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Home My WebLink AboutMiscellaneous - 44 CARLTON LANE 4/30/2018 N LANE � 210/11 06.C-009.0-0092-0000.0 I • SETTLED l69� • • • PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CE1��II�'ICA�IE O F C094.1-'�IA�CE As of: .duly 5, 2011 This is to cert that the individual subsurface disposal system received a SM'YSIACTORTINYPEMOYof the: (pair of Ope at Tank for an On Site Sewage DisposaCSystem By Todd Bateson At: 44 Carlton .Gane 9klap-106.C~Parcel-0092 Xorth Andover, 9WA 01845 The Issuance of this cert cate shafCnot be construedas a guarantee that the system wiCffunction satisfactoriCy. 61_ .feafth Director 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com AC North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: ,�� Q,�,� ��- MAP: LOT: INSTALLER: DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION- DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ��//711 ❑ Contractor reports any changes to design plan ❑ Existing.septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ gallon tank has been installed loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of final grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ gallon Pump Chamber installed ❑ loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX ❑ Installed on stable stone base ❑ H-20 D-Box ❑ Inlet tee (if pumped or >0.08'/foot) ❑ Hydraulic cement around inlet & outlets ❑ Observed even distribution ❑ Speed levelers provided (not required) Comments: Application for Septic Disposal System ' AConstruction Permit - TOWN OF T°°ArsDA,>= f* ORTH AND OVER MA 01845 $250.00— ull Repair �;s,.... (::!!25-00-Compone -%C Important- Important: Application is hereby made for a permit to: When filling out Lj Construct a new on-site sewage disposal system* forms on the oco y 8 e tab key ❑ Repair or replace an existing on-site sewage disposal system" to move your air or replace an existing system component—What? Zb 0 a2.o "V, syr cursor-do not use the return key. IA. Facility Information ar /`'� -1t , C�s4 Address or Lot# Cityrrown A4, t ZE. 2.-*TYPE OF SEPTIC SYSTEM*: 7JUN `� X011 ❑Pump [9-Gravity(choose one) TOWN O?NORTH ANDOVER ***If pump system,attach copy of electrical permit to ap rykDEPARTMENT ❑Conventional System(pipe and stone system) E)Infiltrator or Siodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S.(No D-Box)(Attach Draft Maintenance Agreement) ❑Pressure Dosed(D-Box Present)S.A.S. 2. Owner information Name Address(if different from above) City/Town State Zip Code Telephone Number 3. Installer Information 4 SLS 13ATESON ENTERPRISES,INC. Name111 AR[`II 1 Rf�!!g Name of CtrnpaniANDOVER.iylA 0181.0 Address Cityfrownf �42 State Zip Code Telephone Number(Cell Phone#If posslbe please) 4. Designer Information Name Name of Company Address cityrrown State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•page 1 of 2 r°RTM Application for Septic Disposal System TODAY'S DATE pConstruction Permit - TOWN. OF ORTH ANDOVER MA 01845 $.250.00-Full Repair '�,"°•ne•'t� $125.00-Component SSACHU`�E PAGE 2OF2 A. Facility.Information continued.... 5. Type of Building: esidential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation until a Certificate of Compliance has been issue his Board of Health. Name Date Application A roved By: (Board of Health Representative) NameDate Appjieatio Disappr ed for the following reasons: For Office Use Only: L Fee Attached.? Yes L, No 2. Project Manager Obligation Form Attached. Yes✓ No J. Pump-Sy—stem? If so.,Attach copy ofElectrical Permit Yes_ No ✓ 4. FoundatiaaAs-Eudt?(new construction ronly). Yes No (Same scale as approved plan) .5 Floor Plans?(new construction only): Yes_ No Application for Disposal System Construction Permit•Page 2 of 2 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: (Address of septic system) For plans by (En eer) Relative to the application of (Installer's name) And dated ` ngtn ate Dated !�-'-1 y�-1�oay s ate With revisions dated (Last revised date) I understand the following obligations for management of this project: 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner,contractor,project manager, or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection,without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or M3:company a. Bottom of Bed— Generally,this is the first (15) 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: healdidel2t&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 susp.ension 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. A Inspection of the sand and stone to be used. c. Final inspection by Board offlealth staff or consultant. d. Installation oftaj*D-Box,pipes, stone, vent,pump chamber, retaining wall and other components. G. As the installer. I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner,general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: /p A-.a �� (Today's Date) (Name— rent Signed) — . Commonwealth of Massachusetts Title 5 Official Inspection o mtoll Subsurface Sewage Disposal System Form-Not for V ntary sses;Vats ANDOVUTlI 44 Carlton Lane 1`�WN Cy N011 F Ap Property Address Mike Ebert Owner Owner's Name information is required for North Andover MA 01845 6/17/2011 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Neil James Bateson cursor-d¢not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name � 111 Argilla Road Company Address Andover MA 0 reaan Citylfown State Zipp Code 978-475-4786 S115 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needgef urther Evaluation by the Local Approving Authority 6/17/201 Insp4ct%r's1 Signature V Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form x a Subsurface Sewage Disposal System Form -Not.for Voluntary Assessments 44 Carlton Lane Property Address Mike Ebert Owner Owner's Name information is required for North Andover MA 01845 6/17/2011 - every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: After permit from B.O.H., replace collapsed pipe &new outlet tee in septic tank, inspection from B.O.H. septic system now passes Title 5 Inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y 0 N ❑ ND(Explain below): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts � Title 5 Official Inspection F ' „ � Subsurface Sewage Disposal System Form-Not for Volu tary ssessments 44 Carlton Lane SUN v -all Property Address TOWN OF NORTH ANDOVER Mike Ebert HEALYH OgpAATMENT Owner Owner's Name information is /A required for North Andover MA 01 6/8/2011 every page. Cityrrown State Zip Code _Date of Inspecti / Inspection results must be submitted on this form. Inspection forms may not be altered in any / way. Please see completeness checklist at the end of the form. Important: When filling out A. General Information � forms on the computer,use 1. Inspector: only the tab key to move your Neil J. Bateson cursor-do not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover Ma 01810 Citylrown State Zip Code 978-475-4786 SI 15 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved s stem inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system"/— ❑ Passes ® Conditionally Passes ❑ Fails ❑ Nee4 Further Evaluation by the Local Approving Authority 6/8/2011 Inspectors Si9i Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. '""`This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•09108 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Carlton Lane Property Address Mike Ebert Owner Owner's Name information is required for North Andover MA 01845 6/8/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ® N ❑ ND(Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 r Commonwealth of Massachusetts Title 5 Official IPmfection Form Subsurface Sewage Disposal S Form-Not for Voluntary Assessm is 44 Carlton Lane Property Address Mike Ebert z z Owner Owner's Name information is required for North Andover MA 0184 6/8/2011 every page. City/Town State Zip de Date of Inspection B. Certifi tion (cont.) B) Sys m Conditionally Passe/ardHea ❑ Ob ervation of sewage backuut o igh static water level in the distribution box due to roken or obstructed pipe(s) a b ken, settled or uneven distribution box. System will pa s inspection if(with approvHealth): ❑ broken pipe(s)are rep ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is remove ❑ Y ❑ N ❑ ND (Explain below): distribution box is leveced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system requi pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass i s ection if(with approval of the Board of Health): ❑ broken ipe(s) re replaced ❑ Y ® N ❑ ND(Explain below): ❑ obs ction is rem o d ❑ Y ® N ❑ ND (Explain below): C) urther Evaluation is Required by the Board of Hea Conditions exist which require further evaluation by the Boar f Health in order to determine if the system is failing to protect public health, safety or the environ nt. 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not°for Voluntary Assessments 44 Carlton Lane Property Address Mike Ebert Owner Owner's Name information is required for North Andover MA 01845 6/8/2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ON ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ON ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ON ❑ 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Carlton Lane Property Address Mike Ebert Owner Owner's Name information is required for North Andover MA 01845 6/8/2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Outlet pipe out of septic tank crushed, needs to be replaced. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•09108 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Carlton Lane Property Address Mike Ebert Owner Owner's Name information is required for North Andover MA 01845 6/8/2011 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. 11 ® 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•09108 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 44 Carlton Lane Property Address Mike Ebert Owner Owner's Name information is required for North Andover MA 01845 6/8/2011 every page. Cityrrown State Zip Code Date of Inspection C. Che list Ch ck if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ® ® Pumping information w provided by the owner, occupant, or Board of Health ❑ ® Were any of the cyst components pumped out in the previous two weeks? ® ❑ Has the system r eived normal flows in the previous two week period? ❑ ® Have large vol es of water been introduced to the system recently or as part of this inspectio . ® Were as bui plans of the system obtained and examined?(If they were not available to as N/A) ❑ Was th acility or dwelling inspected for signs of sewage back up? ® ❑ Was a site inspected for signs of break out? ® re 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, imensions, depth of liquid, depth of sludge and depth of scum? ® W the facility owner(and occupants if different from owner) provided with infor tion on the proper maintenance of subsurface sewage disposal systems? The size nd location of the Soil Absorption System(SAS)on the site has been deter ed based on: ® Existing inform ' n. For example, a plan at the Board of Health. ❑ Determined in the fi (if any of the failure criteria related to Part C is at issue approximation of distan is unacceptable) [310 CMR 15.302(5)] . System Information Residential Flow Conditions: Number of bedrooms(design): N/A Number of be (actual): 4 oms DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): N/A t5ins 09/08 Title 5 Official Inspection Farts:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts = v Title 5 Official Inspection FormJ � a�� Subsurface Sewage Disposal System Form-Not for Voluntary Assessm nts TOWN OIC NORTH ANOovER 44 Carlton Lane I HEALTH DEPARTMENT Property Address Mike Ebert Owner Owner's Name information is required for North Andover MA 01845 6/8/2011 every page. Cityfrown 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): N/A Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): N/A t5ins•09/08 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 44 Carlton Lane Property Address Mike Ebert Owner Owner's Name information is North Andover MA 01845 6/8/2011 required for every page. Citylrown state Zip Code to of Inspection D. System Informati Description: R Number of cur ent residents: 2 Does residenc have a garbage grinder? ❑ Yes ® No Is laundry on a eparate sewage system?[if yes separate in ection required) ❑ Yes ® No Laundry system i spected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 year usage(gpd)): Yes Detail: zns Sump pump? ® Yes ❑ No Current Last date of occu ncy: Date Commerci ndustrial Flow Conditions: Type Establishment: esign flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? - ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09108 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 44 Carlton Lane Property Address Mike Ebert Owner Owner's Name information is required for North Andover MA 01845 6/8/2011 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Yes Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Carlton Lane Property Address Mike Ebert Owner Owner's Name information is required for North Andover MA 01845 6/8/2011 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: pumped 2006, owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Measured tank Reason for pumping: Inspect tank, baffle&tee 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Carlton Lane Property Address Mike Ebert Owner Owner's Name information is required for North Andover MA 01845 6/8/2011 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: Original to house, owner Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ® cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4"Cast iron thru wall, 3" PVC in house, no leaks visible Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x5'x4' Sludge depth: 6" t5ins•09108 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 44 Carlton Lane Property Address Mike Ebert Owner Owner's Name information is required for North Andover MA 01845 6/8/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 23" Scum thickness 4" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 19" 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. Inletr tee ok. Outlet tee ok.Outlet pipe to d-box#1 crushed. Needs to be repaired. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Carlton Lane Property Address Mike Ebert Owner Owner's Name information is required for North Andover MA 01845 6/8/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts -- . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Carlton Lane Property Address Mike Ebert Owner Ownees Name information is required for North Andover MA 01845 6/8/2011 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 — Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box#1 ok. D-box cover broken, replaced it. D-Box#2 level&distribution equal. Evidence of carryover. No evidence of leakage, Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins 09/08 Title 5 Official Inspection Forth: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 44 Carlton Lane Property Address Mike Ebert Owner Owner's Name information is required for North Andover MA 01845 6/8/2011 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number:. ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 4 trenches 50' long ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface. 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Carlton Lane Property Address Mike Ebert Owner Owner's Name information is required for North Andover MA 01845 6/8/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Carlton Lane Property Address Mike Ebert Owner Owner's Name information is required for North Andover MA 01845 6/8/2011 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 4v�zE-� �S� Dt^;veu /fir FTI -tea C� L(6? t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Carlton Lane Property Address Mike Ebert Owner Owner's Name information is required for North Andover MA 01845 6/8/2011 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >4 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: Essex County Soil Map. You must describe how you established the high ground water elevation: Essex County Soil Map, Sheet#36 , Canton Soil, Water>6'deep Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Carlton Lane Property Address J Mike Ebert Owner Owner's Name information is required for North Andover MA 01845 6/8/2011 every page. Cityfrown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 • 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 1. System Location: Left front of house, right front of house, left side of house, right side of hou , Le� rear o�fious right rear of house, left side of building, right rear of building, under deck. City/Town State Zip Code 2. System Owner: Name Address(if different from location) Cityfrown State�S7 3 r— 33r- 3 r-GZip Code Telephone Number 9 B. Pumping Record i l �✓U 1. Date of Pumping D Y a 2. Quantity Pumped: Gal t ns 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes 2-f o If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 4 6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Location where contents were disposed: G.L.S.D owell Waste Water Signatu u er Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Summary Record Card generated on 6/3/2011 2:03:51 PM by Karen Hanlon Page r Town of North Andover Tax Map # 210-106.C-0092-0000.0 Parcel Id 17728 44 CARLTON LANE EBERT, MICHAEL 44 CARLTON LANE NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residenti; Size Total 1 Acres FY 2011 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Unt EBERT, MICHAEL Payor 44 CARLTON LANE NORTH ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id.7613_,0-44 CARLTON LANE Last Billing Date 3/2/2011 2100195 02 Cycle 02 Active UB Services Maint. Account No.2100195 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 76.00 /1 UB Meter Maintenance Account No. 2100195 Serial No Status Location Brand Type Size YTD Con 13242307 a Active ERT HH METE METE w Water 0.63 0.63 31 Date Reading Code Consumption Posted Date Varianc 5/2/2011 787 a Actual .15 -189 2/4/2011 772 a Actual 20 3/15/2011 59 11/1/2010 752 a Actual 18 12/13/2010 -559 8/3/2010 734 a Actual 41 9/13/2010 769 5/3/2010 693 a Actual 23 6/9/2010 09 2/1/2010 670 aActual 23 3/11/2010 -12° 11/2/2009 647 aActual 26 12/11/2009 14° 8/3/2009 621 aActual 22 9/11/2009 459 5/7/2009 599 a Actual 16 6/16/2009 -12° 2/3/2009 583 a Actual 18 3/16/2009 -58° 11/3/2008 565 a Actual 44 12/10/2008 —289 8/1/2008 521 a Actual 60 9/12/2008 1929 5/1/2008 461 a Actual 19 6/18/2008 89 2/6/2008 442 a Actual 20 3/14/2008 -519 11/1/2007 422 aActual 38 1/15/2008 -119 8/3/2007 384 a Actual 43 9/14/2007 1279 5/4/2007 341 a Actual 15 6/22/2007 -149 2/21/2007 326 a Actual 27 3/23/2007 -310, 11/1/2006 299 aActual 32 12/22/2006 -310 8/1/2006 267 a Actual 45 9/13/2006 1450, 5/4/2006 222 a Actual 19 6/20/2006 -244 2/1/2006 203 a Actual 25 3/13/2006 104 11/1/2005 178 a Actual 22 12/14/2005 -470, 8/4/2005 156 a Actual 44 9/12/2005 1310, 5/2/2005 112 ,a Actual 18 6/8/2005 40 2/2/2005 94 a Actual 18 3/15/2005 70 �� . �� .�L2/��1 JQ„ /g,�D i2c1-G� G o�'�� . ..._--� �� . �� -o-l��G�mx -��'�.�a�ems' TO: NORTH ANDOVER, MASS. MOM 1 1932- BOARD 90 ZBOARD OF HEALTH FROM: DESIGN ENGINEER Re: Soil Absorption Sewage Disposal System This is to certify that I have Inspected the construction materials of said disposal system at toir 2-,, I'Q,TC7(� Site Location North Andover, Mass. The grades and construction materials are as in my plans and Q'� ss9 specifications dated J�eD'�• ?J , 19 (ja y- F � ' ti 5—, / Z 19 of Z. NAS Reg. Prof.E gine ..22X rian ASO FGIs7� FSSS/OHM-�FlC'"� w M Board of Health (� North '.ndc c SUBSUiME DISPOS46L M-7'SIGN CIWK LIST a LOT APPROVED DM DISAPFRGM DATE Provided: Re3sonss !� c Title V FAIL jlbo� Reg 2.5 ✓ e submitted plan rust show as a 4nim ms the lot to be served-area,dimensione lot #,abutters location and log d ep observation hoes-distance to ties location and results percolation tests-distance to ties design calculations & calculations showing required leaching area �, ocation and dimensions of system-including reserve area existing and proposed contours cation any wet areas within 100' of sewage disposal system or disclaimer-check wetlands mapping h) surface and subsurface drains within 100' of sew-age disposal system or disclaimer (i) location any d i..na a ear ants IYlthi.n 100' of seise disposal system or disclaimer•-P3_,,:-ni:sg Board files 3) kno= sources of vaster supply vi.thi.n 2001 of e:e-.-, ge disposal systam or disclaimer (k) location of any proposed wall to serve lot-1001 from leaching facility ( location of water 33mes on property-102 from leaching facility za) location of benchmark r ivemaya rbage disposals PVC to be used in construction ofile of system-elevations of basement, plumb, pipe, septic tr_nk, stribution box inlets and outlets, distribution field piping and Cher elevations snaxi:nam ground water elevation in area sewage disposal system 47 s) plan asst be prepared by a Professional Fag-ineesr or other professional authorized by lair to pm-pare such plans Reg 6 �Scptic Tanks 4""(a) capacities-1 of flow, grater table, tees, depth of tees, access, pining cleanout 101 from cellar wall or inground a Azmdmg pool (d) 251 from subsurface drains Reg 10.2 Distribution Boxes Lf3b) a) pe greater than 0.08 Reg 10.Zt surtp I . 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