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HomeMy WebLinkAboutMiscellaneous - 46 WINTERGREEN DRIVE 4/30/2018 (2)i y tai tij H North Andover Board of Assessors Public Access _ �Y �x poRTy Of.Y��e i1'O h � 8sn�wus� Return to the Home page click on logo New Search Sales Summary Residence Detached Structure Condo Commercial Comparable Sales • 11 a • • a l • i • . A ! •- • Parcel ID: 210/104.B-0193-0000.0 SKETCH Click on Sketch to Enlarge Page I of 1 Property Record Card Community: North Andover PHOTO No Picturte v1lbl Location: 46 WINTERGREEN DRIVE Owner Name: ALBERT, EDMOND H SHERMAYNE I ALBERT Owner Address: 46 WINTERGREEN DRIVE City: NORTH ANDOVER State: MA ZIP: 01845 Neighborhood: 6 - 6 Land Area: 1.02 acres Use Code: 101 - SNGL-FAM-RES Total Finished Area: 3508 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 733,500 671,000 Building Value: 502,500 460,900 Land Value: 231,000 210,100 Market Land Value: 231,000 Chapter Land Value: LATEST SALE Sale Price: 402,000 Sale Date: 10/12/1988 Arms Length Sale Code: Y -YES -VALID Grantor: J & H REALTY TRUST Cert Doc: Book: 02824 Page: 0214 http://csc-ma.us/NandoverPubAcc/jsp/Home.jsp?Page=3&Linkld=990137 6/14/2007 Town of North Andover F+�'•+HEALTH DEPARTMENT ,sS�CHUst� CHECK #: /OBD( DATE: zlIJ d LOCATION: H/O NAME: e<1 /r CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ \ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ T�i le 5 Inspector $� � Title 5 Report $ ❑ Other. (Indicate) $ 2466 ' Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return koy. r % rab return Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessm 46 Wintergreen Drive Property Address Edmund Albert Owner's Name No. Andover City/Town MA 01845 State Zip Code JUN 13 200 G WN OF NORTH ANDOVER HEALTH DEPARTMENT 06/06/07 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector: Benjamin C. Osgood Jr. Name of Inspector New England Engineering Services, Inc. Company Name 1600 Osgood Street Suite 2-64 Company Address No. Andover City/Town 978-686-1768 Telephone Number B. Certification MA State License Number 01845 Zip Code 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: L& Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority . �LC o Inspect s Signature &l&t�� Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 46 Wintergreen Dr No Andover.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 15 Commonwealth. of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments E 46 Wintergreen Drive Property Address Edmund Albert Owner Owner's Name information is required for No. Andover every page. CitylTown B. Certification (cont.) MA 01845 06/06/07 State Zip Code Date of Inspection 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. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If "not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑■ n broken pipe(s) are replaced obstruction is removed 46 Wintergreen Dr No Andover.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 Wintergreen Drive Property Address Edmund Albert Owner's Name No. Andover MA 01845 06/06/07 City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 46 Wintergreen Or No Andover.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 Wintergreen Drive Property Address Edmund Albert Owner's Name No. Andover City/Town B. Certification (cont.) MA 01845 06/06/07 State Zip Code Date of Inspection C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ER Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ 4 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ n `f Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow ❑ 14 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. ❑ F� Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 46 Wintergreen Dr No Andover.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 Wintergreen Drive Property Address Edmund Albert Owner's Name No. Andover MA 01845 06/06/07 City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No No ❑ V9 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 the system is within 200 feet of a tributary to a surface drinking water supply 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 ❑ 6 the system is within 400 feet of a surface drinking water supply ❑ E� 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. 46 Wintergreen Or No Andover.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 15 Owner information is required for every page. Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 Wintergreen Drive Property Address Edmund Albert Owner's Name No. Andover City/Town C. Checklist nno 01845 Zip Code 06/06/07 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ❑ Pumping information was provided by the owner, occupant, or Board of Health ® Were any of the system components pumped out in the previous two weeks? (❑ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? ❑ Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue Qi approximation of distance is unacceptable) [310 CMR 15.302(5)] 46 Wintergreen or No Andover.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 Wintergreen Drive Property Address Edmund Albert Owner Owner's Name information is required for No. Andover every page. City/Town MA 01845 State Zip Code 06/06/07 Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): L — DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): C, , 0- �, 6 1, �) 3 Number of current residents: Does residence have a garbage grinder? K Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes [0 No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes P No Water meter readings, if available last 2 ears usage �" C -,PD tA5-r 9 ( Y 9 (gpd)) Z .j &C4 its Sump pump? J(] Yes ❑ No Last date of occupancy: r"�r� 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: Last date of occupancy/use: Date Other (describe): 46 Wintergreen Dr No Andover.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 15 Owner information is required for every page. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 Wintergreen Drive Property Address Edmund Albert Owner's Name No. Andover City/Town D. System Information (cont.) Pumping Records: Source of information: MA 01845 State Zip Code General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: 06/06/07 Date of Inspection 4', to, 1,3 fo pyz ab l4 a& ca (2 DS gallons ❑ Yes X No [K 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: /170$ PE(L B4OH 42c-eC zbs Were sewage odors detected when arriving at the site? ❑ Yes 9 No 46 Wintergreen or No Anclover.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .,, 46 Wintergreen Drive Owner information is required for every page. Property Address Edmund Albert Owner's Name No. Andover City/Town D. System Information (cont.) 06/06/07 State Zip Code Date of Inspection Building Sewer (locate on site plan): Depth below grade: Material of construction: t i ❑ 40 PVC ❑ th I feet casIron o er (exp ain). Distance from private water supply well or suction line: " feet Comments (on condition of joints, venting, evidence of leakage, etc.): (2e �a a K.5 6-0 Q, 7 1 NJ � AS C- tit 6A l Septic Tank (locate on site plan): Depth below grade: Material of construction: aconcrete ❑ metal feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 46 Wintergreen Dr No Anclover.DOC - 08/06 ,c�5o v fs-r4�-c.®,yS 4- 4 I- n,tGlptzoUQ c T-111 C- Il Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 15 Commonwealth of Massachusetts y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 Wintergreen Drive Property Address Edmund Albert Owner Owner's Name information is required for No. Andover every page. City/Town 06/06/07 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.): I Teg Mtsi - 1Ze?C,4Ci%-'> 76,0 w►'1)t ScK `Cz PJC. -17YA-f— ki Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal feet ❑ 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 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): 46 Wintergreen or No Andover.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 Wintergreen Drive Property Address Edmund Albert Owner Owner's Name information is required for No. Andover MA 01845 06/06/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ No 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 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): s3eX 1 crVoP Cati+p011®^- i= L-0 •+✓ LIF✓GL 67- RJ �+QDrD -ro �•A-y.If- V)L T-'1�/�, 6-0-0 AL. Presse% W Pump Chamber (locate on site plan): Pumps in working order: Alarms in working order: ❑ Yes ❑ No ❑ Yes ❑ No 46 Wintergreen or No Andover.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 Wintergreen Drive Property Address Edmund Albert Owner's Name No. Andover MA 01845 06/06/07 City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: /-j0%t� SOS Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): R"aot of M ih.f ivivc E✓I-®eACL Oe ?J Q0%AJ OA,,? ��'c., oiL uN.+Sj4-t- EZ63) LJ4 1 46 Wintergreen or No Andover.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 Wintergreen Drive Property Address Edmund Albert Owner Owner's Name information is required for No. Andover MA 01845 06/06/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 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.): 46 Wintergreen Dr No Andover.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 15 Owner information is required for every page. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 Wintergreen Drive Property Address Edmund Albert Owner's Name No. Andover City/Town D. System Information (cont.) MA 01845 State Zip Code 06/06/07 Date of Inspection 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. D 1.5 TA N GC's 2-e 23.0 MoD 2-4.-5 1>. gar 46 Wintergreen Dr No Andover.DOC - 08/06 1 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 15 J Commonwealth of Massachusetts W, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 Wintergreen Drive Property Address Edmund Albert Owner information is required for every page. Owner's Name No. Andover MA 01845 City/Town State Zip Code D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Et' t1414 tht d t 06/06/07 Date of Inspection sima a ep o group vva er. feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record m If checked, date of design plan reviewed: Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: Checked with local excavators, installers - (attach documentation) Accessed USGS database - explain: You must describe how you established the high ground water elevation: 14'a 00 p s Te ^A 2A-ls 6 DA-8�0')u% L•.3 r9/2 C -- Te Te 46 Wintergreen Dr No Andover.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 15 Commonwealth of Massachusetts LHEAL i!!ED City/Town of System Pumping -Record 27 2014 y Form 4 NUR 1-H ANDOVER s• EPARTMF T DEP has provided this form for use -by local Boards of Health. Other forsad; bit the information must be substantially the same as that provided here. Before using -this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left / Right front of house ig ear f ouse Left / right side of house, Left / Right side of building, Left / Right front of building, Left lg o building, Under deck Address n City/Town tate Trp Code 2. System Owner. Name Address (if different from location) City/Town ' State C Trp Code F Telephone Number _ r B. Pumping Record,- . 1. Date of Pumping gate 2. Quantity Pumped: Canons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 9-90 If yes, was it cleaned? ❑ Yes ❑ Na ' 5. Condition of System: 6. System Pumped By. Neil. Bateson Name Bateson Enterprises Inc Company 7. Locale contents were disposed: aL�'S.Q Lowell Waste Water F5821 Vehicle License Number 41 Date t5fbrm4.doc- 06/03 System Pumping Record • Page 1 of 1 RECE Commonwealth of Mass Chsu AsN City/Town of Ado . A System Pumping Record A11 12 2013:XOFKOR711 TH DZPARTMEN� Form 4 TOWN OF NORTH ANDOVEn HEALTH DEPARTMeNT DEP has provided this form for us&by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/ Right front of house, Left/ Right rear of house, Left / ' side of hous Left/ Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address City/Town State Zip Code 2. System Owner l__ -,`e c Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): State .37 —(- ip Code— Telephone Number a, Date 2. Quantity Pumped. Cesspool(s) Septic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition,pf jy� C: p✓�J h. (\_j� 6. System Pumped By: Neil Bateson Name Bateson EnterDrises Inc Company 7. Location where contents were disposed: Lowell Waste Water F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Recons • Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 Sv v t5form4.doc• 06/03 RECEIVED AUG 06 2012 ITOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form'for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left / Right front of hous , ee p Right j j o house, eft / right side of house, Left / Right side of building, Left / Right front of budding, Left / Right rear of building, Under deck Address AA C AwAm ver City/Town State Zip Code 2. System Owner. Name Address (if different from location) City/Town State Zip Code 75-1.(a " Telephone Number B. Pumping Record 1. Date of Pumping Dat_ 2 Quantity Pumped 3. Type of system: ❑ Cesspool(s) �eptic Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 5. Condition of System: Gallons ❑ Tight Tank No I If yes, was it cleaned? ❑ Yes ❑ No 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: L S. Lowell Waste Water —1 It N! F5821 Vehicle License Number —? — 42— La'Z—. Date System Pumping Recons • Page 1 of 1 Commonwealthof assac usetts City/Town of�ECEI1/ED System Pumping Recor Form 4 JUL 3 12008 4 DEP has provided this form for use by local Boards of Health. Other formLf'b��us^e"d?uf�tiiew�R t_ 'c' H�ttNinformation must be substantially the same as that provided here. Before�Is"flr-r cee-v�lf our 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 Location: forms the °�l C,� (�'«' �r computer, use 'T5�'+ V V 1 �'n u only the tab key to move your Addre s l� �,n _ 1 O 4 LJ cursor - do not use the return City/Town State Zip Code key. 2. System Owner: .d Al be< Name Address (if different from location) City/Town Statepp ZipCode q -- O — O Oa �OO J Telephone Number B. Pumping Record 6-17-0% �`�C2 1. Date of Pumping 2. Date Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes YNo If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: cool 6. System Pumped By: Ron DOSS 10a-7 Name Vehicle License Number YetMJ 'Ik1ye,� Eny1r Yl"iY12 1 Company 7. Location where contents were disposed: / VV Signature of Hauler Signature of Receiving Facility t5form4.doc• 03/06' Date Date System Pumping Record • Page 1 of 1 IL Commonwealth of Massachusetts City/Town of RECEIVED System Pumping Record JUN 3 0 2009 U9, Form 4 - TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. Other fo DEPA M T information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: Left fro ; left rear eft sid ho se. ight front, right rear, right side of house. forms on the computer, use only the tab key Address to move your cursor - do not use the return CitylTown State Zip Code key. 2. System Owner: Lem— Name Address (if different from location) Citylrown . State C State C*r6 Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: 8 Cesspool(s) Septic Tank Tight Tank Other (describe): 4. Effluent Tee Filter present? 8 Yes 0-N- If yes, was it cleaned? Yes No 5. Condition of System: �� I�►C.� V A + V\o 1 6. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: ZJQ.L.S.D Lowell Waste Water igna ure of 1-1461hr Date t5forrn4.doc• 06/03 System Pumping Record • Page 1 of 1 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Commonwealth of Massachusetts City/Town of RECEIVED System Pumping Record F,11 UN 3 0 2009 Form 4 ... - DEP has provided this form for use by local Boards of Health.th��f-0i Mjj - put the information must be substantially the same as that provided here. Before using nrs�amr, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left front, left rear, left side of hous . Rig t fron ight rear, right si of ou . Address 1704 City/Town State 2. System Owner: ��ll Name Address (if different from Zip Code CitylTown State ^ �7--SqYop-qode Telephone Number B. Pumping Record 6-33 � 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: 8 Cesspool(s) Septic Tank Ll Tight Tank Other (describe): 4. Effluent Tee Filter present? 0 Yes 2-Vf o If yes, was it cleaned? Yes [] No 5. Condition of System- 6. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location 3ulaere contents were disposed: L.S.D Lowell Waste Water igna ure of Hduthr Date t5form4.doc- 06103 System Pumping Record • Page 1 of 1 iL Commonwealth of Massachusetts City/Town of NORTH ANDOVER, System Pumping Record Form 4 MASSA ED OCT 10 2006 DEP has provided this form for use by local Boards of Health. Thb-Sgste_m P,ump,ingERccord must be submitted to the local Board of Health or other approving auth�rtYI,EALTH DEPARTMENT A. Facility Information Important: When filling out 1. System Location: forms on the �J computer, use _I W / 4-7 7<-e Cry o, only the tab key Address to move your N 4,eC10a e- P— cursor - do not City/Town State Zip Code use the return key. 2 System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping I Type of system: ❑ ❑ Other (describe): State Zip Code _ 1--r 7 6F1111 600s�— Telephone Number O DA / 6 2. Quantity Pumped: Gallons `S Cesspool(s) 9 -Septic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: © C:2, 6. System Pumped By: �55 k srx 2 Name' f Vehicle License Number Compaanny 7. Location where contents were disposed: http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 j oRTM r✓ 0. • Town of North Andover `+�•o;,,,, �: HEALTH DEPARTMENT SScHus° CHECK #: /030 DATE: LOCATION: H/O NAME:�I CONTRACTOR NAME:�C!�(�a©, T_Yye of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ Title 5 Report $— ❑ Other. (Indicate) $ 2 466Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer �I O j L O Z W cr C9 y W Cl) ? Y v c i i w w w 3 d t e a y Q t/1 •� rn O Y G i e w w w 3 a y Q t/1 w 0 N m m IL e w 3 a y Q t/1 •� rn O m o Cn a (a ayi O wo D 0 l a� CL o r„ y o umi 4; O J Z Z Z U V � y c o mCl) a N = y +:. 0 0 0 w Z Z u� o ,O o 1= C) O 5 LLa N E C ] o a n w m y d C d (D a o CO) v ti vii C7 Q a i°- w 0 N m m IL CrEcI DRAIN SERVICE 107 FORESYSTREET; MIDDLETON, MA 01949 (978)774-2772 e ;1 FORM 4 - SYSTEM PUMPING RECORD COMMO EALTH OF MASSACHUSETTS t7l I a*Z, , MASSACHUSETTS SYSTEM OWNER: SYSTEM PUMPING RECORD ��z DATE OF PUMPING: � /' / CESSPOOL: NO �2 YES SYSTEM LOCATION: i 0 QUANTITY PUMPED: K o(-) GALLONS SEPTIC TANK: NO YES - SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE CONTENTS TRANSFERRED TO- DATE: O DATE: INSPECTOR: ,, � � �t� >r4 �i'r e 'x•,�y� rs 7'T� . �'`' t � ��� i?� �" is '' 'i ; I I I I, I Na►�TN �tiDovEl�, MA, CDS ATIOtiS D1 �Q PPRl�VED R�4S4NS 14 �r 20, Laar6 —R, S � : P - F � -(k � �Ouj �Eu-�A � 5CPT'i C Sy STEL IOG51 r�J D,4rt' �-11-h� APr�viNG /urho►��ry � 0/� T E w�a� l�Tco�� � tv c.l�c�► ��(i►5, /`-yew r-�vcs� o �- DwL - . Y, _ CX4V4Tcoly 1JSf EG i toAj RNAL W,5P6�:TloAj Q PPI�C�VEJ� 5fprf C S 1STEM I i 51A U AT Ic- 1" vwrc 7--,54 Ui3Tc p_ r -Fr DisAPMGvFID R�150 Ns FML APPROVAL -lp- -r� 5 S [] F4 I L AP121�?OOING APPRW ngI t-\/ z � M jky r""( A M� jky r""( A v S O TOWN OF NORTH ANDOVER, MASSACHUSETTS ' Y OFFICE or CONSERVATION COMMISSION TELEPHONE 683-7105 PURSUANT TO THE AUTHORITY OF -THE WETLANDS PROTECTION ACT, MASSACHUSETTS GENERAL.LAWS CHAPTER 131, SECTION 40, AS AMENDED, AND THE TOWN OF NORTH ANDOVER'S WETLAND PROTECTION BYLAW, THE NORTH ANDOVER CONSERVATION COMMISSION WILL HOLD A PUBLIC HEARING ON October 12, 1988 AT 8:00 P.M. AT THE TOWN BUILDING SELECTMEN'S MEETING ROOM, 120 MAIN STREET, NORTH ANDOVER, MA ON THE NOTICE OF INTENT OF Riparian Realty Trust TO ALTER LAND AT Lot 1 Berry St FOR PURPOSES OF constructing a two story bldg., and associated appurtenances. PLANS ARE AVAILABLE AT THE CONSERVATION COMMISSION OFFICE, TOWN BUILDING, 120 MAIN STREET, NORTH ANDOVER, MA ON WEEKDAYS, FROM 8:30 to 4;3.0'P.M. AND BY APPOINTMENT. BY: JACK LINDON CHAIRMAN, NACC RUN ONCE IN. THE NORTH ANDOVER CITIZEN ON October 6, 1988 cc: PLANNING BOARD BOARD OF HEALTH PUBLIC WORKS HIGHWAY DEPT. APPLICANT ENGINEER DEQE FIRE CHIEF BLDG., INSP. System Owner F W1,114I.-F OIREEN r i i'7?RTH AACOY-ht. ;'A 0 1 o Ii 141)1 Type: Emergency Cesspool: No Date of Pumping: 9e l 6 I System Pumped By: Contents transferred to: Commonwealth of Mossachusetss : Massachusetts System Pumping Record Routine Yes Wind River Environmental, LLC System Location Fd 16 WIVE �7RTH Af-lr-YiER W 013:5 (:781 684.60(5 Form 4 -- system Pumping Record. -- 24 Septic tank: WYes �� Quantity Pumped: � Gallons Permit #: Date: Pumper Signature: Condition of System/Other Comments Dep Approved from - 12107195 �I Commonwealth of Massachusetts CityifTown of System Pumping Record I '�T v Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health tQ determine the form they use. The System Pumping Record must be submitted to the local Board of Health ouother approving authority. A. Facility Information 1. System Location: Left side of house, Right side of house, Left front of house, Right front of house, eft rear of hou fight rea of house. Left rear of building. Right rear of building. Address Cityrrown State Zip Code 2. System Owner: Name Address (if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping b to 2. Quantity Pumped: Date Gallons 3. Type of system: El Cesspool(s)ESJ Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes, ES /No 5. Condition of System.- 6. ystem: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Locatio ere contents were disposed: G.L.S.D Lowell Waste Water Signature of If yes, was it cleaned? ❑ Yes ❑ No F5821 Vehicle License Number LV Date t5form4.doc- 06/03 System Pumping Record . Page 1 of 1 -C\ Commonwealth of .Massachusetts . City/Town of W° System Pumping Record Form .4 �M SV y DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. S tion: Left front of house, right front of house, left side of house, right side of hous rear of hou , right rear of house, left side of building, right rear of building, under deck. City/Town 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping Date 3. Type of system: ❑ Cesspool(s) ❑ Other (describe): State Zip Code State Zip Code Stat Zip Telephone Number — 2. Quantity Pumped: Gallons Septic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of Sym: 6. System Pumped By: Neil J. Bateson Name Bateson Enterprises Inc. Company 7. LocaUgn where contents were disposed: S. F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1