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Miscellaneous - 46 LIBERTY STREET 4/30/2018 (2)
I 46 LIBERTY STREET 210/105.D-0130-0000.0 - i U� v c� v \) Residential Property Record Card#1 of 1 Parcel Year:2018 PARCEL ID: 210/105.D-0130-0000.0 MAP 105.13 BLOCK 0130 LOT 0000.0 PARCEL ADDRESS: 46 LIBERTY STREET as of:4/24/2017 PARCEL INFORMATION Use-Code: 101 Sale Price: 564000 Book: 9036 Tax Class: T Sale Date: 9/3/2004 Page: 34 Tot Fin Area: 2880 Sale Type: P Cert/Doc: Tot Land Area: 1.1 Sale Valid: Y Owner#1: BELLOSGUARDO, STEPHANE Grantor: ROTHSTEIN, RICHARD Owner#2: BELLOSGUARDO, MARIELINE Address#1: 46 LIBERTY STREET Inspect Date: 12/5/2011 Road Type: T Exempt-B/L%: 0/0 Address#2: Meas Date: 12/5/2011 Rd Condition: P Resid-B/L%: 100/100 NORTH ANDOVER MA 01845 Entrance: X Traffic: M Comm-B/L%: 0/0 Collect ID: RRC Water: Indust-B/L%: 0/0 Inspect Reas: C Sewer: Open Sp-B/L%: 0/0 RESIDENCE# 1 INFORMATION LAND INFORMATION NBHD CODE: 5 NBHD CLASS: 5 ZONE: R1 Style: CL Tot Rooms: 7 Main Fn Area: 1620 Attic: Seg Type Code Method Sq-Ft Acres Influ-1/2/3 Value Class Story Height: 2 Bedrooms: 4 Up Fn Area: 1260 Bsmt Area: 1620 Roof: G Full Baths: 2 Add Fn Area: Fn Bsmt Area: 168 1 P 101 S 43560 1 100/ 206910 Ext Wall: AV Half Baths: 1 Unfin Area: 276 Bsmt Grade: 2 R 101 A 0.1 100/ 760 Masonry Trim: Ext Bath Fix: Tot Fin Area: 2880 Foundation: CN Bath Qual: T RCNLD: 387865 Kitch Qual: T Eff Yr Built: 1992 Mkt Adj: Heat Type: FA Ext Kitch: Year Built: 1987 Sound Value: Fuel Type: O Grade: G Cost Bldg: 387900 Fireplace: 1 Bsmt Gar Cap: Condition: G Att Str Val1: DETACHED STRUCTURE INFORMATION Central AC: N Bsmt Gar SF: Pct Complete: Att Str Val2: Str Unit Msr-1 Msr-2 E-YR-Blt Grade Cond %Good P/F/E/R Cost Class Att Gar SF: 528 %Good P/F/E/R: /100/100/88 PV S 800 1995 A A /50//44 15100 Porch Type Porch Area Porch Grade Factor PT S 540 1995 A A ///88 3400 E 276 VALUATION INFORMATION SKETCH Current Total: 614100 Bldg: 406400 Land: 207700 MktLnd: 207700 Prior Tot: 614100 Bldg: 406400 Land: 207700 MktLnd: 207700 14 23 PHOTO 4 —_---- 12 276 Sq.Ft. 12------------------ 23 39 22 01 40 FMIB 528 Sq.Ft. — FU 1620 Sq.Ft.: — 1260 Sq.Ft. 24 24 8 22 45 4 ".. 46 L-5 LIBERTY STREET 46 LIBERTY STREET JS-2005-0009 Project Detail Report Printed On:Mon Jul 12,2004 Project Name: GIS#: 6580 Project No: JS-2005-0009 Owner of Record ROTHSTEIN,RICHARD A& Map: 105.13 Date Submitted: Apr-26-2004 46 LIBERTY STREET Block: 0130 Status: Open NORTH ANDOVER,MA 01845 Lot: Work Category: Work Location: .46 LIBERTY STREET Zoning: Proposed Use: District: land Use: 101 Proposed Use Detail Subdivision Description Outlet Tee&Pipe to D-Box Only Comments: of Work: Department Status GeoTMS Module: Status File No. Comments: LCDate: Board of Health GREEN FLAG BHJ-2004-0099 7/9/04-Rich Rothstein,H/O called-question regarding flow and size of septic for 5 people. S.Sawyer called bac:spoke to owners wife. Hypothetical--ok for additional bathroom and A to increase to 5 bedroom. Already a 10 room house. Do not increase to over 11 rooms.--p.d. " Permit History r' Type: Permit No: Issue Date Status Work Category Contractor Project No: Description of Work: DWC Component Repair- BHP-2004-0487 Apr-26-2004 SIGNED OFF JS-2005-0009 Repair-Individual Components GeoTMS®2004 Des Lauriers Municipal Solutions,Inc. Page 1 of 1 Po-I e, � • s� LED'] . e c PUBLIC HEALTH DEPARTMENT Town of North Andover Community and Economic Development Division CERTIFICATE OF COMPLIANCE As of: May 22, 2017 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: D-Box Repair only By: Robert Diagle At: 46 Liberty Street Map 105.D Lot 130 North Andover, MA 01845 41ssu of t ' ificate shall not be construed as a guarantee that the system will function satisfactorily. aGrass , HT Public Health Agent 120 Main St.,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web www.northandoverma.gov ` 7 � `J � NONTp O, 9 Town of North Andover ' '•°,,,,° HEALTH DEPARTMENT ,SSACMUSt� U CHECK#: �'/Y DATE: 7 L y ZCSI LOCATION: Zee H/O NAME: �- CONTRACTOR NAME: D ?z -A 9 22 0C 9,3 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) $ E ❑ Title 5 Inspector � $ ❑ Title 5 Report n f $ Other:(Indicate) $ / 7S le�R He UhgentInitials White-Applicant Yellow-Health Pink-Treasurer Commonwealth of Massachusetts Map-Block-Lot 105.D0130 f BOARD OF HEALTH • North Andover CERTIFICATE OF COMPLIANCE THIS IS TO CERTIFY,That the Individual Sewage Disposal System (Construct) by ---RobertDaigle-------------------------------------------------------------------------------------------------------------------- -------- --------------- Installer at No 46 LIBERTY STREET ---------------------------------------------------------------------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. BHP-2017-037 Dated Apri124,_2017 ----------------------------------------------------------------- Printed On:Apr-24-2017 BOARD OF HEALTH ----------------------------------------------------------------------------- • e�" °r�sr , Commonwealth of Massachusetts Map-Block-Lot 105.D0130 BOARD OF HEALTH Permit----- No North Andover -BHP-2017- ----------------------- FEE $175.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Robert-Daigle - ----------------------------------------------------------------------------------------- to(Construct)an Individual Sewage Disposal System. at No 46 LIBERTY STREET as shown on the application for Disposal Works Construction Permit No. BHP-2017-037 Dated April 24,2017 ---------------------- ----------------------------- ----------------------------------------------------------------- Issued On:Apr-24-2017 BOARD OF HEALTH Commonwealth of Massachusetts Map-Block-Lot ' • ��` �. 105.D0130 BOARD OF HEALTH ----------------------- North Andover CERTIFICATE OF COMPLIANCE THIS IS TO CERTIFY,That the Individual Sewage Disposal System (Construct) by --RobertDai_gle------------------------------------------------------------------------------------------------------------------------------------- Installer at No -4-6-LIBERTY-STREET has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. -BH-]P--2-0-1-7---03 Dated April_24,_2017 ----------------------- ------ ----------- --------------------------------------------------- Printed On:Apr-24-2017 BOARD OF HEALTH • 4wtrj , Commonwealth of Massachusetts Map-Block-Lot —• _• 105.D0130 . BOARD OF HEALTH Permit No North Andover BHP-2017-03 11 72 ------- -- FEE $175.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted RobertDaigle - ----------------------------------------------------------------------------------------- to(Construct)an Individual Sewage Disposal System. at No 46 LIBERTY STREET ---------------------------------------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP-2017-037 Dated April 24,2017 ---------------------------------- Issued On:Apr-24-2017 BOARD OF HEALTH AW -. Application for Septic Disposal System AY'S DA E Construction Permit - TOWN OF TO -Full Repair NORTH .ANDOVER, MA 01845 $75 00-Component Important: Application is hereby made for a permit to: When filling out ❑Construct a new on-site sewage disposal system* forms on the computer,use [}Repair or replace an existing on-site sewage disposal system* � ,n i3 only the tab key El Repair or replace an existing system component—What? !✓ is o to move your cursor-do not �® use the return A. Facility Information //++ key. V�� e ►�1 Address or Lot# I/�Z!✓ A6 ( � City/Town2.-*TYPE OF SEPTIC SYSTEM*: ➢ ❑ Pump ❑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) ➢ ❑ Pressure Dosed(D-Box Present)S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES =(no further info. needed) NO=(installer must specify brand of filter before DWC issuance) What is the Make? What is the Model? 2. Owner Inform tion Name Address(if different from above) City/Town State Zip Code F. 7� Email address Telephone Number 3. Installer Informatio y e / '� k � Name Name of Company L ff' yV Address d City/Town StateZip Code F 9 F y� q3 Telephone Number(Cell Phone#if possible please) 4. Designer Information Name Name of Company Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit-Page 1 of 2 ,►`I 1 L l qp►a p lication for Septic Disposal S stem TODAY'S DATE ?onstruction Permit — TOWN OF $350.00 -Full Repair NORTH ANDOVER, MA. 01845 $175.00 -Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: UResidential 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. 1 understand that until a final Certificate of Compliance has been issued by this Boa4of Health, the"fled fled sy tem is not approved. Nam6 Date Application Approved By: (Board of Health Representative) Name Date Application Disapproved for the following reasons: For Office Use Only: 1. Fee Attached? Yes No 2. Project Manager Obligation Form Attached? Yes No 3. Pump Sys tem? If so,Attach cop,v ofElecuical Permit Yes No Applicantreceived copy of "Electrical Inspection Notes for Septic Systems" Yes No Handout? 4. Reviewed approval letter, all paperwork received.? Yes No Missing: 5. Foundation As-Built?(new construction only): Yes No (Same scale as approved plan) 6. Floor Plans?(new construction only): Yes No Application for Disposal System Construction Permit•Page 2 of 2 ! SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: Y (Address of septic syst ) For plans by (Engineer) Relative to the application of v (Installer's name) I And dated (Original ate Dated �Zil�' ( o ay 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 plansrp for to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer,I must call for any and allinspections. If homeowner, contractor, project manager, or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection,without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or my company a. Bottom of Bed—Generally, this is the first (1'� inspection unless there is a retaining wall,which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection—Engineer must first do their inspection for elevations, ties, etc. As-built of verbal OK (or e-mail to: healthdept@townofnorthandover.com) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system, all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade—Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation) and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board of Health staff or consultant. d. Installation of tank, D-Box, pipes, stone, vent,pump chamber, retaining wall and other components. 6. As the installer, I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, eneral kontractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: (T a T's ate) (Name—Print) e— ign y7�- `/.z3 - S33 U�' -- - - - D • 5 7686 � Ili North Andover Health Department (ommunity and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 46 Liberty Street MAP: 105.D LOT: 130 INSTALLER: Robert Daigle DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: l INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ .Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX Installed on stable stone base ©� H-20 D-Box ❑ Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets Fq Observed even distribution Speed levelers provided (not required) Q Schedule 40 PVC Pipe Comments: j l SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel-less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = FINAL GRADE ❑ Loamed ❑ Seeded ❑ Cover per plan Comments: DOCUMENTS NEEDED Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer ❑ As-Built Plan BM = HR = HI = SYSTEM ELEVATIONS ROD AS-BLT INVERT DESIGN INVERT ELEVATION ELEV ELEV Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 TOP Lateral 1 INVERT Lateral 2 TOP Lateral 2 INVERT Lateral 3 TOP Lateral 3 INVERT Lateral 4 TOP Lateral 4 INVERT Lateral 5 TOP Lateral 5 INVERT Lateral 6 TOP Lateral 6 INVERT Top of Chamber Bottom of Bed/Chamber SKETCH PLAN � r CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- ® Waterline 10 10 101 ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh, Inland/Coastal Banka 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib. to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot. Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 ® Drains (Other)Foundation 10(5) 20(10) ® Drywells 20 25 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54,and 10.30,respectively,pursuant to 15.211(3),also by NA wetland bylaws Commonwealth of Massachusetts .T//-T//0/7 Title 5 Official Inspection For . D ..... Not for Voluntary Assessments Subsurface Sewage Disposal System Form U 46 Lib rt_Street Property Address Maryline Bellosguardo Owner Owner's_Name information is MA 01845 04/17/2017 --------- required for every North Andover--------- 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. Important:When A. General Information filling out forms N on the computer, '\0,00 \ use only the tab 1. Inspector: key to move your cursor-do not Gerardo Valentin use the return Name of Inspector key. Wind River Environmental --------- tab -Company—Name 4.6--Lizotte Drive Suite 1000 Company Address Marlborough MA 01752 Ci State Zip Code 800-499-1682 S113834 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 16.000).The system: ❑ Passes conditionally Passes 0 Fails ❑ Needs Further Evaluation by the Local Approving Authority � I-7 � iT_ Inspecto s Signature Date 4Thsysstem 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 1 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ap 46 Liberty Street Property Address Maryline Bellosguardo Owner Owner's Name information is required for every North Andover MA 01845 04/17/2017 - page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments N 46 Liberty Street Property Address Maryline Bellosguardo Owner Owner's Name information is North Andover MA 01845 04/17/2017 required for every —_ _ page. City/Town 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): D-box has heavy deterioration and corrosion. Needs to be replaced. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 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 .H ap 46 Liberty Street Property Address Maryline Bellosguardo _ Owner Owner's Name information is North Andover MA 01845 04/17/2017 required for 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 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 1/2 day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 t Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 Liberty Street Property Address Maryline Bellosguardo Owner Owner's Name information is required for every North Andover MA 01845 04/17/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts -_ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M a 46 Liberty Street Property Address Maryline Bellosguardo Owner Owner's Name information is required for every North Andover MA 01845 04/17/2017 — 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? ® El information 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): 4409pd t5ins.doc•rev.6/16 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 e 46 Liberty Street Property Address Maryline Bellosguardo Owner Owner's Name information is North Andover MA 01845 04/17/2017 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 5 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 Private well 9 ( Y 9 (gP ))� 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 Liberty Street Property Address Maryline Bellosguardo Owner Owner's Name information is North Andover MA 01845 04/17/2017 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: The home owner and Wind River Environmental are Source of information: the sources of the information. Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? The quantity was determined by the pump truck and it was measured. Reason for pumping: To check the structural integrity of the septic tank. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 Liberty Street Property Address Maryline Bellosguardo Owner Owner's Name information is North Andover MA 01845 04/17/2017 required for every 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: 1986 per plans at the Board of Health. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet t Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Private well over 100' feet Comments (on condition of joints, venting, evidence of leakage, etc.): All joints look ok venting is good no leakage. Septic Tank(locate on site plan): Depth below rade: 12 p g 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'x 5' x 5' Sludge depth: 7 t5ins.doc•rev.6/16 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 Liberty Street _ Property Address Maryline Bellosguardo Owner Owner's Name information is North Andover MA 01845 04/17/2017 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" — 2" 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? The dimensions were determined by sludge judge, rod, and ruler. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Recommend yearly service. Inlet and outlet tees are in good condition. Structural integrity of the tank is good. Liquid level to the outlet invert is good. No 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.doc•rev.6/16 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 w0 46 Liberty Street Property Address Maryline Bellosguardo Owner Owner's Name information is required for every North Andover MA 01845 04/17/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6/16 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 46 Liberty Street Property Address Maryline Bellosguardo Owner Owner's Name information is North Andover MA 01845 04/17/2017 required for 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" (Box is 33" below grade) Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is level and distribution to outlets is equal. Some solids carryover, but no leakage. Box has heavy corrosion and deterioration. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 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 46 Liberty Street Property Address Maryline Bellosguardo Owner Owner's Name information is North Andover MA 01845 04/17/2017 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 4@20'wx45' 1 ❑ 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 soil with no signs of hydraulic failure. No ponding and normal vegetation. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth –top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool --- — Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6/16 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 A 46 Liberty Street Property Address Maryline Bellosguardo Owner Owner's Name information is North Andover MA 01845 04/17/2017 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts - Y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 ^ / 46_Liberty_Street Property Address ---— Maryline Bellosguardo Owner Owner's Name ------------—-------------------------------- information is North Andoye_r__ _ _ MA 01845 _ 04/17/2017 required for every _ _ 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: �t Band-sketch in the area below F-1 drawing attached separately � Oval, W11iJl C'L-OY loo wl f 4-- c+ 05 �¢ I s t&ns.doc•rev.6/16 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 ata 46 Liberty Street Property Address Moline Bellosguardo Owner Owner's Name information is required for every North Andover MA 01845 04/17/2017 page. City/Town 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: 8 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: 5/1/1985 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: Design plans at the Board of Health. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form_Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts _ w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 46 Liberty Street Property Address Maryline Bellosguardo Owner Owner's Name information is required for every North Andover MA 01845 04/17/2017 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 • C) z 0 0 C:) C:) 3;o z •a p ON o r o r• o b o M n .o— rt cn ti H rt p H C o Z Fz '� . Report h jN PNUO�R pNTM '� e SO N�F NR�Epp,RTMEN�0 a`.p o �ZN 0 82165 p Workorder# 02 2006 C er Since ' ustom System Location SSACM�S v o 0 0 ECK# 0 C o }rY Home Street 0 Lv` �li( o ibA Loe , Vill vv 845 19181 915-12 w1 s9 ardo Mary ne cupancY `" Household Gc 6 2 8 CD 5 0 0 1 2 3 4 12 12 12 C❑NTI� w 18 16 14 12 22 20 14 12 —_ 0 1000 1g 18 16 14 Tv 6 s 1250 22 20 20 20 18 1b 14 1b ❑ Ant 15Q0 24 22 22 22 20 18 16 ❑ Bo o ►- 2000 2b 14 0CD 0 ❑ B' o -6 Score From Table ❑ r _ Ext Price Disposal? -5 rice $ 535. e Disp ❑ 00 Garbage > 10 Years? +8 ,� e 0 0 990 $ 150'.oo System occupancy? +5 ❑ CD 000 $ 259.'16 Seasonal Used? 11 626 $ 19.50 Bacteria Additive ❑ ;000 eats o _ Total Ad]ustm 3 ❑ o _ 0 0 C Net Score Service Eve Score 6 Months `5 12 Months �-` 6- 18 Months O to 23 0 P 1p49.26 16- 24 months CD -4 ,btotak: S 0.00 24+ o � aA $ 9.26 service eM ce oval $s 1Schedule 110* 7 ❑ Well Constru" - Oct SEPTICS steins, $------ Call(8p0)499-1682 Soil Testing $�— payment Detail: 03/2020 ❑ $eptic o eX xXRe XXXt 3018 Design Approval Am ceip ❑ Septic_ CtiOn�WC) $-- pue on ❑ Septic Disposal Works Constrn Works Installers(DW') leaning ❑ Septic Diosal sp $ ❑ Title 5 Inspector e 5 Report Title 0/ .l 499-1682• ns Specialist. X mer Signature itio custo ❑ Other:(Indicate) ?it at:p3�58 PM gent Initials Both baCCLSs a 500 Healt g Iditi. Tl- 5 1 MET AL :urea. N pink-Treasurer :20 tarlx ie ch bed 401b E N y j R O Health replace System 1n White_Applicant Ye110W_- aVe e con t onal Pass. Otte or Suite 1000,Marlborough,MA01752 Remit payment to 4r U¢ �' � '� _ ,��--,`'"'�- «'..++r'r�" :rtttt/• „tea= lw . ido .4. � � f xti111011111 1* „ asiWIN rt 1 Y i # J gra CW MERMill III IN AMI y # • F� `'i rr ,,. >• s Al �"6'� �i1 a'+ffi t CRY , . �t 'fit �t�€�irs'+`" "d'��` S"A�"..,1� �3 r!' �, if i+ *� "-., < � `�.`•'�� ''x-• m= d . � ♦ � e� d i � � +rix A '� ..-Y ..� 1». , �• *may • t _ �,*„ '�• '�'� y �s fit, ! � �'� 'w'°='�{ � �;�, .� . 4 x x -•. 4 ,y y • • i t,A�_ 1�•k '? � l � 'Z +�� 1' .lei'1 f ,Z t Y♦..' fl�r\�, �.. $ �a!_l `, ���,y`�•,X14�, ` 3 ;tir�' �I`� __ .z �. �•'-�+�- ,"�;� Tadytew. R'� ! e'. ` a Yi, � S�"r I,,i' 7+�!-f` ,� q� ��i•jJ� 4 ¢ x n � 6e Y j aY 1i�e Y •�} l�S4��l� .`LI ,,.�.( .� `� - t. Outlet Tee Before Pumping d { i! •- a� 01 N 14 q Y - D-Box Before Pumping All) IA h!7I`71 ay A _ 7 as �.a �� a �fat.i aYr .'. c t .• �1 �a '�g'i �r+'�- �..1141.�. — y ~ t 41 47 1 _'A _4.v -,i �d T. T `ZP `� y i �1 i `.Y+�+ � • �� RAS �. �k x q� � S`r lrj45v. Commonwealth of Massachusetts City/Town of System Pumping Record NORTH ANDOVER .h 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 within 14 days fro the e`pumg dateJk, accordance with 310 CMR 15.351. A. Facility information Important: TOWN OF NORTH ANDOVER HEALTH when filling out 1. System Location: forms on the 4L Li ber4• �� DEPARTMENT computer,use — ------_ - only the tab key Address / to move yourNl _ ---_ _.. .----- cursor-do not CityfTown T State Zip Code use the return key. 2. System Owner: Name +�+^ Address(if different from location) CitylTown --- —- - — --..-—.- State Zip Code ° Telephone Number B. Pumping Record 1. Date of Pumping pate 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) R"'Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): ----�..----..�___ _—_ ---- ---------.._._...-----------.—..__—.__ 4. Effluent Tee Filter present? ❑ Yes [?"'No If yes, was it cleaned? ❑ Yes VNo 5. Condition of System: 6. System Pumped By: J)m Ga I 1 ark -.---- ---- - -=- h( 7 _ --- - - ---- - -- Name Vehicle License Number Company 7. Location where contents were disposed: ---- --- ._----------_____-__ -----_---- Ipswich-tea# ---- --- -- eatment p er - --_-----.___—____ --- - --._-1�5,`Inr;��.� ,�-- Date ----- Signature of Hauler �'Y1 O Signature of Receiving Facility Date 15form4.doc•03106 System Pumping Record Page 1 of 1 IEC � � Commonwealth of Massachusetts � City/Town of CaY 4 2013 J OF NORTH ANDOVER System Pumping Record NORTH ANDOLTHDEPARTMENT Form 4 h DEP has provided this form fQr 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 within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out 1. System Loc ton: forms on t e /_'� r computer,use "If only the tab key Address )� = to move your �« cursor-do not y(iown - State Zip Code use the return key. 2. System Owner: s +•• Address(if difie-ent from 1oc�on} Cityfrown State Zip Code Telephone Number B. Pumping Record �/�� - ^,-`.3 2. Quantity Pumped: 1. Date of Pumping date Gallons 3. Type of system: ❑ Cesspool(s) P'<eptjc,Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): -- — - - -- 4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By. Kl Name Vehicle License Number r � � Company • 7. Location where contents were disposed: .— - - -ate eofH� D _ _ __ .--------- ----- — gnalure of Receiving Facility Date 15form4.doc•03106 System Pumping Record•Page t of t r 1 fl ` '. -, I .--. TO � DAA, � IM�� AM P FROM PHONE 11-07 OF � c� X MEM --- - - - _. S MS - - f-�--- - - -- - - MG F -- - - -- - --, l 0 E-MAILADDRESS v SIGNED PHONED AC CALL RNED❑ SEE YOU❑ AGAIN ALL❑ yyAS IN ❑ URGENT❑ Town of North Andover OE ,,ORT„1 Office of the Health Department o ? e� :! Community Development and Services Division 27 Charles Street ' " North Andover,Massachusetts 01845 CHU Susan Y. Sawyer, RENS/RS 978.688.9540-Phone Public Health Director. 978.688.9542-Fax %0T RIIIFICAII2 Off' C09VlIDIJANCE As of: April30, 2004 This is to cert that the indi'vidual su6surface disposal system repaired (f) — Components: Outlet Tee cs� Pipe to 1D-Boal Only by Todd Bateson at 46 Liberty Street North Andover, 911A 01845 has been installed in accordance with the provisions of Titre V of the State Sanitary Code and with the North Andover Board of health regulations. The issuance of this certificate shall not 6e construed as a guarantee that the system wilt function satisfactorily. Susa Sawyer, REYfS/9U ftffic Ifealth Director BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HFALTH 688-9540 PLANNING 688-9535 � TO oAU I v �KTnIM P P FROM H . of O CQ i FAX N -�— S M ��E �-- O E-M L A ESS PHONED ACK CALL RNED❑ SEE YOUO❑ AGAIN ALL❑ WAS IN ❑ URGENT❑ s-c . L�� Tem✓' �3 c�c�� '��'ate.-�,,.- � ��- c �.r'O'�. S Town of North Andover / Health Department Date: *lO D 1VLocation: (Indicate Address, if Residential, ame of Business) Check#: 1/ Type of Permit or License: (Circle) ➢ Animal $ ➢ Dumpster $ ➢ Food Service-Type: $ ➢ Funeral Directors $ ➢ Massage Establishment $ ➢ Massage Practice $ ➢ Offal(Septic)Hauler $ ➢ Recreational Camp $ ➢ SEPTIC PERMITS: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ "S tic Disposal Works Construction(DWC)$ ❑ Septic Disposal Works Installers(DWI) $ ➢ Sun tanning $ ➢ Swimming Pool $ ➢ Tobacco $ ➢ Trash/Solid Waste Hauler $ ➢ Well Construction $ ➢ OTHER:(Indicate) _ 037 Z7 Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer ToV'no"of North Andover Health Department Date: ���IVY Location: (Indicate Address, if Residential,"ame of Business) Check#: Type of Permit or License:(Circle) ➢ Animal $ ➢ Dumpster $ ➢ Food Service-Type: $ ➢ Funeral Directors $ ➢ Massage Establishment $ ➢ Massage Practice $ ➢ Offal(Septic)Hauler $ ➢ Recreational Camp $ ➢ SEPTIC PERMITS: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ "S Disposal Works Construction(DWC)$ 43 29. 1� ❑ Septic Disposal Works Installers(DWI) $� C ➢ Sun tanning $ ➢ Swimming Pool $ 1 �' ➢ Tobacco $ ➢ TrashlSolid Waste Hauler $ ➢ Well Construction ➢ OTHER:(Indicate)- 037 Indicate)O47 Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer Town of North Andover, Massachusetts Form No.3 • t AORTN BOARD OF HEALTH p tt�to ,et tip • t i� # DISPOSAL WORKS CONSTRUCTION PERMIT SACHUSE �T Applicant NAME ADDRESS TELEPHONE Site Location •-- ' Permission is hereby granted to Construct ( ) or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. YA11 N,BO MADO TH Fee_ ._ D.W.C. No. Sz p_ I APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: o -U 1 CURRENT INSTALLER'S LICENSE# LOCATION: �v LICENSED INSTA R: SIGNATURE: TELEPHONE# I�Y 1-I a 7a3 CHECK ONE: D wl104 4sz REPAIR: `� NEW CONSTRUCTION: IF NEW CONSTRUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. zO Administrative Use Only D !$ . 00 Fee Attached? Yes No Foundation As-built? Yes No Floor plans on file? No Approval e Date: 6 +w INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North.Andover licensed installer for the construction of the septic system for the property at `� -Q'�` - relative to the application r / for plans by ani dated with revisions dated I understand the following obligations for management of this project: 1. As the installer I am obligated to call for any and all inspections. If homeowner, contra( project manger, or any other person not associated with my company schedules an inspec and the system is not ready then item two shall be applicable. 2. As the installer I am required to have the necessary work completed prior to the applic. inspections as indicated below. I understand that requesting an inspection,. witt completion of the items in accordance with Tile 5 and the Board of Health Regulations r result in a$50.00 fine being levied against my company. a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be d first. Installedmust request the inspection but does not have to be present. b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As-buih verbal OK from engineer must be submitted to Board of Health, after which installer calls st be present for this inspection. With pump system all electr. inspection time. Installer mu work must be ready and able to cause pump to work and alarm to function. c) Final Grade—Installer must request inspection when all rading is complete. Does not have to on site. 3. As the installer I understand that persons or companies not associated with my company Yr.not perform the work required by my company to complete the installation of the syst( identified in the attached application for installation. I further understand that work by othE unlicensed to install .septic systems in North Andover can constitute reasons for denial of t system, and/or revocation or suspension of my license in the Town of North Andover pl significant fines to all persons involved. 4. As the Installer I understand that I must be on site during the performance of the follow construction steps: elevation of the excavation has been reached. a Determination that the proper b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff. d) Installation of tank, D-box, pipes, stone, vent, pump chamber, retaining wall and oth components. 5. As the installer I understand that I am solely responsible for the installation of the system ; per the approved plans. No instructions by the homeowner, general contractor, or any oth persons shall absolve me of this obligation. Undersi ed icensed Septic Installer Date: 6 Disposal Works Construction Permit# t Com onv ealth of Massachusetts Av-&� Massachusetts System Pumping Record System Owner System Location L-� bar S+ Date of Pumping: j � / I ^� quantity Pumped: C�� gallons Cesspool: No IL-1' Yes Septic Tank: No Yes � — System Pumped by: Cameo gfe&'7pew License# Contents transferrred to : Greater Lawrence Sanitary District Date: _ Inspector- ,Pry ra .. age 10 of l 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) i Property Address: 46 Liberty Street_ _North Andover– Owner:_Rothstein Date of Inspection: 4/9/2004 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. To well Garage House A B Driveway Septic Tank D- Bog 20' 45' —► A to Tank=13' A to D-Bog=3112" B to Tank=43' B to D-Bog=3514" t COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION r F t Ip_ 5v TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 46 Liberty Street_ North Andover Owners Name: Richard Rothstein_ j�dVi3 pFRfl GF N� � Owners Address: 46 Liberty Street North Andover,MA 01845_ Date of Inspection:— nspection 5/5/2004 I Name of Inspector: Neil J.Bateson ..---- Company Name: Bateson Enterprises Inc._ �_ ) Mailing Address:_111 Argilla Road_„ ,..---! Andover,Ma.01810_ Telephone Number: (978)4754786 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my " training and experience in the proper fimetion 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 Fail 9 Inspector's Signature: i Date: _5/5/2004 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:After permit from B.O.H.,install new outlet tee in septic tank&replace broken pipe, inspection from B.O.A.,septic system now passes Title 5 Inspection. ****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. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS r 6 DEPARTMENT OF ENVIRONMENTAL PROTECTION'' _ TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 46 Liberty Street_ —North Andover_ Owner's Name:_Richard Rothstein_ Owner's Address:_46 Liberty Street_ _North Andover,MA 01845_ Date of Inspection: 4/9/2004_ Name of Inspector: Neil J.Bateson Company Name: Bateson Enterprises Inc.— Mailing Address:_111 Ar ilia Road_ g � _Andover,Ma.01i10 Telephone Number:_(978)475-4786_ 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: Passes X Conditionally Passes Needs Further Evaluation by the Local Approving Authority ails Inspector's Signature, Date: _4/9/2004_ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments: ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 46 Liberty Street _North Andover— Owner:_Rothstein_ Date of Inspection:_4/9/2004_ 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: X 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.Outlet tee in septic tank&collapsed pipe needs replaced _N 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: N_ 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: N_ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 1 I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 46 Liberty Street _North Andover Owner:_Rothstein_ Date of Inspection:_4/9/2004_ 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 privy ool i is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a -surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance__ "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 'Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 46 Liberty Street_ _North Andover— Owner:_Rothstein_ Date of Inspection:_4/9/2004 D. System Failure Criteria applicable to all systems: You must indicate"yes'or"no"to each of the following for all inspections: Yes No _ No Backup of sewage into facility or sxstem 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'/2 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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 46 Liberty Street North Andover— Owner:_Rothstein_ Date of Inspection: 4/9/2004_ Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Yes ____ Pumping information was provided by the owner,occupant,or Board of Health No Were any of the system components pumped out in the previous two weeks? Yes — Has the system received normal flows in the previous two week period? No_ Have large volumes of water been introduced to the system recently or as part of this inspection? _Yes _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) Yes_ _ Was the facility or dwelling inspected for signs of sewage back up? Yes_ _ Was the site inspected for signs of break out? Yes_ _ Were all system components,excluding the SAS,located on site? _Yes_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _Yes_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _Yes _ Existing information. _ _No_ Determined in the field(if any of the failure criteria related to Part C is 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:_46 Liberty Street _North Andover_ Owner:_Rothstein_ Date of Inspection:_4/9/2004 FLOW CONDMONS RESIDENTIAL Number of bedrooms(design):_4_ Number of bedrooms(actual):_4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):_600 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 readings: No,on well water Sump pump(yes or no): No Last date of occupancy:_Current_ COMMERCIALANDUSTRIAL 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 2004,owner_ Was system pumped as part of the inspection(yes or no): No_ If yes,volume pumped:_,gallons--How was quantity pumped determined. _ Reason for pumping: 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:_17 Years old,7/3/1987, As built plan_ Were sewage odors detected when arriving at the site(yes or no):—No Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 46 Liberty Street _North Andover— Owner:_Rothstein_ Date of Inspection:_4/9/2004_ BUILDING SEWER X locate on site plan) _ _ ( P ) Depth below grade: 20"_.. Materials of construction: _X_cast iron _40 PVC other Distance from private water supply well or suction line Comments(on condition of joints,venting,evidence of leakage,etc.):_4"Cast Iron thru wall& 3"PVC in house,no leaks visible_ SEPTIC TANK: X_(locate on site plan) Depth below grade:_8" Material of construction:_X_concrete _ —fiberglass__polyethylene metal fiber lass —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:_10'x 5'x 4' Sludge depth:—0" Distance from tp of sludge to bottom of outlet tee or bade: 27" Scum thickness:_0" Distance from top of scum to top of outlet tee or baffle:_4" Distance from bottom of scum to bottom of outlet tee or baffle: 21"_ How were dimensions determined: _ 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 badly corroded,needs replaced. No evidence of septic tank leaking. Depth of liquid at outlet invert. _ GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): • °Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 46 Liberty Street _North Andover - Owner:_Rothstein_ Date of Inspection:_4/9/2004_ TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:_X (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-boa level& distribution equal.No evidence of leakage out of d-box. Evidence of solid carryover.Pipe to d-boa needs replaced,partially collapsed._ 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.): L 'Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 46 Liberty Street_ _North Andover Owner: Rothstein_ Date of Inspection: 4/9/2004 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: leaching trenches,number,length: X leaching fields,number,dimensions:_1 Field 20'x 451 _ 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 inspectionxlocate 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 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 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_46 Liberty Street_ _North Andover— Owner:_Rothstein_ Date of Inspection:_4/9/2004 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. To well Garage House A B Driveway SeptiVank D- Boz 20' A to Tank=13' A to D-Boz=3112" B to Tank=43' B to D-Boz=3514" l 'Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 46 Liberty Street_ _North Andover— Owner:_Rothstein Date of Inspection: 4/9/2004_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water _81 _ Please indicate(check)all methods used to determine the high ground water elevation: X Obtained from system design plans on record-If checked,date of design plan reviewed:_5/1/1985 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: Design Plan_ i Tel: (978)475-4786 Fax: (978)475-5451 BATESON ENTERPRISES, INC. Excavating-Water.& Sewer Lines-Septic Systems&Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 46 Liberty Street, North Andover Owner: Rothstein Date of Inspection: 4/9/2004 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. 0NeifllJ. Baesd on Bateson Enterprises,Inc. L4 6 J 27 Charles Street North Andover,MA 01845 Telephone#(978)688-9540 North • • _ Fa-9(978)688-9542 Board of ftx To: eW From: Fax: ��p 10 Pages: Phone: ��"- % 1,� Date: Re: ".Jz/`�/ ��� CC: ❑ Urgent ❑ For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle • Comments: MORTGAO ' INSPECTION PLC"IT PLAN NOR'► , .Q:RN ASSOCIATES, IN H00ri9 GM RXQH M B LZAVA AOTWED4 pm Re'. LOCArlAM 4o LxwftrY 9TREEr PLAN Rk7. lOOED :I7'Y, 9TATv N. AMOVER NA WAL& $- 00' DAM 4 / 94 / E9 JAB �• ��/ �E??: r Lor e tar a o,cl a $raar 70•P6� , v FORM U - IAT RELEASE PORN INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having have been obtained. This does not relieve the applc�lajo=n landowner from compliance with any applicable local r state law, regulations or requirements. o ****************Applicant fills out this section***** * ********* APPLICANT: Phone 'C' LOCATION: Assessor's Map Number Parcel Subdivision Lot(s) J Street i ! or St. Number _ Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Conservation Administrator Date Approved Date Refected Comments Town Planner Date Approved • Date Rejected Comments Food f Insp or-Health Date Approved Date Refected Sept Inspector-Heal h Date Approved 7 Date Rejected ' Comments . Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date 37 .. i ,..,J .'4 `' ��'�' �,,i oil o��,� • 9 CD De If> 2. —s—�•�� -• 'C OCA. ..,,7$J v �r..t rl^ •V. S —` SL Ij ' i ,_�` a a a� tr ,ref � •_* w., to fair. A Sy �J S. s y', rt� //�r�l'�t''x l f� � +.�, Ltr t ��(•k € . �,`j�.�/ d4+ ,y r Og1 � �r'�'I.. ,�r�j 4� r..r'7y"��,�Ti ''lr } . •,ik C.. :. `T`• r ., . . , j�'�f.', t}}x.. /��n" �t � .' f ♦_',yr t r k,�.c � 1.3 y�Fi 1 r r;+ ? 11:YY. . �l rY ,}a •<F� 1. Y L Yom' •�? r L ti j . (� 'fir x nl+ } ,'�t �; . Y Y �':• � i 1rt • '� �� �7d � ��s • 1M y y' r� "��1t �, 7 r• 'x + C ,� r �`'w,� �:�+ i'ki-�," e'' . l wr 'J"'r N' .• ` 'it r�'iP r r Y h +.,t 'rf.f� ��, <�` ' r awt 1• . 1 1�� � � �•a r t ,(rI`nrQ/`�� r ;'a t xft �rfs a }rT t ':�� � Y�j � ° '� ;lu 1• '4'M�,J � �Mr:. � _k �^+' Y "•� •.�e �'c ;y�� Y lf,'. t�x .+x {{a+ N .., .t 1r 'J/ 'k� � polp`g��y.r� t�ic •��,-y., _�, r4J .tt1'ti`• ryr A" �tr ,�/ ,. �"�, d' °f'Mv"� s ;r7!t.��+"irq• ! .{_ ^xJF4 tJ4? ar^Yi:. �'��i�l.? 'f� .. �. .i� �•�• i3O` "C �/• k f ,Yf.i. ^r,'ff '��. �Atid � f. r'' ,'��.xi. fi 243.00 of 110 Lot N� 47,928}s.f. 114' 1,1003...: --� \ —112' aa '— f �`�116 \\ I/9 `/ �� t BENCHMARK Spike.in 3C1 pine . , �. E1. -126.96(93 - 10, ti-:- Existin Site P! f - F g Bales to but! 7 I o Embankment Slope together `� ;,r3 6~–Jin 2 0 3.. flow i (2)2'x 2'x 3' 4. stakes each bale 2x.2.'x 3'stakes(2)each bale ' , ! QM- — r SECTION ✓ 2. TEMPORARY EROSION CONTROL NOT TO SCALE In NORTH ANDOVER, MASS. prepared for Republic Development Corp. 243.00 Scale :I in.= 40'ft. November 6, 1985 W.602nds CARLEWN W. HARVEY of / LAND SURVEYOR AND CONSULTANT __� 36 WEST STREET Loft 5 Proposed Well WHI W N MA V� Lo.c°tion � i 47 928±s.f. or `M }_ 03-10c. ll4 X110 4 1 •,a�.. ``O-is+ `�`_-11 - Zs� "�7sh 3� 'P , •C r / ,bC`, .4 ow`£��. d 40 DENOTES EXISTING CONTOUR oy. top�i� " ��'. �1I16 DENOTES PROPOSED CONTOUR GIIO t� �k \dam `w 118: DENGTES SPOT CONTOUR IlOx 5 �i 'IRJ' i. y )Qsed Site Plan hay boles for temporary erosion control as shown on ?d site,plan. 7 site construction.. rid seed all disturbed areas. temporary erosion control after vegetation is established. all disturbed areas. ocation,sewage system,and topography were taken from pian ,ph J. Barbogallo,R.S. location was shown on sewage system design plan by Joseph agallo; well location is to be approved by Board of Health. Commonwealth of Massachusetts City/Town of NORTH ANDOVER, MASSACHUSETTS System Pumping Record Form 4 �, RECEIVED _ DEP has provided this form for use by local Boards of Health. he s4WIrOAnQ; Re rd must be submitted to the local Board of Health or other approving at thority. TOWN OF NORTH ANDOVER P NT A. Facility Information r" " Important: When filling out 1. System Location: forms on the —7 computer, use only the tab key Address q to move your �Gt b Ayl j ovetr NG ©)V 45 cursor-do not — l use the return City/Town State Zip Code key. Ay 2. System Owner: 0 11 Name — — Address(if different from location) p 0� DL4 City/Town State Zip Code q-�,g q-7 -70 Telephone Number B. Pumping Record 1. Date of PumpingDae 2. Quantity Pumped: I C)o Gallons 3. Type of system: ❑ Cesspool(s) EZSeptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes YNo If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: _�UOGI 6. System Pumped By: im Go l Ian � — L-793 I _ Name Vehicle License Number W n %V�� �Y1 V 1 Y p 11 YY1 ►��(a' Company 7. Locati i&pWater disposed: Treatment Plant _ Ipswich, MA 01938 _ Signature of Hauler Date http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of NORTH ANDOVER, MASSACHUSETTS System Pumping Record i Form 4 DEP has provided this form for use by local Boards of Health. The Sste� m Pu ecord must be submitted to the local Board of Health or other approvin authR EIVED A. Facility Information JAN 2 5 2006 Important: When filling out 1. System Location: TOWN OF NORTH ANDOVER forms on the HEALTH DEPARTMENT computer, use 1 only the tab key Address �n� (�L n r to move your `t1 cursor-do not use the return City/Town State Zip Code key. 2. System Owner: (� — _ S7 RD h A'�� G�E LLS U K�YZ Lr) Name 58 M Address(if different from to ti ) City/TownSta Zip Code Te phone Number B. Pumping Record 1. Date of Pumping �n�� 2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) E�-9'eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee J&r present? [3/Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System• -- .(coo� — - 6. System Pumped By: Name (� Vehicle License Number Company 7. Location where contents were disposed: Signature of_He Date http://www.mass.gov/dep/water pprovals/t5forms.htm#inspect t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Residential Property Record Card PARCEL_ID:210/105.D-0130-0000.0 MAP:105.D BLOCK:0130 LOT:0000.0 PARCEL ADDRESS:46 LIBERTY STREET PARCEL INFORMATION Use-Code: 101 Sale Price: 564,000 Book: 9036 Road Type: T Inspect Date: 07/21/2005 Tax Class: T Sale Date: 09/02/2004 Page: 34 Rd Condition: P Meas Date: 07/21/2005 Owner: Tot Fin Area: 2880 Sale Type: P Cert/Doc: Traffic: M Entrance: X BELLOSGUARDO,STEPHANE&MARIELINE Tot Land Area: 1.1 Sale Valid: Y Water: Collect Id: RB Address: Grantor: ROTHSTEIN, RICHARD Sewer: Inspect Reas: S 46 LIBERTY STREET NORTH ANDOVER MA 01845 Exempt-B/L% / Resid-B/L% 100/100 Comm-B/Lebo Indust-B/L% 0/0 Open Sp-B/L% 0/0 RESIDENCE INFORMATION LAND INFORMATION Style: CL Tot Rooms: 7 Main Fn Area: 1620 Attic: NBHD CODE: 5 NBHD CLASS: 5 ZONE: R1 Story Height: 2 Bedrooms: 4 Up Fn Area: 1260 Bsmt Area: 1620 Seg Type Code Method Sq-Ft Acres Influ-Y/N Value Class Roof: G Full Baths: 2 Add Fn Area: Fn Bsmt Area: 168 1 P 101 S 43560 1 182,080 Ext Wall: FB Half Baths: 1 Unfin Area: 276 Bsmt Grade: 2 R 101 A 0.1 470 Masonry Trim: Ext Bath Fix: Tot Fin Area: 2880 DETACHED STRUCTURE INFORMATION Foundation: CN Bath Qual: T RCNLD: 338431 Kitch Qual: T Eff Yr Built: 1987 Mkt Adj: 1.1 Str Unit Msr-1 Msr-2 E-YR-BIt Grade Cond%Good P/F/E/R Cost Class PV S 800 1995 A A /50//48 12,100 Heat Type: FA Ext Kitch: Year Built: 1987 Sound Value: PT S 540 1995 A A /50// 2,600 Fuel Type: O Grade: G Cost Bldg: 372,300 Fireplace: 1 Bsmt Gar Cap: Condition: G Att Str Val 1: VALUATION INFORMATION Central AC: N Bsmt Gar SF: Pct Complete: Att Str Va12: Current Total: 569,600 Bldg: 387,000 Land: 182,600 MktLnd: 182,600 Att Gar SF: 528%Good P/F/E/R: /100/100/92 Prior Total: 510,900 Bldg: 349,700 Land: 161,200 MktLnd: Porch Tyne Porch Area Porch Grade Factor E 276 SKETCH PHOTO EfU 12 276 Sq.R. 12 �_y�, 4523 '11 40 B/FM 6 528 Sq.R. FU 1620 q.R. 24 24 28 1260 Sq.R. 28 45 .�* 46 L-5 LIBERTY STREET Parcel ID:210/105.D-0130-0000.0 as of 1/18/06 Page 1 of 1 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: 1 D� SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example: left front of ho se) d -.vc 4'- 7DATE OF PUMPING: aj(�UANTITY PUMPED (GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: COMMENTS: � 3 210 r s CONTENTS TRANSFERRED TO: l(� FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** f� APPLICANT: 1�iCJ4 os6j1 2 Phone ��/ - / LOCATION: Assessor's Map Number Parcel Subdivision Lot(s) Street i_/lw zf z s St. Number ************************ fficial Use Only************************ RECOMMEND A O S 0 TO AGENTS: Q Date Approved Ps Conservation Administrator Date Rejected I Comments - I( 1 fv 1�5Se�• eY�S 1�U Date Approved Town Planner Date Rejected Comments Date Approved Food Inspector-Health Date Rejected Date Approved /4/ Septic Inspector-Health Date Rejected Comments Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date M0kTGA "* INSPECTION PLCIT PLAN NOM 0 of—:RN ASSOCIATES, 11` NWRAGM AICMfV Al L.XUU Ii nWrEDV MW Mr. ldtVIF / In 1-0"rxofv AR c..rospry s may r PLAN AEW. 100" :try. 8TATe N. AA OVER NA SCALA` 1- 00' DA TL3% 4 24 93 doe Of 931 2222 Lor s car s 50 ti .. / 70.P6. qtr GmTzrlaro Tek I FURTHER STATE THAT IN MY PROFESSIONAL NOTE: This mortgage Inspection was prepared OPINION the principle slructure/s and somoofy spodflcnty for mortgage purposes and Is not WCo tolled ��y1X Of outbuildings, CONFORM upon es a survey. Northam Associates, Inc. accepts no responsibility for damages resulting from sold rellanc4 by !�C 4rlth the setback requiremonts of the los)toning anyone other than the said mortgagee and Its assigns In '' ordinancos,and that them aro no onomchmonts of major' connection with Its proposed mortgage financing to said S H Impmvemants 9104 way across property tints ex too mortgagor. G shown. PANEL #—7,60 ({O r tr i t l`�p� ALSO; DA'L'E t �{O(4 1115i�— This mortgage inspection was preparedn acca ince No $YM O 1.Property Is IIs n In a Fl Ha:ar vd A o with do 40 adopt" t by th ads for Momserfs ss Loan Y 0 �,Information Is lnsVltldent to determine Rood Hu�t'd. ofI(IL* Sur se adopted by d» AM4,In*. rafts Association Flood Hazard dastertigMd from latest Fod*W Flood of Land Surveyor*and C1uSl Hnpk»ws,Ino. kirurmn*A RAM AMA PMMA ' r,t, "pFpRFH HEALTH ANDOVER/ APR i 0 1995 a- s COMMONWEALTH OF MASSACHUSETTS ' • C"� DEPARTMENT OF ENVIRONMENTAL PROTECTION {' a BUREAU OF RESOURCE PROTECTION fte DIVISION OF WATER SUPPLY . A. PRIVATE GUIDELINES* f i ,g k ,.9 a DANIEL S. GREENBAUM MICHAEL S. DUKAKIS SECRETARY, EOEARS COMMISSIONER, DEP GOVERNOR S Z'dmmlwQ3 W21:10 S6. 2-0 ddtJgmomwo / L Y FAX MESSAGE 10 Cambridge Center CD FAX No. 617) 621-2565 Cambridge MA 02142 (617)252.8000 envtentists, planners,A management consultants CAMP DRESSER & MCKEE To: a DATE: FROM. Rid eLl L006o b FAX No.or CLIENT ,r08OAO-K suiWiv ACINrry CORA OFFICE: AMOUNT pd No. PAGES(INCLUDING COVER) ACCTG,USE ONLY TEAM# MESSAGES J j mceRf, f4ic for y 1 t S �r f J� drL? Itf V ✓ (Ji a J m�Sst��j'1s �1of !� y- �J�� I'd WQ3 WdT1:T0 S6. L0 adU 18 X B L L L 0 C A T I 0 ' This section consists of the following subsections: * General Considerations * Relation to Property Lines and Buildings * Relation to Gas Lines and overhead Power Lines * Relation to Roads and Rights-of-Way * Relation to Surface water and wetlands * Requirements of the State Environmental Code, Title 5 * Additional Considerations glum OONBTDER"TONS Any person intending to have a private well constructed should identify all potential sources of contamination which exist within 200 feet of the site. ere Wh ossible a well should be located up - gradient � gradient of all potential sources of contamination and should be as far removed from potential sources of contamination as the gen- eral layout of the premises and surroundings permit. Addition- ally, every well should be located so that it will be reasonably accessible with proper equipment for repair, maintenance, testing, and inspection. The well should be completed in a water bearing formation that will produce the required quantity of water under normal operating conditions without adversely impacting adjacent wells. Water quan- tity considerations are discussed in the section entitled "Water Quantity (Pumping Test)" (page 47) . RX&;ATZ0N TO ygOVERTY L2NZ§. AIt'fl BIII bIN S Private water supply wells should be located at least ten feet from all property lines. the center line of a well should, if ex- tended vertically, clear any projection from an adjacent structure by at least five feet. gZU2%ON TO GAB LIN'SS A=OVERBEAR POWER LYNLB ,t A well should be located a minimum of 15 feet from a gas line or overhead electric distribution line and should be at least 25 feet from an electric transmission line which is in excess of 50 kv. When subsurface utilities are already in place, Uig Safe should be contacted at least three days before drilling begins.ins. REuazox MO RO„ADS ANp RI_GNTB-OP- All private water supply wells should be located a minimum of 25 feet from the normal driving surface of any roadway or a mini- mum of 15 feet from the road right-of-way, whichever is greater. „... Ud WQ3 WdZI:i0 96. LO (-4Rb of HF,�T�-1 LOT Y -S� l pTaus A� ouC� vEs Q Nc� 5t Tic sy sT� ��� APRzovW6 Aurho►,�iTy , " (fOAJ,PITVj5_ Di�ePPRov� p/�TE ` R�QSoNS i I , prf G SYSTcm 1'v STA t.-,d-T►oA1 '�FX4,,VJTOAJ 94 Q 0455, �tNAL 1V5p�rlo� APPRdVEp UJJTC - 1 APPia)\)JNG ,a�r+�0��,�y �SAPP�ov�17 DarC , R�Oso NS', _ FLIAL APM)VAL DA���' lq APP��ovf , /. BOARD OF .Hf ALTH No.Andover-j Mass . � SUBSURFACE DISPOSAL DESIGN CHECK LIST 5 S 3, LOT # U�����Y. t_ A Vf: __ �........_ APPROVED - DAVE Z—fb- WFC LCCAI, DISAPPROPED DATE Pravid6ds )5 Stt9,ojAl 0,A; Reasonss r Title V FAIL CK Reg 2.5 The submitted plan mast show as a minimums a) the lot to be served-area,dimensions lot t ,abntters Ib location and log deep observation hoes-distance to ties c location and results percolation tests-distance to ties d design calculations & calculations shaving required leaching area (e) location and dimensions of system-including reserve area f) existing and proposed contours (g) location any wet areas within 100' of sewage disposal system or disclaimer-check wetlands mapping (h) surface and subsurface drains within loot of sewage disposal system or disclaimer (i) location any drainage easements within 100' of sewage disposal system or disclaimer-Planning Board Piles (3) known sources of water supply within 2001 of sewage disposal o . system or disclaimer (k) location of aaT proposed well to serve lot-1001 from leaching facilit; (1) location of water lines on property-101 from leaching facility (m) location of benchmark (n) driveways (o) garbage disposals (p) no PVC to be used in construction {q) profile of system-elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and other elevations (r) maximum ground water elevation in area sewage disposal system (s) plan must be prepared by a Professional Bagineer or other professional authorized by law to prepare such plans Reg 6 Septic Tanks (a) capacities-15o;6 of flow.9 water table, tees, depth of tees, access, pumping (b) cleanout (c) 101 from cellar wall or inground swimndng pool (d) 251 from subsurface drains Reg 10.2 Distribution Boxes (a) s o�pe greater than 0.08 Reg 10.11 b) saw a Subsurface Design Check List Page 2 FAIL OK Leaching Pits Leaching pits are preferred where the installation is possible Reg 11.2 a) calculations of leaching area-minimum 500 eq ft 11.4 b) spacing 11.10 c surface drainage 2% 11.1.1 d cover material e) $'x2+x4" splash pad P) tee at elbow g) no bends in pipe from d-box to pipe Ltsnlag Fields Reg 15.1 a) no greater 20 minutes/inch b� area-minimum 900 sed ft 15.4 o construction of field 15.8 d) surface drainage 2 % 3.7 e) 202 from cellar wall or inground sing pool Leaching Teenches Reg 14.1 .✓ a)—cMculations of-leaching area-min 500 sq ft 14.3 All, b) spacing-4 ft min 6 ft with reserve between 14.4 c) dimensions 14.6 ✓ d) construction 14.7 Is) stone 14.10 f) surface drainage 2% Downhill S192e ✓ a) s pe y x = to be shown) b) y/x x 150 = (to be shown) EMS Reg 9.1 is) approval 9.6 b) stand-by power N i r REPUBLIC DEVELOPMENT CORP. 175 Andover Street Danvers, MA 01923 (617) 777-4743 January 23 , 1986 Detective Richard Crane .North Andover Police Department North Andover , MA Dear Detective Crane : I would like to thank you for spending some time with me yesterday on the problem on Liberty Street . Throughout the development of this area we have attempted to , work properly through all the various town departments , and after our meeting with Mr. Osgood in the fall or late summer we were confident there existed no problem with any possible graves . As you correctly assessed the situation in that area , there are considerable numbers of youths using the area as a party ground . That in addition to the continuing use of the areas as a dumping ground has created an area that is uncontrolled . We are , as I indicated to you , desirous of working with you , Mr. Osgood and any other interested party in rectifying what could be an unfortunate and knowing error. My offer to you of having an archaeologcial firm examining the site I believe Qrould be a good idea , insofar as we know there are no records showing where the two graves are located . As I assured you , we will do nothing with that lot until we can determine whether a grave does exist on the site , and if . . so , what can be done to re-inter the remains discovered . Again , I thank you for your time and I hope we can resolve .this matter quickly in deference to all parties . Sincerely , Charles O ' Donnell • N S � t , Y Cu��Ui�u11�1lat111 or f\lassnchuselis Massachusetts gs'llalltl•'UtrnII —5��tieni L'nciTlvn . L 52 � V� (. -�(r Z/ AJC Y o T • , ter•.. Vale of i'wnpinN . S— ; •� �' Quanlll}� huii�p�di � /�Q� Ceast�uuit ��i ►� 1'rs �...� T"Ist•► K"i a yet of es ► License Ni $1'Sllil) 1 UI11t1et1 (tt'; — cuntems transteired 10: Dole Inspector 1 gA Gnano wealth of Massachusetts Massachusetts stem Punning Record System Owner System Location Date of Pumping: Quantity Pumped: gallons Cesspool: No Yes U Septic Tank: No ❑ Yes L�-' System Pumped by: vdte4ort 'Fo&nhimed License# Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example: left front of house) a S rA, `` 1 DATE OF PUMPING: QUANTITY PUMPED_ JSC)b GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: f G53 0 -:F COMMENTS: CONTENTS TRANSFERRED TO: L ' I TOWN OF SYSTEM PUMPING RECORD DATE: SYSTEM OWNER & ADDRESS SYSTEM LOCATION govIo's�v\ (example:left front of house) L\ DATE OF PUMPING: <3 —q,`O Lf QUANTITY PUMPED : GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTBER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste Department of Envirdi6ental Management/Division of Water Resources Y, y WATER WALL COMPLETION REPORT + / WELL LOCATION Address / 1 i 5 4Ar+y Sf City/Town G.S.Quadrangle Map Grid Location Owner �"- ) i h ��I ,�rnPr t t gni AddreAs C/I If. r—+A WELL USE CONSOLIDATED WELL Domestic® Public ❑ Industrial ❑ I Type of Water-bearing Rock T Y 120 Other Water-bearing Zones 11 From LIO To Met�od Drilled 'f}I� _jr 2) From I q c) To 11,0 Dat Drilled ilza2i 2 �_ 3) From 2f, Tc__,L0 4) From To CASING Depth to Bedrock 96 Length Diameter (� Type +7 1h s4-1 UNCONSOLIDATED WELL STATIC WATER LEVEL Water-bearing Materials Feet below land surface Sand: fine❑ medium❑ coarse❑ Date measured 2, ❑ Gravel: fine medium❑ coarse❑ �r'a I�� Screen: GRAVEL PACK WELL Slot# length from to_ Yes ❑ No Split Screen(or 2nd screen) WATER QUALITY TESTS.MADE Slot# length from to Chemical ❑ Biological ❑ Depth To Bedrock PUMP TEST Drawdown feet after pumping days hours at GPM. How measured Recovery feet after hours. LOG of FORMATIONS COMMENTS: (On well or water) Materials From To T P1V\ 0 a tri. �i;• ' �� m ;ILA DRILLER y ti 'A iL Firm j t Address I �'rr"h City Registration No. J_ 1 � perator s ignature Please print firmly BOARD OF HEALTH COPY 25M 10.95.807101 f e e ` c � e Stevens 'Water Analysi's 38 Montvale Avenue • Stoneham, MA 02180 • Mass. (617) 438-6114 * Salem, N.H. (603) 893-3106 'LABORATORY NUMBER: 166317 SAMPLE DATE: 3/25/87 SUBMITTED BY:' Wilmington Pump 639 Woburn Street Wilmington, MA 01887 SAMPLE SOURCE: Artesian well/collected from pump (new well) i Liberty Street, Andover, MA ANALYSIS: According to Standard Methods of Water and Wastewater Analysis, 15th Ed. Total Coliform . . . . . . . . . . . 0 per 100 ml Chlorides. . . . . . . . . . . . . . 6 mg/L pH . . . . . . . . . . . . . . . . . 8.0 Hardness . . . . . . . . . . . . . . 72 mg/L Manganese. . . . . . . . . . . . . . 0.06 mg/L Sodium . . . . . . . . . . . . . . 16 mg/L Iron . . . . . . . . . . . . . . . . 0.09 mg/L Nitrate. . . . . . . . . . . . . . . 0.1 mg/L Nitrite. . . . . . . . . . . . . . . less than 0.10 mg/L COMMENT: The results of these analyses meet the required federal and state standards for drinking water. However, the manganese concentration exceeds the recommended standard. Although manganese is not harmful to your health, it can affect the taste, color and oder of your water. Manganese is frequently found at elevated levels in new wells; however, it is likely that the concentration will decrease when the well is put into regular use. Water quality can vary significantly from time to time due to various local conditions. It is advsiable to haive your water tested in approximately six to twelve months tAChest ne a y c nge in water quality. -fiA c o i Commonwealth of Massachusetts u City/Town of North Andover W° System Pumping Record '1A, SVB J 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 within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information JEN Important:When filling out 1. System Location: forms on the 45 Libert St 7_WN OF NORTHcomputer, use only the tab key Address to move your North Andover Ma 01845 cursor-do not City/Town State Zip Code use the return key. 2. System Owner: Arling Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 5/5/ Gallons 11 2. Quantity Pumped: 1500Date 3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: Xsolids 6. System Pumped By: Chad Tannian Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: rt's Pre-treatme t Plant, 20 So. Mill Bradford, Ma 01835 MAI /" 1 ignature o a ate Signature of Aeeeiving Pacility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 vE._Y---_ N r_Sc__L A-t,&I PO R c�t�v�� f�f�. t._�a�+r� I.c�itk ��sr iso` ;� � �ism a s a�.___-- P�eoPosEa Sue s�RF.�ce SEw�b� blsPOsgc. �/S TEM S Y 5 r3o t !&tie t_I$ Ga..G cxALE S t D E So'x 3.0 8 = /s� -.•�" = 7S4 GetL • 40WAER rr$4-3.SG �( ,� - ? 8G P o• __REPT.! 6 . rc--. Eve C� '��'� _ j� _ /o CA r/o pi ,y ' IaES/G AVER • �// ,. .,-.--- ;2UEAW cr BAQ �2A6ArL LO coM4fo�� WEsTWAjea CIRcc.E m f r No. "AC✓Il/G , 44AsS T Q Epi` r QES/GAJ DATA TYPE OF 8lJ/44WA14v: '�4 •R- ,1? u� //I ni G QAAC4G6 a CELLA,: IYrlfal .� • stud uwsw:+tnrryew�oY PQECAST CONG�E'ETE .57EEPAvE PIT -- %B W.45AJE D C�CZ45/k-L> -Vfi A/F WASf+fEP CQU_S�lY� STD NE �'L" •�l'.4X/.-wuih�' ,�"�"F..�.---� �:�-sL•3cE WstSttE� -AASHO .SCK. T-sI-GOA} � /L` ,al?�xlrLlclM CO✓E.e t C� 33" Q o 0 0 0 Off. O O O O O O Ito c7EE�'"!GE T/T ' SKT/ON Q-A �EEP�IciE r!T- cJEGT/�t! 8-� 4" u45T k'!?d1, S= 003 �EPACaE AeeA /3-,Do SEPTIC rAAJA�- A t" SJCrD pUC SEAL.E> -rO/AJr5, .5 00- 4-5 - Srt.QL.cc�W SEE�ACE Pll- f rSEEP.4f�E .P/T PLA�l! �'�t/L� cS�EC T/01V�S ter' E T L R IJr • rl ' •v M OR 1 GAG INS"PrE"CTION PLCI - PLAN NOM , :RN ASSOCIATES, NMMAGM fi1CM1V 9 I.XMM NOTWrESN MW RE'. JURQ / 189 1,0CArX0VV 40 LIBQ4)rY amwr PLAN Ate'. 10099 :1rY. aTATE: N. AAVO VER NA SCALA? 1- 50' DAM 4 / 24 / 99 JA9 if, 93/ 8222 .00h Lor B Lor e zoo r. r R snwr Naga ' ry J cEnTrrrEv TQ I FURTHER STATE THAT IN MY PROFESSIONAL NOTE: This nwrtgage Inspection was prepared OPINION the principle sUvcd,re/s and"story specifically for mortgage purposes and If not to be tolled `A O( outbuildings, upon as a survey. Northern Assoclates, Inc. aocepts no �� CONFORM responsibility for damages resulting from said rellanoe by >;C Wth the setback requirements of the local toning anyone ocher than the said mortgagee and Its assigns In " ordinances,and that there aro no emosiohmonls of major r;onnectlon wlth Its proposed mortgage rynanclna to sold S Improvements 9104 way scrota property lines except as mortgagor, 6' `p mown. PANEL # Q`�Sf' UQ I l�j PD r ALSO: DATE t 116 1 u mortgl--e inspection was prepare nn act 4KG 1V1,{�� 1 1.Property Is not In a F area, Z1h the 7achn" Standards for Mortgage Loan Y O 2.Property Is In a Flood Huard Arte, ins 0 J,Information Is insuifloleni to determine Flood Huard, p•otlSw y adapted by ngi AAes,Ino. •tts Association Flood Hazard do mmined from latest Fed"Flood of land surveyors and CM Erhgkmwrs,Ino. k,M m&MA AAM L"A 0"1 Z)]TriuJ, i UI Lui 1u. in NORTH ANDOVER, MASS. prepared for Republic Development Corp. 243- 00 Sccle : I In. = 4Q-ft. November 6 , 1965 1Net1dnds CARLETON W GARVEY Of ,� �� LAND SURVEYOR AND CONSULTANT `�� -� � 36 WEST STREET Lot 5Proposed Weill, WNI MA N, MASS. Location A-7928t s-f. o.rCARLFWN~ /�� (mac (�. .l� ~ oo3 c� ll� .. ` VJY.'T7 NO. ?tea ��'�' ,i r!:• ... ' ��1 _ :. .a l++la 'k. O� /��. _ -` ctv1 '�F � tip' • . ' F4 � .,.� M.^° _-...+1".• � ��� �e.i �� W. �-'M6 IAV ` �1��+ °'. .-.r..'r�Vw .� //2' V40a //0` DENOTES EXISTING CONTOUR . 16 18 DE OYES PROPOSED CONTOUR i DENOTES SPOT CONTOUR llo x 5 8 0 Aox .# . . woo � Qsed Site Phan :a,l hay bales for temporary erosion control as shown on )osed site. plan. cern sate C onstruction. n and sued all disturbed areas. ove temporary erosion control after vegetation is established. ,(?re all disturbed areas. S :e location; sewage system, and topography were.taken from glaa 'nseph J. Barbagallo, RS. ' sell location was shown on sewage system design plan by Joseph grbagallo; well location is to be approved by &Ord of Health . T I r Al1O� L 243.00 aids Wet.i. of lo e flQ -• ,,Lo , N8 47 .92 s. . °N or — - �`� /toJ Cr + \ 1. 1003-� Ic� f \gyp' 122 111 114 112' 116 V� E x Ist i n,g Site P1, � s- a Ba fes to buff Embankment Slope-In together _ 2 i (2)2'r 2'x3' 4 . 1►� flow i o stakes each ba e'�� 6 2x 2'x 3' stones (2)each bole , F r �K•r.�� `'"" 'SECTION 2.1 i TEMPORARY EROSION CONTROL NOT TO SCALE we f-La- ,►� a..v o� f-Q s P=t. Lo ea 4/vn S �y I SLA�t/ �S/,IDK//itlra c k S L1 k v r-y P�eovas�v' .Suesu�eF.�c� .S�wAesB I�:SPL.LS,Q�_ /STEM No k�ek/,v lI�/-ells) Z� a,P .e. �.Ca �s� �C/rah ��� /Ga O A .d i S'in Ci Sa..t, .- y S f-2 n1 Ivo l- a ti 6 a G -Q 6 ), /.Nvr..�'f� csCALE OWAI&e= R,-PubLic �v CORP• a 1 LOCAT/oAv: DES/6 AVER �i4RASAePALL O a t "j a p t �: . 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