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Miscellaneous - 49 PADDOCK LANE 4/30/2018 (2)
49 PADDOCK LANE / 210/107.D-0105-0060.0 r a Q-tA-� z�no�;7 5T(� Art f A" NORTH BUILDING PERMIT F TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION - « e Permit NO: Date Received Date Issued: SSACHU`��� IMPORT T:Applicant must complete all items on this-page LOCATION V ! d G} L-an 2 - Print PROPERTY OWNERD+! 0 Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Reside tial Non- Residential ❑ New Building ne family ❑Addition ❑Two or more family 0 Industrial 0 Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg 0 Others: ❑ Demolition ❑ Other 0 Septic 0 Well p Floodplain 0 Wetlands D Watershed District 0 Water/Sewer fl �{S 111 `f f f'�1 �i} Identification Please Type or Print Clearly) OWNER: Name: _r- /rlY al212AA?'z)IJ o.l Phone: 57 Address: I _1 `C .4 CONT TOR Name: Phone: ©8 .37 Address: 1--7 Supervisor's Construction License: Exp. Date: Home)mprovement License: Exp. Date: l Jr ARCHITECT/ENGINEER Phone: Address: Reg. No. I FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $, & FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access tot uaranty fund Signature of Agent/Owner Signature of contracto Plans SubmlTed ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ CJ . L?06 TYPE OF SEWERKGE DISPOSAL _ Public Sewer ❑ Tauning/Massage/Body Art ❑ Swimming Pools ❑ well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM V ANNING IlZ DEVELOPMENT Reviewed OnY110-14 Signature � �— COMMENTS bE14 )A) C)<-15 7n/E Z'3or�Y1,2a� VIONSERVATION Reviewed on .a Si nature -,t Q� COMMENTS 3 F V/EALTH Reviewed ori ` Si nature M COMMENTS-1_)e C- A , L r - U Zoning Board of Appeals:Variance, Petition No: Zoning Decisionlreceipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/si_gnature &Date Driveway Permit DPW Town Engineer: Signature: _ _ y„_-T _ ^Located 384 Osgood Street FIRE 560PN3 TMEN�T, - `'i :,'� `: '�• t• f� . _ + .�_._.....� TemplDumpster�gn�site.4syess�_; -, �:t�' ono, L'ocatetljat5124MainEStreet 9 +reit 3r ,L° :;. ; -- `FiretDepartment�s�ic'nature/date __�' ' �: _` _�, _ . •_ } �; + ; S r , fir. Y rE .,.._ .s� ^��� •r t.-- .--. — „-._ ..� --., .P - ..-. h l L E_ ; i 1 � t 1 ,1 1. . t 1 r ,r ' -' ." •:�. �"l'•= `;�.`>+,•.�_ ' vC-r . `�o � — __..._� _ _rte '. S. J.77f �y f ti� S CA L.E 1 ,1 40 D.a-r�, (SEG Zq� tqg 1 �J F R4►-4 W- C.�ELiN4S � ASSUGIp.TES zc)) EN61NEE�S� A�G4-(tTEGTS a?S"..,? .i'N179�t1�r�+erw.�:�'•..r,a+,-..�.r�ae.•„'vY4.ra..:•.ws..:i:'7K!.r��.s4'a�y:.':r^..�vf�(• � � � \ i-iN ��Y V J,4c7c1 Nb t5 2 Z S�-1-vt�ssb S<rN1-17S�7 71tv�ra �� 19611 t62 7:;(0 ���bQ � p� �,. , a-r'v�g r-� IN c w o 9 z, o V �'� �� „ � pz. :i r) mac. �! I , I .1 1 t I 1 1 ,yam,,. . ,. ,.. ._. . . .. .. I Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 DEP has provided this form for use-by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health 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 Locatio�.�LeIg ont oN�obuilding, Left/Right rear of house, Left/right side of house, Left/ Right side of buil-F-g, Left/Ri Left/Ri htrear of buildin Under deck 99 g� Address LVl Citylrown State Zip Code 2. System Owner. Name Address(if different from location) Citylrown Stat alo(S Telephone Number �= _ r 1 B. Pumping Record J`.3 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No, 5. Condition of System: �! \A,, 51 6. System Pumped By.- Neil y:Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc- Company ncCompany 7. Locatiortwhere contents were disposed: Lowell Waste Water SignAtufe 9t Haule Date t5form4.doc•06103 System Pumping Record•Page 1 of 1 Residential Property Record Card PARCEL_ID:210/107.D-0105-0000.0 MAP:107.D BLOCK:0105 LOT:0000.0 PARCEL ADDRESSA9 PADDOCK LANE FY:2010 PARCEL INFORMATION Use-Code: 101 Sale Price: 622,000 Book: 8746 Road Type: T Inspect Date: 11/02/2009 Tax Class: T Sale Date: 04/29/04 Page: 112 Rd Condition: P Meas Date: 05/06/2008 Owner: Tot Fin Area: 2464 Sale Type: P Cert/Doc: Traffic: M Entrance: X MOULSON,CHRISTOPHER&LAURA Tot Land Area: 1.00 Sale Valid: Y Water: Collect Id: SGC Address: Grantor: NORTON,MARK Sewer: Inspect Reas: M 49 PADDOCK LANE NORTH ANDOVER MA 01845 Exempt-B/L% / Resid-B/L% 100/100 Comm-B/LP/° Indust-B/L% / Open Sp-B/L% / RESIDENCE INFORMATION LAND INFORMATION Style: CL Tot Rooms: 10 Main Fn Area: 1232 Attic: N NBHD CODE: 7 NBHD CLASS: 7 ZONE: R2 Story Height: 2.00 Bedrooms: 5 Up Fn Area: 1232 Bsmt Area: 1232 Seg Type Code Method Sq-Ft Acres Influ-Y/N Value Class Roof: G Full Baths: 3 Add Fn Area: Fn Bsmt Area: 900 1 P 101 S 43560 1.000 225,640 Ext Wall: AV Half Baths: 1 Unfin Area: Bsmt Grade: VALUATION INFORMATION Masonry Trim: Ext Bath Fix: 0 Tot Fin Area: 2464 Current Total: 576,500 Bldg: 350,900 Land: 225,600 MktLnd: 225,600 Foundation: CN Bath Qual: T RCNLD: 350903 Prior Total: 609,000 Bldg: 384,200 Land: 224,800 MktLnd: 224,800 Kitch Qual: T Eff Yr Built: 1987 Mkt Adj: Heat Type: HW Ext Kitch: Year Built: 1981 Sound Value: Fuel Type: O Grade: G Cost Bldg: 350,900 Fireplace: 1 Bsmt Gar Cap: Condition: A Aft Str Val 1: Central AC: Y Bsmt Gar SF: Pct Complete: Aft Str Val2: Aft Gar SF: 576%Good P/F/E/R: /100/100/89 Porch y.pe Porch Area Porch Grade Factor W 228 SKETCH PHOTO W 12 228SgJt 12 24 jq 44 G FUlFM/B 24 576 SgFt 24 1232 SgFt 28 2e 24 44 49 PADDOCK LANE Parcel ID:210/107.D-0105-0000.0 as of 8/24/10 Page 1 of 1 North Andover Board of Assessors Public Access Page 1 of 1 NORTH North Andover Board of Assessors Ot tt��o �1�0 F� T �7S wwno✓•'t4� SwCHU roperty Record Card Click Seat To Return Parcel ID:210/107.D-0105-0000.0 FY:2010 Community:North Andover SKETCH PHOTO Click on Sketch to Enlarge Click on Photo to Enlar e Search for Parcels Search for Sales d Summary Residence Detached Structures Condo 49 PADDOCK LANE `• Commercial Location: 49 PADDOCK LANE Owner Name: MOULSON,CHRISTOPHER&LAURA Owner Address: 49 PADDOCK LANE City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 7-7 Land Area: 1.00 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 2464 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 576,500 609,000 Building Value: 350,900 384,200 Land Value: 225,600 224,800 Market Land Value: 225,600 Chapter Land Value: LATEST SALE Sale Price: 622,000 Sale Date: 04/29/2004 Arms Length Sale Code: Y-YES-VALID Grantor: NORTON,MARK Cert Doc: Book: 8746 Page: 112 http://csc-ma.us/PROPAPP/display.do?linkId=1520029&town=NandoverPubAcc 8/24/2010 S } COMMONWEALTH OF MASSACHUSETTS z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_49 Paddock Lane —North Andover_ -- ". ,'f_R/ Owner's Name:_Mark Norton_ Owner's Address:_49 Paddock Lane_ _North Andover,MA 01845_ Date of Inspection:3/16/2004_ " Name of Inspector: Neil J.Bateson_ i Company Name: Bateson Enterprises Inc._ - Mailing Address:_111 Argilla Road_ _Andover,Ma.01810_ Telephone Number:_(978)4754786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: _X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority F 1 Inspector's Signature: A -U � Date: 3/16/2004 P g _ _ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments: ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 49 Paddock Lane_ _ North Andover— Owner:_Norton_ Date of Inspection:_3/16/2004_ Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. —The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_49 Paddock Lane_ _North Andover— Owner:_Norton_ Date of Inspection: 3/16/2004_ C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool 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. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance__ "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 49 Paddock Lane_ _ North Andover— Owner:_Norton_ Date of Inspection: 3/16/2004 D. System Failure Criteria applicable to all systems: You must indicate"yes"or`no"to each of the following for all inspections: Yes No _ No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool No Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _No_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _No Liquid depth in cesspool is less than 6"below invert or available volume is'/z day flow. _No Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped No— Any portion of the SAS,cesspool or privy is below high ground water elevation. —No Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well. No— Any portion of a cesspool or privy is within 50 feet of a private water supply well. _No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] _No_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 49 Paddock Lane —_North Andover— Owner:_Norton_ Date of Inspection: 3/16/2004 Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes No Yes _ Pumping information was provided by the owner,occupant,or Board of Health No Were any of the system components pumped out in the previous two weeks? Yes_ _ Has the system received normal flows in the previous two week period? _ _No Have large volumes of water been introduced to the system recently or as part of this inspection? Yes _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) Yes_ _ Was the facility or dwelling inspected for signs of sewage back up? Yes _ Was the site inspected for signs of break-out? Yes_ _ Were-all system components,excluding the SAS,located on site? _Yes_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _Yes_ _ Was the facilityowner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _Yes_ _ Existing information. _No_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] Page 6 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 49 Paddock Lane_ _North Andover— Owner:_Norton_ Date of Inspection: 3/16/2004_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_4_ Number of bedrooms(actual):_4_ DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):_600_ Number of currant residents:_3 Does residence have a garbage grinder(yes or no): Yes_ Is laundry on a separate sewage system(yes or no):_No_ Laundry system inspected(yes or no): Seasonal use:(yes or no): No_ Water meter readings:_On well water_ Sump pump(yes or no): Yes_ Last date of occupancy:— Current-COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:_Pumped 2001,owner_ Was system pumped as part of the inspection(yes or no): Yes_ If yes,volume pumped:_1500_gallons--How was quantity pumped determined?_Measured tank Reason for pumping: _Inspect tank&tees_ TYPE OF SYSTEM _X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval _Other(describe):_ Approximate age of all components,date installed(if known)and source of information:_Tank&Field 23years old,12/29/1981,As built plan,D-Boz 3 years old,Info at Board of Health_ Were sewage odors detected when arriving at the site(yes or no):_No Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 49 Paddock Lane_ _North Andover— Owner:_Norton_ Date of Inspection: 3/16/2004_ BUILDING SEWER(locate on site plan)X Depth below grade:_22"_ Materials of construction: _cast iron _X_40 PVC_other Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.):_4"Cast iron thru wall. 3"PVC in house ,no leaks visible_ SEPTIC TANK: X locate on site plan) Depth below grade:_10"_ Material of construction:—X—concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 10'x 5'x 4' Sludge depth —4"_ Distance from top of sludge to bottom of outlet tee or baffle: 23"_ Scum thickness:_611 _ Distance from top of scum to top of outlet tee or baffle:_8" Distance from bottom of scum to bottom of outlet tee or baffle: 15" How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.)_Pumped septic tank Inlet tee ok.Outlet tee ok.No evidence of septic tank leaking.Depth of liquid at outlet invert. _ GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 49 Paddock Lane_ _North Andover— Owner:_Norton_ Date of Inspection: 3/16/2004 TIGHT or BOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.):_D-box level& distribution equal,has flow levelers.No evidence of leakage out of d-box.Evidence of solid carryover,pumped d-box to clean._ PUMP CHAMBER:_(locate on site plan) Pump in working order(yes or no): Alarm in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):_ Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 49 Paddock Lane_ _North Andover— Owner:_Norton_ Date of Inspection: 3/16/2004_ SOIL ABSORPTION SYSTEM(SAS):_X (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: X leaching fields,number,dimensions:_1 Field 22'x 501 _ overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.):_Soil ok.Vegetation ok No sign of ponding to surface. _ CESSPOOLS: (cesspool must be pumped as part of inspectionxlocate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of I 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_49 Paddock Lane_ _North Andover— Owner:_Norton_ Date of Inspection: 3/16/2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. Ato1=30' A to 2=22'2" A to D-Boz=53' B to 1=12'6" Bto2=15'2" C to D-Boz=8613" House To well Driveway GarageA B C Septic Tank 2 1 D- 22' Boz 50' Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 49 Paddock Lane _North Andover— Owner:_Norton_ Date of Inspection: 3/16/2004_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water _4'_ Please indicate(check)all methods used to determine the high ground water elevation: _X_ Obtained from system design plans on record-If checked,date of design plan reviewed:_9/22/1978_ Observed site(abutting property/observation Bole within 150 feet of SAS) Checked with local Board of Health-explain:_ Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: __ You must describe how you established the high ground water elevation:_Design plan_ Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating-Water.& Sewer Lines-Septic Systems&Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 49 Paddock Lane, North Andover Owner: Norton Date of Inspection: 3/16/2004 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. 1 Neil J. Bat on Bateson Enterprises, Inc. COMMONWEALTH OF MASSACHUSETTS Z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS p r d DEPARTMENT OF ENVIRONMENTAL PROTECTION 4 F ti M 5r6 TITLE 5 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_49 Paddock Lane_ _ OF North Andover_ I Owner's Name: Joseph Webb_ �ti'QR;H Owner's Address:_49 Paddock Lane 7�OF F;qR• , ,..: _North Andover_ Date of Inspection:_6/27/2001_ JUN 2 9 ?ODI Name of Inspector: Neil J.Bateson `—- Company Name: Bateson Enterprises Inc._ Mailing Address:_111 Argilla Road_ `- _Andover,Ma.01810_ - Telephone Number: (978)4754786 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper 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 Needs Further Evaluation by the Local Approving Authority F Inspector's Signature: Date: _6/27/2001_ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments:After permit from B.O.H. &installing new d-box with flow levelers,system now passes Title 5 Inspection. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. l TOWN OF SYSTEM PUMPING RECORD i't W1�OF NO"-" At B OF HE!`LT�� DATE. l SYSTEM OWNER & ADDRESS SYSTE 4cv--- (example:left front of house) b0c � 0--P DATE OF PUMPING: �6 J0 QUANTITY PUMPED : GALLONS CESSPOOL: NO S SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROQTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste Town of North Andover, Massachusetts Fpm No.3 BOARD OF HEALTH • t NORT{{ t L DISPOSAL WORKS CONSTRUCTION PERMIT • 7SS^CMUSEt Applicant_ NAME / ADDRESS TELEPHONE Site Location Permission is hereby granted to Construct ( ) or Repair ( ' an IndividualSoilAbsorption Sewage Disposal System as shown on the Design Approval S.S. No. �S CHAIRMAN,BOARD OF HEALTH Fee D.W.C. No. J NEW ENGLAND ENGINEERING SERVICES INC TOW N 0 40 EAD � BOAR]OF W 1 October 14, 1995 North Andover Board of Health Town Hall Annex 120 Main Street North Andover,MA 01845 RE: TITLE V REPORT Enclosed is the Title V report for 49 Paddock Lane,North Andover,MA If there are any questions please call me at my office,686-1768. 'I Yours truly, 1 Benjin C.Osgood Jr. President 33 WALKER RD. - SUITE 22 - NORTH ANDOVER, MA 01845 - (508) 686-1768 o�Ea► Commonwec;M of Massachusetts Oa�NN�PA Executive Office of Environmental Affairs SO�N$OP ooF Department of Environmental Protection o6 William F.Weld Goemot TrudyCoxe Secretary,EDEA . David B. Struhs commiss.one, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION v9 � d�OC fie, . /OoieA AKd0vpie, 1> 4 Properly Address; Address of Owner: Date of Inspection: /U 113 /S j (If different) Name of Inspector: (a,en�Iq ,r;o b-O0 4 j Q Company Name, Address and Telephone Number; NCw �hG� «gyp IznG-i�see, e;nG- �l K'vr'c �� $, C CERTIFICATION STATEMENT 3-y,t `4 O Kale 12`� N - A k dp v� C VVI A 0 got S. g- Ug(, t7Ca2 i certify, that I have personally :aspected the se,vage disposal sv5tem at this address and that the information reported below i; true, accurate and,complete as of the time of inspection. The inspection was periormed based on my training and experience in the proper function and niainti�nance of on-site sewage disposal systems. The system: Passes — Conditionally Passes _-_„ Needs Further Evaluation By the Local Approving Authority Fads Inspector's Signature: V r. Date: 1 p �f3 The .stem Inspector shad submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection If the svctem is a shared system or has a design floe of 10,000 gpd or g,eatc=r, the inspector and the system o- ner shali submit the report to the appropriate regional office of the Deoartment of Environmental Protection. The ori£inal shou'd be sen' i(: :f'e :',Stem uv ner and copies Sil1i. to lilt UUyef, if appliCovit' a:}d the appro,;ng author;;,, INSPECTION SUMMARY: Check66,.C, or D AJ SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated art; indicated below, B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection, Indicate yes, no, or riot determined (Y, N, or ND). Describe basis of determination in all instances, If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health (rev,,sed E!15/95i 1 One V,rrnter Street • Boston, Massachusettx 6o2108 • FAX(617) 556.1042 • Telephone (617) 292.55x0 as �r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A r� nCERTIFICATION (continued) Property Address: (91 t 44';�ce o� j.g 1� �T" �'o U t7 e YVl A• Owner: M A R G i V_ 4� tz"N tv oQ Date of Inspection: 101 /3/91- B) 13/9B] SYSTEM CONDITIONALLY PASSES (continued) T Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box, The system will pass inspection if(with approval or the Board of Health): broken pipets) are replaced obstruction is removed distribution box is levelled or replaced "i•e system rec,ulred purrlp:ng more than tour times a year due to broken or obstructer; pipe(s;, The system will !rspe.,ion ir" ;v.it;' ar)proval of the Board o7 Health): broken ppeis; are replaced obstructio!t is removed 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 (the system is failing to prorecr the public heath, safety and the environment, 1) SYSTE.'s1 WILL PASS 11N4ESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MAr,'•,�E•v WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cossp0o1 cr prl i; v;rhir 50 feet of a surface eater lir 1.. thin 50 fee!. Of a bo'derlmg vegetated lNedand or a salt marsh. 2; SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC N'ATER SUPPLIER, IF A!'PROPRIATE) DETERMINE, `!TAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND 5IAFETY AND THE ENVIRONMENT: in- wsier'l na- a sen!ic rani, ana soil absorption System aria IS Nvitnin •ilial Itti Iv a .0 I,.,.c waic!, Surface v:aier sunpiv T!:r• s ' tP ha. a sPt;; , tank and .soil absorption system and is within a ?nne I of a pi.i):Ic water supply well T The system h.;: a sept!c tank and soil absorption system zinc; is within 50 feet of a pri.a; water supply well. ine S >lr,n: nn; ,: sept c tank and soil absorption system and ;s less than 1010 feet but ,en' or ',_,'e from a priv.:;: ',,,,ttPr supol•, wel'i, unirss a well water analysis for coliform bacteria arid volatile organic compounds indicates that the w-: .s free from pollution from that facility and the presence of amn-onia nitrogen and nitrate Nitrogen is equal to or less t.:an S ppm. D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defin:,.t ul 310 CMR 15.303. The for this determination is identified below, The Board of Health should be contacted to determine what will be necessary to the failure. Backup of sewage into facility or system component due to an overloaded or claggec' Sel.5 or cesspool. __.. Discharge or ponding of effluent to the surface of the ground or surface waters due to ,:o overloaded or clogged ce'>pocl !revised ¢115/95 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.A CERTIFICATION (continued) Property Address: y PA c4 UG k LA. N. l4vt ,o vaP, m 4 Owner: ►'YUP A e6e, r -�e riN fU r1L rL Date of Inspection: Jo >I�3 (9i D) SYSTEM FAILS (continued):. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. _, Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. _.._ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipets(. Number of times pumped •,,,_ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I of a public well, Amy porion 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. If the well has been, analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen, E) LARGE SYSTEM FAILS: The following criteria appy to large systems in addition to the criteria above: The deSi'Ln fioJ N of s')5;en, is 10,000 gpd or greate (targe System' and the system 15 a significant threat to pub.-lic health and safety and rhe lnv rormen; because one or more of the following conditions exist, the systen,. 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 s}stern is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone Il.of a uUb;,Q wafer soppl\ well, The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00, Please consult the local regional office of the Department for further information, (revised 8;15/95: 3 Opp SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: �-/ cj 9 U t A ri Q Owner: 1^� (�QG J� -�,eay_a tE ot_ Date of Inspection: CF:r ck if the follow ing have been done r' Pumping information -as requested of the owner, occupant,_and Board of Health. K'ione of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period Large volumes of water have not beer•, introduced into the system recently or as part of this inspection. /�fl As built plans have been obtained and examined. Note if they are not available with N/A. V/The faclaN or cl vellrng vias inspected for signs of sewage back-up. Il The system does not receive non-sanitar,� or industrial waste flow The site was inspectea for signs of breakout. VAP system components, excluding the Soil Absorption System, have been located on tf,e site, ^The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. / J! The size and location of the Soil Absorption System on the site has been determined based on existing information or appr(�,,i; ated i?`, non, .niruSi�e method Thr- nt, G.." ,. ,; _„". i�I; :..'�'.. ^o` \•.. c �'nVl Isn -,ak of rnl !i nn on the proper main?nan F' �uk)- Surface Disposal S, tem (rev:,sed 8/15/95; 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: �{�7 P1 C �j Vk 4 Owner; m 9 R(9 i iS Q Iv Ot t- 4-- Date of Inspection: 57 FLOW CONDITIONS RESIDENTIAL: Design flew: Qallons Number of bedrooms: Number of current residents: y 'Garbage grinder (yes or no',"_ ; Laundry connected to system (yes or no):_�L Seasonal use (yes or no: 1W Water meter readings, if available: U— G0L Last date of occupant,,: 0 e 1}n CO,MMERCIAUINDU_STRIAI._: Type of establishment. Design flow: gallons/da; Grease trap present: (yes or no) Industrial Waste Holding Tank present: (yes or not— Non-sanitary waste discharged to the Tale 5 system: lyes or no)_,__ Water meter readings, if availab e._ Last date of occupancy OTHER: (Describe' Last date of occupancy: GENERAL INFORMATICN PUMPING RECORDS and source of information. S11� n(,- I995 ak, CcJz ou ry LX12 System pumped as part of inspection: (yes or no! If yes, volume f .,mi>c:' 15'00 pallont Reason for pumping -ro :C11SPee i' LC TYPE OF SYSTEM t./ Septic tank!distnbution bowsoii absorption system Single cesspool Overflow cesspool _ Frivv Shared systen (yes or no! ( f yes, attach previous inspection records, if any,, Other (explain)_-T APPROXIMATE AGE of all components, date installed (if known) and source cf information: J 3 V e g e S Sewage odors detected "hen arriving at the site (yes or no) (revised 8.115/95, S N SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C f SYSTEM INFORMATION (continued) Property Address: P, 4--c,A v e'eW Owner: ►r1 rti RC9 i c C VA to it✓k— Date of Inspection: sol � ! 55 SEPTIC TANK: (locate on site plan) Depth below grade:-&-4 rade: C-1 Material of construction. Yconcrete _„_metal —FRP ^other(explaini /5 UO !rA c- Dimensions: Sludge depth: Q. " Distance from top of sludge to botiorri of outlet tee or baffle:12af: Scum thickness: O D:s:a:-ce from top of scum. tc top of outlet tee or baffle, d Distance from bottom of scum to bottom of outlet tee or baffle:.q Comments; ;recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) "�A►� 0(4 — lee' sA R 5 L 'I Oe d �' t o q�e b n �!a A ��P C �^Q" L J,1%- SC-k ,4PVC 0 L e i s eie CREASE TRAP:_ ,cafe on site plan Dep". be!ov, grade plater al of construct on _concrete _metal _FRP _otheriexplain` D-imensons. - Sc,.rn thickness. Distance from top of seem ;o top of outlet tee or baffle: ;rlpt le. or '�•?rn from bU;to .. trt,(:ommendation for purr;, n . c. ce :i ;:e c' ir?iet and outlet tees or baffles, depth of liqu d level in relation to cutlet invert, structure �:�• ;, evidence o. Ire^:Se38'i5/95, 6 9s -1n�7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 41 'rr 0Cr< Lw , ti � x} 60vrra I vnA Owner: M i2 ; 1z (S e O In K tx vZ Date of Inspection: TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below-grade: Material of construction: —concrete _„_metal _FRP __,_other(explaln) Dimensions: Capacity: gallons Design flow:______.__galIon vda'. Alarm level;__.,,.,_____,,,_. Comments: (condition of inlet tee, Condit r..,n o- alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level abo\e ou•.It Invert• D Comments: , i I �,,,, - n„,.,; C••Irj�,-rn r� cnlir;c Ca^'�f,�c, a•didenCa Of INaKage into or out of bOY etc, 1 r:r,c rre, ar.d d -aox s l C v� �. . s i�(> 'du"nG� or• CaxRy ove+� AL4tio04l. S"cP FE'OgCy C11.7 02 D e 4-v,e 4-e 4e - - PUMP CHAMBER:_,,, (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) 7 (revised 8/15/95; CIS. � a.. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �4 -7 Owner: ,yn A R G BQ Q n vt c°oL Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): ;locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If rot determined to be present, explain: �o k o e 0 Type leaching pits, nurnber:____ leach ng chambe•s, number:___- leaching gaileries, number: k leaching trenches. numberjength, F 46 leaching fields, number, dlmenslons PGS �� Oi 4M i overflow cesspoo!. number`_ CornrnerntE .note cond;UO', of soil. signs cf hvdraulic failure, level of ponding, condition of ve etit i /Lc7 r3 Yi D��crZ o tY /�V��c'A��,'G �"•p_�___� /Lr - CESSPOOLS: (!ocate on site piar Numbe, and configuration. ehti, (Op O. liq'J'C tr., Depth of solids lade: Dep!!-, of scum layer P u't14nslcns of cess`Fool:. ,._-- M Materials of construc,ion' _ inQi,:ailon of ground,.%aie, -^,- fl0�ti' tces5por-1 musi be pumped as part of Inspection) signs o. h.draulic failure, level of ponding, condition of vegetation, etc.) Comments: (note condau r of ser PRIVY: _ (locate an site pian) Materials of construction - Depth of solids: Comments: (note condition of soil, signs of i-,ydraulic failure, level of ponding, condition of vegetation, etc,)-------- 8 tc,)._ p__}"__s :e:'_sed 8/15/951 • C,., SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C p„ �" / SYSTEM INFORMATION (continued) Property Address: r h'�cc G !-ld A-, cl�,,we e, Vo Owner: 4ec-"e- 'jS CE'K rt e Date of Inspection; 51 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' It � I I t.2X: S � � nl. A � l` L fl DEPTH TO GROUNDWATER Depth to groundwater: b feet method of determination or approximation: ! S t i ►+� q tIL rev:sed 8;'15/951 9 BOARD OF HEALTH NORTH ANDOVER, MA 01845 978-688-9540 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: Com—f/— a / CURRENT INSTALLER'S LICENSE# LOCATION: /Y,? PA ��QULJ� ,�✓ LICENSED INSTALZXsI- -254 SIGNATURE: TELEPHONE# 12�-- CHECK ONE: REPAIR: NEW CONSTRUCTION: 1D— _SoX `� NEW CONSTUCTION, EASE ATTACH FOUNDATION AS-BUILT. Administrative Use Only $-1-68:86 Fee Attached? Yes No Foundation As-Built? Yes No Floor Plans? Yes No Approval Date: (�� D INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the �'U property at P19�cI relative to the application of D W WOoi✓dated 6---f f—52 / for plans by and dated with revisions dated I understand the following obligations for management of this project: 1. As the installer I am obligated to call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item two shall be applicable. 2. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Tile 5 and the Board of Health Regulations may result in a$50.00 fine being levied against my company. a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As-built or verbal OK from engineer must be submitted to Board of Health, after which installer calls for inspection time. Installer must be present for this inspection. With 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. Does not have to be on site. 3. As the installer I understand that persons or companies not associated with my company may not perform the work required by my company to complete the installation of the system identified in the attached application for installation. I further understand that work 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 in the Town of North Andover plus significant fines to all persons involved. 4. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached. b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff. d) Installation of tank, D-box, pipes, stone, vent, pump chamber, retaining wall and other components. 5. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Und tgn Licensed Septic Installer l Date: r �� Disposal Works Construction Permit# i Board of Health NOrth+'Andover,Mass SUBSURFACE DISPOSAL DESIGN CHECK LIST LOT PPROM DATE DISAPPROVED DATE_____.,, 'rovided: J Reasons: FAII. C 'itle � plan L4�OMS=3 teg 2.5 The submitted / a) the lot to be served-area,dimensions lot ##abutters location and log deep observation Mes-distance to ties c location and results percolation tests-distance ties eachin design calculations & calculations showing requiredg area v . e location and dimensions of system-including reserve area X existing and proposed contours „/(g) location any wet areas within 100 1 of sewage disposal system or • disclaimer-check wetlands mapping (h) surface and subsurface drains within 100' of sewage disposal / system or disclaimer (i) location any drainage easements within 1 ' of sedge disposal 00 / system or disclaimer-Planning.Board files l/(3) known sources of water supply within 2001 of sewage disposal system or disclaimer ( ) location of any proposed well to serve lot-100 from leaching facility 1) location of water lines on property-10' from leaching facility J( (m) location of benchmark n) driveways garbage disposals no PVC to be used in construction i e septic tank (q profile of system-elevations of basement, plumb, p p , eP , distribution box inlets and outlets, distribution field piping and Other elevations Ar) maximum ground water elevation in area sewage disposal system S) plan mast be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Reg 6 Septic Tanks (a) capac t es- 50% of flow, water table, tees, depth of tees, access, pumping (b) cleanout (c) 10t from cellar wall or inground swimming pool (d) 251 from subsurface drains . Reg 10.2 Distribution Boxes a) s pe greater 0.08 Reg 10.1 b) sump Subsurface DesignCheck List Pae 2 1 ; FAIL Cg Leaching Pits Leaching pits a preferred where the installation is possible Reg 11.2 a) calculations f leaching area-minimum 500 eq ft 11.4 b) spacing 11.10 c surface a 2% 1,1.11 d cover matekal e) I'x2+x4m splash pad f) tee at bow g) no bins in pipe from d-box to pipe f LeachingFields Reg 15.1 WV a no greater 20 minutes/inch b area-minimum 900 s4 fL 15.4 c construction of field 15.8 d) surface drainage 2 % 3.7 ✓ e) 201 from cellar mn or inground and mmd.ng pool LeachingIDem+c s Reg 1.4.1 a)aalculaons eaching area-min 500 sq ft b spacing-4 min 6 ft with reserve between 14,4 c� dimensions 14.6 d constrnc on 14.7 a stave 14.10 f surfs a drainage 2% Downhill Slo e a slope y x = be shown b� y/x X 150 (to be shown EMS Reg 9.1 a) approval 9.6 ib) stand-by power r.. TO: J A NORTH ANDOVER, MASS. BOARD OF HEALTH FROM: �'� �� �,. ��( t 1.IAS � � DESIGN ENGINEER Re: Soil Absorption Sewage Disposal System This is to certify that I have inspected the construction materials of said disposal system at L.-O T tOA► f---7A P Dock- L-AJ 6; Site Location North Andover, Mass. The grades and construction materials are as specified in my plans and specifications dated A , 19 and s ilt flL-L- '30 , 19b) G R g.Prof.Engine /Reg.Sanitarian Board of Health North An40_11 MasSEPTIC SYSTEM IN ALLATICK CHBCK LIST LOT APNOTED DATE DISAPP OVED AVATICF1 OK FAIL 4 / � ea9gZ18T ' t - FAIL OK t 1. Distance Tot € a. Wetlands i b. Drains C. Well ' 2. Water Line Location i 30 No PVC Pipe J✓ - $. Septic Tank " a. -Tees -_Length & To Clean Ont Covers. b. Cement Pipe to Tank- On Both Sides of Tank \ � \ 5. Iri s tribut3on Box � a. Covers & Box - No Cracks \ b. All Lines Flowing E6al Amounts c. No Back Flow 6. - Leach Field or Trench a. Dimensions b. Stone Depth c. Capped_Rids } d. Clem Double Washed Stone' 7. Leach Pits a. Dimensio b. epth 1 - t c. ash Pads Teas e. Cmmt Pipe to Pit - Both Sides f. Clean Double Washed Stone S 8. No Garbage Disposal 9. Final Grading Inspection 10. Barricading*Covered System Built Submitted_ _ - a. Lot Location b. Dimmsions of System c. Location with Regard-to Perc Test { d. Elevations e: Water Table 3 r Board of Health North Andovsr,Masa 4C � . SUBSURFACE DISPOSAL DESIGN CHECK LIST LOT PPROM DATE DISAPPROVED DATE_ rovided: Reasons: BA19 itle V FA# ab _ ag 2.5 a submitted plan must show as a min{mm= the lot to be served-area,dimensions lot #,abutters location and log deep observation hoes-distance to ties location and results percolation tests-distance to ties sign calculations & calculations showing required leaching area location and dimensions of system-including reserve area f existing and proposed contours g) location any wet areas within 1001 of sewage disposal system or disclaimer-check wetlands mapping vkh) surface and subsurface drains -,*!.thin 1001 of sewage disposal system or disclaimer i) location any drainage easements within 1001 of sesage disposal system or disclaimer-Planning Board files 3) = sources of -aster supply within 2001 of sewage disposal system or disclaimer k)/location of any proposed well to serve lot-1001 from leaching facility ) location of water lines on property-101 from leaching facility (m location of benchmark "driveways garbage disposals no PVC to be used in construction q) profile of system-elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and Other elevations 1110 maximum ground water elevation in area sewage disposal system ,/ s) plan mast be prepared by a Professional Engineer or other professional authorized by law to prepare such plana deg 6 Septic Tanks I ra) capacities--I % of flow, -pater table, tees, depth of tees, rbaccess, pumping cleanout 4,5/ 10' from cellar -Fall or inground swimming pool d) 251 from subsurface drains sg 10.2. Distribution Boxes slope greater 0.08 �g 10.4 Kb) sung s Subsurface Deaiga Check Mat Page 2' FAIL 0K Leaching Pita Leaching p 4s are preferred where the installation is possible Reg 11.2 a) calculat ons of leaching area-minimum 500 eq ft 11.4 b) spacin 11.10 csurfs 5 drainage 2% 11.11 d� covematerial e) 21 Al" splash pad f f teat elbow g) n1bends in pipe from d-box to pipe Leaching_Fields Reg 15.1 no greater than 20 minutes/inch area-mi.nimsm 900 eq ft 15.4 r construction of field 15.8 surface drainage 2 % 3.7 Ve) 202 from cellar wall or inground mdmzndng pool • I Leachin M •hes j Reg X11.3 b calculation o eaching area-min 500 sq ft • spacing-4 min 6 ft with reserve between a 14.4 c di�sio 14.6 d) constrac on :L4.7 e) stone 1h.10 f surface drainage 2% Dow1hill Slope a s o e y x = to be shown b y/ x 150 (to be shown s Reg 9.1 a) royal 9.6 b) s d-by poorer t i Commonwealth of Massachusetts RECEI , City/Town ofF u,p System Pumping Record MAY2 9 2007 Form 4 TOWN OF NORTIA ANDOVER L H DEPA HEARTMEN1" DEP has provided this form for use by local Boards of Health. Other fo y�e-asedI but th 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- formson the computer,use only the tab key Address p f_ / ,( to move your � � �'�,/ cursor-do not Cityrrown State Zip Code use the return key. 2 System Owner: TA�qu Name 11 Address(if different from location) City/Town St Zip Code Telephone Number B. Pumping Record t) a3 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes �o If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of Sys emC� ig 6. Systerp P mped By: ' Name Vehicle License Number Company 7. Location ere contents wer isposed: a � Signatt#ofKattler Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 COMMONWEALTH OF MASSACHUSETTS z F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a d DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 49 Paddock Lane_ _North Andover Owner's Name: Joe Webb_ Owner's Address:_49 Paddock Lane_ , ° O cv _North Andover,Ma. 01845_ Date of Inspection: Name of Inspector: Neil J.Bateson ' r Company Name: Bateson Enterprises Inc._ Mailing Address:_111 Argilla Road_ _Andover,Ma.01810_ Telephone Number:_(978)475-4786 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes X_ Conditionally Passes Needs Further Evaluation by the Local Approving Authority F ' i � Inspector's Signature: /1Date: 5/25/2001_ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 49 Paddock Lane_ _North Andover_ Owner: Webb Date of Inspection: 5/25/2001 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: _X One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. D-Box needs replaced. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. N_The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: ,N_ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: _N The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 49 Paddock Lane_ _North Andover— Owner: Webb Date of Inspection: 5/25/2001 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. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 49 Paddock Lane_ —North Andover— Owner• Webb Date of Inspection:_5/25/2001 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ _No_ Liquid depth in cesspool is less than 6"below invert or available volume is less than YZ day flow _No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ —No_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. No Any portion of a cesspool or privy is within a Zone 1 of a public well. _ _No Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ _No Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or`ho"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ — the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 49 Paddock Lane_ _North Andover— Owner: Webb_ Date of Inspection:_5/25/2001_ Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Yes_ _ Pumping information was provided by the owner,occupant,or Board of Health No Were any of the system components pumped out in the previous two weeks? Yes_ _ Has the system received normal flows in the previous two week period? No Have large volumes of water been introduced to the system recently or as part of this inspection? Yes_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) Yes_ _ Was the facility or dwelling inspected for signs of sewage back up? Yes_ _ Was the site inspected for signs of break out? _Yes — Were all system components,excluding the SAS,located on site? _Yes_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? _Yes_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Yes_ _ Existing information.For example,a plan at the Board of Health. _No_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 49 Paddock Lane_ North Andover– Owner: _Webb Date of Inspection:_5/25/2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_4_ Number of bedrooms(actual):_4— DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):_600_ Number of current residents: Does residence have a garbage grinder(yes or no):_Yes_ Is laundry on a separate sewage system(yes or no):_No_[if yes separate inspection required] Laundry system inspected(yes or no):_ Seasonal use:(yes or no):_No_ Water meter readings:_On well water_ Sump pump(yes or no): Yes_ Last date of occupancy:_Current COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:_Pumped last year,owner Was system pumped as part of the inspection(yes or no):_No_ If yes,volume pumped:Jgallons--How was quantity pumped determined?— Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: 20 Years old.12/29/1981 As built plan._ Were sewage odors detected when arriving at the site(yes or no):_No_ Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_49 Paddock Lane_ _North Andover— Owner: Webb Date of Inspection: 5/25/2001 BUILDING SEWER(locate on site plan)X Depth below grade:_22" Materials of construction:—X—cast iron X 40 PVC other(explain): Distance from private water supply well or suction line:_>100' Comments(on condition of joints,venting,evidence of leakage,etc.):_4"cast iron thru wall.3"PVC in house. No leaks._ SEPTIC TANK: X locate on site plan) Depth below grade:_10"_ Material of construction:—X—concrete_metal_fiberglass polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 10'x 5'x 4'_ Sludge depth 2" Distance from top of sludge to bottom of outlet tee or baffle: 25"_ Scum thickness: 2"_ Distance from top of scum to top of outlet tee or baffle:_8" Distance from bottom of scum to bottom of outlet tee or baffle:_19" How were dimensions determined:_Subtract scum&sludge depth to tee length._ Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.):_Inlet tee ok.Center baffle ok.Outlet tee ok.Depth of liquid at outlet invert.No evidence of leakage. GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction: concrete_metal_fiberglass__polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 49 Paddock Lane_ North Andover- Owner: Webb Date of Inspection:_5/25/2001T i I TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_0_ Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): _D-box level&distribution equal.Evidence of leakage,has bad corrosion.D- box needs to be replaced.Evidence of carryover. PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 49 Paddock Lane_ _North Andover— Owner: Webb Date of Inspection:_5/25/2001_ SOIL ABSORPTION SYSTEM(SAS): X_(locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: _X leaching fields,number,dimensions:_1 Field 22'x 50'_ overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.):_Soil ok.Vegetation ok.No sign of ponding to surface._ CESSPOOLS: (cesspool must be pumped as part of inspectionxlocate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 49 Paddock Lane_ _North Andover_ Owner: Webb Date of Inspection: 5/25/2001_ i 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. 1I House To well Driveway Garage A B C 3 2 1 Septic Tank D- 22' Box A to 1=30' Ato2=26' Ato3=22'2" A to D-Box=53' BtoI=12'6" Bto2=13' Bto3=15'2" C to D-Box=8613" Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_49 Paddock Lane_ North Andover_ Owner: Webb Date of Inspection: 5/25/2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 4 feet Please indicate(check)all methods used to determine the high ground water elevation: _X_Obtained from system design plans on record-If checked,date of design plan reviewed:_9/22/1978_ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation:_ As per design plan Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating-Water.& Sewer Lines-Septic Systems&Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 49 Paddock Lane, North Andover Owner: Webb Date of Inspection: 5/25/2001 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Neil J. Bat on Bateson Enterprises,Inc. Commonwealth of Massachusetts City/Town of RECEIVED System Pumping Record Form 4 SEP 2 8 2009 DEP has provided this form for use by local Boards of Hea t�9ftg ftkft 11 IEW d, but the information must be substantially the same as that provide m, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left side of house, Right side of hous eft front of hou , Right front of house, Left rear of house, Right rear of house. Address q q ` Ln tw`1�f OZ4 City/Town State Zip Code 2. System Owner: Name Address(if different from location) Cityrrown State,..-,, SL4y jp Cod„ Telephone Number B. Pumping Record 1. Date of PumpingDate" ` 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: o 6. System Pumped By: Neil Bateson Name Vehicle License Number F5821 Bateson Enterprises Inc Company 7. Location where contents were disposed: Lowell Waste Water 5 n ur of Haul r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 S - .1 _a S f z - � SRL\�' � As,A' � �' 1 C � � �� �jn o. IN r A � c> -,/c- r-, Mir ,� Sca.LE ► '� = 4o ' Da,,-�� (fat at . Ztj� Ic�g I !`-� FRAh11C GGE-L-1?jgS AS:3UCtATES EI�SGtNEEQ3 AG2C1-IIT�GTS r i 48rjb Gf MOFTM,� [ �?•` ` • 0 Town of North Andover HEALTH DEPARTMENT SACMUS! CHECK#: � AT-:xhv LOCATION: H/O NAME: CONTRACTOR NAM • W- .v Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ TitleTInspector $ n"Title 5 Repo ��� $`� '.'v ❑ Other. (Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer Commonwealth of Massachusetts I Title 5 Official Inspection Form a. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Propert Address _ Owner Owner's Name �, �'"`�'� information is ------- required forAU ll; State Zip Code Date of Inspection every page. City own Inspection results must be submitted heckl st at theoend of the f on forms may not be altered in any way. Please see completeness c Important: A. General Information SEP �}�� When filling out Ti , forms on the computer,use 1. Inspector: p �/ TOWN XPi NCIt1�M ANDOVER only the tab key C r I < J /� HEALTH Q810ARTMUNT to move your J cursor-do not Name of Inspector _ GI yVj p- use the return f-� s�V.1 : f key. Company Name � O/ A Company Address �� fGs U Y t l state Zip Code ,eom Cityrrown -� 6 / v r 5� �) 9 License Number Telephone Number B. Certification I certify that I have personally inspected accurate ate and complete as of thosal e me of the his nspectess ion. The inspection the information reported below is true, proper function and maintenance of on site was performed based on my training and eroved system inspnce in the ctor pursuant to Section 15.340 of sewage disposal systems. I am a DEP app Title 5(310 CMR 15.000).The system: ['�Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Date I actor's Signature The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of Coe eletthe i spectoing this e and the system ownehe system is d hall submit bm t thesystem or has a design flow of 10,000 gpd or gr stem owner report to the appropriate regional office of the DEP. The original should be sent to the system 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. ksP 0e+ff I Title 5 Official Inspection Form:Subsurface sewage Disposal System•Page 1 of 17 t51ns•09/08 Commonwealth of Massachusetts Title 5 official Inspection Form -Not for Voluntary Assessments Subsurface Sewage Disposal System Form Property Address Owner Owner's Name Information is State Zip C Date of Inspection required for Ci (town every page. tY B. Certification (cont.) Inspection Summary: Check A,B,C;D or E/always complete all of Section D A) System Passes: it [�J I have not found any information 10 CMR 15.3041exist.ates the failure cof eiteriarnot revaluat d aiteria re e in 310 CMR 15.303 or In 3 indicated below. Comments: vl/V B)System Conditionally Passes: tem upon completion of the replacemen repair, as approved by replaced or repaired. The sys ❑ One or more system components as described in the"Conditional Pass" se tion need to e p the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for following statyements. if"not determined, "please explain. hether l or is The septic tank is metal and substantial infiltrover 20 ation taat on oe sxfiltration or tank failure tais imminent.System structurally unsound, exhibits will pass inspection if the existing tank is replaced h a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if' is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is le than 20 years old is available. ❑ Y ❑ N ❑ (Explain below): Title 5 official inspection Form Subsurface Sewage Disposal system•page 2 of 17 t5ins.09108 Commonwealth of'Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments A , Property Address Owner Owner's Name Information is required for State Zip Code Date of Inspection every page. Cityrrown B. Certification (cont.) B) System Conditionally Passes(cont.); ❑ Observation of sewage backup or breakout or high static water level ' the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or unev distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ ❑ 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 pump' g more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspectio if(with approval of the Board of Health): ❑ broken pipe(s re replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstructio s removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Re/aa uired by the Board of Health: ❑ Conditions exist which reer evaluation b he Board of Health in order to determine if the system is failing to prlic health, saf or the environment. 1. System will pass unrd of He h determines in accordance with 310 CMR 15.303(1)(b)that the syot fu Toning in a manner which will protect public health, safety and the environ❑ Cesspool or priv50 feet of a surface water ❑ Cesspool or priv50 feet of a bordering vegetated wetland or a salt march t51ns•09/08 Title 5 official Inspection Form Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewaagge�Disposal System Form Not for Voluntary Assessments Property Address Owner Owner's Name Information is required for State Zip Code Date of Inspection every page. Cityrrown B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) deterimes 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 S is within 100 feet of a surface water supply or tributary to a surface water sup p . ❑ The system has a septic tank and SAS and the SAS is within a Z e 1 of a public water supply. El The system has a septic tank and SAS and the SAS is wit ' 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SA s 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 analy ' , performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presenc of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other ilure 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,/ ❑ L✓J Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ l✓J 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 ❑ El Liquid depth in cesspool is less than 6"below invert or available volume is less 0than M day flow t5ins•09108 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 a ` w /v Property Address d Owner owner's Name Information is -- required for State Zip Code Date of Inspection everypage. Cityrrown B. Certification (cont.) Yes No E] Required Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ['f 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 cesspoolwell withis less than 100 feet no acceptable water tqualty analysis. [This ter than 50 feet from a private water supply performed at a DEP certified system passes if the well water analysis, p 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.] ❑ This 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 syste ust serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes"or"n to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 0 feet of a surface drinkiing water supply ❑ ❑ the system is wi In 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system i located in a nitrogen sensitive area (Interim Wellhead Protection Area- IW or a mapped Zone II of a public water supply well If you have answered"yes" o any question in Secon E the system.is bove the large system has failed The owner o operator of any large or answered yes In Sectl n D a 9l upgrade system considered awiicant threat under310 CMR 15.304. Thte system olled w er should d contactt the lapp opriiatehe with system in accordance with regional office of the Department. l5ins•09108 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name Information is State Zip Code Date of Inspection required for every page. Cityrrown 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? (Z( ❑ Were as built plans of the system obtained and examined? (If they were not available note as NIA) (� ❑ Was the facility or dwelling inspected for signs of sewage back up? [� ❑ Was the site inspected for signs of break out? C ❑ 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 dimensions, depth of liquid, depth of sludge and depth of scum?construction, [� ❑ Was the on the neo(and er ma ntenance off different ubsurface sewage disp sal systems? information p P This size and location of the Soil Absorption System (SAS) on the site as been determined based on: ❑ Existing information. For example, a plan at the Board of Health. (� ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (actual): Number of bedrooms (design): /r DESIGN flow baseon d 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 6 of 17 t5ins-09/08 Commonwealth of Massachusetts Title 5 official Inspection Form ments Subsurface Sewage Disposal System Form-Not for Voluntary A e7(9 4Q c4vc-6. w Property Address Owner owner's Name Information is State Zip Code Date of Inspection required for �ity/Town every page. D. System Information Description: S Number of current residents: ❑ Yes lJ No Does residence have a garbage grinder? E( to sewage.system? [if yes separate inspection required] Yes CJ No Is laundry on a separa �� ❑ Yes ❑ No Laundry system inspected? ❑ Yes �No Seasonal use? r �'�1' Vrk�- ' Water meter readings, if available(last 2 years usage(gpd)): i We-I �Ov S Detail: Yes ❑ No Sump pump? (!�_Uueg-t Last date of occupancy: 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.): ❑ Yes ❑ No Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? Yes ❑ No Non-sanitary waste discharged to th itle 5 system? ❑ Water meter readings, if availa . 15ins-09108 Title 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 Property Address Owner owner's Name Information is State Zip C Date of Inspection required for every page. City/Town D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: 0 / Source of information: ❑ Yes L.ER/No Was system pumped as part of the inspection? If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: [� Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Attach a copy of the current operation and Innovative/Alternative technology. of latest inspection ection of the I/A system eby system obtained f operatorrom eundern contract copy ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 8 of 17 t5ins•09/08 Commonwealth of Massachusetts � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w Property Adress Owner Owner's Name Information is required for State Zip Code Date of Inspection every page. Cityrrown D. System Information (cont.) Approximate age of all components, date installed (if known)and source of info rmation: Were sewage odors detected when arriving at the site? ❑ Yes ErNo Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron 2'40 PVC ❑ other(explain) V/Y Distance from private water supply well or suction line: feet Comments (on condition of joints,venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: LI concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) f/ 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 Title 5 Official Inspection Form Subsurface Sewage Disposal system•Page 9 of 17 t5ins-09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name Information is required for State Zip Code Date of Inspection everypage. City/Town D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness " Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle y� / > How were dimensions determined? S�u el t e PL/ ,e Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 04 v c� 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 out t tee or baffle Distance from bottom of scum to b om of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 10 of 117 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name Information is required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee o affle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, a 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 ❑ lyethylene ❑ 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 rm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09108 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Assessments Subsurface Sewage Disposal System /Form Not for Voluntary -P—roperty Address Owner Owner's Name Information is __— required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) 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.): 1 - �o pump Chamber(locate on site plan): ❑ Yes ❑ No pumps in working order: ❑ Yes ❑ No Alarms in working order: Comments (note condition of pump chambe condition of pumps and appurtenances,etc.): Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: ------------------ Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 12 of 17 (t5ins•09/08 Commonwealth of Massachusetts Title 5 official inspection Form menta Subsurface Sewage Disposal System Form Not for Voluntary Ass �nf Property Address Owner Owner's Name Information is State Zip C Date of Inspection required for every page. Cityrrown D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ number, length: leaching trenches leaching fields 01—d--X5 number, dimensions: d ❑ number: overflow cesspool ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): r - v 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 ❑ Yes ❑ No Indication of groundwater i ow (t5ins•09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form KOM Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Ad8ress Owner Owner's Name Information is required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of nding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic (lure, level of ponding, condition of vegetation, etc.): Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 14 of 17 (t5ins•09/08 Commonwe*alth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - Property Address Owner owner's Name Information is State Zip C Date of Inspection required for City/Town every page. D. System Information (cont.) of the tem including ties to Sketch of Sewage Disposal System: Provide a viewnchmarks.eLo atewage iallll wells wosal ith n 100 feet. Locate at least two permanent reference landmarks or be Check one of the boxes below: where public water supply enters the building. e hand-sketch in the area below �4av ❑ drag win attached separately / 14 3 a v � s Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 15 of 17 (t5ins•09/08 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 411 Property Address Owner Information is Owner's Name required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells b Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: [� Obtained from system design plans on record If checked, date of design plan reviewed: !7 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: 00, Before filling this Inspection Report, please see Report Completeness Checklist on next page. Title 5 Official Inspection Form Subsurface Sewage Disposal system-Page 16 of 17 (t51ns-09106 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner Owner's Name Information is required for State Zip Code Date of Inspection every page. Citylrown E. Report Completeness Checklist Ir Inspection Summary: A, B, C, D, or E checked E inspection Summary D (System Failure Criteria Applicable to All Systems)completed System Information- Estimated depth to high groundwater d Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file T5ins•09/08 Title 5 official Inspection Form Subsurface Sewage Disposal System•Page 17 of 17 F ti Commonwealth of Massachusetts City/Town of W° System Pumping Record REC Form.4 JUN �� 4 U 11 DEP has provided this form for use by local Boards of Hea h. Other forriis may be u d, but the information must be substantially the same as that provide TA%N Qle1�Tt�rt►�mlo rm, check with your local Board of Health to determine the form they use. The ust be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Locati : Le�6 , htfront of house, left side of house, right side of house, Left rear of house, right rde of building, right rear of building, under deck. City/Town State Zip Code 2. System Owner: , 1 ( zx� U Name �— Address(if different from loZt' ) City/Town State Zip Code 2 S 6 Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of S�jr� 6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Location-w ere contents were disposed: S Lowell"steWpter Signafurg of auler Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1