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Miscellaneous - 439 BOXFORD STREET 4/30/2018
439 BOXFORD STREET e t 210/105.C-0054-0000.0 \ i i i i Lf. v� MAP # LOT # ----_. PARCEL # STREET -�j_Y.._. .____...... CONSTRUCTLON APPROVAL HAS PLAN REVIEW FEE BEEN PAID? YES NO PLAN APPROVAL: DATE �f//j7l!?-S APP. BY._ _ �_ DESIGNER: rll�P,Gf�/lJ/1/1S/�� J`4'05��/ PLAN DATE. CONDITIONS WATER SUPPLY: TOWN WEL WELL PERMIT ��� DRILLER._...5 /C ,C..N_��._S__._._.._........................ WELL TESTS: CHEMICAL DA I E APS'RUVED..71-ah-�__ BACTERIA I DA I E f11=NRUVED 7/.9/9 BACTERIA II DATE APP ROVED COMMENTS: FORM U APPROVAL: APPROVAL TO ISSUE- DATE ISSUED CONDITIONS: FINAL APPROVAL: . ALL PERMITS PAID NO WELL CONSTRUCTION APPROVAL �, NO SEPTIC SYSTEM CONSTRUCTION APPROVAL YE5 NO OTHER YES NU ANY VARIANCE NEEDED YES _NU FINAL BOARD OF HEALTH APPROVAL: DATE: /Z3� ...BY: _ a IS THE INSTALLER LICENSED? -, YES NO ` TYPE OF CONSTRUCTION: "� NE REPAIR £" NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YES NO , CONDITIONSOF. A - PPROVAL YES NO (FROM FORM U) !: —ISSUANCE OF PERMIT ` YES NO =IDWC 'PERMIT N0. INSTALLER: /1� BEGIN INSPECTIONO - EXCAVATION ,INSPECTION: ; NEEDED: fY = i t•.. • ' It .. .. ,. _sK _ • ♦ t \ SASSED DY .:CONSTRUCTION INSPECTION: NEEDED: •= AS BUILT PLAN SATISFACTORY:' .. . .': . APPROVAL. TO BACKFILL: DAT •� �'l Z HY FINAL . GRADING APPROVAL: DATE �� /� BY FINAL CONSTRUCTION APPROVAL: DATE: BY of AORT �� t 0 L9 4. Town of North Andover �.'•,,,,,..�, HEALTH DEPARTMENT CHECK#: "15�07w" DATE: LOCATION: `�� H/O NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type. $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ 0,STitl 5e Report ❑ Other. (Indicate) $ 2509 Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer . Department of Environmental Management/D(vision of Water Resour es WELL COMPLETION RE WELL LO ATION Ed PH ION Addr V i lb N S E W of �� (reef (circlet City/Tow n—(�L �'t'�F Tf1�—�r�/12 � V g�� 1 Well owner r f c�'�" a eX F,,n e— (road) C Address A-)oe ll 114d6i6e v N S E W of (m!. a tenths! cle) Board of Health permit obtained: yes W no❑ iii(ersect. w/ acrr-r WELL USE WELL DATA Domestic0public❑ Industrial ❑ Total well depth ft. Monitoring ElOthDeer I to beds ,eft. Method drilled Water-bearing tock unconsolidated material: ����-- Date drilled Description CASING Water-bearing zones: ^� Type Pf ` 1) From --Sy(O To J6© Length 1�fl-ft. Dia(.I.D.} (0 in. 2) From To Length into bedrock (t. 3) From To Gravel pack well: dia. Protective well seal: Screen: dia. Grout-E3 Other KIVP51 ate_ Slot v length from_to STATIC WATER LEVEL(all wells) Static water level below land surface 10 ft. Date— WELL ate WELL TEST(production wells) Drawdown ft. after pumping hr.-ZU>—min.atf_gpm How measured—Recovery ft. after—hr.—min. 0 LOG of FORMATIONS COMMENTS Materials From To e Driller lV O rim Firm r /J Address q City/TownT-4Z r 1/ Supervising Driller Reg.#- k4 or nature is ng regist dwell dr!ller Please print firmly BOA OF HEALTH Y Town of North Andover, Massachusetts Form No. 1 p%ORTH -1BOARD OF HEALTH 16 0 3�o z�Eo ib 'VOt ', o ba L VA APPLICATION FOR SITE TESTING/INSPECTION ��SSACHUs���h Applicant "bwj�Q_ ►n NAME ADDRESS TELEPHONE TELEPHONE fW� Site Location ` �bX TyYC4 Sl Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time_ &;q Az 9,r06 411 -CHAIRMAN,BOARD OF HEALTH Fee___ o Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH OF�t"o 'b q�0 6 0� 19 0 4� V U A `� 4 .......E , ^' " APPLICATION FOR SITE TESTING/INSPECTION �9SSACHUSE��h Applicant NAME ADDRESS TELEPHONE Site Location Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts Form No.2 f MORT" BOARD OF HEALTH 1 F w P DESIGN APPROVAL FOR AT ;ass^CN°5``� SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant ` 1-� �(J�S— Test No. Site Location Reference Plans and Specs. ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. CHAIRMAN,BOARD OF HEALTH Fee Site System Permit No. L(3 9 $O XFOEb S%. I�0• /�JJ UC F- �M4. L-n-r 1 lwl(l z Z.( :•F � 13 / u '14' WELL ) y, �S ELEVATIONS TAKEN AT TOP OF PIPE THIS IS TO CONFIRM THAT I HAVE INSPECTED THE CONSTRUCTION OF THE DWELLING ELEV.: 1v�,G,a• SAID DISPOSAL SYSTEM LOCATED ON TANK IN: LOT 1. '"L;ja'�.1:;:'1�U S-T TANK OUT: THE C5AbES ARE--.'.AS SPECIFIED IN THE D-BOX IN: ►�,t�.'l(n PLA ' D' SPECIFIOATIONS DA D c 4AA & D-BOX OUT: ln•� `�� BY , HJONDA SOC., END OF DISTRIBUTION 'e�61-1 LINE A: 11.50,'1;2 B: lIt...S,��� ter. „• � -/ �l% js C: D T D: AS-BUILT SEWAGE DISPOSAL MARCHIONDA & ASSOC., INC, SYSTEM PLAN ENGINEERING AND PLANNING CONSULTANTS 62 MONTVALE AVE., SUITE I IN STONEHAM, MA. 02180 �p =l•1vv�I uv';!. (617) 438-6121 AS PREPARED FOR SCALE: � .. wI DATE: �' IS��13 M & A FILE No.: U COMMONWEALTH OF MASSACHUSETTS 7/3 A`7 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ,K�-L -P,- Vz r DEPARTMENT OF ENVIRONMENTAL PROTECTION Y o TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 439 Boxford Street_ North Andover_ Owner's Name:_Michael Poirier _ RECEIVED Owner's Address:_50 Rocky Brook Road_ North Andover,MA 01845 Date of Inspection 7/3/2007_ JUL 0 5 2007 Name of Inspector: Neil J.Bateson_ TOWN OF NORTH ANDOVER Company Name: Bateson Enterprises Inc. HEALTH DEPARTMENT Mailing Address:_111 Argilla Road_ _Andover,MA 01810 Telephone Number:_(978)4754786_ 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 F Inspector's Signature: 41 Date: _7/3/2007_ 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 I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_439 Boxford Street _North Andover_ Owner:_Poirier_ Date of Inspection: 7t3/2007_ Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain._ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of l l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_439 Boxford Street _North Andover — Owner:_Poirier— Date oirier_Date of Inspection: 7/3/2007_ 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 l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_439 Boxford Street _North Andover — Owner:_Poirier_ Date of Inspection: 7/3/2007_ D. System Failure Criteria applicable to all systems: You must indicate"yes"or`no"to each of the following for all inspections: 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'h 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 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. 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 T _ 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 1I 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:_439 Boxford Street _North Andover_ Owner:_Poirier_ Date of Inspection:_7/3/2007_ 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? Yes_ ____ Were as built plans of the system obtained and examined? 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. _Yes_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CNIR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_439 Boxford Street North Andover– Owner:_Poirier_ Date of Inspection: 7/3/2007 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_4_ Number of bedrooms(actual):_4_ DESIGN flow based on 310 CMR 15.203_660 Number of current residents:_3 Does residence have a garbage grinder(yes or no): No_ 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 reading:_On well water_ Sump pump(yes or no):_No Last date of occupancy:_Current_ COMMERCIALM4DUSTRIAL 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 Sept 05,owner_ Was system pumped as part of the inspection(yes or no): Yes_ If yes,volume pumped:_1500_gallons--How was quantity pumped determined? Measured tank_ Reason for pumping: _Inspect tank&tees_ TYPE OF SYSTEM 1 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 i 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 14 Years old,9/15/1993, as built plan._ 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:_439 Boxford Street _North Andover_ Owner:_Poirier_ Date of Inspection:_7/3/2007 BUILDING SEWER_X_ (locate on site plan) Depth below grade:_18"_ Materials of construction: _cast iron _X 40 PVC—other Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.) _4"PVC thru wall,3"PVC in house,no leaks visible SEPTIC TANK: X Depth below grade:_6"_ 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:_10'x 5'x 4' Sludge depth:—3"_ Distance from top of sludge to bottom of outlet tee or baffle: 22"_ Scum thickness:_5" Distance from top of scum to top of outlet tee or baffle:_8" Distance from bottom of scum to bottom of outlet tee or baffie: 16"_ How were dimensions determined:_Tape Measure_ Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc Pumped septic tank.Inlet tee ok.Outlet tee ok.Depth of liquid at outlet invert.No evidence of septic tank leaking._ 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:_439 Boxford Street _North Andover— Owner:_Poirier_ Date of Inspection: 7/3/2007_ 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 (lute on site plan) Depth below grade 48"_ Depth of liquid level above outlet invert: 0 Comments(note if box is level and distributi_on to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.)_D-box level&distribution equal.No evidence of leakage.Evidence of light carryover,pumped d-box to clean.D-box cover broken,replaced it._ 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:_439 Boxford Street_ _North Andover— Owner:_Poirier_ Date of Inspection:_7/3/2007_ 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 trench,number,length:_2 trenches 36'long_ — leaching field,number,dimensions: overflow cesspool,number: innovative/alternative system Typetname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.):—Soil ok.Vegetation ok.No sign of ponding to surface._ CESSPOOLS: Number and configuration:— Depth—top of liquid to inlet invert:— Depth of sludge 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 Property Address:_439 Boxford Street_ _North Andover— Owner:_Poirier_ Date of Inspection: 7/3/2007 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 Well 0/ Driveway House A Septic Tank D-Box A to Tank=5516" A to D-Box=7016" B to Tank=3418" B to D-Box=41'3" Page-11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_439 Boxford Street_ _North Andover — Owner:_Poirier_ Date of Inspection:_7/3/2007_ SITE EXAM Slope_Slight_ Surface water_No_ Check cellar _Dry_ Shallow wells_No_ Estimated depth to ground water >4'_ Please indicate(check)all methods used to determine the high ground water elevation: X Obtained from system design plans on record-If checked,date of design plan reviewed:_5/7/1993_ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain:__ Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: _ You must describe how you established the high ground water elevation: As per design plan,No water 4'deep_ Commonwealth of Massachusetts 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 Important: when fining out 1. System Location: forms the computer,use only the tab key Address to move your Q,x,�`��—� cursor-do not use the return City/Town State ITip Code key. 2. System Owner. VQ �0\ C, ems_ Name 1ml Address(if different from k�callon) CitylTown State Tp Code Telephone Number B. Pumping Record 1. Date of Pumping 3-O C S g pie 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) [3-Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes [-1qo— If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. SysteP n A By : J Name Vehicle License Number Company 7. Location-where cots re disposed: �. '. ? -- Sgn aider Date t5fonn4.doc•06/03 System Pumping Record•Page 1 of 1 . „ r Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating-Water& Sewer Lines-Septic Systems&Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 439 Boxford Street, North Andover Owner: Poirier Date of Inspection: 7/3/2007 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. Neil J. Bateson Bateson Enterprises, Inc. Commonwealth of Massachusetts City/Town of RECEIVED System Pumping Record JUL 0 5 2007 r` Form 4 TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. Other fo may4* sadj tW eT 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 Important: When filling out 1. System Location: forms on the ((� computer,use ` only the tab key Address �� �-,y oa� / ,– Q- to move your ��}– ��.rC.3�, cursor-do not Citylrown State Trp Code use the return key. 2. System Owner: Name ILEI Address(if different from location) City/Town State n Zip Code Telephone Number �T 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 [moo If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: nn ,, ' 6. Syste P mp@d By: _ Name r� I�. Vehicle License Number Company 7. Locatio Where; ts �re disposed: Sign r auler Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 •01' , RECEIVED .1 W ,�•" ....r . .. , DEC 0 6 2005 "ST-EA•i PU1, PINO R?' pK .TOWN OFNORTH ANDOVER HEALTH DEPARTMENT oll y2 ' NA rM or st;Rvrc xv�rrN;, RZA • 1 1 000 r P v u. v 4,'t�r r x YY C 38 r.� 8rV'>'' u INMUMS N�n4.5 SOLtvNMY9Y�� O1�{eR•�XPl �IN t'VMMtNTs, �vtr l'trNl'y Itc�irryr�XKb r1�• ' y TbWN OF NORT 'ANIJOVER - SYSTEM PUM-pING R CO R-D HM OWNER & ADDRESS SYSTEM LOCATION —' '— �0 (ezgmple: left front of house) U;\'I'C OF PVMPIN0 <: .,.'. �r QUANTITY C'UM1'GDl. t.u.� � YES SEPTIC TANK: NO.— yE5 Vol N -\TUBE OFSERYICEs ROUTINE EMERGENCY CUOD CONDITION.. FULL TO COYER HRAYY CREASCl3AFFLLS IN 1'I,ACI? ROOTS LEACHFIELD RUNJACK_ CXCESSI'YE SOLIDS FLOODED S0LIUS ,-CA RRYOYER .,p�Hu (EX%A.IN) 1,Lm PUM ('CD 0Y: CU)l�I RNTS: r: o.N 1'(:'N IrS tRANSIT, C, R RED TO: s 1VDf'- i >91Vl6ver C-3•c�• STEMT SEPTIC TANK SERVICE )ZG Anon Sf 47 RAILROAD STREET Nd/lh A nizw,,i- BRADF`ORD, Mh 01835 La.-- 1 Sl-ob 14 978-372-7471 rnS' G11 Lie- MONTH OF 0 ber mac MONTMY REPORT FOR TOWN of ,VQ .Al w DATE ADDREss ------ GA ONS COW&M f 0-a dsq let" S". i� 111 -16 e-13 9 10-16 3e6 ��s s f Ili-l"� -5'25- & 75 10-1-7 36 xf 33 fd 5-cit) 55 16-d5 136 ,teriiM I l I Rd �` Town of North Andover, Massachusetts Form No.3 AORTH BOARD OF HEALTH 19 q-5 Of 11• O 9 ...... DISPOSAL WORKS CONSTRUCTION PERMIT ,SSACFIUSEt Applicant NAME 0 ADDRESS TELEPHONE Site Location Z-07- / ZLX,cOzeb 51- Permission is hereby granted to Construct ( ) or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN,BOARD OF HEALTH Fee d D.W.C. No. `�" 1-:07" ���� �aX�'a•P0 Si AS-BUILT CHECK LIST and FINAL INSPECTION Proposed Elevations As-Built Elevation House Tank IN TankOUT 134,0 34,0 104, 1¢ . D-box IN 1J0,76 D-box OUT Trench Inverts J� tel( Line 1 rJ'L?o�O / ��f� I Line 2 ;36� /30, Line 3 Line 4 Bottom of Exc. Stone OK? D-box checked? Pipes cemented? I FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: 1 C L- N I L O C K __1F&1 C Phone LOCATION: Assessor's Map Number Parcel � Q Subdivision Lot(s) Street X F Q� L s St. Number ************************Official Use Only*********************��l RECOMMENDA ONS OF TOWN AGENTS: Date Approved C nservation Administrator Date Rejected zz Comments 164�.A Date Approved U Town Planner Date Rejected Comments Date Approved Food Inspector-Health Date Rejected Date Approved 7 Aa.I 3 Septic Inspector-Health Date Rejected Comments 4 Public Works - sewer/water connections M/ - driveway permit ��L ��i✓� (o l L Fire D;e artment /, 4 <- �✓ � off- ��-Ei `eG-�,�o�--��'_-�-���3:�-�-t���i.��vst.E.�r��C�L- ✓/ Received by Building Inspector Date ' WELL DATABASE . ' ADDRESS: t3l a,.. AGE OF WELL: WELL DF=ER. '3 WELL PERmI T 5-714 WELL LOCATION: t —.--WEL-L-PERtiiIT DATA: 7-�'^ S 3 DEPTH OF WELL: 34' C� TYPF OF W=: a- RIL L FDIC b. DUG, c. L-NIKINO WN TYPE OF WATT BEARING ROCK- WA= OCK:WA R AYALY=DAA ,�^ l^ �1 IRGH MANGANESE: Y _ ffL�IIZON: Y N - O CCN7A'1C\d= Y N WELL DATABAE E ADDRESS: - AGE OF WELL: WELL DRILLER: WELL PERMIT T: WELL, LOCATION: WELL PE.21YET DATE: DEPTH�OF WELL: TYPE OF WELL: a. DRILLED b. D Ga c. Ui\�K�L OWN TYPE OF WATER BEARING ROCK: WATER ANALYSIS DATE: HIGH NIANGANESE: Y N HIGH IRON: Y N OT=CONTANINA�NiTS: Y N NUMBER FEE 'y THE COMMONWEALTH OF MASSACHUSETTS $25 . 00 ....T-OWN------ of --------MORTE...AhMCLVFM.............................. This is to Certify that .......S.k.i-114-n.g.s -&--- ...Sons .................................................................... .................. .. .......... NAME ............2.6-9...E!rQqt;.Q;r...Hill. -------------.Road......qqj.j i s ...... ....... ........................................................... ADDRESS IS HEREBY GRANTED A LICENSE . ...... .... For ........Wel.L..Dnilling..ker-mit-=...Lot...#.I...jDjQ2;.f Qiz�i__5-tre-e.t ........................................................................................................................................................................... ........................................................................................................................................................................... ...................................................................................................................................... ........ ...... ........................ This license is granted in conformity with the Statutes and ordinances relating thereto, and expires-Pe c e.mb-e.r....3.1.......1993. . . .................u4ess sooner auppendecL �rgvoked. .......... .... . .. ...... ...... .. ..... ... ........... ... . ......................... ...... - May ....... �7.............................. ----3. ............ ....19.93 ................. ... ....... ............. ............ . .. .............. FORM 433 HOBBS 8 WARREN. INC. li /fro rite em r dtyCt��C1CVr AY C• 66 OTTUTOM ROAD WESTFORD, MA 01886 (508) 6928395 FAX (508) 692.0078 I-OW649•TFAT Report Numbert C-WPB--8970 RepOrt Datei June 14, 1993 cliahtl sample Taken Att Wilmington Pump supply inc. flintlock P.O. sox 517 Hoxtord St. Wilmington, MA 01887 N. Andover Lot 01 8elnp1.e Taken Syiclient ons June 11,X992 CERTIFICATE or ANALYSIS I TEST PARAMETEns EPA Max RESULTS UNITS Tota]. Coliform 0 $ Per 100ml calcium No Limit 15.4 mg/L Coappar (B) 1.3 -<0.02 mq/L Iron (a) 0.3 0.24 mg/L magnesium No Limit 1.2 tag/L MangAhose (a) 0405 001 mq/T• sodium ^ 20 13.7 mq/L Potassium (8) No Limit 0.6 mq/L Alkalinity (s) 140 Limit 70.5 tug/L Ammonia No I,1mit r.0.03 mg/L chloride (s) 250 4.7 nog/L Chlorine (total) 0,7 0.48 fig/L Color (s) l6 5 CPUs Conductivity No Limit lea umhos/cul rHardneoa No Limit 4e MV/1' ltif.t•aLes(as .N) (P) i0 0.03 mq/L Nit:ri-tes(ae N) 1 — K0.01 mg/U pH (B) G.s�8.5 7.7 OU Odor (B) 3 0 TON sulphatee (a) 250 17.1 mq/L Turbidity 5 9i93 NTU Sediment poe/neq Deg HT-Not Tented, #-Value Excoode SPA STD, TNTC-Too Nt3Tneroue to CpuYlt —Background Bacteria Noted, °-EFA Advisory Limit �-Exceeds EPA Adviaory Limit (t')-Primary EPA standard, (s)=secondary EPA Standard (max affect aesthetica of drinking water i.e. tastof color, etc.) This water oample, as tested, meets or •xaaada $PA health standards for the parameters listed above. The quality of this water is accepted as POTABLE according to EPA standards. !•[aneauliusetto state certified Mioh di P. Carlsont for Tooting Laboratory 8MA040 ThorstennOn Lsbbr,tory Inc. BUAR0 UP Town of North Andovcr , I�Dss . Dote ,'ermi C i� ' APPLICATION FOR WELL & I'UHP PERF1I'r - ,ppcation . is hereby made for permit to drill a well ( ) . Application . ade to install ( ) a pump system . Lot �1 - ... . . . —�.ocaCion : Address Address I' �i rc�°cJ P� r c 1 � s A d d r e s s ,�l- WX .�//rel c 1 1c11 Con tractorSLfir✓�s X Dump Contractor • D ca^ ddress Tei . `4ELL CONTRACTOR ( To be completed at tin1e of pulnp test: ) Well Well used for �r , ryPe of • !1 Size of Casing Diameter of Well , Depth of Bed Rock Depth casing into L'ed Rock .Was Seal Tested? Yes P�) No (_) Date. of Tcsting_�a el De pth ••o-f!,7-e] l — � Well Endcd ill Wha.t. Flatcrial x�— /D Delive Depr_h to Water- rs S Gals . Per t•1in . for 4 hour ( hours a t GI'M Drawdown feet after pumping Date of Completion '` . 3 lin urc I-I Contractor PUI1P INSTALLER (To be' f'ilIcd i.n' before insta ]. l.ation ) d Pump 'Type Use Size & Name Pump Water Pump Delivers__ GPM Si•r,c of I'cink i Material Used in Well : Cast Iron pipe p Well Pit ( _) or Pitless Adapter ( _) Was sleeve used to protect pipe? Ycs (_) 1�0 ( _) -rypc or Namc Well Seal Date I e~ rE�'ri�rl�i�rii•�4�'r 'rt4�'ri4���'c�tiir�'r�!c�4t'rt4t4tktYt4�'tt'r�r�'c�4�4��ttiir�'r�r�4�`r�'rt4�'rti'�t'c,'r�'rti`r,`::';b:.:,r,'r;,tr,., ,r,:,. . :;;z,. :, , ,, ,, ,, ,, , Date 'later analysi-s . repor-t submitted to Board of llealtlz Do _z release given tD owner of record & bldg . Insp --1j Inspector J Town of North Andovcr , tlass . Date rs 19 Fermi t APPLICATION FOR WELL & PulliP PERMIT i � cation . is hereby made for permit pp to drill Application is , m ) a pumpsystem ade to install (— '. Lo t �1 .ocation : Address &- ,&Z S' — f /, Address � �t•� c� ' /Y �7iYc Ya<J t',+� "T c L owner r�ltLicC-� ;-Lts f-ci�'S Acidress�' -;/ Jell Contractor pump Contractor Address__ rel . 7ELL CONTRACTOR ( To be completed at time of pully test ) Well used for 6,1 Y P T e o f Well ��:�, ; �,• --�-- Size of Casi.nl; Diameter of Well _ Depth of Bed Rock Depth casing into L'eci hock Was Seal Tested? Yes (_) No (—) Date. of 'I'csting Well I:ndcd its Wliz.t• t-iaterial ,Depth ••o•f'J-e-�_-i— Depth to Water- Deliver°rs __Gals . Pcr Min . for 4 ho ( hours at G1'rt Drawdownfeet after pumping_______ Date of Completion inn -ure Contractor _�. _ .r. ,L_ -:�:moi.iC�C•:. .. r. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..iC.. .. .. .. .. .. .. .. .. .. .. -:. .. .. .. ' in. •' be. fore PUriP INSTALLER (To befilledType i nsta7. J.atiIo���nT�p) 1Y �e Used Size & Name Pump --- ------ --- --- GPM Siie of I <IIl1C _ Water Pump Delivers_ I1<� stic ( 1 Pi e Material Used in (Jell : Cast Iron ( _) (�nJ v.1 11 ' zed ( _) — P Wc11 Pit ( _) or Pi_ Lless •Adapter ( _) � ) NU ( ) I�YPc or t'�ainC Well Seal Was sleeve used, to protect Pipe . Yes ( _ _ Date L .f)C TDS .Ga �crr,`cletirr,��`c 't�t�'ct'r�F�`r�rir�`r,`r�`r�`r�4t4t4�`tt4�'t�4�'ri4t4rr�'t�ti`t `r ��4 �r�'r�'rti'r�'ri're'r5r;: :;'.: .:,c,r,c�c,.,r,c::,:•.c•.:V,-:: ,, , , " ,, ,t , to hoard of liealtlz Date •later analysis . repor-t submitted Di- -e release given to owner of record & 131c1s . Insp 11— th Inspector PLAN REVIEW CHECKLIST ADDRESS ENGINEER A2191C'C/f/DNQ,9 /i�DSAl✓ GENERAL 3 COPIES STAMP '�-� LOCUS_k NORTH ARROW SCALE CONTOURS PROFILE &--- SECTION C/ BENCHMARK v SOIL & PERC INFO ELEVATIONS -/ WETS. DISCLLAIMER 6--' WELLS & WETLANDS_ WATERSHED?J�a DRIVEWAYi/ (Eley) WATER LINE �--� FDN DRAIN SCH40 TESTS CURRENT? V/5 S SEPTIC TANK MIN 1500G. L- . 17 INVERT DROP t- / GARB. GRINDERY( '}200% EDF) 25' TO CELLAR i,,� MANHOLE TO GRADE ELEV 6� GW 01C D-BOX SIZE # LINES �2 FIRST 2' LEVEL STATEMEN,T/v INLET 136.17 - OUTLET /3P.30 = 7 (2 11 OR . 17 FT) TEE REQ'D? V LEACHING RESERVE AREAy 4' FROM PRIMARY?6,--' 100' TO WETLANDS 4,,---2% SLOPE `�"� 1001 TO WELLS 1,-' 351 TO FND & INTRCPTR DRAINS OK 4' TO S.H.GW L./ 325' TO SURFACE H2O SUPP L/ 4' PERM. SOIL BELOW FACILITY MIN 12" COVER FILL? (--" (25' if above natural elev; (10' if be ow) BREAKOUT MET? TRENCHES MIN 660 gpd--,,—/ SLOPE (min . 005 or 6"/1001 ) �� >3 ' COVER? - VENT SIDEWALL DIST. 2X EFF. W OR D (MIN 61 ) 1/ IS RESERVE BETWEEN TRENCHES?24/0 IN FILL? MUST BE 10MIN. Z---- 4" PEA STONE? BOT leo X, LDNG + SIDE X LDNG TOT 23 (L x W x #) (G/ft2) (DxLx2x#) x fik PC 97 Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection William F.Weld Goftcnor Trudy Coxe Argeo Paul Celluccl S + LL Gorsmor David B.Struhs Cotntnieslorw SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 413 / /3 X) $r/`e e T" "V. /}4,01,v t/1- Address of Owner. Date of Inspection: y/21 '7'7 (If different) NarneotInspector- Benjafiin C. Osgood Jr. Company Name,Address and Telephone Number. New England Engineering Services, Inc. I 33 Walker Road, North Andover, Ma 01845 CERTIFICATION STATEMENT Tel. 508-686-1768 Fax. 508-685-1099 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: —Z Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: /1�� Q Date: t1/y1/'g The System Inspector shall( mut a copy of this ' ion Zportto the Ainspection. If the PPrevin8 Authority within thirty(30)days of completing this system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall subunit 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. INSPECTION SUMMARY. Check A,B, C,or D: A] SYSTEM PASSES: have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired The system,upon completion of the replacement or repair,passes inspection. 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, cracked, structurally unsound,shows substantial infiltration or exh.1tration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a Conforming septic tank as approved by the Board of Health. (revised 11/03/95) I One Winter Street • � Boston,Massachusetts 02108 • FAX(617)556-1049 At Telephone(617)292-5500 A i J Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: y3 91S C,x.Fp S� A) - �n(y� v tA- �/Y)A Owner. SiE�t NEvvco�vt3 Date of Inspection: B)SYSTEM CONDITIONALLY PASSES (continued) — Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(g) 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 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 the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. — The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. — The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. — The system has a septic tank and soil absorption system and 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. 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: y 3 9 a�X Fp�•Q S� /✓ /'�.�y� vt Owner. Date of Inspection: ylz�/Q� D) SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined 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. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. — Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. — Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. — Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped — Any portion of the 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 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. 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. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves 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 and the environment because one or more of the following conditions exist; — 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) The owner or operator of any such system shall bring the systemand facility into full compliance with the groundwater treatment requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the n proem gr Department for further information. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: /-Go &1? Owner, s ✓e Date of Inspection: /vow <<�M b '11 Z,1,7 Check if the following have been done: Aef'umping information was requested of the owner,occupant,and Board of Health. .dNone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ,LA0 built plans have been obtained and examined. Note if they are not available with N/A. ZThe facility or dwelling was inspected for signs of sewage back-up. ZThe system does not receive non-sanitary or industrial waste flow ✓ The site was inspected for signs of breakout. ✓All system components,excluding the Soil Absorption System,have been located on the site. 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 existing information or approximated by non-intrusive methods. Z"The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address Owner: 5-'CJ L? A),1—::7 Date of Inspection: RESIDENTIAL; FLOW CONDITIONS Design flow: of�ona p.-.t— Number of bedrooms: Number of current residents Garbage grinder(yes or no): Laundry connected to system(yes or no)* Seasonal use(yea or no): Water meter readings,if available: Last date of occupancy: ,✓, .?'T COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow-__-gallons/day 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) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and a urce of information: hrjM nN /V1 AV O f� !9'9'6— QL'!1 6w/✓C /e Syste pompe&as part or inspection. (yes or no) ✓ If yes,volume pumped: /SD�, gallons Reason for pumping: ro f Ns D TYPE4F SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach prtwious inspection records, if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source of information: _ Iy Gcr2-s Sewage odors detected when arriving at the site: (yes or no)L(/ (revised 11/03/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C n SYSTEM INFORMATIOnN(continued) Property Address; y 3 R f?jo j<(;D Owner. Date of Inspection: SEPTIC TANK:_ (locate on site plan) Depth below grade: _ Material of construction:✓concrete metal_FRP_other explain) Dimensions:_ L5-cc:, Sludge depth Z , Distance from top of sludge to bottom of outlet tee or baffle:3 c- Scum thickness: O, Distance from top of scum to top of outlet tee or baffle: //.Z „ Distance from bottom of scum to bottom of outlet tee or baffle:–LLL y„ 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.) TAA)A i n/ &y'>i:> GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction:_concrete_metal_FRP—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: 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.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4/3 N � V✓fiL Owner. �C t(✓C NC v✓ G c>.r1 ami Date of Inspection: y�z i�9 7 TIGHT OR HOLDING TANK_ (locate on site plan) Depth below grade: Material of construction:_concrete_metal_FRP other(explain) Dimensions: Capacity:_ gallons Design flow: ¢allons/day Alarm level: 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: C� Comments: (note if level and distribution is equal,evidence of solids carryover,^^evidence of leakage into or out of box,etc.) - BU X / /ill C1 b '1 tY ! "✓f i V a � c7 t? v PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(;yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Addre's's: yjy g,, k � St Owner. ti. frncS�J u Date of Inspection: S TE.i F N P„� << �,,, g SOIL ABSORPTION SYSTEM(SAS):_ (locate on'site plan, if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: leaching pita,number:_ leaching chambers, number._ leaching galleries, number- leaching umberleaching trenches,number,length: 2 ►r'teic ked leaching fields, number,dimensions: overflow cesspool, number: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condi of vegetation etc.) oCESSPOOLS:_ (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(cesspool must be pumped as part 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: Depth of solids: Dimensions: Comments: (nota condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation etc.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C nSYSTEM INFORMATION(continued) Property Address: Owner. S/c.c Date of Inspection: lUe "y/2i �Q7 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100, /mak II 6 O c D DIS DEPTH TO GROUNDWATER I Depth to groundwater feet method of determination or approximation: .0--f fps; (revised 11/03/95) 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property 439 Boxford Street, North Andover, MA Owner's name Peter and Josephine Lau Date of Inspection April 25 , 1995 PART A CHECKLIST Check if the following have been done: X Ppmping information was requested of the owner, occupant, and Board of Health. X None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The site was inspected for signs of breakout. X All system components, excluding the SAS, have been located on the site. .X 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. X The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. X The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential 4 number of bedrooms 3 number of current residents N garbage grinder, yes or no Y .; laundry connected to system, yes or no N seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: On site well Current Last date of occupancy GENERAL INFORMATION Pumping records and source of information: No record of pumping as per owner and Board of Health files Y System pumped as part of inspection, yes or no if yes, volume pumped 1500 gal. Reason for pumping: to inspect condition of tank, tees etc . Type of system X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy - N Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) Approximate age of all components. Date installed, if known. Source of information: Const. September, 1993 (as-built plan) N Sewage odors detected when arriving at the site, yes or no g SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: X (locate on site plan) depth below grade: 10" material of construction: X concrete metal FRP other(explain) precast conc. tees dimensions: L = 10 ' W = 6 ' Inv. = 49" sludge depth 3311 distance from top of sludge to bottom of outlet tee or baffle 4" scum thickness R" distance from top of scum to top of outlet tee or baffle distance from bottom of scum to bottom of outlet tee or baffle. 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, recommendations for repairs, etc. ) condition of tees is good, liquid level at invert, structural integrity is good, no leakage or infiltration observed, high concentration of grease observed DISTRIBUTION BOX: X Depth below grade = 45" (locate on site plan) 0" depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc. ) DIM' s = 16" x 16" , outlets level, equal distribution, 4"0 sch. 40 P.V.C. inlet tee, liquid level @ inv. , outlet pipes 4"0 P.V.C.(Sch.j0) some solids carry over observed PUMP CHAMBER: N/A (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc. ) 1C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : X (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type leaching pits and number leaching chambers and number leaching galleries and number leaching trenches, number, length 2 trenches @ 38 feet = 76 L.F. leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil , signs of hydraulic failure, level of ponding, conditi n of ve e tion recom ndations for maintenance or repairs, etc. ) no signs of failure observe some surface erosion noted above S.A. S. CESSPOOLS (locate on site plan) : number and configuration N/A . .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 ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) PRIVY: (locate on site plan) materials of construction N/A dimensions depth of solids Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc. ) 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' See as-built sewage disposal system plan for this site by M�,rchionda and Associates, Inc. dated: 9/15/93 on file with the North Andover Board of Health (copy attached) . DEPTH TO GROUNDWATER 90" depth to groundwater method of determination or approximation: - see soil data on plan of subsurface disposal system for this site by Marchionda & Assoc. dated 5/7793 on file with Town of North Andover Board of Health. No evidence of wet basement to 6 ' below grade. 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined" , explain why not) N Backup of sewage into facility? N Discharge or ponding of effluent to the surface of the ground or surface waters? N Static liquid level in the distribution box above outlet invert? NA Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? N Required pumping 4 times or more in the last year? number of times pumped 0 N Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: N below the high groundwater elevation? N within 50 feet of a surface water? N within 100 feet of a surface water supply or tributary to a surface water supply? N within a Zone I of a public well? _ N within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? _N within 50 feet of a private water supply well? N less than 100 feet but greater than 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 analy; for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Leslie P. Godin Company Name Merrimack Engineering Services Company Address 66 Park Street, Andover, MA 01810 Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are . consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems. Check one: X I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15. 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. �J Inspector' s Signature C'h" Date Original to system owner Copies to: North Andover Board of Health Buyer (if applicable) y Approving authority ZlklSz, ' I" 7'o i i � I I ; i i �I RECEIVED ,/. Commonwealth of Massachusetts P City/Townof NORTH ANDOVER MASSA CH81SETTS,� j System Pumping Record TOWN HEATH IaEPARTf DONT R form 4 DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1, Syste L Ca o forms on the computer,use Ncv�() ri only the tab key Aadrs� to move your cursor-,do not "a . AA , use the return City o state 1) Zip C key,,. 2. Snw"ner a m . . Name Address(if different from location) Cltyrrown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: Date Gallons 3. :Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank Other(describe): 4 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,'was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. S tem Pumped By: me Vehicle Ucense Number Company ' 7, Location where contents were disposed: SI of a. g Date http:/Avww.mass.gov/dep/water/ perrovals/t5forms:htm#Inspect r�' t5form4.docc 06/03 System Pumping Record-Page t of 1 ii; i FORM 4—SYSTEM PUMPING RECORD RECEIVED Commonwealth of Massachusetts JUN 19 2013 TOWN OF NORTH ANDOVER North Andover, Massachusetts HEALTH DEPARTMENT System Pumping Record System Owner: System Location: Keith Lanzillo 439 Boxford Street 439 Boxford Street North Andover j North Andover, MA 01845 Date of Pumping: 4/30/13 Quantity Pumped: 1,500 gallons Cesspool: No ® Yes ❑ Septic Tank: No ❑ Yes System Pumped by: D.F. Clark, Inc. License: BHP-2013-0030. Contents transferred to: Ipswich Wastewater Treatment Plant Date: Inspector: I , / l ♦ ♦ y 1 ♦ r • ♦ a I r - Ol i �D zd Ln Q o d h O I 4 LL' • N vj NJ `f C w m _ LU V � CCC -- --------------------------------------------- ---------------------------------------------------------- ---_--- - I � KO 1 7--_�/� 1 / / 47 dl aJ i N`" I j � I i --- . -. - _-_.tid'; -.�;?.."1t3�7e*-^'q:�a•ar.�•-'r�.r.-'✓ :a..,.: �, .- i � � - �.y,�se.y,r - .... .war � . t r,�/�_E T`� Town �l / , z � � �� over 0 L Al 'ort dover, Mass. *70 L �/ / 19 COCH C„ > > ORATED P'I? \C9 H, , E� BOARD OF HEALTH Food/Kitchen - _ Septic SystemPERMIT T r BUILDING INSPECTOR THIS CERTIFIES THAT............. �rl./.... .O.I� ...x !.......................,.................................... "" Foundation has permission to erect" . buildings ........ Rough�C, �a to be occupied aS 1. ..... 6x ine � Provided that the person accepting this permit shaWin every respect conform to the terms of the application on file in Fin this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of -),3- Buildings in the Town of North Andover. PERMIT FOR FOUNDATION ONLY PL BB .G I SPEYTo VIOLATION of the Zoning or Building Regulations Voids this Permit. REGULATED BY PARA. 114.8.5. B.C. GO ` v � PERMIT EXPIRES IN 6 M FM p �.�o v UNLESS CONSTRUCTION STARTS • u C) ELECTRI AL INSPECTOR • Roug PERMIT FOR FRAM E/B U f s_ , 4 .1 ... Service BUILDING INSPECTOR DATE: ��� Final FEE P�IIJD ifixt►lc_✓ hermit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough P Y Final No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner PLANNING FINAL 3� f',�� CONSERVATION ELl2. FINAL Street No. (%rT � Smoke Det. _ SEWER/WATER-1'fa :9 13 FI NAL 6 6 a DRIVEWAY ENTRY PERMIT I-OT 1 �� (,1 z 7—(o ":A-:: � j , ���'� to _.. ' ✓ ' - ._ --. �.r 14 i Pj .�. ► . '+- / � ! _ ""` ih� WELL t Al rt�d►Gy- c► I ELEVATIONS TAKEN AT TOP OF PIPE THIS IS TO CONFIRM THAT I HAVE INSPECTED THE CONSTRUCTION OF THE DWELLING ELEV.: 1".r`a.iu:a. SAID DISPOSAL SYSTEM LOCATED ON TANK IN: 13¢. t;D LOT 2 =:'�*' TANK OUT: �, ,( THE Gf5AbES ,ARE'? AS SPECIFIED IN THE D—BOX IN: -1 t0 PLA ' '..AND""SPECIFICATIONS DA D D—BOX OUT; BY A. ' HIONDA & SOC., S. . J. END OF DISTRIBUTION41. G�-� LINE A: t!A;), B: X h C: --- C AEL p-SpI D T D: AS-BUILT SEWAGE DISPOSAL MAPCHIONDA & ASSOC., INC. SYSTEM PLAN ENGINEERING AND PLANNING CONSULTANTS 62 MONTVALE AVE., SUITE I IN STONEHAM, MA. 02180 617) 4-38-6121 N© 1 AS PREPARED FOR SCALE: ( ��,. j� DATE: M & A FILE No.: tt �'°. �. r- ^��� � i �.... �-... i �Y 1 = Z,ZCi 4 VV V � WELL ' _x x .. V _ 1 ELEVATIONS TAKEN AT TOP OF PIPE THIS IS TO CONFIRM THAT I HAVE INSPECTED THE CONSTRUCTION of THE DWELLING ELEV.: M5,L.J. SAID DISPOSAL SYSTEM LOCATED ON TANK IN: LOT 1 .,s.'��;,?� - TANK OUT: 3�",��' THE G��bE ARE", AS SPECIFIED IN THE D—BOX IN: PLA '"._ 6—SPECIFIbATIONS DA D D—BOX OUT: BY HJOND & rSOC., r END OF DISTRIBUTIONG�1 ' LINE A: 11 x�; (�.:c�, 3 C: �- by C AEL *,oQ0SA I DATE' D: AS-BUILT SEWAGE DISPOSAL MARCHIONDA & ASSOC., INC. SYSTEM PLAN ENGINEERING AND PLANNING CONSULTANTS 62 MONTVALE AVE., SUITE I IN STONEHAM, MA. 02180 (617) 438-6121 AS PREPARED FOR SCALE: DA TE: � a M & A FILE No.: � �� ` Septic System Information 439 BOXFORD STREET Printed On: Thursday,July 05, 2007 System ID: BHS-2002-0218 General System Information Latest Permit Information Calcaluted Design Flow: Test Pits Septic Tank Disposal Trench Design Flow: One Two Capacity: Number.- Design umber.Design Flow Provided: Minutes per inch: Width: Width: Total Flow: Depth: Length: Length: Seasonal: No No Depth to Water: Diameter. Leaching: Grinder. No No Soil Type: Depth: Laundry. No No Inspections: 1 Inspected: Expires: Inspector: Status: 07/03/2007 Neil J. Bateson Passes Comments: Title 5 1 GeoTMS@ 2007 Des Lauriers Municipal Solutions, Inc. Page 1 of 1