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Home My WebLink AboutMiscellaneous - 45 SHANNON LANE 4/30/2018 (2) 45 SHANNON LANE 210/1070000.0 ' v r I r � I v North Andover Board of Assessors Public Access Page 1 of 1 NOR7h North Andover Board of Assessors � s �SSACMUStt roperty Record Card Click Seal To Return Parcel ID:210/107.A-0231-0000.0 FY:2010 Community:North Andover SKETCH PHOTO Click on Sketch to Enlarge Click on Photo to Enlarge i Search for Parcels a, Search for Sales .h Summary Residence Detached Structure Condo 45 SHANNON LANE Commercial Location: 45 SHANNON LANE Owner Name: "SHIAN,DANIEL A SUSAN M KESHIAN Owner Address: 45 SHANNON LANE City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 7-7 Land Area: 3.17 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 3940 s ft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 750,900 794,500 Building Value: 508,800 553,200 Land Value: 242,100 241,300 Market Land Value: 242,100 Chapter Land Value: LATESTSALE Sale Price: 371,000 Sale Date: 04/25/1991 Arms Length Sale Code: Y-YES-VALID Grantor: COOLIDGE CONSTRUCTIN Cert Doc: Book: 03245 Page: 0309j 1 http://csc-ma.us/PROPAPP/display.do?linkId=1519536&town=NandoverPubAcc 6/17/2010 NORTiN q Q �tLID 16' NO o =F � PY CO[NICMCNC wKK V �J,9 q°OATEo �Pa�'l9 SSACHUS� PUBLIC HEALTH DEPARTMENT (ommunity Development Division CERT FIC4rIE OF COM1'GIANCE As of: June 30, 2010 This is to cert that the individual subsurface disposal system received a MW ACTORTIMTECTIOYof the: WfpCacement of a System Component: Outlet Tee Foran On Site Sewage D 5 osalSystem By: ToddBateson At: 45 Shannon .Gane 5Wap-107.,X; Parcel 231 XorthAndover, 9VA 01845 The Issuance of this certiftate shall not 6e construed as a guarantee that the system will function satisfactorily. ZusWan . yer, Public Ifealth Director 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com TOWN OF NORTH ANDOVER NORTH Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 1600 OSGOOD STREET; Building 2-36 NORTH ANDOVER, MASS CHUSETTS 01845CH SacHus Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director �}11, 978.688.8476—FAX ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: MAP: LOT: G � INSTALLER: DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPE TION: DATE OF FINAL GRADE INSPECTION: C� SITE CONDITIONS ❑Existing septic tank properly abandoned ❑Internal plumbing all to one building sewer Comments: ❑Topography not appreciably altered SEPTIC TANK ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading Monolithic construction ❑ Water tightness of tank has been achieved (Visual or Vacuum Test or Water held for 24hrs) ❑ Inlet tee installed, centered under access port ❑ Outlet tee (gas baffle or effluent filter) installed, centered under access port ❑ 24" inch cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present ❑ Hydraulic cement around inlet & outlet Wastewater System Documentation—Feb 2006 Page 1 of 6 l R TOWN OF NORTH ANDOVER NORT„ Office of COMMUNITY DEVELOPMENT AND SERVICES 0- . , "°L HEALTH. DEPARTMENT p 1600 OSGOOD STREET;Building 2-36 NORTH ANDOVER,MASSACHUSETTS 01845 SNCHUS .Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX Comments.- PUMP omments:PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ Combo Tank installed. Size: ❑ 1000 gallon Pump Chamber installed H-10 loading Monolithic 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 ❑ 24" inch cover to within 6" of final grade installed over pump access port ❑ Water tightness of tank has been achieved Visual testing ❑ Hydraulic cement around inlet & outlet Comments: ADVANCED TREATMENT TECHNOLOGY ❑ Type of treatment device: ❑ Installed per manufacturers requirements ❑ All components working in accordance with manufacturer's requirements Comments: Wastewater System Documentation—Feb 2006 Page 2 of 6 Map-Block-Lot Commonwealth of Massachusetts 107.A0231 ----------------------- 3�°}�'��a Board of Health Permit No o a BHP-2010-0619 North Andover ----------------------- FEE + oi, - ; P.I. $125.00 F.I. 34�WSyS DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted _Todd Bateso_ n ---------------------------------------------------------------------------------------- _ to(Repair-OUTLET TEE)an Individual Sewage Disposal System. atNo 45 SHANNON LANE --- ----------- ------------------------------------------------------------------------------------ - ----------- - 0 -_6.1 Dated. June_17,-2010-------- --- ---- - -- --- ----- - __ � --- as shown on the application for Dis osal Works Construction Permit No. BHP-2010 C� _________________ Issued On:Jun-17-2010 Board of Health e of �N SNC Applicationifor Septic Disposal System #• A Construction Permit — TOWN OF TODAY'S DATE 4VV ORTH ANDOVER, MA 01845 o,.00_—Full Repair C �`' 7 5.00-Component Important: Application is hereby made for a permit to: When filling out — forms on the El Construct a new on-site sewage disposal system* computer,use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key to move your ❑ Repair or replace an existing system component—What? .0— 7�R_ cursor-do not use the return key. A. Facility Information �� 1� Address or Lot# led�a City/Town d • �� t* YPE OF SEPTIC SYSTEM*: t7PE Gravity(choose one) ***If pump system,attach copy of electrical permit to application*** Conventional System(pipe and stone system) ❑ Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system. ❑Pressure Distribution S.A.S.(No D-Box)(Attach Draft Maintenance Agreement) ❑Pressure Dosed(D-Box Present)S.A.S. 2. Owner Information Name � ,'5:kRA AOAI Address(if diff� /erent from above) IVO r AA /4 Ctty/Town State Zip Code C1 'y —. alp 7 Telephone Number 3. Installer rIInformation Name Name of C mpanyfoARC3ItJ.A��, Address City/Town State Zip Code �`�$' WS—o17o3 Telephone Number(Cell Phone#if possible please) 4. Designer Inform ion CFAy) `T781 Name Name of Company Address City1rown State Zip Code Telephone Number(Best#to Reach) Application for Disposai System Construction Permit•Page t of 2 ORT �a Application for Septic Disposal S stem � �r� + '�••�� t Construction Permit - TOWN. OF TODAY'S DATE f. /.' ORTH ANDOVER MA 01845 $250.00-Full Repair 9ss,�C,,,,set $125.00 -Component 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 iss,oqby this Board of Health. Na Date Application Ap r ved By: ( lyd of Health Representative) Name Date ApP0ation l4isappr ed fort following reasons: For Office Use Only: L Fee Attached.? Yes No 2. Project Manager Obligation Form Attached. Yes No I Pump S sy tem? Ifso;Attach copy ofElectrical Permit Yes No 4. Foundation As-Built?(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: S h 4,✓-1V0e� T�I r (Address of septic system) For plans by (Engineer) Relative to the application of 1 d tR Sri/✓ (Installer's name) And dated ngina ate Dated _ l `7-4 I oday 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 Tide 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or my company. a. Bottom of Bed–Generally,this is the first(1S) inspection unless there is a retaining wall,which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection–Engineer must first do their inspection for elevations,ties,etc. As-built of verbal OK(or e-mail to: healthdept@townofnorthandover.com) from the engineer must be submitted to the Board of Health,after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system,all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade–Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation)and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer,I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board ofHealth staff or consultant. d. Installation of tai*D-Box,pipes, stone, vent,pump chamber, retaining wall and other components. 6. As the installer. I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner,general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: (Today's Date) ZIP` l� ��yes✓ 7a—me– rtnt (Name tgne . . f . LRE bfin 9_ Commonwealth of Massachusetts ---- Title 5 Official Inspection Form014Subsurface Sewage Disposal System Form - Not for Voluntary AssessANDOVER RTMENT M 45 Shannon Lane Property Address Michael Flanagan Owner Owner's Name information is required for every North Andover MA 01845 page. Citylrown 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:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not David Chandler use the return Name of Inspector key. Sewer Works VOR,� Company Name 26 Hillside Ave. Company Address Westford MA 01886 City/Town State Zip Code 978-692-4410 S137 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: E Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority r 9/19/2014 In ctor's ignature 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 t r Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 45 Shannon Lane Property Address Michael Flanagan Owner Owner's Name information is North Andover MA 01845 required for 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: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old" or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 45 Shannon Lane _ Property Address Michael Flanagan Owner Owner's Name information is required for every North Andover MA 01845 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Shannon Lane Property Address ----- - - - - - - - ---- Michael Flanagan Owner Owner's Name information is North Andover MA 01845 required for every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 45 Shannon Lane Property Address Michael Flanagan Owner Owner's Name information is required for every North Andover MA 01845 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Shannon Lane 1y Property Address --- --— -- - Michael Flanagan Owner Owner's Name information is required for every North Andover MA 01845 page. CitylTown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Shannon Lane_ Property Address Michael Flanagan Owner Owner's Name information is required for every North Andover MA 01845 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 244 gpd 9 ( Y 9 (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: na 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts _ F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Shannon Lane Property Address Michael Flanagan Owner Owner's Name information is North Andover MA 01845 required for every page. City/Town 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: Owner __ Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 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 45 Shannon Lane Property Address Michael Flanagan Owner Owner's Name information is required for every North Andover MA 01845 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: installed 1989 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 28 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.): Septic Tank (locate on site plan): 18"with Cl cover to grade on center Depth below grade: lid 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: 10.5'x5.5' -- - Sludge depth: 15" t5ins•3/13 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 45 Shannon Lane _ Property Address Michael Flanagan Owner Owner's Name information is North Andover MA 01845 required for 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 -19-- ------- 1" Scum thickness Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? observation and measurement Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): recommend pumping every two years; both baffles are intact, no signs of any cracks or leaks, liquid level at outlet invert 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i i it Commonwealth of Massachusetts -: Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M i 45 Shannon Lane Property Address Michael Flanagan Owner Owner's Name information is required for every North Andover MA 01845 page. Cityfrown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Shannon-Lane— Property hannonLaneProperty Address Michael Flanagan Owner Owner's Name information is required for every North Andover MA 01845 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): 011 Depth of liquid level above outlet invert - 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.): Depth 12"; observed level even flow out of Dbox; no solids observed in Dbox, no leaks or cracks observed; system vented off Dbox 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.): pump system is constructed using two float system. Pump chamber has cast iron cover to finish grade, estimated_pump chamber size is 500 gallons pump and floats switch in good working order_ " If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts ----- W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 45 Shannon Lane Property Address Michael Flanagan Owner Owner's Name information is required for every North Andover MA 01845 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 3@ 45' ❑ 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.): sandy soils observed, did not observe any hydraulic failure, no ponding, no damp soils; grass over leach area wwith trees on edge 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-3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Shannon Lane Property Address Michael Flanagan Owner Owner's Name information is North Andover MA 01845 required for every State Zip Code Date of Inspection page. Cityrrown 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 i i I Commonwealth of Massachusetts -- - W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Shannon Lane Property Address Michael Flanagan Owner Owner's Name information is required for every North Andover MA 01845 page. City/Town 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ° 45 Shannon Lane Property Address Michael Flanagan Owner Owner's Name information is required for every North Andover MA 01845 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope Yf::�5 ® Surface water ® Check cellar Y ® Shallow wells N Estimated depth to high ground water: 4'+ below trench bottoms 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: 8/9/2009 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: You must describe how you established the high ground water elevation: Review of original plans prepared by design engineer indicates leaching area was designed and constructed minimum 4' above established high ground water. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts - v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Shannon Lane _ Property Address Michael Flanagan Owner Owner's Name information is required for every North Andover MA 01845 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ 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•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Shannon Lane Property Address —--——------ --— —-------— —-----—— Michael Flanagan Owner information is Owner's Name required for every North Andover MA 01845 page. City/Town State Zi Code P 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 7Q � tk Dr i VewCL G o C- E. j�o�D Qex F IL4 ` - 3916 tt t5ins-3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 y • I P Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form-Not for Voluntary Asse ment �� _ ? �o M ,•''t 45 Shannon Drive Property Address �LQTF�HoepAR Dan Keshian v��NV�R Owner Owner's Name information is required for North Andover MA 01845 6/21/2010 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: 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 few Citylrown State Zip Code 978-475-4786 SI15 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 system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑Nr'sSignature er Evaluation by the Local Approving Authority 6/21/2010 Ins 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 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 �,M s•' 45 Shannon Drive Property Address Dan Keshian Owner Owner's Name information is required for North Andover MA 01845 6/21/2010 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: ® 1 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., install new outlet tee with gas baffle, 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 ❑ N ❑ ND (Explain below): t5ins-09108 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 • , t Commonwealth of Massachusetts �ECEIV0 _ Title 5 Official Inspection Form � Q�o a Subsurface Sewage Disposal System Form Not for Voluntary Assessm is TOWN OP NORTH ANDOVER 45 Shannon Drive HEALTH DEPARTMENT Property Address Daniel KeshianTZ37r Owner Owners Name information is required for North Andover MA 01845 6/12/2010 every page. City/Town 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. Imparant: A. General Information [z-r When filling out L 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 VQ 111 Argilla Road fk 10 Company Address Andover Ma 01810 'e0/n City/Town State Zip Code 978-475-4786 SI15 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 ❑ Needs Further Evaluation by the Local Approving Authority 6/12/2010 Inspe o Signature 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 • In. r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Shannon Drive Property Address Daniel Keshian Owner Owner's Name information is required for North Andover MA 01845 6/12/2010 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: 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Shannon Drive Property Address I Daniel Keshian Owner Owner's Name information is required for North Andover MA 01845 6/12/2010 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 ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-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 45 Shannon Drive Property Address Daniel Keshian Owner Owner's Name information is required for North Andover MA 01845 6/12/2010 every page. City/Town 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 tee in septic tank 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•09/08 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 M ,•�'"p 45 Shannon Drive Property Address Daniel Keshian Owner Owner's Name information is required for North Andover MA 01845 6/12/2010 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•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 45 Shannon Drive Property Address Daniel Keshian Owner Owner's Name information is required for North Andover MA 01845 6/12/2010 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): ' 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins-09108 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 45 Shannon Drive Property Address Daniel Keshian Owner Owners Name information is required for North Andover MA 01845 6/12/2010 every page. Cityfrown 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 Seasonaluse? ❑ 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 45 Shannon Drive Property Address Daniel Keshian Owner Owner's Name information is required for North Andover MA 01845 6/12/2010 every page. Cityrrown 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 2009, 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&tees 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 UA 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 45 Shannon Drive Property Address Daniel Keshian Owner Owner's Name information is required for North Andover MA 01845 6/12/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 21 years old, 8/9/1989 as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 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: 2 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: 2" 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 45 Shannon Drive Property Address Daniel Keshian Owner Owner's Name information is required for North Andover MA 01845 6/12/2010 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 N/A Scum thickness 2.1 Distance from top of scum to top of outlet tee or baffle N/A Outlet tee off Distance from bottom of scum to bottom of outlet tee or baffle N/A How were dimensions determined? Tape Measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumped septic tank. Inlet tee ok. Outlet tee corroded off. 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 M 45 Shannon Drive Property Address Daniel Keshian Owner Owner's Name information is required for North Andover MA 01845 6/12/2010 every page. Cityrrown 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 �M ,•�''r 45 Shannon Drive Property Address Daniel Keshian Owner Owner's Name information is required for North Andover MA 01845 6/12/2010 every page. City/Town 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.): Pump cycled on then off. Pump ok. Alarm has audible&visual Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins-09108 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Shannon Drive Property Address Daniel Keshian Owner Owner's Name information is required for North Andover MA 01845 6/12/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 3 trenches 55' 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•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 M SV'V`v 45 Shannon Drive Property Address Daniel Keshian Owner owner's Name information is North Andover MA 01845 6/12/2010 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•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 .�' 45 Shannon Drive Property Address Daniel Keshian Owner Owner's Name information is required for North Andover MA 01845 6/12/2010 every page. Cityrrown 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 �ctve�� Rouse �� rJ 0 S ' t✓ /� 0 t efU'.31t T 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 45 Shannon Drive Property Address Daniel Keshian Owner Owner's Name information is required for North Andover MA 01845 6/12/2010 every page. Cityrrown 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: 1/16/1989 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: You must describe how you established the high ground water elevation: As per design plan test pit data Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form M Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 45 Shannon Drive Property Address Daniel Keshian Owner Owner's Name information is required for North Andover MA 01845 6/12/2010 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® 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 i Summary Record Card generated on 6/4/2010 9:47:34 AM by Lisa Evans Page 1 Town of North Andover Tax Map # 210-107.A-0231-0000.0 Parcel Id 18056 45 SHANNON LANE KESHIAN, DANIEL 45 SHANNON LANE NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 3.17 Acres FY 2010 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until KESHIAN,DANIEL Payor 45 SHANNON LANE NORTH ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id.22351.0-45 SHANNON LANE Last Billing Date 6/2/2010 2100215 02 Cycle 02 Active UB Services Maint. Account No.2100215 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 34.20 /1 UB Meter Maintenance Account No.2100215 Serial No Status Location Brand Type Size YTD Cons 36185615 a Active ERT HH b Badger w Water 0.63 0.63 23 Date Reading Code Consumption Posted Date Variance 5/3/2010 38 a Actual 9 6/9/2010 -36% 2/1/2010 29 a Actual 14 3/11/2010 -45% 11/2/2009 15 a Actual 15 12/11/2009 0% 9/9/2009 0 n New Meter 0 12/11/2009 0% 8/3/2009 3811 m Manual estimate 45 9/11/2009 140% 5/7/2009 3766 m Manual estimate 20 6/16/2009 14% MSG 2/2/2009 3746 m Manual estimate 17 3/16/2009 -64% MSG 11/3/2008 3729 a Actual 49 12/10/2008 -15% 8/1/2008 3680 a Actual 56 9/12/2008 381% 5/2/2008 3624 a Actual 11 6/18/2008 -27% 2/6/2008 3613 a Actual 17 3/14/2008 -69% 11/1/2007 3596 aActual 52 1/15/2008 77% 8/2/2007 3544 a Actual 29 9/14/2007 40% 5/4/2007 3515 a Actual 15 6/22/2007 82% 2/28/2007 3500 m Manual estimate 15 3/23/2007 -81% 11/2/2006 3485 a Actual 61 12/22/2006 -17% 8/1/2006 3424 aActual 70 9/13/2006 411% 5/4/2006 3354 a Actual 14 6/20/2006 -18% 2/2/2006 3340 a Actual 17 3/13/2006 98% 11/3/2005 3323 a Actual 8 12/14/2005 7% 8/10/2005 3315 a Actual 8 9/12/2005 -53% 5/11/2005 3307 a Actual 16 6/8/2005 5% 2/14/2005 3291 a Actual 16 3/15/2005 33% 11/16/2004 3275 aActual 13 12/17/2004 -88% Vit._ 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 tQ determine the form they use. The System Pumping Record must be submitted to the local Board of Health of-othor approving authority. A. Facility Information 1. System Location: Left side of house, Right side of house, Left front of houe, Right front of house, Left rear of house, Right rear of house. Left rear of building. Right rear of bui Address l� Cityrrown —1 Y \vv ) State Zip Code W 2. System Owner: Name Address(if different from location) City/Town Stat, Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes _ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: LA czl Ocx)'Mo CIA-0-6o �/I�z 6. System Pumped By: Q Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location ere contents were disposed: .L.S.D Lowell YVaste Wter Signature of ul Date t5form4.doc•06103 System Pumping Record.Page 1 of 1 .> 7" z 11 god r 1 � v ,uu�sy ZZ r 1 y t� /J Z �Z SCO SLOPE 1eeOO1 eEit o1ENT ��ZH OF Y �. (/50) X — /50 — _ . .. . . .. . ... . . .... . .. .. . . .. . c . c I m H DESION ELEV4T/ON 4T.. .(TOP OF 57ONE) _ o 2889'' EX/5TIN6 ELEk1aT1ON ,4T.. . .. .. . . 2EQUi�EDNAL fl-EX..4T/ON.5 oE51i�!N A5 BUW- 45 f31//L T INV P/PE OL/T OF/-/OUSE rev /NV P/PE INTO T4NK /? f,3`<' - ra 0SU,B -SU,e�,�CE D/SPD �l L /NV. PIPE OUT OF TANK / l SYSTEM /NV PIPE INTO D. BOX l a 5- y5 �� `� INV PIPE OUT OF D. BOX -3, T 78 /N INV END OF PIPE t n FOI W,d TE2 EL EV4 TION ,4 VER 4C,E 5 TONE SCOL E DEPTH .4T PeOBE NOTE.- 71115 PL4N /5 NOT ,4 w4,ee.4NTY C14R/5TIQNSEN SERGI , INC. OF T11E SYSTEM BUT ,4 PCIeIF/C.47-10N 1&0 SUMMER 5MEET HAVER14ILL,MASS. OF Tf1E LOC,4TION OF T,-1E EX/STING 112- ST�UCTU2ES. L4 R of KQ N Nott b( NdI�TN �ti iX��EI�� NtA. ��'�'" •�.�---^ .^ lig �QPLI CAtiJ I Coo�.tDC� O wEt..L �P ouCD i�f'G s5 StPVIC S1rs i�M vEs►<� ,�PPt�ovt;D DArt' 7-cv- � 8 APR�Ovw6 /0r►101-�iTy � cR� Sal r7Df 5 GoT 5 (, 154 c•�ROVEp Dq"t 5 , O cv osuc RC�SoNS : JoST 6C- � 57-p4 iC-AT ,D� ____ � StPT'!C SYSTEM I�SiA Ll.,QT►o�1 eXQU/JT(ol-) 1tiSt�t^G►r�,v U/J�C 7-/� SSS ❑ F4It_. �i�AL t�15PF�rlon� AP�i�ovEp TC , APPi4DvrNG ,q�t�toi�iry� DiSApj7Ro\j6D D,arC R�So NS' l -10 Appolv-t AviHoRl�/