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Parcel ID: 210/107.D-0073-0000.0 Community: North Andover
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Summary
Residence
Detached Structure Available
Condo
Commercial
Comparable Sales
Location: 47 PENNI LANE
Owner Name: BOGOSIAN,CRAIG A
JUDY E TAYLOR-BOGOSIAN
Owner Address: 47 PENNI LANE
City:NORTH ANDOVER State: MA ZIP: 01845
Neighborhood: 7-7 Land Area: 1 acres
Use Code: 101 -SNGL-FAM-RES Total Finished Area: 2464 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 592,800 547,000
Building Value: 356,300 331,800
Land Value: 236,500 215,200
Market Land Value:236,500
Chapter Land Value:
LATEST SALE
Sale Price: 1 Sale Date: 08/19/1993
Arms Length Sale Code: F-NO-CONVNIENT Grantor: BOGOSIAN,CRAIG
Cert Doc: Book: 03810 Page: 0293
http://csc-ma.us/NandoverPubAcc/jsp/Home.jsp?Page=3&LinkId=992083 7/9/2007
±-Commonwealth of Massachusetts
Title' S Official Inspection Form.
Subsurface Sewage Disposal System Form-Not for Voluntary'Assessments ! ��
47 Penni Lane
Property Address
Muhamed'Yamin
Owner Owner's Name
information is
required for every North Andover MA 01845 10/20/2012
page. City/Town- State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection fomis-m not�be,alered4. any
way. Please see completeness checklist at the end of the form.
IF .
� i�
Important:When A. General Information
�V �ga12
filling out forms
on the computer,.
use only the tab 1. Inspector: TOWN OF.NORTH ANDOVER
key to move your HEALTH DEPARTMENT
cursor-do not Nicholas Boraczek
use the return Name of Inspector
key.
Boraczek's Septic
ICI Company Name
7 Chisholm Road
Company Address
Kingston NH 03848
Cityrrown State Zip Code
9783748803 S113475
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑- Fails
❑ Needs Further Evaluation by the Local Approving Authority
10/30/2012.
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. if the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate.regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""*"This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the".future under
the same or different conditions of use.
r
e
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
Title, 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Penni Lane
Property Address
Muhamed Yamin
Owner Owner's Name
information is
required for every North Andover MA 01845 .. .10/20/2012
page. Cityrrown State Zip Code Date of Inspection .
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete aliof"Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments: ------
System in good working condition on date of ins pec%on.Recommended to have system reinspected
after 2 weeks of normal flow.
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•11/10 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
47 Penni Lane
Property Address
Muhamed Yamin
Owner Owner's Name
information is
required for every North Andover MA 01845 10/20/2012
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N. ...❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Y
,. 47 Penni Lane
Property Address
Muhamed Yamin
Owner Owner's Name
information is North Andover MA 01845 10/20/2012
required for every
page. Citylrown 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/day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Penni Lane
Property Address
Muhamed Yamin
Owner Owner's Name
information is
required for every North Andover MA 01845 10/20/2012
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
1:1 ® 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 thisibi m.]
❑
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.
i
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Penni Lane
Property Address .
Muhamed Yamin
Owner Owner's Name
information is
required for every North Andover MA 01845 10/20/2012
page. _ Cityrrown State Zip Code Date of,inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board.of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS,'located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® E] Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
i
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
�. 440
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
° 47 Penni Lane
Property Address
Muhamed Yamin
Owner Owner's Name
information is
required for every North Andover MA 01845 . 10/20/2012
page. Cityrrown. State Zip Code Date of Inspection
D. System Information
Description: _
1,500 gallon septic tank, 1,000gallon pump chamber, distribution boz;Land°SAS.
Number of current residents: - o-vacant
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes 0 No
Water meter readings, if available last 2 ears usage d N/A
9 ( Y 9 (gP ))�
Detail:
Sump pump? ❑ Yes Z. No
Last date of occupancy: unknown
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•11/10 Tide 5 official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 '
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Penni Lane
Property Address
Muhamed Yamin
Owner Owner's Name
information is
required for every , North Andover : MA 01845 10/20/2012
page. Cityrrown State. Zip Code Date of Inspection
D. System Information (cont.) ,
Last date of occupancy/use: Date
' Other(describe below):
General Information
Pumping Records: _ v
Source of information: Board of health
Was system pumped as part of the inspection? ® Yes ❑ No
If yes,•volume pumped: 1,500
gallons
How was quantity pumped determined? Meter on truck .
Recommended
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑' Single cesspool
❑ Overflow cesspool
❑ Privy
t
❑ Shared system(yes or no) (if yes, attach previous inspection rrecords, 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
ElTight tank. Attach a copy of the DEP approval.':
i
❑ Other(describe):
1
t5ins-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17
j }
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Penni Lane
Property Address
Muhamed Yamin
Owner Owner's Name -
information is
required for every North Andover MA 01845 10/20/2012
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
5 years old.July of 2007. Board of health
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan): -
Depth below grade: 2.5
feet
Material of construction:
❑cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feeetet +
Comments(on condition of joints, venting, evidence of leakage, etc.):
System in good working condition on date of inspection.
Septic Tank(locate on site plan):
Depth below grade: 1.5
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: 10'6"x5'8"x4'3"
Sludge depth: 4inches
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 'Official Inspection Forma.
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Penni Lane
Property Address
Muhamed Yamin
Owner Owner's Name
information is
required for every North Andover MA 01845 .10/20/2012
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
�. Distance from top of sludge to bottom of outlet tee or baffle a feet
Scum thickness 3 inches .
Distance from top of scum to top of outlet tee or baffle 3 inches
Distance from bottom of scum to bottom of outlet tee or baffle 1:8.inches,
How were dimensions determined? Mesuring stick
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 to pump every 2 years, Inlet and outlet tee baffles and structure of septic tank in good
condition on the date of inspection.
I
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-11/10 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
47 Penni Lane
Property Address .
Muhamed Yamin
Owner Owner's Name
information is
required for every North Andover MA 01845 10/20/2012
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or bafflecondition, 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Penni Lane
Property Address
Muhamed Yamin
Owner Owner's Name
information is
required for every North Andover MA 01845 10/20/2012
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box level and in good working condition with no evidence of leakage in or out of the box on the
date of inspection.
Pump Chamber(locate on site plan):
Pumps in working order: ® Yes ❑ No
Alarms in working order: ® Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pump chamber in good condition, pump and floats are in good working condition
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
SAS located and in good working condition on the date of inspection
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form .
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Penni Lane
Property Address
Muhamed Yamin
Owner Owner's Name
information is
required for every North Andover MA 01845 10/20/2012
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
leaching pits number:
❑ leaching chambers number::
❑ leaching galleries number:
i.._
❑ leaching trenches number, length:
4 leach lines
® leaching fields number, dimensions: 36'x13'
❑ overflow cesspool number:
❑ innovative/alternative system
�r
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding; damp soil, condition of
vegetation, etc.):
No signs of hydraulic failure, no level of ponding, no damp soil on the date of inspection
7
i
S
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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
j
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Penni Lane
Property Address
Muhamed Yamin
Owner Owner's Name
information is
required for every North Andover MA 01845 . 10/20/2012
page. Cityfrown 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.):
no signs of hydraulic failure, everything in good working condition on date of inspection.
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.):
i
f
i
t5ins•11/10 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
tle 5 Official Inspection Form .,
Subsurface Sewage Disposal System Form-Not for Voluntary,,Assessments i.
47 Penni Lane
Property Address
Muhamed Yamin
Owner Owner's Name
information is.
required for every North Andover '_ MA .01845 90/20/2012
page. Cityrrown, State. Zip Code Date ot!nspection
D. System Information (cont.)
_,..: Sketch,Of Sewage Disposal System: Provide a view of the sewage-41sposal:.systemi including ties.to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
boo a eh� �*Egoo
..
{ti
puMp 3 0
�1
y
5 .
1
n
to
.1 .1:: ..
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
CorOinonwealth of Massachusetts
Title 5.O.ffcial insection Form!
subsurtace Sewage Disposal System Form=Not for'Voluntary Assessments t� r
` 47 Penn! Lane,
Property Address
dress
. '
"[
Owner Owner's Name r
information is
required for every'"North'Andoyer. MA .01845 ._ :: e10/20/2012
page, CityrTown . ;, state Zip Code .;:Date of Inspection
D. System Information (cont.)
Y Site'Exam
.. J� Check Slope p
® `Surface water
".
R'Check cellar.
Shallow wells
Estimated depth to high ground water: 30 inches
feet
Please indicate all methods used to determine the high ground water elevation..
® _ Obtained from system design-plans on record .F: u n
- -., 4/25/2007
If checked, date of design plan reviewed: pate,
w Observed site(abutting property/observation hole within 150 feetof.SAS)
s ,
` ,EChecked with local Board of Health explain r
❑ < < Checked with local excavators, installers-(attach documentation)
.t
[] Accessed USGS database-explain: , ,
• . i
You must describe how you established the high ground water elevation:':'
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-11/10 Title 5 Official Inspection Form:subsurface Sewage Disposal System-Page 16 of 17
is
f
Commonwealth of Massachusetts
941
Title 5 Official Inspection Form
Subsurface.Sewage
D,isposall..S.yst_em Form -Not for Voluntary'Assessments
47 Penni Lane
Property Address
Muhamed Yamin
Owner Owner's Name
information is
required for every North Andover MA 01845. 10/20/2012
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed-
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
TOWN OF NORTH ANDOVER NORrM
Office of COMMUNITY DEVELOPMENT AND SERVICES or°•''.o''�
HEALTH DEPARTMENT '
JUL 2 4 2007 400 OSGOOD STREET a•c,
NORTH ANDOVER, MASSACHUSETTS 01845 �'ss��►w5*`�
TOWN ter NUH_i y I MDOVER
HEALTH DEPARTMENT 978.688.9540-Phone
- er,REHS/RS 978.688.8476-FAX
Public Health Director E-MAIL:healthdept@townofnorthandover.com
WEBSITE:hllp://www.townofnorthandover.com
TOWN OF NORTH ANDOVER
SEPTIC DISPOSAL SYSTEM - INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System O constructed; ( '6 repaired;
by
(Print Name)
located at 7 f�Q/�/�l �w 6—. fT/Ka0
(Installation Address)
was installed in conformance with the North Andover Board of Health approved plan, originally
datedDR
nd last Revised on ,with a design flow of
Y
per gallons day. The materials used were in conformance with those
g P
specified on the approved plan;the system was installed in accordance with the provisions of 310
CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with the
approved plan. All work is accurately represented on the As-built which has been submitted to
the Board of Health.
Bed inspection date: 7 q - C5
Engineer 4-epresentative(Si ature)
And-Print ame
Final inspection date: 72 3 ^®-
0
Engine Represent v Signature)
• C� - P�
And-Pjnt Name
Installer: (Signature) Date:
And-Print Name
Engineer: (Signature) Date:
And-Print Name
.77CEIVED
AS-BUILT CHECKLIST
JUL 2 4 2007
TCS' y,; <i ANDOVER
Flr: .7�41'Z.TMENT
LOT NUMB
ER, STREET NAME 7
ASSESSORS MAP& PARCEL NUMBER 5 -1
_ LOT LINES & LOCATION OF DWELLINGS
LOCATIONS & DIMENSIONS OF SYSTEM,
INCLUDING RESERVE
TIES Ti
a. FRO
b. FRO,
LOCATI (�
TESTS
E
4 i ELEVATI
TOP OF FI
LOCATIOT S
WITHIN 15
LOCATION.- -yytil--tK, GAS, ELECTRIC LINES, CABLE
✓ DISTANCES FROM CORNERS OF HOUSE TO CENTER OF
TANK & D-BOX
ORIGINAL STAMP & SIGNATURE
IMPERVIOUS AREAS -DRIVEWAYS, ETC.
NORTH ARROW
1J LOCATION &ELEVATIONS OF BENCHMARK USED
TRS-CEIVED
AS-BUILT CHECKLIST JUL 2 4 2007
TC` ANDOVER
LOT NUMBER, STREET AME
.---
N
J /
ASSESSORS MAP & PARCEL NUMBER
LOT LINES.& LOCATION OF DWELLINGS
LOCATIONS & DIMENSIONS OF SYSTEM,
INCLUDING RESERVE
TIES TO LOT LINES & DWELLING, WELLS
a. FROM SEPTIC TANK
b. FROM LEACH AREA
LOCATIONS OF DEEP HOLES &PERC
TESTS
ELEVATIONS OF DISPOSAL SYSTEM
_ TOP OF FDN ELEVATION
I
LOCATIONS OF WELLS, DRAINS, WATERCOURSES
WITHIN 150' OF SYSTEM
✓� LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE
DISTANCES FROM CORNERS OF HOUSE TO CENTER OF
TANK & D-BOX
ORIGINAL STAMP& SIGNATURE
IMPERVIOUS AREAS -DRIVEWAYS, ETC.
NORTH ARROW
r �
V LOCATION & ELEVATIONS OF BENCHMARK USED
RE: 102 Spring Hill Road- Plan Modification Page 1 of 3
DelleChiaie, Pamela
From: Dan Obrzut[dobrzut@millriverconsulting.com]
Sent: Thursday, August 09, 2007 11:16 AM
To: Sawyer, Susan; DelleChiaie, Pamela; 'Daniel Ottenheimer(E-mail)'; 'Marianne Peters (E-mail)'
Subject: RE: 47 Penni Lane Construction Inspection
Please find attached the construction inspection checklist for the project referenced above.
I apologize for the delay. Please feel free to contact me with any questions
Dan Obrzut
I
i
i
i
8/9/2007
4 NORTH q
O •. i.E D
O
!- 7D
PUBLIC HEALTH DEPARTMENT
Community Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 47 Penni Lane MAP: 107D LOT: 73
INSTALLER: Jon Soucy
DESIGNER: New England Engineering Services
PLAN DATE: 04/25/07
BOH APPROVAL DATE ON PLAN: 06/22/07
INSPECTIONS
TANK INSPECTION: i
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION: 07/20
DATE OF FINAL GRADE INSPECTION: I
SITE CONDITIONS
® Existing septic tank properly abandoned
® Internal plumbing all to one building sewer
❑ Topography not appreciably altered
Comments:
SEPTIC TANK
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
® 1500 gallon tank has been installed
H-10 loading Monolithic construction
® Water tightness of tank has been achieved
(Visual or Vacuum Test or Water held for 24hrs)
® Inlet tee installed, centered under access port
® Outlet tee (gas baffle or effluent filter) installed,
centered under access port
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com
NORTIi
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9
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SSACHUS�
PUBLIC HEALTH DEPARTMENT
Community Development Division
® 24" inch cover to within 6" of final grade installed over
one access port, must be over outlet of tank if effluent
filter is present
® Hydraulic cement around inlet & outlet
Comments: One (1) compartment tank installed
f
i
PUMP CHAMBER
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ Combo Tank installed. Size:
® 1000 gallon Pump Chamber installed I
H-10 loading Monolithic construction) r
® Inlet tee installed, centered under access port
® Pump(s) installed on stable base
® Alarm float working
® Pump On/Off floats working
® Separate on/off floats
® Drain hole in pressure line
® 24" inch cover to within 6" of final grade installed over !
pump access port
® Water tightness of tank has been achieved
Visual testing
® Hydraulic cement around inlet & outlet
Comments: Hydromatic pump has been substituted with Barnes pump
DISTRIBUTION-BOX i
® Installed on stable stone base
® Inlet tee (if pumped or >0.08'/foot) `
® Hydraulic cement around inlet & outlets I
® Observed even distribution
❑ Speed levelers provided (not required)
Comments:
1600 Osgood Street,North Andover,Massachusetts 01845 .
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
tAORT01 T►ORT01
0 11 t%-ED 1", O4 tLED 6 1-
0
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� Dy cocnunawmw- 4• � �A_D9 cocnc newmw 1'
7a ADRATED P.Pa`,`<(�SHC HUs7
SSgCHUs�
PUBLIC HEALTH DEPARTMENT PUBLIC HEALTH DEPARTMENT
Community Development Division Community Development Division
SYSTEM ELEVATIONS CRITICAL SETBACK DISTANCES
Mark those distances checked in the field against the design plan and regulatory
INVERT IN FIELD PLAN INVERT ELEV. setback
Benchmark 4.05 / 104.5 100.00
Building Sewer OUT 8.02 / 95.70 95.70 Tank SAS Sewer
Septic Tank IN 8.37 / 95.35 95.35 ❑ Property line 10 10 --
Septic Tank OUT 8.48 / 95.24 95.10 ❑ Cellar wall 10 20 --
Pump Chamber IN 95.08 ❑ Inground pool 10 20 --
Pump Chamber OUT 8.41 / 95.47 95.33 ❑ Slab foundation 10 10 __
Distribution Box IN 2.88 / 100.84 100.94 F-1 Deck, on footings, etc 5 10❑ Waterline 10 10 101
Distribution Box OUT 3.03 / 100.69 100.77 ❑ Private drinking well 75 1002 50
Lateral 1 INV 3.08 / 100.64 100.67 ❑ Irrigation well 75 100
Lateral 1 TOP 2.99 / 101.06 101.00 ❑ Surface Water 25 50
Lateral 2 INV 3.02 / 100.7 ❑ Bordering Vegetated Wetland ,
Lateral 2 TOP Salt Marsh, Inland/Coastal Banka 75 100
Lateral 3 INV 3.07
Lateral 3 TOP ❑ Wetlands bordering surface
Lateral 4 INV 3.11 water supply or trib. (in Watershed) 150 150
Lateral 4 TOP ❑ Trib. to surface water.supply 325 325
❑ Public well 400 400
❑ Interim Wellhead Prot. Area
❑ Reservoirs 400 400
*Chambers are all installed at required ❑ Drains (wat. supply/trib.) 50 100
elevation within acceptable tolerance. ❑ Drains (intercept g.w.) 25 50
❑ Drains (Other)Foundation 10(5) 20 (10)
❑ Drywells 20 25
*No setback issues on this site.
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
1600 Osgood Street,North Andover,Massachusetts 01845 1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
NORr1
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3� 96 6 OL
O 1*
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OCNKnaww:w`y1'
�9SSacHus�t�y
PUBLIC HEALTH DEPARTMENT
Community Development Division
SOIL ABSORPTION SYSTEM (General)
.� Bottom of SAS excavated down to 6 in into 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
❑ Retaining wall (boulder/ concrete / timber/ block)
❑ Final cover as per plan
i
Comments:
r
SOIL ABSORPTION SYSTEM (Gravel-less Chambers)
® Brand and Model of Chamber Infiltrator Quick 4
® Number of chambers per row Nine (9)
® Number of rows (trenches) Four (4)
® Laterals installed and ends connected to header (and
vented if impervious material above)
® Elevations of laterals and chambers installed as on
approved plan
Comments:
I
CONTROLPANEL
® Alarm & Pump are on separate circuits
® Alarm sounds when float is tripped
® Location of control panel:
❑ Rated for exterior if placed outside
® Alarm signal located inside
Comments:
I
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 918.688.8476 Web www.townofnorthandover.com
Commonwealth of Massachusetts Map-Block-Lot
107.D-0073-
aR^ Board of Health -----------Permit No------------
x . BHP-2007-0237
North Andover -----------------------
.iia r':4' P.I. FEE
�ssncwu551 F.I. $250.00
-----------------------
Disposal Works Construction Permit
Permission is hereby granted John_Soucy--------------------------------------------------------------------------------- -------
to(Repair)an Individual Sewage Disposal System.
at No 47 PENNI LANE
as shown on the application for Disposal Works Construction Permit No. BHP-2007-023 Dated July 09,2007
Issued On:Jul-09-2007 c f tha
Of pORTN � `
O �
h = F
Town of North Andover
HEALTH DEPARTMENT
cplus
CHECK#: DATE: 9 4
t �
LOCATION:
H/O NAME:
CONTRACTOR NAME:
r
lype 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 $
42 Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
❑ Title 5 Report $
❑ Other. (Indicate) $
` /f
5 $ Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer
of "O.oT"qti Application for. Disposal System -7- 15-o-7
� c TODAY'S DATE
° Nonstruction Permit - TOWN OF
, 01845 $ 250.00—Full Repair
ORTH ANDOVERMA
$125.00 -Component
gSSwCHUS��
Important: Application is herebv made fora permit to:
When filling out �repair
struct a new on-site sewage disposal system*
forms on the
computer, use or replace an existing on-site sewage disposal system*
only the tab key
to move your ❑ Repair or replace an existing system component—What?
cursor-do not
use the return
key. A. Facility Information
z L
rab Address or Lot#
renAn City/Town Az t -14010r✓4n r
2.- * PE 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) (Attach Draft Maintenance Agreement)
❑ Pressure Dosed (D-Box Present) S.A.S.
2. Owner Information
c, Q7 oS t a@iv►
Name �7
J r4¢Wl�
Address(if different from above)
City/Town State Zip Code
Telephone Number
3. Installer Information
o d u►,c SO
Name Name of Company
P . 8o ( t
Addr ss
Cityrrown State Zip Code
Telephone Number(Cell Phone#if possible please)
4. Designer Information
aG oke o ..liV► _
Name Name of Company
z <
Address
,�/�'�.. t�t/�y, �-• a t �l C.� ►Mit- G`r�(�
City/Town State Zi Cp od
2 `7c�— `lam bo' �l�7S
Telephone Number(Best#to Rea h
Application for Disposal System Construction Permit-Page 1 of 2
,,0R7H q Application for Septic Disposal System 7- 3
O.t, eo re.ti0
� TODAY'S DATE
r. ° op Construction Permit — TOWN OF -
�,'• , ''' ORTH ANDOVER MA 01845 $250.00-Full Repair
� $125.00 -Component
9SSACHuye�
PAGE 2OF2
A. Facility Information ontinued....
5. Type of Building: Residential Dwelling or❑Commercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore-described
on-site sewage disposal system in accordance with the provisions of Title 5 of the
Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of
North Andover, and not to place the system in operation until a Certificate of Compliance has
been issued by this Board of Health.
0 du LA 2- 9 a7
Name Date
Ap lication Appr (Board of Health Representative)
b7
Name Date
Application Disapproved or the following reasons:
For Office Use Only:
1. Fee Attached. Yes No
2. Project Manager Obligation Form Attached. Yes No
3. Pump System? If so,Attach copy ofElecuical Permit Yes No
4. Foundation As-Built?(new construction ronly): Yes No
(Same scale as approved plan)
5. Floor Plans?(new construction only): Yes No
Application for Disposal System Construction Permit•Page 2 of 2
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
L! L 4-Jv e-
(Address of semc system) For plans by
ngineer)
Relative to the application of ZL0 1�c
(Installer's name) And dated
ngin ate
Dated /-- -7 p
I oday's date With revisions dated
(Last revised date)
I understand the following obligations for management of this project:
1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to
performing any work on a site. I must have the approved plans and the permit on site when any work is
being done.
2. As the installer, I must call for any and all inspections. If homeowner, contractor,project manager, or any
other person not associated with my company schedules an inspection and the system is not ready, then
item three shall be applicable.
3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as
indicated below. I understand that requesting an inspection,without completion of the items in accordance
with Title 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or
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: healthdeptQtownofnorthandover.com) from the engineer must
be submitted to the Board of Health, after which installer calls for an inspection time. Installer must
be present for this inspection. With a pump system, all electrical work must be ready and able to
cause pump to work and alarm to function.
c. Final Grade—Installer must request inspection when all grading is complete. Installer does not
have to be on-site.
4. As the installer, I understand that only I may perform the work (other than simple excavation)and I am required
to complete the installation of the system identified in the attached application for installation. I further
understand that work done by others unlicensed to install septic systems in North Andover can constitute
reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of
North Andover, significant fines to all persons involved are also possible.
5. As the installer, I understand that I must be on-site during the performance of the following construction
steps:
a. Determination that the proper elevation of the excavation has been reached.
b. Inspection of the sand and stone to be used.
c. Final inspection by Board ofHealth staff or consultant.
d. Installation of tank, D-Box,pipes, stone, vent,pump chamber, retaining wall and other
components.
6. As the installer, I understand that I am solely resl2onsible for the installation of the system as 12er the
a1212roved 121ans. No instructions by the homeowner, general contractor, or any other 12ersons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer: Z41.
oday's Date)
Ll1-
ame—Print) (Na '
0"Ce U"onpi
The Co�mnzonwealth of Massachusetts
Department of Public Safery
i Om4wicy Fee Chocked
BOARD OF FIRE. PREVENTION REGULATIONS 527 CMR 12.W 3,W ("We WON
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
MI wo*to be wformed in socordanve oft the Ma*w-huAaft Electrical Coda527 CMR 12:00
(PLEASE PRINTAN INK OR TYPE ALL INFORMATION) Ow '-
e , 411-_1/ !2 -7
City or Town of TO the Inepwor of Wir",
The underOgned applies for a permit to perform, t N. olectcioal wo*, deseribed balow-
Lac&Wn(Street&Numtw)
Oww or Tenant
OwnWe Addrea*
Is this pwmit in ccK►uncflpp with a bulidIng permit; Yes No (Chack Appropriate Box)
Purpose of Rulldlog
_ fz �_-zzz Utility Auftrization No,
Exisfing Service Amps Voltr
Ovs&*ad a'___UndgW No.of Motors
Amps Volft Ovwhaad Undord No.of MeWm
Numbw of Fooders and Ampacity
LocaMon and Nature of Proposed Electrical Wo*
Total
No.d LOWIno Outloft T-o
Nof Ho_tTUbs______ Na of Transformers KVA
No.of Lighting Fixtures Swimming Pool AbovoI Generatom
MW 11 i KVA
NO.Of PAIGOPWI0 OUIWR No/of Oil BuFners filo,of Emergency LigHIM
Battery Unft
No,of Switch outle" No.of Gas bsimm, FIRE ALARMS NO.Of
No.of Rangn No.of Air Coew- ..'Tow No.of Detwdon and
tons Initiating Devices
H TOW
No,of Dlapo*Ws No.d PUMPS 8 KW No.of Soundln,�Davic"
No.of Dishwashem Soaix/Arw Heating KW No,of S016�4wnw
DatectI06/ftun&V Devices
W.o4 Dryers Nof VA"o
Heating Devices KW LOGO[I MUNAIW
[jother
Na of o. Low
Nm at War H"M KW wiring
No.Hydre Massage Tubs --No-of McAors TOW HP
OTHER:
INSURANCE COVEhAGE: PuMant to Me Mquiremoilts of Masoachue*fts Oorieral Laws
I have a current Liabiky Insurance PANk.y including Completed Operatiom coywogo or op gutastaolim equivaiew, yES NO
0 have submitted valid proof of son*to oft office, yES1a___N0E1
V you have ch4K*Qd VE,%pleose indkmte Oie rAw of coverage by oheaking the apprcnxiate fox_
INSUFtANCE[]r BOND 11 OTHER (masse swify)
F-slm*%d Value of]Eledrk*Work 6 (Expiration Do(a)
wxk to start_zZEL,
Slaned under Me ponaMos of podury-,
FIFM
UC.No. , 2
signature_
Addm"
Ait,TOO,No-
OWNER'S INSURANCE WAIVER: I sm*war#that the Iioease# 00 t 41111 thea Inoormoce coverage or its sub$U"jel equIvalero se
mQuIred by Mamachugo*Gww*Lawg,www tiet my loonv#uro on IhIs pwmit APDWMim waives"tismwwome't
ciwoar Age tp#.,w ctw*0,.j
KwWm Of PERMff FEE s
The Commonwealth of Massachusetts Oft un
Department of Public ,safety
bocuw"L Not Ct+WW
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3/90 0Wft Moo)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
AIIwork to be psrkxmsd 1n accordance with fie Masnoweatie Efedrkei Code.527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date
city or 'Town Of 11Y _z7/ To the ihspector of Wirer.
The undersigned opplies for a permit to perform the electrical work described below.
Location(Street&.Number) y 7 0 �_
Owner or Tenant C',xds/ter
Owner's Address
Ia tits permit In co*nctlan with a bulldhtg permit: Yes 0 No CT' (Check Appropriate Box)
Purpose orsugoing L t ly Authoduiion No.
�r►dgrd 0- -No.of Meters
Mdgrd ❑ No.of Moh nt
`Date. ... ..� /. .'Q..
f pOR7H�
TOWN OF NORTH ANDOVER Told
F :.. MMIL p Qi Tmr4Ibrmers MVA
. .
PERMIT FOR WIRING h(vA
'� •r,o �`� a�Frnergensy-t�pi�tlr�q-:___ - _._.
,SSACMUS�
RE ALARMS Na of
of Detecdon and
This certifies that ............... .....
tinting Devices
has permission to perform .......... e� f.` l �` t/ '� f b'of SoundDevices
C
" {c.of
wiring in the building of ........... .Z:,'2.� iaRscti tq Dsvtose
goal❑ Co n[3 Other
at......�'�. ......... ..�j. f...........!!1/ North Andover,Mass. ow hbttW
Wing
Fee.. � ... ..... . f. ..�T:.
ELEcnuce[;INSPE
Check #
75 'i 1 �.,�
µ,.. "Berl equivalent. YES L? NO C
1 haw submitted 414 proof of sane to this offace. YES Noll
0 you have chocked YES,please indicate the type of cxvoage by ohaddnp:the appropriate box.
INSURANCE L+J BOND D OTHER 0 (Please Shakily)
Estimated Value of Eteatdcd Work$ l� (t.xpiretlon gate)
Work to atart 1'i2C
Signed under the penalties of perlurY:
MRM NAME / t.IC.NO.� Z
L mise�e od<_ 1 -- signature t..IC. No..�� /
f .4 Q� etw,Tel.Na
Address L: J�< � /i?,iiY��5;� �/ ,�7l Aft.Tet.Na
OWNER'S INSURANCE WAIVER: 1 am aware that the tioeneee does not the Insurance covenQe or its subster tai equivalent as
required by Massachusetts Gerard Laws.and that my signature on this permit appiicatlon Waitrse this rewiremett.
Owner ❑ Agent E3 tPisaw check ore)
Telephone No.
(Signature&Owner or AmM PERM FEES
--
DelleChiaie, Pamela
From: DelleChiaie, Pamela
Sent: Monday, July 16, 2007 9:34 AM
To: Grant, Michele
Subject: 47 Penni Lane
Importance: High
Hi Michele,
John Soucy just called, and he is ready for a BB inspection. I told him you or I would call him to let him know when you
can go out. His number is: 603.216.7175. Let me know when is okay for you, and I will get the file ready. Thanks.
,601 R¢gArds,
Pwyy¢�w D¢BB¢G�lfiwi¢
Health Department Assistant
Town of North Andover
1600 Osgood Street
Building 20,Suite 2-36
North Andover,MA o1845
$978.688.9540-Phone
A 978.688.8476-Fax
http://www.townofnorthandover.com
healthdept@townofnorthandover.com
1
f NORTh
060 to
� «w�:wK« +•
�4AOR�teo nPay,�y
9&-1 CRU
PUBLIC HEALTH DEPARTMENT
Community Development Division
June 22, 2007
Craig Bogosian
47 Penni Lane
North Andover, MA 01845
oy���ryi
RE: Septic System Desig^ ""=F;,F&Vet, North Andover,Map 107D,Lot 73
Dear Mr. Bogosian,
The North Andover Board of Health has completed the review of the septic system design plans,
for the above referenced property, submitted on your behalf by New England Engineering
Services, dated April 25, 2007. This plan has been approved. The approval includes a Local
Upgrade Approval as found attached. This plan is valid for two years from the date of this
approval.
The design has been approved for use in the construction of an onsite septic system for a 4-
bedroom house(maximum 9-room). During this time, a licensed septic system installer must
obtain a permit and complete this work, and a Certificate of Compliance be endorsed by the
installer, designer and the Town of North Andover. In the event an imminent health problem
such as sewage backup into the dwelling is occurring, the North Andover Board of Health may
reduce the time period for which this plan is valid.
This approval is subject to the following conditions:
1. If site conditions are found in the field to be different from those indicated on the design plan
and/or soil evaluation, the originally issued Disposal System Construction Permit is void,
installation shall stop, and the applicant shall reapply for a new Disposal Systems
Construction Permit.
2. It is the responsibility of the applicant and/or the applicant's septic system designer, septic
system installer or other representative to ensure that all other state and municipal
requirements are met. These may include review by the Conservation Commission, Zoning
Board, Planning Board, Building Inspector, Plumbing Inspector and/or Electrical Inspector.
The issuance of a Disposal System Construction Permit shall not construe or imply
compliance with any of the aforementioned requirement.
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
Your effort to provide a properly functioning septic system for your dwelling is greatly
appreciated. The Health.Department may be reached at 978-688-9540 with any questions you
may have.
Since ,
XSusan Y. Sawyer, /RS
Public Health Director
Encl: list of licensed septic system installers
Form 9B for owner records
Cc: New England Engineering Services
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
•f Commonwealth of Massachusetts
Q D2 City1rown of
L
ocalace r
pp
U Approval
p9
Foram 913
DEP has provided this form for use by local Boards of Health if they choose to do so.
The Local Upgrade Approval is to be completed by the local Board of Health and a signed copy provided
to the system owner.
A. Facility Information
int:
when fining out 1. Facility Name and Address
forms on the
computer,use Craig Bogosian
only the tab key Name
to move your fig Penni Lane
cursor-do not
use the return Street Address
key. North Andover MA 01845
Cityrrown State Zip Code
2. Owner Name and Address(if different from above):
A10R Name Street Address
Cny/Town State
Zip Code Telephone Number
3. Type of Facility(check all that apply):
® Residential ❑ Institutional ❑ Commercial ❑ School
4. Design flow per 310 CMR 15.203: 440
gpd
5. System Designer: Ben Osgood Jr. ® PE f-1RSName
1600 Osgood St, Bldg 20 North Andover MA 01845
Suite 2-64 City/Town State,ZIP
B. Approval
1. Local Upgrade Approval is granted for:
❑ Reduction in setback(s)—specify:
❑ Reduction in SAS area of up to 25%: SAS size,sq.ft. %reduction
49 Penni Lane fomm9b•rev.7/06
Local Upgrade Approval• Page 1 of 1
0
• t• Commonwealth of Massachusetts
fnNIMMOMMa Cityfrown of
Local Upgrade Approval
Form 9B
B. Approval (continued)
❑ Reduction in separation between the SAS and high groundwater.
Separation reduction tt
Percolation rate minAnch
Depth to groundwater tt
❑ Relocation of water supply well (explain):
® Reduction of 12-inch separation between inlet and outlet tees and high groundwater
® Use of only one deep hole in proposed disposal area
® Use of a sieve analysis as a substitute for a perc test
List local variances granted not requiring DEP approval per 310 CMR 15.412(4):
List variances granted requiring DEP approval:
North Andover Health Dept.
Approving Authority
Susan Sawyer, Health Dir. 6/22/07
Print or Type Name and Title Signature Date
49 Penni Lane form9b•rev.7106
Local Upgrade Approval* Page 2 of 2
A
NEw ENGLANDENGINEERING SERVICE, INN
1600 Osgood Street
Building 20 Suite 2-64
North Andover, MA 01845
Ibl: (978) 686-1768 Is Fax: (978) 327-6138
www.neengineeringinc.com April 23, 2007
Project# 1355
Ms. Susan Sawyer
No. Andover Board of Health
1600 Osgood Street
No. Andover,MA 01845
Re: 47 Penni Lane,No. Andover,MA R CENED
Form 9-A Local Upgrade Approval Request
MAY 0 12007
Dear Ms. Sawyer, T. 1
q!-; : -=NORTH ANDOVER
IE ;L I H DEPARTMENT
The purpose of this letter is to request that the above referencedpropertybe included in
the upcoming Board of 14ealth meeting agenda to discuss the following Local upgrade
approval request:
Local !!pgrade de Approvals Required:
1. Allowthe use of a sieve analy sls to determine loading rate in lieunf—'
percolation test. Title 5, section 15.405(1).
2. Reduction in offset distance between the estimated' �S
the septic tank inverts from 12"required by Title 5,
If you have any comments or questions please do not hesitµt QUA/ &
Sincerely, � a'`" s
Benjaantn C. Osgood,
President
s �
NEw IENGLAND IENGMEIUNG SERVICE-9 INC.
1600 Osgood Street
Building 20 Suite 2-64
North Andover, MA 01845
TIM: (978) 686-1768 • Fax: (978) 327-6138
wwwneengineeringinc.com Ap;il23 2007
Project# 1355
Ms. Susan Sawyer
No. Andover Board of Health
1600 Osgood Street
No. Andover,MA 01845
Re: 47 Penni Lane,No.Andover,MA RECEIVED
Form 9-A Local Upgrade Approval Request
MAY 0 12007
Dear Ms. Sawyer, T Vr;.C;I:NORTH ANDOVER
SEAL i H DEPARTMENT
The purpose of this letter is to request that the above referenced property be included in
the upcoming Board or Health meeting agenda to discuss the following'Local upgrade
approval request:
Local Upgrade Approvals Re aired:
1. Allow the use of a sieve analysis to determine loading rate in lieu of performing a
percolation test. Title 5, section 15.405(1).
2. Reduction in offset distance between the estimated seasonal high groundwater and
the septic tank inverts from 12"required by Title 5, Section 15.227(5)to 1".
if you have an-y comments or questions
please do not hesitate to contact this office.
Sincerely,
G G
Benalrsn C. Osgood,
President
F CommonWvealth of Massachusetts
City/Town of No. Andover
Form 9A - Application for Local Upgrade Approval
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.
Form 9A is to be submitted to the Local Board of Health for the upgrade of a failed or nonconforming
septic system with a design flow of less than 10,000 gpd, where full compliance, as defined in 310 CMR
15.404(1), is not feasible.
System upgrades that cannot be performed in accordance with 310 CMR 15.404 and 15.405, or in full
compliance with the requirements of 310 CMR 15.000, require a variance pursuant to 310 CMR 15.410
through 15.415.
NOTE: Local upgrade approval shall not be granted for an upgrade�pLoposaal#hadchu�de t e addition of
a new design flow to a cesspool or privy, or the addition of a neJpdesign;f[Idw Above-t#�e exi ing approved
capacity of an on-site system constructed in accordance with eitAer the 1978 Code or 310 C R15.000.
2007
A. Facility Information
Important: TOWN OF NORTH ANDOVER
P HEALTH DEPARTMENT
When filling out 1. Facility Name and Address:
forms on the
computer,use Craig Bogosian
only the tab key Name
to move your 47 Penni Lane
cursor-do not
use the return Street Address
key. No Andover MA 01845
City/Town State Zip Code
QQ 2. Owner Name and Address (if different from above):
Same as Above
Name Street Address
City/Town State
Zip Code Telephone Number
3. Type of Facility(check all that apply):
® Residential ❑ Institutional ❑ Commercial ❑ School
4. Describe Facility:
5. Type of Existing System:
❑ Privy ❑ Cesspool(s) ® Conventional ❑ Other(describe below):
Installation of a subsurface sewage disposal system
6. Type of soil absorption system (trenches, chambers, leach field, pits, etc):
Leach Field
Form 9A Application for Local Upgrade Approval revised.doc•rev. Application for Local Upgrade Approval* Page 1 of 4
7/06
k, Commonwealth of Massachusetts
City/Town of No. Andover
a
o Form 9A — Application for Local Upgrade Approval
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.
A. Facility Information (continued)
7. Design Flow per 310 CMR 15.203:
Design flow of existing system: 440
gpd
Design flow of proposed upgraded system 440
gpd
Design flow of facility: 440gpd
B. Proposed Upgrade of System
1. Proposed upgrade is (check one):
❑ Voluntary ❑ Required by order, letter, etc. (attach copy)
❑ Required following inspection pursuant to 310 CMR 15.301: Unknown
date of inspection
2. Describe the proposed upgrade to the system:
Replace leach field and system components
3. Local Upgrade Approval is requested for(check all that apply):
® Reduction in setback(s)—describe reductions:
Reduction in separation distance between the ESHGW and septic inverts from 12" required by Title 5
Section 15.227(5)to 1"
❑ Reduction in SAS area of up to 25%: SAS size,sq.ft. %reduction
❑ Reduction in separation between the SAS and high groundwater:
Separation reduction
ft.
Percolation rate min./inch
Depth to groundwater ft
Form 9A Application for Local Upgrade Approval revised.doc•rev. Application for Local Upgrade Approval* Page 2 of 4
7/06
.,� Commonwealth of Massachusetts
City/Town of No. Andover
Form 9A - Application for Local Upgrade Approval
^M °r 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.
B. Proposed Upgrade of System (continued)
❑ Relocation of water supply well (explain):
❑ Reduction of 12-inch separation between inlet and outlet tees and high groundwater
❑ Use of only one deep hole in proposed disposal area
® Use of a sieve analysis as a substitute for a perc test
❑ Other requirements of 310 CMR 15.000 that cannot be met—describe and specify sections of the
Code:
If the proposed upgrade involves a reduction in the required separation between the bottom of the soil
absorption system and the high groundwater elevation, an Approved Soil Evaluator must determine the
high groundwater elevation pursuant to 310 CMR 15.405(1)(h)(1). The soil evaluator must be a
member or agent of the local approving authority.
High groundwater evaluation determined by:
Armond Parrazzo 4-17-07
Evaluator's Name(type or print) Signature Date of evaluation
C. Explanation
Explain why full compliance, as defined in 310 CMR 15.404(1), is not feasible. (Each section must be
completed)
1. An upgraded system in full compliance with 310 CMR 15.000 is not feasible:
No other location on the lot
2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible:
An alternative system would be cost prohibitive.
Form 9A Application for Local Upgrade Approval revised.doc•rev. Application for Local Upgrade Approval•Page 3 of 4
7/06
.. Commonwealth of Massachusetts
A` City/Town of No. Andover
Form 9A - Application for Local Upgrade Approval
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.
C. Explanation (continued)
3. A shared system is not feasible:
No other adjacent is available
4. Connection to a public sewer is not feasible:
Public sewer is not available in the area.
5. The Application for Local Upgrade Approval must be accompanied by all of the following (check the
appropriate boxes):
❑ Application for Disposal System Construction Permit
❑ Complete plans and specifications
❑ Site evaluation forms
❑ A list of abutters affected by reduced setbacks to private water supply wells or property lines.
Provide proof that affected abutters have been notified pursuant to 310 CMR 15.405(2).
❑ Other(List):
D. Certification
"I, the facility owner, certify under penalty of law that this document and all attachments, to the best of my
knowledge and belief, are true, accurate, and complete. I am aware that there may be significant
consequences for submitting false information, including, but not limited to, penalties or fine and/or
imprisonment for deliberate violations."
C
acilit wner's Signature Dam'
Benjamin C. Osgood Jr. P.E. (Agent for Owner)
Print Name
New England Engineering Services, Inc. lJ Z �Q7
Da��
1600 Osgood Streeet No. Andover, MA
Preparer's address City/Town
01845 (978)686-1768
State/ZIP Code Telephone
Form 9A Application for Local Upgrade Approval revised.doc•rev. Application for Local Upgrade Approval, Page 4 of 4
7/06
North Andover Health Department NORry
1600 Osgood Street ° ."V- . q6
Letter of Transmittal o� �`�'' �. " '° °°�,
Building 20, Suite 2-36 1- %
North Andover, MA 01845 s
e"" •v
978.688.9540 - Phone Page / of 44
978.688.8476— Fax SSACHUS�h
healthdeptO-)townofnorthandover.com-E-mail
www.townofnorthandover.com-Website
TO: DANIEL OTTENHEIMER DATE:
COMPANY:MILL RIVER CONSULTING FROM: Pamela Dellet6iaie,Health Department Assistant
Re:
Phone: 1.800.377.3044 or 978.282.0014
Fax: 978.282.0012
We are sending you: oil Test Application O Plans for Review O Other
These are transmitted as checked below:
[]As Required DAs Requested
REMARKS:
COPY TO: Homeowner Fax#
Or
ailed
OPY TO: Fox
Or
ailed
(aPY T0: Fax#
Or
Mailed
TOWOOF NORTH ANDOVER honrh
Officeof COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
16ob Oa3OODST REET� QUI I-DING 20- SUITE 2-36
NORTH AND0.1ER, S�CHIJSEff 845
Susan Y. SaNyet, FREH S, RS 978.68 .9540 -Phone
Public Health Director MAR 2 `OiP78,ffi.8476 FAX
healthd
A
TOWN Olte , W
AJ(wnof northandover.com
HEALI H[�L
APPLICATION FOR SOIL TESTS
DATE: MAP& PARCEL: Q 7- Taffe11 73
LOCATION OF SOIL TESTS: .--- A-.7 ':R:nn I Lac . N lo. A doytr
OWNER: q�mosian —Contact#– q79- bY2- J-71-3
j
APPLICANT: �
�tjffllo Contact
ADDRESS
ENGINEER: T"-(Jjfl.�
qjj�.FV . Contact# n b
�j ROJA.ift -
CERTIFIED SOIL EVALUATOR: Tr
Intended Use of Land: Resident i'"bdivision C&�n�eFamily��9 Commercial
IsThis: Repair Testing: 1' en Undeveloped Lot Testing:_ Upgradefor Addition:
In the Lake Cochichewick Wclershed? Yes No
THE FOLLOWING MUST BE INCLUDED WITH THISFORM
> Proof of land ownership(Ta(bill,or letter from owner permittingtest)
> 8.5-x 11_Plot plan& Location of Testing(please indicate test Pit siteson the Plan)
>
Fee of$42500 per lot for new construction. This covers the minimum two deep holes and
two percolation tests required for each disposal area. Feeof$360.00 per lot for repairs or upgrades.
GENERAL INFORMATION
> Only Certified Soil Evaluators may perform deep hole inspections.
> Only Mass. Registered Sanitarians and Professional Engineers can design septic plans.
> At least two deep holes and two percolation tests are required for each septic system disposal area
> Repairs require at least two deep holes and at least one percolation test,Ithediscretionofthe BOH
representative.
> Full perymentwill be required for all additional tests within two weeks of testing.
> Withi n 45 days of testing,ascat ed plan(no smaller than 1-100)shall be submi tted to the Board of Health
showi ng the I ocati on of ad I tests(i nd udi ng aborted tests).
> Within60daysof testing soil evaluation formsshall besubmitted. REUIVED
RECE
Please Do Not Write Below This Line P _
APR - 3 2007
0
TOWN OF NORTH ANDOV�R
Approval Dat LT I
N.A. Conservation Commission Approval Dat . EHEALTH DEPARTMENT
Signature of Conservation Agent: 11111'Jji
Date back to Health Department: (stamp in):
U0 4 cA:NVV, tv� fg)Aj //-1?CM IK #VAK 1100 OLNI
"I
r-0, Wq-t-Rt IVA,
l
--
C
LA I\J E
Page 1 of 1
I
DelleChiaie, Pamela
From: Marianne Peters [mpeters@millriverconsulting.com]
Sent: Monday, April 23, 2007 8:18 AM
To: Dan Ottenheimer; 'Lisa Kozel LeVasseur'; Marianne; Grant, Michele; DelleChiaie, Pamela; Sawyer,
Susan
Subject: 47 Penni Lane Soil Results attached
Attached please find the soil eval results for 47 Penni Lane.
Please call if questions.
Marianne Peters
Mill River Consulting
2 Blackburn Center
Gloucester, MA 01930
978-282-0014 ph
978-282-0012 fx
www.millriverconsulting.com
III
I
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4/23/2007
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TO: NORTH ANDOVER, MASS U- 19 75
BOARD OF HEALTH
FROM: DESIGN ENGINEER Re: Soil Absorption Sewage
System Inspection
Y p
This is to certify that I have inspected the construction of the said disposal system at
Z- 7 jeFAIAll 4A ' North Andover, Mass.
SITE LOCATION
The grades and construction are as specified in my plans and specifications dated
OF Mqs
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SMUGLI2/CS/V03/L046 REPORT # 122 TOWN OF NORTH ANDOVER YEAR 2009 PERIOD 07 TO 06 PAGE: 1
TIME: 14:03:33 OPTION ID HEALTH 122 BUDGET CONTROL REPORT 5100
PREPARED: MAY 03, 2004 DEPT: 5100 HEALTH DEPARTMENT AS OF: MAY 03, 2004
YTD YTD YTD PCT
LINE CUR MONTH ORIGINAL ADJUSTED ACTUAL UNEXPENDED YTD AVAILABLE EXP
FUND DEPT ITEM PROD LOC TOTAL EXP BUDGET BUDGET EXPENDED BALANCE ENCUMBERED BALANCE BAL
---- ---- ---- ---- ---- ----------- ----------- ----------- ----------- ----------- ----------- ----------- ---
001 5100 5111
SALARIES - FULL TIME 9,361.56 157,128.00 157,128.00 95,671.83 61,456.17 .00 61,456.17 60.9
FUND-GENERAL FUND
001 5100 5112
WAGES - PART TIME 3,403.39 13,900.00 13,900.00 39,199.79 25,299.79- .00 25,299.79-282.0
001 5100 5130
OVERTIME .00 .00 .00 544.45 544.45-
.00 544.45- 0.0
001 5100 5140
LONGEVITY .00 750.00 750.00 .00 750.00 .00 750.00 0.0
001 5100 5311
ADVERTISING .00 .00 59.51 59.51 .00 .00 .00 100.0
001 5100 5316
CONTRACTED SERVICES .00 1,500.00 1,135.30 1,036.71 98.59 98.59 .00 91.3
001 5100 5321
CONFERENCES IN STATE .00 520.00 561.00 561.00 .00 .00 .00 100.0
001 5100 5322
TRAINING & EDUCATION .00 .00 250.00 250.00 .00 .00 00 100.0
001 5100 5341
TELEPHONE 144.57 2,268.00 1,746.10 1,263.46 482.64 482.64 .00 72.4
001 5100 5342
POSTAGE SERVICES .00 850.00 754.30 700.00 54.30 .00 54.30 92.8
001 5100 5420
OFFICE SUPPLIES 192.94 600.00 791.92 712.02 79.90 .00 79.90 89.9
001 5100 5482
VEHICLE FUEL .00 .00 127.19 127.19 .00 .00 .00 100.0
001 5100 5596
UNIFORMS AND CLOTHING .00 75.00 75.00 75.00 .00 .00 .00 100.0
001 5100 5711
AUTO MILEAGE 75.60 .00 400.70 396.30 4.40 .00 4.40 98.9
001 5100 5730
DUES AND SUBSCRIPTIONS .00 760.00 240.00 240.00 .00 .00 .00 100.0
001 5100 5780
OTHER CHARGES AND EXPENSES .00 .00 29.98 29.98 .00 .00 .00 100.0
SMUGLI2/CS/V03/L046 REPORT # 122 TOWN OF NORTH ANDOVER YEAR 2004 PERIOD 07 TO 06 PAGE: 2
TIME: 14:03:33 OPTION ID HEALTH 122 BUDGET CONTROL REPORT 5100
PREPARED: MAY 03, 2004 DEPT: 5100 HEALTH DEPARTMENT AS OF: MAY 03, 2004
YTD YTD YTD PCT
LINE CUR MONTH ORIGINAL ADJUSTED ACTUAL UNEXPENDED YTD AVAILABLE EXP
FUND DEPT ITEM PROJ LOC TOTAL EXP BUDGET BUDGET EXPENDED BALANCE ENCUMBERED BALANCE BAL
---- ---- ---- ---- ---- ----------- ----------- ----------- ----------- ----------- ----------- ----------- ---
DE P T T 0 T A L ------------- ------------- ------------- ------------- ------------- ------------- ------------- -----
5100 HEALTH DEPARTMENT 13,178.06 178,351.00 177,949.00 140,867.24 37,081.76 581.23 36,500.53 79.2
------------- ------------- ------------- ------------- ------------- ------------- ------------- -----
GRAND TOTAL 13,178.06 178,351.00 177,949.00 140,867.24 37,081.76 581.23 36,500.53 79.2
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SMUGLI2/CS'/VO3/LO16 REPORT # 122 TOWN OF NORTH ANDOVER YEAR 2004 PERIOD 07 TO 06 PAGE: 1
TIME: 14:03:33
OPTION ID HEALTH 122 BUDGET CONTROL REPORT 5100
PREPARED: MAY 03, 2004 DEPT: 5100 HEALTH DEPARTMENT AS OF: MAY 03, 2004
YTD YTD YTD PCT
LINE CUR MONTH ORIGINAL ADJUSTED ACTUAL UNEXPENDED YTD AVAILABLE EXP
FUND DEPT ITEM PROJ LOC TOTAL EXP BUDGET BUDGET EXPENDED BALANCE ENCUMBERED BALANCE BAL
001 5100.5111
SALARIES - FULL TIME 9,361.56 157,128.00 157,128.00 95,671.83 61,456.17 .00 61,456.17 60.9
FUND-GENERAL FUND
001 5100 5112
WAGES - PART TIME 3,403.39 13,900.00 13,900.00 39,199.79 25,299.79- .00 25,299.79-282.0 f
001 5100 5130
OVERTIME .00 .00 .00 544.45 544.45- .00 544.45- 0.0
001 5100 5140
LONGEVITY .00 750.00 750.00 .00 750.00 .00 750.00 0.0
001 5100 5311
ADVERTISING .00 .00 59.51 59.51 .00 .00 .00 100.0
001 5100 5316
CONTRACTED SERVICES .00 1,500.00 1,135.30 1,036.71 98.59 98.59 .00 91.3
001 5100 5321
CONFERENCES IN STATE .00 520.00 561.00 561.00 .00 .00 .00 100.0
001 5100 5322
TRAINING & EDUCATION .00 .00 250.00 250.00 .00 .00 .00 100.0
001 5100 5341
TELEPHONE 144.57 2,268.00 1,746.10 1,263.46 482.64 482.64 .00 72.4
001 5100 5342
POSTAGE SERVICES .00 850.00 754.30 700.00 54.30 .00 54.30 92.8
001 5100 5420
OFFICE SUPPLIES 192.99
600.00 791.92 712.02 79.90 .00 79.90 89.9
001 5100 5482
VEHICLE FUEL .00 .00 127.19 127.19 .00 .00 .00 100.0
001 5100 5596
UNIFORMS AND CLOTHING .00. 75.00 75.00 75.00 .00 .00 .00 100.0
001 5100 5711
AUTO MILEAGE 75.60 .00 400.70 396.30 4.40 .00 4.40 98.9
001 5100 5730
DUES AND SUBSCRIPTIONS .00 760.00 240.00 240.00 .00 .00 .00 100.0
001 5100 5780
OTHER CHARGES AND EXPENSES .00 .00 29.98 29.98 .00 .00 .00 100.0
SMUGLI2/CSAV03/L045 REPORT # 122 TOWN OF NORTH ANDOVER YEAR 2004 PERIOD 07 TO 06 PAGE: 2
TIME: 14:03:33 OPTION ID HEALTH 122 BUDGET CONTROL REPORT 5100
PREPARED: MAY 03, 2004 DEPT: 5100 HEALTH DEPARTMENT AS OF: MAY 03, 2004
YTD YTD YTD PCT
LINE CUR MONTH ORIGINAL ADJUSTED ACTUAL UNEXPENDED YTD AVAILABLE EXP
FUND DEPT ITEM PROD LOC TOTAL EXP BUDGET BUDGET EXPENDED BALANCE ENCUMBERED BALANCE BAL
---- ---- ---- ---- ---- ----------- ----------- ----------- ----------- ----------- ----------- ----------- ---
DE P T T 0 T A L ------------- ------------- ------------- ------------- ------------- ------------- ------------- -----
5100 HEALTH DEPARTMENT 13,178.06 178,351.00 177,949.00 140,867.24 37,081.76 581.23 36,500.53 79.2
------------- ------------- ------------- ------------- ------------- ------------- ------------- -----
GRAND TOTAL 13,178.06 178,351.00 177,949.00 140,867.24 37,081.76 581.23 36,500.53 79.2