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Home My WebLink AboutMiscellaneous - 505 FOREST STREET 4/30/2018 (4)+E � a.. � � t r ` i �, �� I .�� r �� , _ f �, � . .� �� North Andover Board of Assessors Public Access Page 1 of 1 woRxy Town Of NOYt h A do.voov, 32�°`Y a"oma Beare of°Assessors, h � Property s Return to the Home page click on logo Record Card Parcel ID:210/106.B-0007-0000.0 Community: North Andover New Search SKETCH PHOTO Click on Sketch to Enlarge Click on Photo to Enlarge Sales Summary Residence 1 Detached Structure Condo Commercial Comparable Sales .,...."' ..„ .AST . 505 FOREST STREET Location: 505 FOREST STREET Owner Name: RAYNER,JOHN F. Owner Address: 505 FOREST STREET City:NORTH ANDOVER State:MA ZIP:01845 Neighborhood:6-6 Land Area:2.06 acres Use Code: 101 -SNGL-FAM-RES Total Finished Area:2167 sqft ASSESSMENTS CURRENT YEAR ;PREVIOUS YEAR Total Value: 474,500 507,000 Building Value: 257,800 267,700 Land Value: 216,700 239,300 Market Land Value:216,700 Chapter Land Value: LATEST SALE Sale Price:450,000 Sale Date:06/25/2003 Arms Length Sale Code:Y-YES-VALID Grantor:PLISINSKI,PAUL J. Cert Doc: Book:07957 Page:0226 i http://csc-ma.us/NandoverPubAcc/jsp/Home.jsp?Page=3&Linkld=1181284 3/13/2008 BUILDING PERMIT of NoRTN 1:96 '. TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION - Permit NO: Date Received 4 • ' O cwc p` 9 �RATEO ,P SSACHU`�� Date Issued: IMPORTANT:Applicant must complete all items on this page A 104 Ar" --R 51/VNER C7- F i .• ' fPARCEZO ring x" MAPNO� �� NI,NG DIS:TRIC,T _s _.�Hstonc Distnctyes ino� - . - II � u Machine`Shopie`s. TYPE OF IMPROVEMENT PROPOSED USE Res' ential Non- Residential ❑ New Building ne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: *-Demolition ❑ Other _ ��.. .. t i '' lFl doo pail n OrWetla� nds � 1 °® Septic A, _.� � ' �� Wa"te shetl District; y° ateF1Sewer - M� r �DESC IPTION OF CORK TO BE PREFORMED: Iden 'ficat*on Please Type or Print Clearly) OWNER: Name: . \Q4L4 4ifik Phone: Address: s �Lle ,CON jRA --`T®R :Name N [9$✓�;Tl _ 1 �._�Phone. Addrss DGx 1 � i�' . �5 777 S,upenlisors Construction jL�icenses a E�xp� Date} "4 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ;Sign-a�turegen�t/Owner� � ;�.f e Srgnatureof�contractor .:�,� �,,. � ,'-,' Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE,OF'SEWERAGE DISPOSAL public Sewer ❑ Tanning/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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on : Signature 0' COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit .f DPW Town Engineer: Signature: L i FI=R�DEPAR�TMENT � Located 384 Os ood Street Temp ELIZ sten on sits, yes ono � .; w Locateda"t 124Main Streets s IFire Deparfm ne t gnature%y i si date t s i' f DELINEATION BY ; ; EX15►GNU .. D'URSO / WELL �c1 o SEE PLAN REF. #4. c31�, S \ ILL LOT 2 _ -'8C11 134,476 S.F. • � - ,, �`\ `. \ �1 X6,2>, .�� .\�, . ` • \ `•--� SEE PLAN REF #3. �, \ • gQ/� ca.. .. CROP. DET BASIN +-,j'J C3 2� .' , ' • ��y,/ TOP ELEV 109.5 / a � 30T ELEV 106.5 6 0 . OUTLET WIER EL 108.75 RIP–RAP SPILLWAY ,/ C24 X-,IL 98 06, '7 �O /O O 6> �� Q .2 � LOT e 89,912 S.F o - 2 SEE .PLAN. REF. #3•- .8 C25 rt C26 ' �`��. .: .\ -114 ,• 25' NO DISTURB" ) \ �, 'Q \ ' ` C241e'. '''f —712 APPROX. LOCATION GE �, .�'.,yyA _ v OF SEPTIC SYSTEM LEG[ • �• C21 C22 s' .• ! �f /I _ \ —110 it wc QQ' G GV ; Yr _50~ "NO BUILD" .� ti Alc� . .-;,.. � C.E3. 06 •------ ,J �`b o� 'o� O h C.L.F. �, n0 v �— D -- _ _ _ A M.H. r.. `\ 100' WETLAND _ o�� S.M.H. BUFFER - �' _- - - � � E.T.C. - -__ __ --- Q O.H. 44, ,�� R.C.P. � U.P. HYD. WELL DATABASE j ADDRESS: vJ AGE OF WELL: WELL DRILLER: WELL PERNIIT WELL LOCATION: ' WELL PERMIT DATE: DEPTH OF WELL: TYPE OF WELL: a.. DRILLEDb. DUG c. tii OWN TYPE OF WATER BEARING ROCK- WATER ANALYSIS DATE: HI MANGANES � E. Y N HIGH IRON: Y N OTHER CONTAMINANTS: Y N WELL DATABASE ADDRESS: L� / AGE OF WELL: WELL DRILLER: WELL PERMIT#: WELL LOCATION-- WELL OCATIO NWELL PERMIT DATE: DEPTHF WELL: S. TYPE OF WELL: a.. DRILLED b. DUO c. UNKNOWN TYPE OF WATER BEARING ROCK: - WATER ANALYSIS DATE: HIGH MANGANESE: Y N HIGH IRON: Y N OTHER CONTAMINANTS: Y N Septic System Information 505 FOREST STREET Printed On: Wednesday,April 16, 2008 System ID: BHS-2002-0714 General System Information Latest Permit Information Calcaluted Design Flow: Test Pits Septic Tank Disposal Trench Design Flow: One Two Capacity: Number.- Design umber.Design Flow Provided: Minutes per inch: Width: Width: Total Flow: Depth: Length: Length: Seasonal: No No Depth to Water: Diameter: Leaching: Grinder. No No Soil Type: Depth: Laundry: No No Hauling/Pumping Listin Quantity Tyne System Type Pumped Pumped By Transferred To Disposed At Date Pumped allons Routine Septic Tank Andover Septic 06/19/2002 1000 Inspections: Inspected: Expires: Inspector: Status: 03/17/2008 Benjamin C.Osgood,Jr. Passes Comments: Title 5 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Page 1 of 1 Y NORTH r 32 '! 8 F p Town of North Andover �` '• HEALTH DEPARTMENT ,SSACNus�t CHECK#: DATE: �� LOCATION: �� 1-1/0 NAME: .__��l� y CONTRACTOR 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 1$': ❑ Sun tanning y $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal'Works Installers(DWI) $ ❑ Title 5 Inspector $ 0--Title 5 Report i ❑ Other:(Indicate) $ Health Agent/Initials, 4 White-Applicant Yellow-Health Pink-Treasurer; ` Commonwealth of Massachusetts F TitleOfficial G r� � 5 O tial Inspection F7ssessC VV D Subsurface Sewage Disposal System Form - Not for Voluntants G2008Y r 7G ox 505 Forest Street R 2- Property Address John Raynor TOWN OF NORTH ANDOT R Owner Owner's Name information is required for No Andover MA 01845 3/17/08 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Benjamin C. Osgood, Jr. cursor-do not Name of Inspector use the return key. New England Engineering Services, Inc. Company Name r� 1600 Osgood Street Suite 2-64 Company Address No. Andover MA 01845 City/Town State Zip Code 978-686-1768 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: asses 4 ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority L Inspecto' Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15 ' 9 t t ` Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 505 Forest Street Property Address John Raynor Owner Owner's Name information is required for No Andover MA 01845 3/17/08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: 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 TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 ! Commonwealth of Massachusetts N u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 505 Forest Street M Property Address John Raynor Owner Owner's Name information is required for No Andover MA 01845 3/17/08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines.in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments cM °° 505 Forest Street Property Address John Raynor Owner Owner's Name information is required for No Andover MA 01845 3/17/08 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: j D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No."to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or E] clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ElStatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ElLiquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ [►� Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Er- Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. TITLE 5 FORM 2007.DOC-08/06 Title 5 Official.Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 505 Forest Street Property Address John Raynor Owner Owner's Name information is required for No Andover MA 01845 3/17/08 every page. City/Town State Zip Code Date of Inspection . B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ [� Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ 9, Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0" Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet . from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ y The system is a cesspool serving a facility with a.design flow of 2000gpd- 10,000gpd. ❑ ET" The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ a 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. TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 505 Forest Street Property Address John Raynor Owner Owner's Name information is required for No Andover MA 01845 3/17/08 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No [/ ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Ud Were any of the system components pumped out in the previous two weeks? 2 ❑ Has the system received normal flows in the previous two week period? ❑ Er- Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ENIq Were as built plans of the system obtained and examined? (if.they were not available note as N/A) ❑ [' Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? ❑ Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑/ ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] TITLE 5 FORM 2007.DOC-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 505 Forest Street M Property Address John Raynor Owner Owner's Name information is No Andover MA 01845 3/17/08 required for I every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder? ❑ Yes V No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes 'o No Laundry system inspected? ❑ Yes [2 No Seasonal use? ❑ Yes R1 No Water meter readings, if available(last 2 years usage (gpd)): Sump pump? ❑ Yes E& No Last date of occupancy: G`'r -- T Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 . Commonwealth of Massachusetts Title 5 Official Inspection Form ac Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 505 Forest Street Property Address John Raynor Owner Owner's Name information is required for No Andover MA 01845 3/17/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes X No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: [� Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1q7 1977 Were sewage odors detected when arriving at the site? ❑ Yes [X No TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15. • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � M 505 Forest Street Property Address John Raynor Owner Owner's Name information is required for No Andover MA 01845 3/17/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): i Depth below grade: fee Material of construction: cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on co/n��dition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): �r Depth below grade: fee Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: < l Distance from top of sludge to bottom of outlet tee or baffle 2 Scum thickness Z Distance from top of scum to top of outlet tee or baffle to Distance from bottom of scum to bottom of outlet tee or baffle 2 y 4 How were dimensions determined? -A OVA,&,)(LE si1c.IL— TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 505 Forest Street Property Address John Raynor Owner Owner's Name information is required for No Andover MA 01845 3/17/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7-e9Nl� tN lsooD cflNr� ilo,J� C�2ass �,A�F1��% �1.a cauc t'�� '}"G�- I✓1 G o J � GF>A�� .�SD rt_ N � e.J fl U G L? OF G.G Ri/,+4'L� N I A• Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): )U 10q- Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: i ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 505 Forest Street Property Address John Raynor Owner Owner's Name information is required for No Andover MA 01845 3/17/08 every page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): l,3o x RLI /3e tow GrucQe- Depth of liquid level above outlet invert O " 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.): g�K (A O V% ca-pl',a yA Co,,eA e, ,c Le-(� cc vires Srf J u i 0 C f7�3T�2I geACl 6 i- G.E I N a 62 O.S Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No TITLE 5 FORM 2007 DOC•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 505 Forest Street Property Address John Raynor Owner Owner's Name information is required for No Andover MA 01845 3/17/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑. leaching chambers number: ❑ leaching galleries number: i ❑ leaching trenches number, length: /+ leaching fields number, dimensions: Xy0` .} ❑ 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.): A-o-co C>r fi(GL,D woos r�1oaAAt-L- ti IaeAf-e PDNo-LJ5 tAM P .SZA Lr 02 L)NA-i$ H L GG-ET7`�Z�ON TITLE 5 FORM 2007.DOC-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 �M 505 Forest Street Property Address John Raynor Owner Owner's Name information is required for No Andover MA 01845 3/17/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) /V(d-Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): M(A, Privy(locate on site plan): ` Materials of construction: j Dimensions I Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): TITLE 5 FORM 2007.DOC-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments YC�M 505 Forest Street - Property Address John Raynor Owner Owner's Name information is required for No Andover MA 01845 3/17/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. �v use V� 4N`' ®---- w µ��sE O Co v A - TAri 14,8 j - T4,v)r, Gev� g,to A- L; iar -;;5 s TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 505 Forest Street M Property Address John Raynor Owner Owner's Name information is required for No Andover MA 01845 3/17/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: heck Slope [Surface water N oN []"Check cellar r> - vt [a'Shallowwells ✓A--NG Estimated depth to 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: Date [� Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: El Checked with local excavators, installers documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: tat CC n e-. C, Cl-e_ 1,` tA 2A%'Fl2 T4ec.L T—j i2',GAL-, 2 Gco w DC-0 a!119 ,A O S�eY c3, �j��....• ��. TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 f COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS g DEPARTMENT OF ENVIRONMENTAL PROTECTION r I ,y TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION -- --�- n T6! ,a sN OF[t'ORP Property Address: 505 Forest Street p North Andover,MA MAR ' 2003 Owners Name: Paul&Margaret Plisinski Owners Address: 505 Forest Street North Andover,MA s Date of Inspection: 01/14/03 Name of Inspector: Richard A. Briscoe Company Name: R. A. Briscoe. Inc. Mailing Address: 61 Garrison St. Groveland, MA 01834 Telephone Number: [9781372-2200 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 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 systems 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 .s Inspector's Signature: Q Date: Z • 20 - 03 The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within thirty30 days of completing this inspection. If the system is a shared system or has a design flow( des o of 10 000 d Y P 9 P Y Y 9 � 9P or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. 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 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. Title 5 Inspection Form 6/15/2000 Page 1 ' Page 2 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 505 Forest Street North Andover,MA Owner: Paul&Margaret Plisinski Date of Inspection: 01/14/03 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 needs 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, or 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 is a Certificate of Compliance indicating that the tank is less than 20 years old is avaliable. ND Explain: _Observation,of sewage backup or breakout 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 the 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: 2 Page 3 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 505 Forest Street North Andover,MA Owner: Paul&Margaret Plisinski Date of Inspection: 01/14/03 C. Further Evaluation is Required by the Board of Health: AIA _Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1. System will pass unless the 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 protect the public health and safety and the environment: _The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet to 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 I 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 1.00 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 coloform 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 was triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION (continued) Property Address: 505 Forest Street North Andover,MA Owner: Paul&Margaret Plisinski S Date of Inspection: 01/14/03 D. System failure criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X 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 pipe(s). Number X of times pumped . Any portion of the SAS, 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. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coloform 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 A�,l are triggered. A copy of the analysis must be attached to this form.] i!W (Yes/No)The system fails. I have determined that one or more of the above failure criteria exists as described in 310 CMR 15.303, there fore 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"yes"or"no"as to each of the following: (The following criteria apply to large systems in addition to the criteria above) The design flow of system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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. 4 i • Page 5 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 505 Forest Street North Andover,MA Owner: Paul&Margaret Plisinski Date of Inspection: 01/14/03 Check if the following have been done: You must indicate either"Yes"or"no"as to each of the following: Yes No Pumping information was requested of the owner, occupant, and Board of Health. J Were any of the system components pumped out in the previous two weeks ? 1C _ Has the system received normal flow in the previous two week period ? Have large volumes of water been introduced to the system recently or as part of this inspection ? X Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up ? Was the site inspected for signs of break out -- _ Were all system components, excluding SAS, located on site? _ Were the septic tank manholes were uncovered, opened, and the interior of the inspected for condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum ? _ Was the facility owner(and occupants if different from the 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 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) [15.302(3)(b)] } 5 Page 6 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 505 Forest Street North Andover,MA Owner: Paul&Margaret Plisinski Date of Inspection: 01/14/03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): Number of bedrooms(actual)--L DESIGN flow,based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 33 Number of current residents: Z Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system) (yes or no): .tro; [If yes,separate inspection required] Laundry system inspected (yes or no): 4/0 Seasonal use(yes or no): &V Water meter readings, if available (last 2 year's usage(gpd)): Sump pump (yes or no): Ae!2 , Last date of occupancy: /Lry COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow based on 15.203): god Basis of design flow(seats/persons/sqft, 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: //r y� Was system pumped as part of inspection: (yes or no): If yes, volume pumped gallons- How was the quantity pump determined? Reason forum in :' P P 9 TYPE OF SYSTEM Septic tank, distribution box, soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no)(if yes, attach previous inspection records, if any) Innovative Alternative technology. Attach copy of the current operation and maintenance contract(to be obtained from the system owner) Tight Tank Attach a copy of DEP Approval Other(describe): Approximate age of all components, date installed (if known)and source of information: /3F 7 3 Were sewage odors detected when arriving at the site: (yes or no) 6 Page 7 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 505 Forest Street North Andover,MA Owner: Paul&Margaret Plisinski Date of Inspection: 01/14/03 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction:,v cast iron_40 PVC_other(explain): Distance from private water supply well or suction line Comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: (locate orr site plan) Depth below grade: / Material of construction: concrete_metal_Fiberglass_polyethylene_ other(explain) If tank is metal, list age—Is age confirmed by Certificate of Compliance (yes/no): (attach a copy of certificate) Dimensions:. /ZSR Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: A4,L Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: Comments:(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, evidence of leakage, etc.): GREASE TRAP: /VV(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.): 7 Page 8 of 12 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 505 Forest Street North Andover,MA Owner: Paul&Margaret Plisinski Date of Inspection: 01/14/03 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 Qr no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): 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 is equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): 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.): 8 Page 9 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 505 Forest Street North Andover,MA Owner: Paul&Margaret Plisinski Date of Inspection: 01/14/03 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located, explain why: Type leaching pits, number: leaching chambers, number: leaching galleries, number: leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) CESSPOOLS: A"O(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration:. Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater(yes or no):_ Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: /w (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.): 9 i Page 10 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 505 Forest Street North Andover,MA Owner: Paul&Margaret Plisinski Date of Inspection: 01/14/03 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. 10 ' t Page 11 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 505 Forest Street North Andover,MA Owner: Paul&Margaret Plisinski Date of Inspection: 01/14/03 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater fr�e Feet Please indicate all the methods used to determine high groundwater elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: 11 Page 12 of 12 R. A. BRISCOE, INC. 61 GARRISON ST. GROVELAND,MA 01834 TEL.(978)372-2200 FAX(978)372-2450 SEPTIC SYSTEMS:DESIGNED, BUILT, REPAIRED AND PUMPED Title V Inspections Title V Inspection Report Property Address: 505 Forest Street North Andover,MA Owner: Paul&Margaret Plisinski Date of Inspection: 01/14/03 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. e II R. A. Briscoe 12 o ; ICS 7rtoez o j 0 `� ,----- ` rF_ OL-TLET 10043-1 o ~ `—• '� c-�D- 0X AUT ET �� t NLET- D OF FIELD--� 4${ 4y 00a75(94@50) o TAN K OUTLET z 1�to�Ot55o77f rPROFILE Im e - -. ALE .tun-16-99 11s16A North Andover .Com.' Dev 566 668 9542 P.01 • � � ..• _._. •. —fin• r�N rr.. ... ...•. - I � • •, �'. .5on� ..-�--•-- �r 10i • I V ' ..A ' tt f't ♦Y " ty� t [ � f T . Address .,5 0.5 �0�ES-7 57" Title of File Page of Date File Open: Date file closed: Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes: action Document/ document/ Num• Action Department Board of Appeals — Board of Health — Planning Board — Con servation Commission — Buiiding Department . � G April 23, 2003 Paul Plisinski 505 Forest Street N. Andover, Ma. 01845 _ kf��4 vt re��1L� 1 j Town of North Andover - Division of Community Development& Services FAPR 2 5 2003 } Attention—Health Director, Sandra Starr Dear Ms Starr, ' c Attached is a copy of the approval letter I received for the septic system on lot 2 of my property. Unfortunately, I have been unable to proceed with construction of this lot due to litigation involving the abutting subdivision's present and previous owners and the Town. In January of this year it appeared there was agreement with all parties but that agreement has since collapsed. Therefore, I am requesting a two-year extension of my septic system approval until this matter is resolved and construction can begin. Please notify me if there is anything else I have to do in order to get the requested extension. Yours Truly, Paul Plisinski i II To"n-of North Andover F APR OfficQ Of the Health DepArtment Community Dewelopmentand Semrices aivision 27(--harles 59 reel NuifJ-i Andover, Maqsach Sandia Starr 8)W,9,54(1 -,4kdfh L36-nt.-far RIA(478j)FA-5-1,1542 h4umary 8,<tflt2 Bill I loft Profe'sSionai Land 8 w Ices .61 GarfiFA.)n Stj-ftt, Grovelarid,MA 018-34 Rc.: 50-V505M)wstStreet f7csaz 73t3: Thi is rp T")ti'Cv YOU that the platin da wd 11476`011 torr the proposed hi-itne at 503/5ws rest Street alive lVenapprowd for a dwelting,Wath a maydr-Tual life.leveln(I IFYOu haw any questiom,ple.ase-do"of C*J.11.the Board of I:jv.,Jjtfj office r11: Sinecrery, SuTdra ISIa.rr,R.S,(',EO. ILc filo 11,prector cc'VHNiwki file I TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: /Z M� SYSTEM OWNER & ADDRESS SYSTEM LOCATION ` (example: left front of house) IC:6_U0 74- ISS, D.,- TE OF PUMPING: CA !� G�'Z QUANTITY PUMPED/e-*-O GALLON'S Cl_SSPOOL: NO f/'- YES SEPTIC TANK: NO YESy� NATURE OF SERVICE: ROUTINE l/ EMERGENCY OBSERVATIONS: GOOD CONDITION Y FULL TO COVEIZ HEAVY GREASE BAFFLES 1N PLACE �- ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: CONIMlENTS: (:O:N'1'IiN'I'S TRANSFERREDTO: VL/ VJ/1JJr VV.JV JV VJt JV V11 JI CWFIR•I I Fll iIUV N CIT, r-Ruc 04 ainst,Ah o41- A �1 'S arc c amu! sGl-D,p MW 01633 anS' l ,PP .fl 978"379471 Lr` NOW I my RMIOFC Pm MWN or A14 ADCRWS G �o do o LIM l 5a5 rc d its krl 9? S.err . .. `6� /3qa/ M s� ..•-11V'_ �aORT4 of R IOYCE TOWN CLEE� K NORTH ANDOVER 10^`11 'SS,CHUStit SEP 16 2 47 'Sb TOWN OF NORTH ANDOVER MASSACHUSETTS BOARD OF APPEALS Any appeal shall be filed within(20)days after the nr date of filing of this notice in the office of the Town Clerk. NOTICE OF DECISION PROPERTY: 505 Forest St. NAME: Paul & Margaret Plisinski DATE: 9/9/98 ADDRESS: 505 Forest SL PETITION: 024-98 North Andover, MA 01845 HEARING: 7/14/98 &8/11/98 &9/8/98 The Board of Appeals held a regular meeting on Tuesday evening the 8"'of-September, 1998, upon the application of Paul & Margaret Plisinski, 505 Forest St., North Andover, MA requesting a Variance from the requirements of Section 7, paragraph 7.2, of Table 2, within the R-1 Zoning District, for street frontage. The following members were present: William J. Sullivan, Walter F. Soule, Robert Ford, Ellen McIntyre, and George Earley. The hearing was advertised in the Lawrence Tribune on 6/30/98 &7/7/98 and all abutters were notified by regular mail. Upon a motion made by Walter F. Soule and seconded by Robert Ford, the Board of Appeals unanimously voted to GRANT a Variance of 61.24 feet of frontage on Forest Street for Lot#1 as shown on proposed subdivision sketch by Applewood Survey Company, dated June 3, 1998 for the following: 1. That the total existing lot of 5.15 acres is shaped oddly in that frontage on Forest Street equals 288.76 feet and that rear lot line equals 607.51 feet. 2. That a wetland existing of 72,862 sq. ft. (1.67 acres) is across the two lots. 3. The issuing of this variance is not more detrimental than presently existing. 4. That only one single family residence may be built in the uplands area of Lot#2. 5. That any access to Lot#2, as shown on proposed subdivision sketch by Applewood Survey Company dated June 3, 1998, to utilize upland access to this Lot#2 shall be over adjacent parcel of land Lot#1 by easement, covenent, or common driveway, to avoid filling of wetlands, as shown on above reference drawing. (Reference Michael Howard's, North Andover Conservation Administrator, memo to Zoning Board of Appeals dated July 1, 1998). Voting in favor: William J. Sullivan, Walter F. Soule, Robert Ford, Eden McIntyre, George Earley. The petitioner has satisfied the provision of Section 10, paragraph 10.4 of the Zoning Bylaw and that the granting of these variances will not adversely affect the neighborhood or derogate from the intent and purpose of the Zoning Bylaw. NOTE: The granting of the Variance and/or Special Permit as requested by the applicant does not necessarily ensure the granting of a Building permit'as the applicant must abide by all applicable local,state and federal and building codes and regulations,prior to the issuance of a ttgjiding permit as requested by the Building Commission. BOARD OF APPEALS Xz1:1 � f William J. Sullivan, Chairman Zoning Board of Appeals /deccct8 F-3 1..1-1_. , I I , =��6 eN �9�t� d�fU�trr`� S �� .� r a OWN SEP IJ, 54 CD Memo n � � � � � �' . I 'JUL 7 lccQ To: Mr.William Sullivan, Chairman—Zoning Board of Appeals 7., From: Michas D. Howard, Conservation Administrator CC: Mr.Al Manzi, Conservation Commission Chairman Kathleen Colwe!l,Town Planner Date: 7-1-98 C cl(je6c,77e d RE: Staff Recommendation—Petition: #505a Street (Plisinski) Per your request,this Department has performed a preliminary reAeNof the above referenced petition which we understand is before the Zoning Board of Appeals (ZBA) on July 141h, 1998. 1 have reAeNed the plans submitted by the applicant and note that a large wetland resource area exists on the subject lot'. By virtue of this petition,it may be infer that the applicant will eventually seek permits to develop a portion of the parcel in question. I would like to take this opportunity to dwffy the position of the Ccnserraton Department should a deve!opment p—,_=a1.comz forth at same future date. Conservation on 310 CMR 10.53.1(3)(e) of the Ma usetts Wedand Protection Act provides the Cons n Ccmmis_cin with the discretion to allow certain work to proceed via an Order of Conditions although the work may not meet the performance standards set t forth in the regulations. The purpose of 310 CMR 10.53(3)(e) is to allow projects in whi6 wetands will be crossed with a new roadway to provide access to otherwise unreachable upland areas. The Commission would have to determine at the time of flung that no reasonable alternative means OT access from a public,cry to uplands of the same owner is available. The Commission may require the applicant to utilize ucland access over an adiacent oarr--J of land owned by the aoclicn t.orwhjdi the acolicant has a be-iencial cwnershio of.to avoid fillina of wetlands. I will note at this time that the ap fic:ant obviously awns the Ip tancent lot and that the existing dweifingAculd not pre-dude the Commission from requiring him or her to utilize that lot in cr:1-e-to access the"new lot". There have been siimzficrs in Town where a property owner was re--,u red 1 ' to re;=-te an existing dwelling so that an access roadway could bebuftwithout advers6l impacting the wetland resource area-. Ean m project of course is reAeNed on it's own merits and the nature of propoSedw0n<l In summary,this Department is not opposed to the-reque,before the Zoning Board of Appeals as any decision rendered is independent of any future action by the Commission. We do apprec*ate the opportunity to go on record at this eat state and,by virtue of this correspondence,provide the appliczrit with dear direction we!I in advance of any site'plans. Iank you. ' This wetland de!ineztcn has not been formally approved by the North Andover Conservation Commission in ac=rtancewfth the Massac^iusetts We*Jand Protection Ac:or North Andover Wetland EyLaw. However, ficr!he purposes of our review we presume it to be aczurnte as depiced. pORYp TOWN OF NORTH ANDOVER �aOi.,ao ya��oLv HEALTH DEPARTMENT 27 CHARLES STREET �9 NORTH ANDOVER, MASSACHUSETTS 01845 sACHUS Sandra Starr,RS., C.H.O. Telephone(978)688-9540 i Public Health Director FAX(978)688-9542 June 4, 2003 Mr. Paul Plisinski 505 Forest Street North Andover, MA 01845 Dear Mr. Plisinski, At the May 22, 2003 Board of Health meeting, it was voted by the Board to allow Mr. And Mrs. Paul Plisinski of 505 Forest Street a two-year extension for septic construction due to ongoing litigation regarding a neighboring subdivision. A motion was made by Cheryl Barczak to approve the extension, and seconded by Mr. Markey. All Board members were in favor. . Sincerely Brian LaGrasse Health Inspector /pd cc: File r r. April 23, 2003 j MAY rho Paul Plisinski 505 Forest Street N. Andover, Ma. 0184445 Town of North Andover Division of Community Development& Services Attention—Health Director, Sandra Starr Dear Ms Starr, Attached is a copy of the approval letter I received for the septic system on lot 2 of my property. Unfortunately, I have been unable to proceed with construction of this lot due to litigation involving the abutting subdivision's present and previous owners and the Town. In January of this year it appeared there was agreement with all parties but that agreement has since collapsed. Therefore, I am requesting a two-year extension of my septic system approval until this matter is resolved and construction can begin. Please notify me if there is anything else I have to do in order to get the requested extension. Yours Trul J Paul-P i�nski i r s Town of North Andover a� Nfl orp qM Office of the Health Department O p Community Development and Services Division 27 Charles Street North Andover, Massachusetts 01845 OHMg Sandra Stair Telephone(978)688-9540 Health Director Fax(978)688-9542 January 8, 2002 Bull Holt Professional Land Services 61 Garrison Street Groveland,MA 01834 Re: 503/505 Forest Street Dear Bill: This is to notify you that the plans dated 11/26!01 for the proposed home at 503/505 Forest Street have been approved for a dwelling with a maximum of eleven(11)rooms. if you have any questions,please do not hesitate to call the Board of Health Office at 978-688-9540. 0. Sincerely, Sandra Starr,R.S:;C.H.O. Health Director cc: Plisinski Be SS/smc BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS o DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET,BOSTON,MA 02109 617-292-5500 t �y ARGEO PAUL CELLUCCI TRUDY COXE Governor Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address:505 Forest Street, North Andover Name of owner: Paul &Margaret Poisinski Address of Owner.Same Date of Inspection:6/16/99 Name of Inspector:Richard A. Briscoe I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: R.A. Briscoe. Inc. Mailing Address: 61 Garrison St., Groveland, MA 01834 Telephone Number:(9781372-2200 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 Inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: Passes _Conditionally Passes _Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: (� The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and,the approving authority. NOTES AND COMMENTS Tow,/ ! F NORTH ANLOSOA.9D OC ES%�'"! Hc STH 1iiU 1999 4 (revised 9/2/98) � I � Page 1 of 12 j a J • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:505 Forest Street, North Andover Owner: Paul & Margaret Poisinski Date of Inspection: 6/16/99 INSPECTION SUMMARY: Check A, B, C, or D: A.SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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 needs to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the septic tank is replaced with a conforming septic tank as approved by the Board of Health. 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 of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than four 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 I (revised 9/2/98) Page 2 of 12 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 505 Forest Street, North Andover owner: Paul & Margaret Poisinski Date of Inspection: 6/16/99 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 the public health,safety and 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 THE PUBLIC HEALTH AND 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 PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: I The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis 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. Method used to determine distance (approximation not valid) 3) OTHER i (revised 9/2/98) Page 3 of 12 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 505 Forest Street, North Andover Owner: Paul & Margaret Poisinski Date of Inspection: 6/16/99 D.SYSTEM FAILS: Alt You must indicate"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the 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. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.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: P14 You must indicate"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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. The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. (revised 9/2/98) Page 4 of 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 505 Forest Street, North Andover Owner: Paul & Margaret Poisinski Data of Inspection: 6/16/99 Check if the following have been done: You must indicate either"Yes"or"No"as to each of the following: Yes No _ Pumping information was requested of the owner,occupant,and Board of Health. _ None 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 been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined.Note if they are not available wiz/AD _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow x _ The site was inspected for signs of breakout. _ All system components,excluding the Soil Absorption System,have been located on the 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. The size and location of the Soil Absorption System on the site has been determined based on: _ Existing Information. Ex.Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)) The facility owner and occupants,(if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal System. I (revised 9/7/98) Page 5 of 12 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 505 Forest Street, North Andover Owner: Paul& Margaret Poisinski Date of Inspection: 6/16/99 FLOW CONDITIONS RESIDENTIAL: Design flow: .p.d./bedroom. Number of bedrooms(design): Number of bedrooms(actual) 3 Total DESIGN flow: 6 0 Number of current residents: Z Garbage grinder(yes or no):_,W Laundry(separate syatem)(yes or no):,deo; If yes,separate inspection required. Laundry system inspected(yes or no):_a Seasonal use(yes or no)-.__&O Water meter readings,if available(last two year's usage(gpd): Sump Pump(yes or no) Last date of occupancy: p1CO/ co CO M M E RCIAL11N D U STR IAL: Type of establishment: Design flow: Gallons/day (Based on 15.203) Basis of design flow: 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 vailable: Last date of occupancy OTHER:(Describe) Last date of occupancy:_ GENERAL INFORMATION PUMPING RECORDS and source of information: ��J7 System pumped as part of inspection:(yes or no)�� If yes,volume pumped gallons j Reason for pumping: &Z7'�'Ue-7/0n' 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 re cords if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract. Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all,cgmponents,date installed(if known)and source of information: /J 73 Sewage odors detected when arriving at the site:(yes or no) (revised 9/2/98) Page 6 of 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 505 Forest Street, North Andover Owner: Paul & Margaret Poisinski Date of Inspection: 6/16/99 BUILDING SEWER: (Locate on site plan) Depth below grade: 02 Material of construction: cast iron_40 PVC_other(explain) Distance from ate water supply well or suction line Diameter Comments: (condition of joints,venting,evidence of leakage,etc.) SEPTIC TANK:_ (locate on site plan) Depth below grader Material of construction.yconcrete metal_Fiberglass_Polyethylene other(explain) If tank is metal,list age_Is age certified by Certificate of Compliance_(Yes/No) Dimensions: /2 5'- (r¢L Sludge depth: 6 a Distance from top of sludge to bottom of outlet tee or baffle: 2 Scum thickness:_0 Distance from top of scum to top of outlet tee or baffle: yo Distance from bottom of scum to bottom of outlet tee or baffle: / S� How dimensions were determined: Comments: �i9��/cps �,v ��,gc,C (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.) GREASE TRAP: (locate on siteIan P ) Depth below grade: Material of construction:_concrete_metal_Fiberglass_Polyethylene other(explain) I� — 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: (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.) (revised 9/2/98) Page 7 of 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 505 Forest Street, North Andover Owner: Paul & Margaret Poisinski Date of Inspection: 6/16/99 TIGHT OR HOLDING TANK:(Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: <- Material of construction: concrete_metal_Fiberglass_Polyethylene other(explain) Dimensions: . Capacity: oallons Design flow: aailons/day Alarm present: Alarm level: Alarm in working order_Yes; No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: �s (locate on site plan) Depth of liquid level above outlet Invert: 0 Comments: (note If level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.) � � c 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.) (revised 9/7/98) Page 8 of 12 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 505 Forest Street, North Andover Owner: Paul & Margaret Poisinski Date of Inspection: 6/16/99 SOIL ABSORPTION SYSTEM(SAS):_ (locate on site plan,if possible;excavatinot required,but may be approximated by non-intrusive methods) If not located,explain: Type: leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: / 2p yo2 overflow cesspool,number: Alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) PRIVY:---1d (locate on site plan) Materials of construction: Dimensions: sol' Depth of p ids. Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) (revised 9/2/98) Page 9 of 12 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM INFORMATION(continued) Property Address: 505 Forest Street, North Andover Owner: Paul& Margaret Poisinski Date of Inspection: 6/16/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100'(locate where public water supply comes into house) i revised 9/2/98 Page 10 of 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 505 Forest Street, North Andover Owner: Paul & Margaret Poisinski Date of Inspection: 6/16/99 NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow: Moderate: Deep: SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater TY- Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from'Design Plans on record Observation of Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators,installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) SrJi °5 s ,vim D //Z, (revised 9/2/98) Page 11 of 12 R. A. BRISCOE, INC. 61 GARRISON ST. GROVELAND,MA 01834 TEL.(978)372-2200 FAX(978)372-2450 SEPTIC SYSTEMS.-DESIGNED, BUILT,REPAIRED AND PUMPED Title V Inspections Title V Inspection Report 6/16/99 Property Address: 505 Forest Street, North Andover Owner. Paul & Margaret Poisinski Date of Inspection: 6/16/99 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. R. A. Briscoe Page 12 of 12 Y 4 2 t- 4 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD d DATE: , , SYSTEM OWNER& ADDRESS SYSTEM LOCATION �r. . �O l.S iris lL/ (example: left front of house) t y w p d , F,fSr��f�z'.lG,t y� 1 •• r. ?J:..'y'' ,',:1. ata.. y:rl. .t r ... .. .. .. ... . . .. DATE OF'PUMPING: �i-�-� QUANTITY PUMPED y GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES„ NATURE OF SERVICE: ROUTINE y EMERGENCY i1BSERVATIONS: -GOOD CONDITION„ =FULL TO COVE HEAVY GREASE R BAFFLES IN PLACE F ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER O T HEIS(EXrLAIN) SYSTEM PUMPED BY: �biJ , r`, , . : � e f C.� 1 i t t of Ch n 4.t'v�t� QMIVIENTS: 2� fCf ,,tt,wl ,rJ� r �,=f��•,I l F , ►>>l ,yylA��ryFAf�t't 1��',��,{ {' }2�Nri E z!1311?ks Jl 1, t 1. r ,�,.,._.,� "`^" •,.--_-_^^�"�' I z. �. . \ It rIR CON N S TRANSFERREDE T aF iFf9�: ; u ,�, TO: p �tX'�c - d FORM 4 - SYSTEM PUMPING RECORD Commonwealth of Massachusetts North Andover, Massachusetts System Pumping Record System Owner System Location Paul Plisinski Paul Plisinski 505 Forest Street 505 Forest Street North Andover, MA 01845 North Andover,MA 01845 Type: Emergency ❑ Routine Cesspool: No Yes ❑ Septic Tank: No ❑ Yes Date of Pumping : 6/21/99 Quantity pumped: 1000 gallons System Pumped by: R, A. Briscoe, Inc. Permit#: Contents transferred to: Haverhill Waste Water Contents disposed at: a Haverhill Waste Water Date: 6/21/99 Pumper Signatur Condition of system/other comments: JUL 191999 j Commonwealth of Massachusetts City/Town of NORTH ANDOVER, MASSACHUSETT System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. The S stem Pum in d must be submitted to the local Board of Health or other approving aut oritYRECEIVED A. Facility Information LHEALTH 6 2009 Important: When filling out 1. System Location: RTH ANDOMEIR forms on the �" PARTMENT computer,use �- only the tab key AddrQss to move your 1 . cursor-do not dig". use the return City/Tow In DOOM State Zip Code key. 2 System Owner: Name — Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallo s Od 3. Type of system: ❑ Cesspool(s) i Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes [?"ITo- If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Na e Vehicle License Number WAS _--— Company 7. Location where contents were disposed: G.L.S.1% -- �* --- Signature of Hauler Date http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect t5form4.doc•06103 System Pumping Record•Page 1 of 1 I