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North Andover Board of Assessors Public Access
Parcel ID: 210/104.A-0065-0000.0 Community: North Andover
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440 WINTER STREET RJ
Location: 440 WINTER STREET
Owner Name: KING, THOMAS C
PENELOPE Y KING
Owner Address: 440 WINTER STREET
City: NORTH ANDOVER State: MA ZIP: 01845
Neighborhood: 6 - 6 Land Area: 1.02 acres
Use Code: 101- SNGL-FAM-RES Total Finished Area: 2543 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 479,800 448,400
Building Value: 269,700 254,000
Land Value: 210,100 194,400
Market Land Value: 210,100
Chapter Land Value:
LATESTSALE
Sale Price: 104,900 Sale Date: 06/29/1982
Arms Length Sale Code: Y -YES -VALID Grantor: QUINN EUGENE G
Cert Doc: Book: 01587 Page: 0092
http://csc-ma.us/NandoverPubAcc/J*sp/Home jsp?Page=3&LinkId=807724
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9/8/2006
Commonwealth of MassachusettsF--ik-E—CEEIVE
City/Town of
System Pumping Record JUL 15 2008
g` Form 4
WHEALLTH DEPARTMENT OF NORTH ER
DEP has provided this form for use by local Boards of Health. Other u , 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:
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forms on the
computer, use
only the tab key Address
to move your q
cursor- do not Cityfrown State Tp Code
use the return
key. 2. System Owner:
Name
ren Address (if different from location)
Citylrown StateAE^FCod
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
V-7-- (0 z
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Date 2. Quantity Pumped: Gallons
Cesspool(s) Septic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes DIE' If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Systeme (4p V -\,o �
A
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System Pumped By: �A ;--�
Name Vehicle License Number
Company
7. Location whey*ntents e
Signature
Date
System Pumping Record • Page 1 of 1
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor do not
use the return
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rum
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
C IVSD
AUG - 6 2007
TO," r'4'5RFH ANDOVER
V iEAJH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility information
1. Systr
0,-(- keuse
Address ,� o uj� <�
City/Town Stat Zip Code
2. System Owner.
Name
Address (if different from location)
City/Town StateZip Code�
Telephone Number
B. Pumping Record
1. Date of Pumping �2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) E3 -Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Fitter present? ❑ Yes to if yes, was it deaned? ❑ Yes ❑ No
5. Condition of System:
GI
SysteT P m By:
Name ehicle License Number
Company
7. Locatio;�Te cont
Date
—t -t/ -C7
t5form4.doc- 06103 System Pumping Record • Page 1 of 1
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Town of North Andover
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'li7s +�.e HEALTH DEPARTMENT
SAC MUSt01
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CHECK #: diJ
LOCATION:
H/O NAME:T.�/i/r%�b
i'
CONTRACTOR NAME: s./ elx Z/0�r
Type of Permit or License: (Check box)
❑ Animal
$
❑ Body Art Establishment
$
❑ Body Art Practitioner
$
❑ Dumpster
$
❑ Food Service - Type.
$
r'
❑ Funeral Directors
$
t
s
❑ Massage Establishment
$
❑ Massage Practice
$
❑ Offal (Septic) Hauler
$
❑ Recreational Camp
$
k
❑ 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) $
❑�itle5
pector $
El'.., port
❑ Other: (Indicate) $
1 785L -'A/
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: _440 Winter Street
_ North Andover_
Owner's Name: _Thomas King
Owner's Address: _440 Winter Street
_ North Andover, MA 01845_
Date of Inspection: 8/10/2006
Name of Inspector: Neil J. Bateson_
Company Name: Bateson Enterprises Inc._
Mailing Address: _111 Argilla Road_
_Andover, Ma. 01810_
Telephone Number: _( 978 ) 475-4786
RECEIVED
SEP - 6 2006
TpHEALLTH DEPARTMENT OF NORTH
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: Date: _8/10/2006_
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.
C:f
ie
Page 2 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: _440 Winter Street_
_ North Andover—
Owner: _ King_
Date of Inspection: _8/10/2006 _
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:
�y
' Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: _" Winter Street_
_ North Andover_
Owner: Kinn
Date of Inspection: _8/10/2006_
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 I 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 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 440 Winter Street _
_ North Andover—
Owner: King_
Date of Inspection: _8/10/2006 _
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
— the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped
Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
Page 5 of l l
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: _440 Winter Street _
_ North Andover _
Owner: King_
Date of Inspection: _8/10/2006_
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
Yes _ Pumping information was provided by the owner, occupant, or Board of Health
No Were any of the system components pumped out in the previous two weeks ?
Yes_ _ Has the system received normal flows in the previous two week period ?
No Have large volumes of water been introduced to the system recently or as part of this inspection ?
N/A _ Were as built plans of the system obtained and examined?
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 bales 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
_N/A_ _ Existing information.
_Yes_ _ Determined in the field (if any of the failure criteria related to Part Cis at issue approximation of
distance is unacceptable) [3 10 CMR 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: 440 Winter Street
_ North Andover
–
Owner: King_
Date of Inspection: 8/10/2006_
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): _N/A Number of bedrooms (actual): _3
DESIGN flow based on 310 CMR 15.203 _N/A _
Number of current residents: _3
Does residence have a garbage grinder (yes or no): _Yes_
Is laundry on a separate sewage system (yes or no): _No_
Laundry system inspected (yes or no):
Seasonal use: (yes or no): _No_
Water meter reading: Yes _
Sump pump (yes or no): –Yes _
Last date of occupancy: —
Current—COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR 15.203): _gpd
Basis of design flow (seats/persons/sgft,etc.): —
Grease trap present (yes or no):
Industrial waste holding tank present (yes or no):
Non -sanitary waste discharged to the Title 5 system (yes or no): —
Water meter readings, if available: —
Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: Pumped last year, owner _
Was system pumped as part of the inspection (yes or no): Yes_
If yes, volume pumped: _1000_ gallons -- How was quantity pumped determined? _Measured tank
Reason for pumping: _Inspect tank & tees_
TYPE OF SYSTEM
X Septic tank, distribution box, soil absorption system
_ Single cesspool _ Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
_ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be
obtained from system owner)
Tight tank — Attach a copy of the DEP approval
_ Other (describe): _
Approximate age of all components, date installed (if known) and source of information:–O
riginal, owner_ aRilglgk
GK, ZSSGSSc"'�s '��
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: _440 Winter Street
_ North Andover
Owner: King_
Date of Inspection: _8/10/2006_
BUILDING SEWER _ X _ (locate on site plan)
Depth below grade: _26"
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.
SEPTIC TANKS: X
Depth below grade: _16"
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: 7' x 5' x 4'
Sludge depth6"_
Distance from top of sludge to bottom of outlet tee or baffle: 21" _
Scum thickness: _6"_
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: _15"_
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. Tank located under cement apron
around porch. Inlet baffle ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of septic tank
leaking in or out. _
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 l l
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 440 Winter Street_
_ North Andover—
Owner: King_
Date of Inspection: _8/10/2006_
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 BOXS: _X_
Depth below grade _ 30"_
Depth of liquid level above outlet invert: _0"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):_ D -box level & distribution equal. No evidence of leakage. Evidence of
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 I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _440 Winter Street _
_ North Andover_
Owner: King_
Date of Inspection: 8/10/2006_
SOIL ABSORPTION SYSTEM (SAS): _X (locate on site plan, excavation not required)
If SAS not located explain why:
Type
leaching pits, number:
leaching chambers, number: —
leaching galleries, number:
_X leaching trenches, number, length: _5 trenches 45' long _
_ leaching field, 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 oL Vegetation oL 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 (continued)
Property Address: _440 Winter Street _
_ North Andover
—
Owner: King_
Date of Inspection: _8/10/2006_
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
Driveway
Water
House
D -
Boz
Porch
B A
Septic Tank
A to Tank =12'
A to D -Boz = 28110"
B to Tank =13'6"
B to D -Boz =14'7"
' Page l l of l l
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _440 Winter Street _
– North Andover
—
Owner: King_
Date of Inspection: _8/10/206_
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 26' _
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record - If checked, date of design plan reviewed: —
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain: _
Checked with local excavators, installers- (attach documentation)
X Accessed USGS database -explain: Essex County Soil Map_
You must describe how you established the high ground water elevation: _ Essex County Soil Map, Sheet # 30,
Charlton Soil, Water >6' Deep _
i Summary Record Card generated on 8/11/2006 2:43:54 PM by Elaine Barclay Page 1
• Town of -North Andover
Tax Map # 210-104.A-0065-0000.0
440 WINTER STREET
KING, THOMAS C.
440 WINTER STREET
N. ANDOVER, MA
01845
Class 101 Single Family Property Type 1 Residential
Size Total 1.02 Acres
FY 2006
UB Mailing Index
Name/Address Type Loan Number Active/Inact. From Until
KING, THOMAS C. Payor
440 WINTER STREET
N. ANDOVER, MA
01845
UB Account Maint.
Account No Cycle Occupant Name Active/Inactive
Bldg Id. 18165.0 - 440 WINTER STREET Last Billing Date 7/5/2006
3180193 03 Cycle 03 Active
UB Services Maint.
Service Code Rate Charge Multiplier/Users
MISCFEE ADMIN FEE 0.635/8 7.82 1/
WTR WATER 01 ALL METER SIZE 73.10 /1
UB Meter Maintenance
Serial No
Status
Location
16748919
a Active
ERT
Date
Reading
Code
6/21/2006
512
a Actual
3/23/2006
491
a Actual
1/3/2006
475
a Actual
9/26/2005
452
a Actual
6/21/2005
432
a Actual
3/24/2005
411
a Actual
12/17/2004
390
a Actual
9/28/2004
373
a Actual
6/15/2004
353
a Actual
4/27/2004
34.3
a Actual
12/22/2003
313
n New Meter
Brand
Type Size
METE METE
w Water 0.63 0.63
Consumption
Posted Date
21
7/10/2006
16
4/17/2006
23
1/17/2006
20
10/14/2005
21
7/15/2005
21
4/5/2005
17
1/14/2005
20
10/8/2004
10
7/30/2004
30
5/17/2004
0
12/22/2003
YTD Cons
0
Variance
15%
-13%
13%
-13%
9%
2%
12%
-7%
-14%
0%
0%
A � J
B ATE S ON ENTERPRISES, INC.
Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service
111 Argilla Road Andover, Mass. 01810
Title 5 Inspection Report
Property Address: 440 Winter Street, North Andover
Owner: King
Date of Inspection: 8/10/2006
Tel: (978) 475-4786
Fax: (978) 475-5451
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 qJ.Bateson
Bateson Enterprises, Inc.
` TOWN OF K1- �AI-er
SYSTEM PUMPING REC01 "Eg -
DATE: - a 5
SYSTEM OWNER & ADDRESS
AUG U 5 2005
TOWN
HEJF
ALTH'0 ARTM TER
SYSTEM LOCATION
(example: left front of house)
�'M
DATE OF PUMPING: - 0 S QUANTITY PUMPED: k O NO GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO:
G.L.S.D J
Lowell Waste
TOWN OF .N- �Ad(xje(
SYSTEM PUMPING RECORD
DATE: - ( 1-63
SYSTEM OWNER & ADDRESS
cv
4 2003
SYSTEM LOCATION`"
(example: left front of house)
DATE OF PUMPING: O QUANTITY PUMPED: l 0 O a GALLONS
CESSPOOL: NO J YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE +✓ EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE
LEACE FIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO:
System Owner
(1011111 nwe Ith of Massachusetts
I " , Massachusetts
System Pumping Record
System Location
LfC-)
W) �A-ex-
Date of Pumping: �! ��' (?g Quantity Pumped: ` % gallons
Cesspool: No Yes U Septic Tank: No U Yes H�
System Pumped by: vett`edea grf&vwidej License #
Contents transferrred to : Greater Lawrence Sanitary District
Date: Inspector:
1 'a o NOR f$A,...-
H
i
3 izq
System Owner
Com >onw alth of MassachuseUs
Massachusetts
system Purnping Record
System Location
q LIC tu, 1
J
Date of Pumping: �'� Quantity Pumped: / C.�-C-� gallons
Cesspool: No ( YeS LI Septic Tank: No
System Pumped by: iarejea Ga&` ftmed License #
Contents transferrred to : Greater Lawrence Sanitary District
Date: Inspector:
Yes_
4227
M011T1
Of 4a •,ti0
Town of North Andover
HEALTH DEPARTMENT
,SS4CNUSt
CHECK #: DATE: /
LOCATION:
H/O NAME: Z,cQ
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)
$
❑Tit
Inspector
$
Title 5 Report
❑ Other. (Indicate) $
17
cl/w-
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
4227
10RTq
0
aimWIAL
F
• : Town of North Andover
HEALTH DEPARTMENT
,SS�CNU�+t4 '
CHECK #:ICO DATE:
LOCATION:'�7�(�
H/O NAME:
CONTRACTORNAME:
Tyne
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 Sustems:
❑ Septic - Soil Testing $
❑ Septic - Design Approval $
❑ Septic Disposal Works Construction (DWC) $
❑ Septic Disposal Works Installers (DWI) $
O $
lS
InspectorTitle
5 Report $`w' " • "
❑ Other. (Indicate) $
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
Owner
information is
required for
every page.
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key
v l�
low
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Asses:
440 Winter Street
Property Address
Thomas King
Owner's Name
North Andover
City/Town
MA 01810
State Zip Code
RECEIVED c�
AUG 0 4 2009
ANDOVER
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.
A. General Information
1. Inspector:
Neil J. Bateson
Name of Inspector
Bateson Enterprises Inc.
Company Name
111 Aroilla Road
Company Address
Andover Ma 01810
City/Town State Zip Code
978-475-4786 SI15
Telephone Number
B. Certification
License Number
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of,
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Nee s Further Evaluation by the Local Approving Authority
7/29/2009
Inspectord SignatM Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins - 09/08 Title 5 Official Inspection Fonn: Subsurface Sewage Disposal System . Page 1 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
440 Winter Street
Property Address
Thomas King
Owners Name
North Andover MA 01810 7/29/2009
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:
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17
La
_i
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
440 Winter Street
Property Address
Thomas King
Owner's Name
North Andover MA 01810 7/29/2009
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if (with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
❑ Y ❑ N ❑ ND (Explain below):
❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if (with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17
-a
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
440 Winter Street
Property Address
Thomas King
Owners Name
North Andover MA 01810 7/29/2009
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:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes
No
❑
®
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑
®
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑
®
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑
®
Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 day flow
t5ins • 09108
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area — IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17
Commonwealth of Massachusetts
Title 5
Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,..'
440 Winter Street
Property Address
Thomas King
Owner
Owner's Name
information is
required for
North Andover
MA 01810 7/29/2009
every page.
Cityrrown
State Zip Code Date of Inspection
B. Certification
(cont.)
Yes
No
❑
® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑
® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑
® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑
® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑
® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑
® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑
® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑
® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area — IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17
1 1 '
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
440 Winter Street
Property Address
Thomas King
Owner Owner's Name
information is
required for North Andover MA 01810 7/29/2009
every page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ ® Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑
Was the site inspected for signs of break out?
® ❑
Were all system components, excluding the SAS, located on site?
® ❑
Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑
Was the facility owner (and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑
Existing information. For example, a plan at the Board of Health.
® ❑
Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): N/A Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): N/A
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
440 Winter Street
MA 01810
State Zip Code
7/29/2009
Date of Inspection
D. System Information
Property Address
❑
Thomas King
Owner
Owner's Name
information is
required for
North Andover
every page.
Cityrrown
MA 01810
State Zip Code
7/29/2009
Date of Inspection
D. System Information
Yes
❑
No
❑
Description:
❑
No
❑
Yes
❑
No
Number of current residents:
3
Does residence have a garbage grinder?
®
Yes
❑
No
Is laundry on a separate sewage system? [if yes separate inspection required]
❑
Yes
®
No
Laundry system inspected?
❑
Yes
❑
No
Seasonal use?
❑
Yes
®
No
Water meter readings, if available last 2 ears usage d
9 ( Y 9 (gP ))�
Yes
Detail:
Sump pump?
Last date of occupancy:
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
Industrial waste holding tank present?
Non -sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
Gallons per day (gpd)
❑ Yes ® No
Current
Date
❑
Yes
❑
No
❑
Yes
❑
No
❑
Yes
❑
No
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17
Owner
information is
required for
every page.
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
440 Winter Street
Property Address
Thomas King
Owner's Name
North Andover
City/Town State
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
Pumping Records:
Source of information:
01810 7/29/2009
Zip Code Date of Inspection
Date
General Information
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Type of System:
Pumped 2008, owner
1000
gallons
Measured tank
tank
® Yes ❑ No
® 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
M Sa r 440 Winter Street
D. System Information (cont.)
7/29/2009
Date of Inspection
Approximate age of all components, date installed (if known) and source of information:
Original, owner
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer (locate on site plan):
Depth below grade: 2.5
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" PVC thru wall to septic tank. 3" PVC in house, no leaks visible.
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
® concrete ❑ metal
1.6
feet
❑ fiberglass ❑ polyethylene ❑ other (explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate)
Dimensions: Tx 5'x 4'
Sludge depth:
4
❑ Yes ❑ No
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17
Property Address
Thomas King
Owner
Owner's Name
information is
required for
North Andover MA 01810
every page.
Cityrrown State Zip Code
D. System Information (cont.)
7/29/2009
Date of Inspection
Approximate age of all components, date installed (if known) and source of information:
Original, owner
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer (locate on site plan):
Depth below grade: 2.5
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" PVC thru wall to septic tank. 3" PVC in house, no leaks visible.
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
® concrete ❑ metal
1.6
feet
❑ fiberglass ❑ polyethylene ❑ other (explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate)
Dimensions: Tx 5'x 4'
Sludge depth:
4
❑ Yes ❑ No
t5ins • 09/08 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
,•'' 440 Winter Street
t5ins • 09/08
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
21"
6
6"
15"
7/29/2009
Date of Inspection
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 baffle ok. Outlet tee ok. Depth of liquid at invert. No evidence of leakage.
Tank located under concrete apron around porch.
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
Dimensions:
Scum thickness
feet
❑ fiberglass ❑ polyethylene ❑ other (explain):
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
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17
Property Address
Thomas King
Owner
Owner's Name
information is
required for
North Andover MA 01810
every page.
Cityrrown State Zip Code
t5ins • 09/08
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
21"
6
6"
15"
7/29/2009
Date of Inspection
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 baffle ok. Outlet tee ok. Depth of liquid at invert. No evidence of leakage.
Tank located under concrete apron around porch.
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
Dimensions:
Scum thickness
feet
❑ fiberglass ❑ polyethylene ❑ other (explain):
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
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
M 440 Winter Street
Property Address
Thomas King
Owner Owner's Name
information is
required for North Andover
every page. City/Town
MA 01810 7/29/2009
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:
Design Flow:
Alarm present:
Alarm level:
gallons
gallons per day
❑ Yes ❑ No
Alarm in working order:
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
❑ Yes ❑ No
"Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
15ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
440 Winter Street
Property Address
Thomas King
Owner Owner's Name
information is
required for North Andover MA 01810 7/29/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D- box level & distibution equal. No evidence of leakage. No evidence of carryover.
Pump Chamber (locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System " Page 12 of 17
" Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Foran - Not for Voluntary Assessments
440 Winter Street
Owner
information is
required for
every page.
Property Address
Thomas King
Owner's Name
North Andover
Cityrrown
D. System Information (cont.)
State
01810
Zip Code
7/29/2009
Date of Inspection
Type:
❑
leaching pits
number:
❑
leaching chambers
number:
❑
leaching galleries
number:
®
leaching trenches
number, length:
❑
leaching fields
number, dimensions:
❑
overflow cesspool
number:
❑
innovative/alternative system
5 trenches 45'
long
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 • 09/08 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
440 Winter Street
Property Address
Thomas King
Owner Owner's Name
information is
required for North Andover MA 01810 7/29/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
l5ins • 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
440 Winter Street
Property Address
Thomas King
Owner Owners Name
information is
required for North Andover MA 01810
every page. Cityfrown State Zip Code
7/29/2009
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
Oc-
w al
�G
m
skpA c'
v�-
�--�3�x Concsz.�e.
I W'7 n
Q- o�
:-:,;;Is 1 1011
t5ins • 09108 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 15 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Foran - Not for Voluntary Assessments
440 Winter Street
Property Address
Thomas King
Owner's Name
North Andover
Cityrrown
D. System Information (cont.)
Site Exam:
®
Check Slope
®
Surface water
®
Check cellar
® Shallow wells
AAA AAnAA .
7/29/2009
State Zip Code Date of Inspection
Estimated depth to high ground water: >6
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
E
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 # 30, Charlton Soil, Water> 6' deep
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
440 Winter Street
Property Address
Thomas King
Owner Owner's Name
information is
required for North Andover MA 01810
every page. Citylrown State Zip Code
E. Report Completeness Checklist
7/29/2009
Date of Inspection
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information — Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17
Summary Record Card 7generated on 7/27/2009 11:36:51 AM by Karen Hanlon Page 1
Town of North Andover
Tax Map # 210-104.A-0065-0000.0
Parcel Id 16292
440 WINTER STREET
KING, THOMAS C.
440 WINTER STREET
N. ANDOVER, MA
01845
Class 101 Single Family Property Type 1 Residential
Size Total 1.02 Acres
FY 2009
UB Mailing Index
Name/Address
Type
Loan Number
Active/Inact. From
Until
KING, THOMAS C.
Payor
440 WINTER STREET
N. ANDOVER, MA
01845
UB Account Maint.
Account No
Cycle
Occupant Name
Active/Inactive
Bldg Id. 18165.0 - 440 WINTER STREET
Last Billing Date 7/8/2009
3180193
03 Cycle 03
Active
UB Services Maint.
Account No. 3180193
Service Code
Rate
Charge
Multiplier/Users
MISCFEE ADMIN FEE
0.635/8
7.82
1/
WTR WATER
01 ALL METER SIZE 44.07
/1
UB Meter Maintenance
Account No. 3180193
Serial No Status
Location
Brand
Type Size
YTD Cons
16748919 a Active
00
METE METE
w Water 0.63 0.63
78
Date
Reading
Code
Consumption
Posted Date
Variance
6/10/2009
724
a Actual
13
7/20/2009
-4%
3/18/2009
711
a Actual
15
4/29/2009
5%
12/15/2008
696
a Actual
14
1/20/2009
-17%
9/15/2008
682
a Actual
18
10/10/2008
-9%
6/10/2008
664
a Actual
18
7/16/2008
12%
3/14/2008
646
aActual
16
4/11/2008
31%
12/17/2007
630
a Actual
13
1/22/2008
-38%
9/14/2007
617
a Actual
19
10/12/2007
-6%
6/21/2007
598
a Actual
23
7/20/2007
5%
3/16/2007
575
a Actual
21
4/16/2007
-9%
12/13/2006
554
a Actual
21
1/19/2007
6%
9/19/2006
533
a Actual
21
10/20/2006
0%
6/21/2006
512
a Actual
21
7/10/2006
15%
3/23/2006
491
a Actual
16
4/17/2006
-13%
1/3/2006
475
a Actual
23
1/17/2006
13%
9/26/2005
452
a Actual
20
10/14/2005
-13%
6/21/2005
432
a Actual
21
7/15/2005
9%
3/24/2005
411
a Actual
21
4/5/2005
2%
12/17/2004
390
a Actual
17
1/14/2005
12%
9/28/2004
373
a Actual
20
10/8/2004
-7%
6/15/2004
353
a Actual
10
7/30/2004
-14%
4/27/2004
343
a Actual
30
5/17/2004
0%
Commonwealth of Massachusetts
City/Town of
System Pumping Record
M v> 1
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 side of house, Right side of house, Left front of house, Right front of house,
e rear of house` Right rear of house.
----------------
Address F L4 0 I!N
o
City/Town ( State Zip Code
2. System Owner:
Name v
Address (if different from location)
City/Town
State �� S _ `r a s ip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date — 2. Quantity Pumped
3. Type of system: ❑ Cesspool(s) Septic Tank
❑ Other (describe):
I or -r-')
Gallons
❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes D -Wo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
V') o:�'w.cLA
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
G.L.S.D Lowell Waste Water
Signature of Hauler
t5form4.doc• 06/03
Vehicle License Number F5821
Date
System Pumping Record • Page 1 of 1