address Anil & Nancy Kumar Owner Owner's Name information is required for North Andover MA 01845 5/27/15 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system 3a72- Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil over system is dry,grassy and consistant with surounding yard with no signs of ponding, breakout or abnormal vegetation. 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 t5ins - 3/13 ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts H Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Wintergreen Drive Owner information is required for every page. Property Address Anil & Nancy Kumar Owner's Name North Andover MA 01845 5/27/15 City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Wintergreen Drive Property Address Anil & Nancy Kumar Owner's Name North Andover MA 01845 5/27/15 CitylTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately NA"X�-2 /07- t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Wintergreen Drive Property Address Anil & Nancy Kumar Owner's Name North Andover City/Town D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: RAA niRar% 0LdW' uN wue 5/27/15 Date of Inspection 4' Below SAS 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: 7/11/86 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Plan on file for the desian of this system. ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Soil testing was performed for the design of this system on 3/25/85 & 5/15/84 by Dan O'Connell & Steve Durso, witnessed by Mike Graf & Mike Rosati, groundwater was found at elevations ranging from 128.00-138.00, the bottom of leaching trenches are at 132.00 (per plan). This system was installed in an elevated (above natural grade) area with a 4' seperation from groundwater, it is not interfacina with aroundwater. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Wintergreen Drive Property Address Anil & Nancy Kumar Owner's Name North Andover MA 01845 5/27/15 City/Town State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems) completed E System Information — Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Sj"rAry Rocwd card ganatalad Q» OW2016 3.21 41 PM by Mwirean WA06y Page I Town of North Andover Tax Map # 210-104-8-0203-0000.0 Parcel Id 16527 43 WINTERGREEN DRIVE KUMAR, ANIL 43 WINTERGREEN DRIVE N. ANDOVER, NIA 01845 .............. . Class 101 Single Family .... . . . ... . ... .. Property Type 1 Residential Zoning2 I Residential ZonIng3 I Residential Size Total 1,28 Acres FY 2015 ......... . ...... . ............ ............... .. UB Mailing Index Name/Address Type Loan Number Activelinact. From Until KUMAR, ANIL Payor 43 WINTERGREEN DRIVE N. ANDOVER, MA 01845 US Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 18042.0 - 43 WINTERGREEN DRIVE Last Billing Date 4116MI5 3180071 03 Cycle 03 Active UB Services Maint. Account No, 3180071 Service Code Rate Charge Multi plierlUsers MISCFEE ADMIN FEE 0.63518 7,82 it WTR WATER 01 ALL METER SIZE 60.80 11 UB Meter Maintenance Account No, 3180071 Serial No status Location Brand Type Size YTD Cons 32945227 a Active 00 b Badger w Water 0,630,63 637 Date Reading Code Consumption Posted Date Variance 311812015 700 a Actual 16 4/28/2015 -9% 12/15/2014 684 a Actual 17 1115/2015 43% 9/1612014 667 a Actual 32 10/1512014 88% 6112J2014 635 a Actual 16 7/16/2014 -8% 3/14/2014 619 a Actual 17 4/11/2014 13% 12/1612013 602 a Actual 16 1/17/2014 -9% 911312013 586 a Actual 17 1011512013 0% 611412013 569 a Actual 16 7/24/2013 0% 3/2012013,— ,553 a Actual 18 4/2212013 13% 12/13/2012 535 a Actual 14 1/912013 -30% 911912012 521 a Actual 22 1011512012 -16% 6118/2012 499 a Actual 25 7/16/2012 6% 3/2012012 474 a Actual 24 4/1412012 11% 12/19/2011 450 a Actual 22 1/17/2012 -23% 9/1612011 428 a Actual 29 1011312011 72% 611312011 399 a Actual 16 7/2012011 14% 311512011 383 a Actual 14 4/13/2011 27% 12/15/2010 369 aActual 11 1/12/2011 -79% 9/1612010 358 a Actual 55 10115/2010 157% 6/14/2010 303 a Actual 20 7/15/2010 26% 3118/2010 283 a Actual 17 411412010 7% 12/14/2009 266 a Actual 15 1/12/2010 -17% 9/16t2009 251 aActual 20 10/15/2009 16% 6/1012009 231 a Actual 15 7/20/2009 25% 311712009 216 a Actual 13 412912009 41% 12/1512008 203 a Actual 9 1/20/2009 .30% 9/1612008 194 a Actual 14 10110/2008 -26% 611012008 180 a Actual 17 7116/2008 21% 3114/2008 163 a Actual 14 4/1112008 -17% L�77k ✓ ':sem`% - s w w 3 � � i' " I .1 tk I 7-r. ■ 41, lk ko of 1 1 NMI { r14L a f Y _ rsf i 5 ite V. q19 W1 •2&Application for Septic Disposal System Construction Permit -TOWN OF TOD — Full Repair NORTH ANDOVER, MA 01845 $125.00 Component Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system* ❑ Repair or replace an existing on-site sewage disposal system* EjXepair or replace an existing system component— What? A. Facility Information RECEIVED City/Town QWN OF NORTH ANDOVER 2.- *TYPE OF SEPTIC SYSTEM*: 4 HEALTH DEPARTMENT ➢ ❑ Pump C9 -Gravity (choose one) ***If pump system, attach copy of electrical permit to application*** ➢ aConventional System (pipe and stone system) ➢ ❑ Infiltrator or Biodiff user (Gravel -Less) (Attach a copy of your certification to install this type of system.) ➢ ❑ Pressure Distribution S.A.S. (No D -Box) ➢ ❑ Pressure Dosed (D -Box Present) S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES = (no further info. needed) NO = (installer must specify brand of filter before DWC issuance) What is the Make? 2. Owner Information Name Address (if different from above) City/Town Email address 3. Installer Information What is the Model? State Zip Cod Telephone Number r6TCr-- ame Name of Company 7 ?d &i,&) a� < i Address x A City/Town StateZip Code Telephone N um berw(Cell Phone # if possible pl ase) 4. Designer Information Name Address City/Town Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 • Application for Septic Disposal System . Construction Permit -TOWN OF NORTH ANDOVER, MA 01845 PAGE 2OF2 A. Facility Information continued.... 5. Type of Building:'&Residential Dwelling or ❑Commercial B. Agreement TODAY'S DATE $ 250.00 — Full Repair $125.00 - Component 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. 1 understand that until a final Certificate of Compliance has been issued by this Board of Health, the installed system is not approved.' Cf, T_:CC 9 ?//57 Name Date Representative) Date Application Disapproved foitiie following reasons: For Office Use Only: 1. Fee Attached? Yes=_/ No 2. Project Manager Ohligation Form Attached? Yes No 3. Pump System? If so, Attach copy of Electrical Permit Yes No Applicant received copy of "Electrical Inspection Notes for Septic Systems" Yes No Handout? 4. Reviewed approvalletter, all paperwork received? Yes No 5. Foundation As -Built? (new construction only): Yes No (Same scale as approved plan) 6. Floor Plans? (new construction only): Yes No Application for Disposal System Construction Permit • Page 2 of 2 Commonwealth of Massachusetts Map -Block -Lot 104.60203 BOARD OF HEALTH -------- No Permit N ------------ North Andover - BHP -2015-0365 ---------------------- P.I. FEE F.I. $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Peter B-reen - ---------------------------------------------------------------------------------------------- to (Repair) an Individual Sewage Disposal System. at No 43 WINTERGREEN DRIVE -------- b --60k ------------------------------------------------------------------------------ as shown on the application for Disposal Works Construction Permit No. BHP -2015-036 D- st -28-, 2015- ----- -------- IS--��--- Issued On: Aug -28-2015 BOARD OF HEALTH North Andover Health Department (ommunity and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 43 Wintergreen Dr. MAP: 104.13 LOT: 0203 INSTALLER: Peter Breen g1Now-lif DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: ` �e� , DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: SEPTIC TANK ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION -BOX / []' Installed on stable stone base H-20 D -Box ❑ Inlet tee (if pumped or >0.08'/foot) [✓� Hydraulic cement around inlet & outlets [ Observed even distribution [v Speed levelers provided (not required) Ev Schedule 40 PVC Pipe Comments: (�j . (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION -BOX / []' Installed on stable stone base H-20 D -Box ❑ Inlet tee (if pumped or >0.08'/foot) [✓� Hydraulic cement around inlet & outlets [ Observed even distribution [v Speed levelers provided (not required) Ev Schedule 40 PVC Pipe Comments: (�j . � 11 A SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: Y31 �--4TY-s C �r l (Address of septic system) Relative to the application of (Installer's name) Dated o ay s ate For plans by And dated With revisions dated I understand the following obligations for management of this project: (Engineer) (Original ate (Last revised date) 1. As the installer, I am obligated to obtain all permits and Board of Health approved plansrp for 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 reauesting 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 (V5 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 of Health 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 Mans. No instructions by the homeowner. general contractor. or anv other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: (Today's Date)— V� �f X jy,)IUA�, 1 (Name —Print) (Name —Signed) Commonwealth of Massachusetts Q low City/Town of System Pumping Record Form 4 u,p t5form4.doc• 06/03 RECEIVED TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 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, Left / Right rear of house/ right lde bf hous Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address �—+3 j ,,i \_ Citylrown 2. System Owner. Name Address (if different from location) Cityrrown �Ytu,�P-, • State Zip Code stater—0 ij Code Telephone Number B. Pumping Record 9, -cam-('� 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 1 P o f If yes, was it cleaned? ❑ Yes ❑ No 5. Conditiop of bsteJ�� _ SSSS tcA� 1 4 C� 6. System Pumped By: Neil Bateson F5821 7 Name Bateson Enterprises Inc Company Vehicle License Number 2-1�-f`t.4 Date System Pumping Record • Page 1 of 1 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 OCT 2 3 2008 I TOY.'N C, f., a r ,no,1cR 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 front, left rear, left side of house. Right front, right rear rlht side of house. Address / t 3 j Q '�, . , , y� �� A i' City/Town ✓`J l/��� L/�/� tate jam/ Zip Code 2. System Owner: Name Address (if different from location) Citylrown State Telephone Number B. Pumping Record t62 "�) 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: El Cesspool(s) = eptic Tank 0 Tight Tank p Other (describe): 4. Effluent Tee Filter present? [I Yes 0-I4o If yes, was it cleaned? 0 Yes Ej No 5. Condition of System: ,n (��>� V\- 6. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: Lowell Waste Water d . - l -moo'--oma of H u r Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Systein Owner �(`onuno wealt of Massachusetts r ti assachusetts System Pumping Record System Location uvul C24— Ll j Wt, d—aTr, Date of Pumping: �'� Quahtity Pumped: A gallons Cesspool: No (.Yes U Septic Tank: No U System Pumped by: vat`edea 1-&,T mw License # Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: Yes f�i TOWN C) SYSTEM UA SYSTEM OWN ER, & ADDRESS DATE OF PUMPING——: (TM ANDOVER NNO RECORD SYSTEM LOCATION 4-eCi skri RECEIVED OCT 0 5 2004 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 511 ---- PUMPED:- ....... C0SPOOL NO-..." YES SOPUC Talik: NO- YES NArukiioi, SERVICE: ROU -rINE­-,—­-EMER(jhN(')' 013SERVA TIONS: GOOD CONDITION FULLTU COVER HEAVY ORSASE WE BAFFLES IN PLACE ROOTS LEACHRELD RUN BACK EXCESSIVE SOLIDS --FLOODED SOLID CAkRYOVERl'-­­­ OTHER EXPLAIN System pwnpcd by 5�017 q/ 177a. WMMENTS. C0NIhNI'S f'KANSFhRREDI-(j I I(l�p OF HF�1LT 1-i l.oT ?� WwfE�C �R NoI�TH Ati DdUEI-� , M.4, � QP�i CAti I _ G�ijsso (•v,QT6R SO! PLY -FL."TbWnl ❑ oJEu.- APPROQeor 55 - 1 StPT'I C Sl► s —IEti1 D��Sj <-� /JPi-I�OvlN6 /JUT'FIOI?1Ty Co,J91TVJ5 = �I5APPpovep RQ* SoNS D 5 7L '5 PT'I C S% STEM W SiiO U ATIOAJ 4'XCjV4T(o1A1 )N<PC6 ► totil V4rC 6 ZL►-V -P 1315 ❑ FAIL. FwA� luSp�Tlon� APPROOED U4TCK-6 -�% APIJIQDV1/VG AVTHL-Rtry 9-*/ d�1�IT�0IJAL (�5�.i IONS �1F- A►-�y) A DISAPP)�OvED J�CASo NS FItiAL APPPpvAL 0o�E -�%�% APPRNW6 /6v;NoRl �\ 6 1,07 .SLOPE /?6011) (-/50) X = /50 = .. DE3/61Y EXIST/N� ELE�Qriory Fl- EVQT, IN I/ PIPE OUT 01c1/OUSE /31/, �b /NV P/PE /NTO T4NK / 3�/, 60 /NV PIPE OUT OF TQNA' /3Y, y3 /3626 /NV /o/PE /NTO D. BOX /,3.3,53 /33 , ?-& /NV P/PE OUT OF D. BOX /33,x( X33,/8 /NV END OF PIPE/33,00 2133 ,00 r3Z, 3 /33,00 13Z, icf W,,4TE'R EL Ek1,4 T/ON ,4 VER�4E STONE DEPTH 47 1P)E03E NOTE: TI//S PLAN /S NOT ,4 R 41PR.4NTY OF TX/E SYSTEM BUT 4 YE2/F/CQ7-10N Of T#E LOCQT/ON OF TW1E EX1.ST/NC ST�UCTU2ES. SUB - SU,eF4CE D SYSTEM /N NOR77-t AA113UVE-r.) s`Y'XS, > FOR C11,e/ST/QNSEN EN- 61M MINCA, /NC. //4 ACENOZ.4 .4 VE., 11,,4YEPl//L L, M,4.