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HomeMy WebLinkAboutMiscellaneous - 507 SALEM STREET 4/30/2018 (2) 567 SALEM STREET _ 210/038.0-0107-0000.0 qS Dia PUBLIC HEALTH DEPARTMENT Town of North Andover Community and Economic Development Division CERTIFICATE OF. COMPLIANCE As of: 10/12/16 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Replacement of Septic Tank By: Todd Bateson At: 507 Salem Street Map 038.0 Lot 0107 N9r)th An over, MA 01845 I" suance of this ce i ia�ate hail not be construed as a guarantee that the system will function satisfactorily. Grant Public Health Agent �J 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com • TPI, j, c,E.,z., .,fie • North Andover Health Department Community and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 507 Salem St. MAP: 038.0 LOT: 0107 INSTALLER: Todd Bateson DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS S N TANK INSPECTION: 10� DATE OF BED BOTTOM IN tTION: DATE OF FINAL CONSTRUCTION INSPEC DATE OF FINAL GRADE INSPECTION- SITE CONDITIONS 4 Contractor r [Existing se' ,n/1 ❑ Internal plun U I ❑ Topography Comments: --— Y SEPTIC TANK ❑ Building severer in continuous grade, on compacted firm base ❑ Cleanouts per plan Bottom of tank hole has 6" stone base / Weep hole plugged 1500 gallon tank has been installed H-10 loading Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port �r North Andover Health Department Community and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 507 Salem St. MAP: 038.0 LOT: 0107 INSTALLER: Todd Bateson DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: v>> DATE OF BED BOTTOM IN PECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Contractor reports any changes to design plan Existing septic tank properly abandoned' ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan Bottom of tank hole has 6" stone base Weep hole plugged [ 1500 gallon tank has been installed H-10 loading Monolithic tank construction ❑ Watertightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROLPANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX ❑ Installed on stable stone base ❑ H-20 D-Box ❑ Inlet tee (if pumped or >0.08'/foot) ❑ Hydraulic cement around inlet & outlets ❑ Observed even distribution ❑ Speed levelers provided (not required) ❑ Schedule 40 PVC Pipe Comments: a ITDJ Commonwealth of Massachusetts Map-Block-Lot 038.00107 BOARD OF HEALTH Permit No North Andover BHP-2016-0298 - P.I. - --------------- FEE F.I. $175.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd-Bateson to(Repair)an Individual Sewage Disposal System. at No 507 SALEM STREET as shown on the application for Disposal Works Construction Permit No. BHP-2016-029 d September 29,2016 --------------- ---------------------------- FILE COPY Issued On: Sep-29-2016 BOARD OF HEALTH ----------------------------------------------------- E r.k,• i , Application for Septic �isposai S�stero TODAY'S DATE Construction Permit — TOWN OF goo'-Full Repair NORTH ANDOVER MA 01845 cornponent 17� Important: Application is hereby made for a permit to: When filling out F1 Construct a new on-site sewage disposal system; forms on the Repair or replace an existing.on-site sewage disposal'system" computer,use El�p 7 only the tab key a air or replace an existing system component–Mat?? la to move your cursor-do not A. Facility Information use the return So 17 key. .S�i� ��• � �► Address or Lot# SEP 2 9 2016 cityrrown �� , 2.-*TYPE OF SEPTIC SYSTEM*: TOWN OF NORTH ANDOVER ➢ ump ❑Gravity(choose one) HEALTH DEPARTMENT —if pump Sy ,attach copy of electrical permit to application"` ➢ Conventional System (pipe and stone system) •J ➢ E] Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to insta 1 this pe of system.) ➢ ❑Pressure Distribution S.A.S.(No D-Box) ➢ ❑Pressure Dosed(D-Box Present)S.A.S. / No ➢ [-] Does the system require an effluent filter? yes V !f yes, does plan specify make and model of filter? YES=(no further info. needed) NO=(installer must specify brand of filter before DWC issuance) What is the Make? What is the 1fMode2e 2. Owner Information Mame S'�`7 S�L��-- Address(if different from above) Al + Q iY S �� f•�-�U` State Zip Code City/Town q 780 $-4 At Telephone Number 3. Installer Information Name of C mpany Name BATMON ENT /I/ ��y' 'g ARGILLA ROAD Address ANDOVER, MA 01810 State Zip Code Cityrr own F/3--,Y 7,0 y Telephone Number(Cell Phone#if possible please) 4. Desi Iner'lnforMLtion Name of Company 7NameStateZip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 t dRTN.. Ap;pliCation..for Septic Disposal_ys#ern o 0 : ' TODAY'S DATE a Construction Pg. .rrnit TONT O �'� ORTH :NDbY. MA $:250.60 T Full Repair 01845 '=A�,a, ° '� $1200.-Component PAGE 2O 2 A. Facility.Information continued.,., S. Type-of Building: esidential Dwelling or(3Commercial B. Agreement The underslgned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system.ln accordance with the provls/ons of Title 5 of the Environmental Code,as well as the Local Subsurface Disposal Regulations for the Town of .North Andover, and not to place.the system 1n operation.until a Certificate of Compliance has been Issued ,V this Board of Health. 9-A. •-�� Name Date i Applicati Appro B : (Board of Health Representative) Name Date Applicat n DN pproved.for the following reasons: For OM6.Use OnJV: 1 Pee Attached. Yes _ No 2. ProjectManager Obligation Form Atta Yes No 3.: Puma System? Ifso) b f 1 1 P it'. Yes No 4. Foundation As-Built?(new construction•ronly), Yes• No (Same scale as approved plan) — A FloorPLws?(hew construction-only); Ye No Applfcatfon{or•p�sppsai ystem: onMrudton permR Race 2 if s *V LIGATIONS An f?ic•Ngt&Andoverlicwcdfns fo4io aumdo'ft.•th6scoas}►dtemfc►t.tht,�pro ttyat" R*fi d to*Uppmd*s of g _>q 7PSOAJ ' st:ma Abd dlftd ee Dated kloaars A WYdt i+cvWont dated • . . {mese 'aed tx} �� I vatlerQittad the faBOWIng obligations fot s sa mt of his roTccC i. As the instal I iw�.obligset�ed to obtaits tiIIpe.a�rits sadosrd ct' arlthppsaPed pleas to • +peg tmy.' dna R e3be: �• st>ttatle. .I, call nap and a$'ipdoaa: I£hapcp�vsi �coatmctcK.psojectmatHgrs.or anp a�urltam=not o4ociated whiz my c=pmy m4m�•aa loser oat end the system is=tuldj4 then hem d>tecslmtb , ble- 11bter x SII. SID�v�GA1C W02�[ to the 23 ld4Ded ., aP� M+ in i +Ytaey� .I"' p - :tusc is a iiicJr I, b ahba�d• _ a ii agacq IFM nothm W bC prest�t tf jia iitap far avabs_t*etc. t• Y • I atb OK(vs C-mdi1 to t Stash theafganer roust • }iR�tlblf3i •L+tl' . tied �u.8c�d•Of '�D2•!2I . IYew?#b► r �s.+pec�pn tune. I�asmllet must bepz+eae ><f+ar ,� 1t It -ben Wy attd:ebiC ca :. carted gar p.ttias3c ti .. C. •_ast uir ani rogt t aspeedon ache i ll edla Is entrspittc: Isi94a docs z'ot ' ' have#o be: te.' � • :. ''. •- ' . •, • : , ' . 4. As the icaft-I�d thst ottly'guy g tSc'�otbtrtb r s e Via)�ind'I ani's fired m cmplm 1I 4iw,t tett t of the sit itt#1 •,i ipplibl.9-W fu hfatMation.j, 5.. Ab thcfaadtlte�.Y nt su�aa� u t =t thtr•pct sof�t caastcm �a Det+�rlaaa�ttLwt.�pmperekhr�pftlteavrl�•bs�rs�e�cheal is IasW 4at&,C'Wd�ead84*0*U usaat • r~ 'Pia:lsaarpe�a�by�autoial.�fe�iltherl�ffarco�suh�uat�• • . • . - d Ia:j oft a�ak,I]-- aaq�►,$ftw,vent,P F htnYber,ta+�is srstl other . b. As thflee y�,�;�matst„ °iL-�+for tiet�tta, „�.tf the t9vdtetn �Trr► ' • �� i.wA 3w.t4,T�iA�:�.L f�`����1F.MiSIM�,Qt�Yi�„i+�iMRl���ik$!{ UudezogwdU Soptic.Ift Cz'od Dx,�J`. . I� • '• .'• '•. ..' b .• '.�:�+.moi. . • •' , _, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 507 Salem Street Property Address Mark Perry Owner Owner's Name information is North Andover MA 01845 10/12/2016 required for every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. m oiren flMgout A. General InformationRECEIVED forms on the OCT 18 2016 computer,use 1. Inspector: onlythe tab key Y to move yourNeil J. Bateson TOWN OF NORTH ANDOVER cursor-do not � use the return Name of Inspector key. Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover MA 01810 City/Town State Zip Code 978-475-4786 S115 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 10/12/2016 Inspecto s S nature 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 507 Salem Street Property Address Mark Perry Owner Owner's Name information is required for North Andover MA 01845 10/12/2016 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: After permit from B.O.H., install new septic tank, inspection from B.O.H., septic system now passes Title 5 Inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3113 Title 5(Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments j 507 Salem Street Property Address Mark Perry Owner Owners Name information is required for North Andover MA 01845 10/12/2016 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately -IV b = X116 Ir it it -o A-aI t 9 3 u vuoi-e a_ �6'e'n P_ t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 507 Salem Street Property Address . Mark Perry Owner Owner's Name information is required for North Andover MA 01845 8/22/2016 every page. City(rown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. RECEIVED Important: A. General Information When filling out forms on the AUG 2 9 2016 computer,use 1. Inspector: only the tab key TOWN OF NORTH ANDOVER to move your Neil J. Bateson HEALTH DEPARTMENT cursor-do not Name of Inspector use the return key. Bateson Enterprises Inc. �53T Company Name VQ 111 Argilla Road Company Address Andover MA 01810 Cityrrown State Zip Code 978-475-4786 S115 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes Fails ❑ Needs urther Evaluat' n by the Local Approving Authority / 8/22/2016 Inspedtort 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 conditio s at the time of inspection and under the conditions of use at that time.This inspection does n t address how the system will perform in the future under the same or different conditions of dse. 1 A. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 507 Salem Street Property Address Mark Perry Owner Owner's Name information is required for North Andover MA 01845 8/22/2016 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: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ® Y ❑ N ❑ ND(Explain below): Septic tank 6"from outlet invert, tank leaking t5ins-3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 507 Salem Street Property Address Mark Perry Owner Owner's Name information is required for North Andover MA 01845 8/22/2016 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 507 Salem Street Property Address Mark Perry Owner Owner's Name information is required for North Andover MA 01845 8/22/2016 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17 J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 507 Salem Street Property Address Mark Perry Owner Owner's Name information is required for North Andover MA 01845 8/22/2016 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 507 Salem Street Property Address Mark Perry Owner Owner's Name information is required for North Andover MA 01845 8/22/2016 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): N/A Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): N/A t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 V \ VVIIIIIIVIIwCQI�II VI 1T14*.74W1U*1ULW Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 507 Salem Street Property Address Mark Perry Owner Owners Name information is required for North Andover MA 01845 8/22/2016 every page. City/Town State Zip Code Date of Inspection D. System Information Description: i 5 Number of current residents: Does residence have a e a garbage gander? ® Yes ❑ No Is laundry ona separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Yes Detail: Sump pump? ® Yes ❑ No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 507 Salem Street Property Address Mark Perry Owner Owners Name information is required for North Andover MA 01845 8/22/2016 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Last month, owner Was system pumped as part of the inspection? ❑ Yes ® 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)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 507 Salem Street Property Address Mark Perry Owner Owner's Name information is required for North Andover MA 01845 8/22/2016 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Tank original, pump tank, d-box&leach area replaced 4/29/1989, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 4 feet Material of construction: ® cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): 4"Cast Iron through floor Septic Tank(locate on site plan): Depth below grade: 3 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Tx 5'x 4' Sludge depth: 0 t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 507 Salem Street Property Address Mark Perry Owner Owner's Name information is required for North Andover MA 01845 8/22/2016 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle N/A Scum thickness Distance from top of scum to top of outlet tee or baffle N/A=Tank leaking Distance from bottom of scum to bottom of outlet tee or baffle N/A How were dimensions determined? Tape Measure 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 baffle ok. Outlet baffle ok. Outlet tee ok. Depth of liquid 6"below outlet invert, evidence of leakage. Center cover has riser 3"deep. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 507 Salem Street Property Address Mark Perry Owner Owner's Name information is required for North Andover MA 01845 8/22/2016 every page. City/rown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 507 Salem Street ,p Property Address Mark Perry Owner Owner's Name information is required for North Andover MA 01845 8/22/2016 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box level &distribution equal. No evidence of leakage. No evidence of carryover. Pump Chamber(locate on site plan): Pumps in working order: ® Yes ❑ No" Alarms in working order: ® Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump tank ok. Pump ok.Alarm ok. Alarm has both audible&visual. *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Titre 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 507 Salem Street Property Address Mark Perry Owner Owner's Name information is required for North Andover MA 01845 8/22/2016 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 field 25'x 40' ❑ 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. Vegetaion ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 official inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 II • <fCommonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 507 Salem Street Property Address Mark Perry Owner Owner's Name information is required for North Andover MA 01845 8/22/2016 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 507 Salem Street Property Address Mark Perry Owner Owner's Name information is required for North Andover MA 01845 8/22/2016 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch,Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately CP 9W4) 0 _H 0 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 507 Salem Street Property Address Mark Perry Owner owner's Name information is required for North Andover MA 01845 8/22/2016 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >4feet 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: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: Essex County Soil Map. You must describe how you established the high ground water elevation: Essex County Soil Map, Sheet#30, Canton Soil,Water>6'deep. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 507 Salem Street Property Address Mark Perry Owner Owner's Name information is required for North Andover MA 01845 8/22/2016 every page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist I E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems)completed E System Information—Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i I t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Summary Record Card generated on 8116/2016 2:54:39 PM by Karen Hanlon Page 1 Town of North Andover Tax Map # 210-038.0-0107-0000.0 Parcel Id 10410 507 SALEM STREET MARC & LAUREN PERRY 507 SALEM STREET NORTH ANDOVER, MA 01845 I Class 101 Single Family Property Type j 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.09.Acres FY 2017 UB Mailing Index Name/Address Type Loan Number Active/inact. From Until MARC&LAUREN PERRY Owner 507.SALEM STREET NORTH ANDOVER,MA 01845 KEVIN McDONALD Previous Customer Inactive 10/3/2011 507 SALEM STREET NORTH ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 16089.0-507 SALEM STREET Last Billing Date 7/26/2016 3160131 03 Cycle 03 Active UB Services'Maint. Account No.3160131 Service CodeRate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER. 01'ALL METER SIZE 140.68 /1 UB Meter Maintenance Account No.3160131 Serial No' Status Location Brand Type Size YTD Cons 1633703.0 a Active 00 METE METE w Water 0.63 0.63 986 Date Reading Code Consumption Posted Date Variance 6/6/2016 1981 a Actual 32 8/2/2016 7% 3/2/2016 1949 a Actual 28 4/22/2016 -12% 12/3/2015 1921 a Actual 32 1/20/2016 -61% 9/3/2015 1889 a Actual. 83 10/16/2015 71% 6/3/2015 1806 a Actual 48 7/24/2015 42% 3/4/2015 1758 a Actual 33 4/28/2015 -3% 12/5/2014 1725 a Actual 35 1/15/2015 -37% 9/4/2014 1690 a Actual 56 10/15/2014 50% 644/2014. 1634 a Actual 37 7/16/2014 37% 3/5/2014 1597 a Actual 27 4/11/2014 -1% 12/4/2013 1570 aActual 27 1/17/2014 -7% 9/5/2013 1543 a Actual 29 10/15/2013 24% 6/7/2013 1514 a Actual 24 7/24/2013 9% 3/7/2013 1490 a Actual 22 4/22/2013 -20% 12/5/2012 1468 aActual 27 1/9/2013 -24% 9/6/2012 1441 a Actual 36 10/15/2012 6/7/2012 1405 a Actual 38 7/16/2012 -5% 3/8/2012 1367 a Actual 40 4/14/2012 52% 12/8/2011 1327 aActual 20 1/17/2012 58% 9/30/2011 1307 f Final Bill 22 9/30/2011 -3% 6/2/2011 1285 a Actual 17 7/20/2011 3% 3/4/2011 1268 a Actual 16 4/13/2011 16% 12/7/2010 1252 a Actual 15 1/12/2011 -23% 9/3/2010 1237 a Actual 19 10/15/2010 -20% 6/2/2010 1218 a Actual 23 7/15/2010 -4% 3/.4/2610 1195 a Actual 24 4/14/2010 -5% 07 GILBERT RRA aaB_ .! 71 F 44 Flea St. SKET NO. AnA. - or• --NO—ANDOVER, MA 01845 Phone 682.9864 CALCULAt'ED BY DATES � CHECKFO BY DATE.. SCALF. , i { f t � g•_, f i I I I i t i � � 6 1 i 1 1 1 � i_ , t E t ^' 1j ..ww'^y(Yy''1�,,i 1 s�1,.+"—r 1_ , • S _. ___..__ _ •..,_i-.__, _ ___.i_ 4 _«�_,_. , 1 1 i 1 Y lI ` ,Commonwealth of Massachusetts Title 5 Official Inspection Form RECEIVED Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 507 Salem St. NOV 2 4 2009 Property Address TOWN OF McDonald HEALTH DEPARTMENTER Owner Owner's Name information is required for every North Andover MA 01845 11/10/2009 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Chad Jablonski use the return Name of Inspector key. Jablonski & Sons Inc. � Company Name 167 Willow Ave. Company Address Haverhill MA 01835 City/Town State Zip Code 978-360-9358 4574 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 'I h 3AP917 I pector's, ;atreThe systempect shall submit a copy of this inspection report to the Approving Authority (Board of Health orwithin 30 days of completing this inspection. If the system is a shared system or has a desigw of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o ,Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 507 Salem St. Property Address McDonald Owner Owner's Name information is required for every North Andover MA 01845 11/10/2009 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SAS and all components in good working order. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): I t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �w 507 Salem St. Property Address McDonald Owner Owner's Name information is required for every North Andover MA 01845 11/10/2009 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w . ' 507 Salem St. Property Address McDonald Owner Owner's Name information is required for every North Andover MA 01845 11/10/2009 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply I 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No Backup of sewage into facility ors stem component due to overloaded or ❑ ® clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins•09/08 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 507 Salem St. Property Address McDonald Owner Owner's Name information is required for every North Andover MA 01845 11/10/2009 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No E] ® Required pumping more than 4 times In the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. The system fails. I have determined that one or more of the above failure E] ® criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or no to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 15ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 b Commonwealth of Massachusetts PT Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 507 Salem St. Property Address McDonald Owner Owner's Name information is required for every North Andover MA 01845 11/10/2009 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ 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. ® El approximation in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): n tk Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): J1 I l5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 507 Salem St. Property Address McDonald Owner Owner's Name information is required for every North Andover MA 01845 11/10/2009 page. CitylTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 6 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Attached 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: — t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 507 Salem St. Property Address McDonald Owner Owner's Name information is required for every North Andover MA 01845 11/10/2009 ' page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): i General Information Pumping Records: North Andover BoH Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: na gallons How was quantity pumped determined? na Reason for pumping: na Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w.4 507 Salem St. Property Address McDonald Owner Owner's Name information is required for every North Andover MA 01845 11/10/2009 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed if known and source of information: PP 9 P ( ) Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3.5'feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Sewer runs under footing Septic Tank(locate on site plan): 3' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) I If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ® Yes ❑ No Dimensions: 8.5' x 5.5' x 5.5' " Sludge depth: 3 — — t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 �. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 507 Salem St. Property Address McDonald Owner Owner's Name information is required for every North Andover MA 01845 11/10/2009 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness. 1" 5.. Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? measuring tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank structurally sound inlet and outlet baffles in good working order Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: j Scum thickness Distance from top of scum to top of outlet tee or baffle I Distance from bottom of scum to bottom 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 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 507 Salem St. Property Address McDonald Owner Owner's Name information is required for every North Andover MA 01845 11/10/2009 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t51ns•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - .Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 507 Salem St. Property Address McDonald Owner Owner's Name information is North Andover MA 01845 11/10/2009 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on siteplan): 0" Depth of liquid level above outlet invert I Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is level and distributing equally Pump Chamber(locate on site plan): Pumps in working order: ® Yes ❑ No Alarms in working order: ® Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump Chamber structurally sound, pump and alarm in good working order Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I i i t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 507 Salem St. Property Address McDonald Owner Owner's Name information is North Andover MA 01845 11/10/2009 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1-25' x 40' ❑ 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.): no sign of hydraulic failure or ponding Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-09/08 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 507 Salem St. Property Address McDonald Owner Owner's Name information is North Andover MA 01845 11/10/2009 required for every y page. Cit crown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I Commonwealth of Massachusetts ANI - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 507 Salem St. Property Address McDonald Owner Owner's Name information is North Andover MA 01845 11/10/2009 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 56 o� Anz, i000,5� A _ Z3 ` ia� C_ fgi�r A p 2-3 c, > I E t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts _ W Title 5 Official Inspection Form ,Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 507 Salem St. Property Address McDonald Owner Owner's Name information is North Andover MA 01845 11/10/2009 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 4' under leach field 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 �� Cda If checked, date of design plan reviewed: Date + ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: 'Fob 1. a "� t, L e�G.►a F t CL'i7 i� APC'�o>< , 2. �' r1 r3v✓ C C-LL A 2 �,E�iy �� •a j ;,�M.t� QU M t� — i Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 507 Salem St. Property Address McDonald Owner Owner's Name information is required for every North Andover MA 01845 11/10/2009 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Summary Record Card generated on 11/13/2009 12:25:16 PM by Karen Hanlon Page 1 Town of North Andover • Tax Map # 210-038.0-0107-0000.0 Parcel Id 10410 507 SALEM STREET KEVIN McDONALD 507 SALEM STREET NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 1.09 Acres FY 2010 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until KEVIN McDONALD Payor 507 SALEM STREET NORTH ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 16089.0-507 SALEM STREET Last Billing Date 10/7/2009 3160131 03 Cycle 03 Active UB Services Maint. Account No.3160131 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 97.82 /1 UB Meter Maintenance Account No.3160131 Serial No Status Location Brand Type Size YTD Cons 16337030 a Active 00 METE METE w Water 0.63 0.63 150 Date Reading Code Consumption Posted Date Variance 9/2/2009 1145 a Actual 24 10/15/2009 4% 6/2/2009 1121 a Actual 22 7/20/2009 1% 3/6/2009 1099 a Actual 23 4/29/2009 -3% 12/3/2008 1076 a Actual 23 1/20/2009 -26% 9/4/2008 1053 a Actual 32 10/10/2008 19% 6/3/2008 1021 a Actual 26 7/16/2008 1% 3/5/2008 995 a Actual 26 4/11/2008 9% 12/5/2007 969 a Actual 22 1/22/2008 16% 9/12/2007 947 a Actual 21 10/12/2007 -17% 6/11/2007 926 a Actual 26 7/20/2007 -20% 3/8/2007 900 a Actual 32 4/16/2007 13% 12/5/2006 868 a Actual 27 1/19/2007 -22% 9/7/2006 841 a Actual 35 10/20/2006 -12% 6/9/2006 806 a Actual 35 7/10/2006 14% 3/22/2006 771 a Actual 39 4/17/2006 -1% 12/12/2005 732 a Actual 36 1/17/2006 -25% 9/12/2005 696 a Actual 53 10/14/2005 3% 6/3/2005 643 a Actual 46 7/15/2005 38% 3/5/2005 597 m Manual estimate 33 4/5/2005 -1% 12/6/2004 564 aActual 33 1/14/2005 -11% 9/9/2004 531 a Actual 41 10/8/2004 10% 6/4/2004 490 a Actual 20 7/30/2004 -17% ---�^• TO F NORTH ANDOVL W $OARD OF HEALTH COMMONWEALTH OF MASSACHUSETTS �- EXECUTIVE OFFICE OF ENVIRONMENTAL AFF RS IA DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: ra-7 moi'=�+'� �T Name of Owner Lc:cr nrSt rQ- n I �} �c:•"Ar&uf'ft 01CY. Address of Owner: � (E'Kxu..ct r� 1 rC�P . odcue Date of Inspection: ;I ouewt Name of Inspector.(Please Print) rvtnetLX C-) •. ���� I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: t _ Making Address: 44 r1 — Telephone Number: CERTIFICATION STATEMENT 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 r• _ Fails r Inspector's Signature: Date: Jit, 41 _[K8 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•Environmemal Protection. The original should be sent to'Ttm system owner.and copies sent to the buyer, if applicable, and the approving authority. . NOTES AND COMMENTS � ISI revised 9/2/98 Pagel of 11 A 4 Printed on Recycled Paper m ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A �f -. Qp /(�� CERTIFICATION (continued) Property Address:v� �JG� ric,. 1„14Cuer Owner: �GL(vy ar`A Ky Date of Inspection: i i to 6 INSPECTION SUMMARY: Check A, B, C, o/ A 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 need 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 NO). 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 the 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 existing septic tank is replaced with a complying septic tank as approved by the Board of Health. e Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructedi e s or due to a broken, settled or uneven distribution box. The system will pass inspection if(with a P f ( ) approval P Health). of the Board of broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumPhIg-more than fourtimes a year-due to broken or obstructed pipe(s). The-system wilhpess-• inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed I � r revised 9/2/98 Page 2of11 t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(contirxred) ` Property Address:50-7,3 (k F k'1� S C• �lJJ.1�lr1C5ci�l�f r (k Owner: Date of Inspecow: C. FURTHER EVALUATION LIST 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.PRQTECT THE PUBLIC HEALTH.AND SAFETY AND.THE ENVJBONMENT: Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 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 revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D. SYSTEM FAILS: You must indicate either "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)ntofecility ousystem component•duetto an overloaded orclegged-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. li 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 lastear NOT due to clogged gged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. I 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. I 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: 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: The system serves a facility with a design flow of 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 witbin•200 feet of a ifibutary to a eurfsos 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 i 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 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B «- CHECKLIST Property Address:SCR Owner: I..aroy irt: Date of Inspection: ([l a I l Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No _ Pumping in was provided by the owner, occupant, or Board of Health. --Non — _ e of the system compoaents baww.abeen Pua►pe"rat J eas rates during that period. Large volumes of water have not beentintroduced8ntoithessystemstem hecently or aspart of this ws flow inspection. _ As built plans have been obtained and examined. Note if they are not available with NIA. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. 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 o f the septic or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth o ank was inspected for condition of baffles The size 9 p f scum. and locatiQ[�of,the Soil A sorption System on-the site has been . } Y►ty�Kc l ry„ determined based on: Existing information. For example, 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.occu laaats,if different from-o.wnethwere.provided.with inf=ation-on.tha4uzper4naintanaucs of SubSurface Disposal Systems. I I revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property address:E07 Sa(om S; eT, (06. 0. r Owner: harry Arjiro Date of Inspection: RESIDENTIAL: FLOW CONDITIONS Design flow: g.p.d./bedroom. Number of bedrooms(design):_ Number of bedrooms(actual): Total DESIGN flow Number of current residents: Garbage grinder jyes or no): y��, Laundry(separate system) (yes or no):1 O;- If yes,separateinspection,required _ Laundry system inspected (yes or no) Seasonal use(yes or no): AL Water meter readings,if available(last two year's usage(gpd): ,o Sump Pump(yes or no):�., Last date of occupancy: (% 7/90 COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gpd ( 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 available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION f PUMPING RECOR S and source of' formation_: Vis: - - . System pumped as part of inspection: (yes or no) z If yes, volume pumped- '•cam gallons - Reasonforum in P P 9� TYPE OF SYSTEM L/_ 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other �� `►.� c �Sy� APPROXIMATE AGE of all components, date installed{if known)-and source of,iwformation: Sewage odors detected when arriving at the site: (yes or no)1 rub revised 9/2/98 Page 6of11 s: ;44ii( SMUU604A/CS/UO5/LO04 TORN OF NORTH ANDOUER DATE: 11/16/'x" TERMINAL NO: 000 CONSUMER METER F/M TIME: 10: 18:t._'`. Acct : 01 -4367000-0 GIROUD CLAUDE 507 SALEM ST: Meter No: 001 Rev Mtr/#: N 000 Book: 16 Page: 43670.00000 Meter Flg: 0 [' Connector: ] Digits: 4] Dim Cd: A] Multiplier: ] Arb #: Manf Cd: ] Units: Pipe Size: ] Len: ] Type: Req: 00/00/00 Inst : 00/00/00 Cnct : 00/00/00 Disc: 00/00/00 Cd: t , kirk Cd: ] Mt Code: ] Met Loc: ] In/Out : Notes: 5/8 TRY ] Serial #: 0020590603 Bgn: Cur: 3025 C Prev: 3025 E 2nd Prev: 3018 A [2 From: 05/12/98 To: 08/05/98 Cur2: Prev2: Next : 00/00/00 Cns. Cr: 20-Mth Bill : 03 User: ] -------------------------- Consumption Information ------------------------- --- First 12 Billing Months ------[3] 1 ------ Last 12 Billing Months -------[4; ' 09/98 C 03/97 20 E 109/95 17 E 03/94 17 E 06/98 7 E 12/96 339-A 106/95 16 E 12/93 15 E 03/98 A 09/96 16 E 103/95 16 E' 09/93 20 E 12/97 27-E 06/96 16 E 112/94 16 E 06/93 9 A 09/97 20 E 03/96 16 -E 109/94 17 E 03/93 17 A 06/97 20 E 12/95 16 E 106/94 16 E 12/92 18 A First 12 Total: 235- 1 Last 12 Total : 194 <ESC> to Enter New Meter Number <M>odify, <D>elete or <N>ext _ �,,:,,. . „ ..' .:: ..::::.. _..:.:::-_. - #ot�Eic�c t+[� rns Ess: TOtt t>F NORTH TQ F OF iETH 1�k 9 Aks .......:...:............ .............. _...................................................................:. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �{ PART C SYSTEM INFORMATION(continued) Property Address: `rj 7 SStH Yt� � E ; Owner: �arry 11rck1At :F Date of Inspection: Tai�CIFi BUILDING SEWER: (Locate on site plan) Depth below grade: 3S Material of construction: X cast iron_40 PVC_other(explain) Distance from Private water supply well or suction line Diameter-AL -�-+ C mments: (condition of jo'nts, venting,evidence of leakage,-etc.) , SEPTIC TANK:_ (locate on site plan) Depth below grade:3 Material of construction: concrete_metal_Fiberglass _Polyethylene—other(explain) If tank is metal,list age_ 1s.age-confirmed by Certificate of Compliance_(Yes/No) Dimensions- P'L 5 5` Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:_ _- Distance from top of scum to top of outlet tee or baffle: G f Distance from bottom of scum to bolt m of outlet tee or baffle: ` How dimensions were determined: Comments: (recommendation for pumpin , condition of inlet and outlet tees or-baffles, dept of liquid level in relation to outlet invert, 'tructuralln egri y, evidence of le ge,etc.) all i '{ 1 e c r ,r, r C�t' •t 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: (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 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:Sb7&t k-:VIA S T1-ee7-/ (lac..11ASC,:A-, Owner: fy Date of Inspection: !(/ :z 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: gallons Design flow: gallons/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:_ (locate on site plan) Depth of liquid level above outlet invert: c 13w'U-4.ou'r{pr f Comments: (note:if level and distributio is equal, e4idenee of solids carryover, evidence of leakage into or out of box, etc.) X11 PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No)l Comments: ( ote ccoonndition of pu p chamber,condition of pump and appu enances 1 , etc.) r 11'14 revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION(continued) Property Address: S07 �!iC'Ef✓i� 'W•1')`'IC�LiLI` Owner: "P('y Ara 1 L0 Date of Inspection: SOIL ABSORPTION SYSTEM(SAS):_ (locate on site plan,if possible:excavation not required,location may be approximated by non-intrusive methods) If not located,explain: I Type: leaching pits, number:_ leaching chambers,number:_ leaching galleries,number:_ leaching trenches,number, length: leaching fields, number, dimensions i overflow cesspool,number:_ Alternative system: j Name of Technology: I Comments: j (note c ndition of soil, signs of hydraulic failure, level of po ding, damp soil, condition of vegetation, etc.) Sbl t P (,*t( (v r•7 Si ' � 1 001' 4.141 C' yd CESSPOOLS:_ (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensiods of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) 0 Comments: (note condition of soil, signs.of hydraulic failure, level of-ponding,condition of,vegetation, etc.) PRIVY:_ (locate on site plan) Materjals of construction: Dimensions: Depth of solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation;etc.) revised 9/2/98 Page 9of11 I i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C + r n SYSTEM INFORMATION(continued) Property Address:rl�6� Owner: Y Date of Inspection: i t�a(l YI C ............. te 1'u Qc . : SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:55;7 SOJE'It Smec Owner: �a;cy Arskvo Date of Inspection: 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 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed.Site(Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data . Describe how you established the High Groundwater Elevation. (Must be completed) II ��- S n� S��s;�-.�-� t s S�rr��c�� t� �l •�c•-�r cl Eu�:�zt��, c�•. Y :� ,�•r QC). ..S � f' C.L;c.% j r C'C _ �e1�-r 1 j V1 J L .:.i.'✓ Cs't'- .6Ll0.iO\ �' G� �lt'.sk t"111LJ t (q:��T�`'1'•. �`1.0 i l�L iGe _ E �L(>Ci J£� `�" i CcJli.11 icer../ �' 't 44 l - ` ' ' 't +� C'1 ic�� :�c;�- ��+ �� c f4 1 q S P(;-j't� t, ` � 11r7•� �.%:�'�C:c.-t'E 3 A& •�4-(/I C4 IIS I � revised 9/2/98 page 11 of 11 i i Commonwealth of Massachusetts RECEIVED City/Town of 2014 System Pumping Record JUL ' Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use--by local Boards of Health. Other forms may be'used, but the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health 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 LocatioOing., Left /Right ont of hous Left/Right rear of house, Left/right side of house, Left/ Right side of bu /Rig on o uilding, Left/Right rear of building, Under deck Address /11% 7 city/Town State Zip Code 2. System Owner. Name Address(if different from location) Citylrown State Code Telephone Number _ t B. Pumping Record Lf 1.1. Date of Pumpinggate 2. Quantity Pumped: Gallons i? 3. Type of system- ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yeas No If yes, was it cleaned? ❑ Yes ❑ No. 5. Condition of SystemV� 6. System Pumped By.- Nell y:Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: Lowell Waste Water Sig a 9t Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 RECEIVE® Commonwealth of Massachusetts u City/Town of jil 29 ?013 System Pumping Record TOWN OF NORTH ANDOVER � Form 4 IHEALTH DEPARTMENT DEP has provided this form for use-by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/Right front of house, Left/Right rear of house, Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address City/Town State u� Zip Code 2. System Owner. Name Address(if different from location) Citylrown State � L Zip Code 4 Telephone Number B. Pumping Record _ r7 -- -C3 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) ET Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes D-9-0 If yes, was it cleaned? ❑ Yes ❑ No S. Condition of System: i • 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locationere contents were disposed: Lowell Waste Water signAtufe I Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts RECERE�D N W City/Town of North AndoverOCT 10 X011 } System Pumping Record Form 4 TOWN NORTH ANpt�V(wR �M HEALTH DEPARTMENT SV DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out 1. System Location:forms on the computer,use only the tab key Address to move your No.Andover ma 01845 cursor-do not use the return City/Town 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: Gallons 3. Type of system: ❑ Cesspool(s) optic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: CDna/ 6. stem Pumped-P 1e Name Vehicle License Number Stewart's Septic Service j Company 7. Location where contents were disposed: nTewart's Pre-treatment ant, 20 So. Mill Bradford, Ma 01835 I nature of Haul r Date �j Signature a eiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 i My," /1••'��" I'.�:riti'::,LUa,;��+' K'''f'r� t t`�{,11 1 ' I 5•' :��.�h''7'°I)/,,q y�/l�f tl'I, !Y,J,1 I I.r.,J•1 11'1 II li'', �. l r E CE i V E D ,r � , a ( I r r�.y�' 'i. r � ,; i ;�;�,8�5 I,� • .SEC .0 S 2;009 ,1 I:•, r r I T9•�IADG�� "/fir �}„Il,t! � ,� l'•'�j ld/l � ,I �`lu r�i r�li vi• ' •Q�Prhll plOvld�dlhlr 10//nlo/ " ' I V11 IOC11 8 C'' Oolln of oino! I AAcO VI,I'U^,• ,np 1:OnI , A' Facll ' I I ty n(.orm� �(jo .',) ,'.I IJ•:ld! �"'!(II cam/(J '�' �/ , ..( �, :•,IYZ I,;,� r►em Own '�' � � ' . 1x,111 I II'lY),'!�H yl 1�a'y�iJ l,;�, U:Ir„(/yr!LPN�,��� r •'�' •`` °'•„ t '1,', Ile r' �,(r!1'1'I'/v 4r Ir'��y r r�r'I�,�Cil'I%,'• C (\�/��//,,',/,J�,� N 141 0 Illnl IQ'n buVon) �C)N,I Pumpin g.fIa'gord' I' 1• '� �� Of lo of PvmpinQ ' 2 ' ;, ,�•; r ,,, 01:1 P y�l�om;•', ' .• ' r•(��Ocher�� 11'.,r �' ISS' !d�` If►�("D{(.t, 1nr? n roe :!{;,;,1• Y9 '11I11`/�i'fl !'ti1�IY,J(!{/,�1�119' ) �8 I! C'Odn007 '1 1jP4 OV1114'i y�' j��`�''C'I•' !-' r r t' ) V 167 • ,./r/;'1�1 rY/ru`;' . 1,x11 :11,•,r''r C ��/ �V v '.,111{1'1' (1,,:n r.{I a,l 8y. ,r•' r r .. •• �.,irlr ;�u'I,l��r1J'' �11�1��' 1/Y, •1 ,I;'ly i 1• / i i,' 1)'' r Ir •� 1 1� r v { ! `�� <�^�ti•;'lly , 1 '' '; � "I' ( Ylnlul 'Jcdnll ' ?,• `�,1 ,Ili «Vli� ►�r;���'11 l;! ;'�l;;,I,�1�f:,/�I:' , � • .... '•:/•r '1,'1,,Ir,/�III�� '�r'1�1 , I ,�i(,e/0 d1,1p0300: I i ,I , •I m 1 , r •'1 . . � � •I: r r �,,','„ r .GI r' ,lar „ , � �� ..:';;'•';�;,:Y;;,.:1;'';.'r Sl7nl„vyl Ih'ly4(�y�,�y,f,,r.',,,r,l, ^ .III � �� ,IA ' ei/epp(9y 0141QrmP. InI�ocl '� i4i'i�lf,'. :,trlii''��liS`,I'K�'•>:i��•r:r,uh: 4?•'.1��•'.'.. �': �'..y... ',� 1 SS,fjqq jj1, ',I. 'K. r' 1-' ;:TTd' ;•i'•.%;•1!�y.`%;?;:i; 'r ♦ �'�' r�`•1,�,'l'4�'��'lliity'./'il ufl.y tJ;• /;.�,., •,�., VER ORTH'ANbO MAS'SACHU ;,.,r;. .••, ,• .,ul, S E TT S ,� S xQQtT1 r`. .. .,0 �'r�'lh,� ♦ .1 •' IW,� r p.l n. Ip�ec rd' •) 1�j� `IOW ,4',MY } + ��y 1)x,..113•{!i•:^l'!r .. V''�•�L••.�'J . ,.rti"0����f/��j•11 1.✓'!:'h�.lrn +�Y y!Ye`,1i.i;1..1•.�.: I�Ilfi %: It'1 `,1}y�I;F'ti yl,:�: , 1�.1 ,,.%'.�' r r; 1/t;ar,?.ni, •� 1 t a,y.. !}i"1:•G'wf; IRK ,% pr-kded�4 form for•us by ,% be :ubi 114'd to the.local't3oard of Heal ealt The System Pumping Recorc ], {` th or other approving authority, A Facility lnforl 'ation ' ;"�tmjZortant::' i ;,':' .:;? ,`•`','.' ::., :`;;•'�;' ' '1 TOWN OF NORTH ANDOVER J,;.Wherf(]tilr]Q out' System l.ocatlon;` ! HEALTH DEPARTMENT only the tab key Address to move your ,.arson•do(lot ' ' `liss+'the�rowm•�% ' <� �;. tY/To� •'' �'...,. .,. • � State p� �r I� p Coda. •y�•..+)7 yr;•Li '.S Stem OWr18t;•r 'F`.' '.'. �" ► . ,`.: ':My�1� RI 1.1>i1N.e,':,1��'�1• '+t.'V:t. 11'ilN�lr�rl�•LY :1. ,, ,/:.+; ,,,.Name• '�>., r• ,-•.,,r••;.r: lt::.'::Y..: . Address(If ditrerent from location) ll// State' Cod ,., •.: �' ,`:,Nri` .. .r, Telephone �--__ D umber ..,..�P;um.pJg:,�e,�ord;''" .I,r'.•1'.,, . • Ilr!`, !N�Dl�� :1 . { 5 +r It• �•� I•' �'1,, 084'of Pumping'; 2Quant) Dale ' ty Pumped: '' ' " • ' Gallons �+ TYp,e P(system;; Q. Cesspool(s) Septic Tank C3 Tight Tank •, __ _ __r r�%Other(descrlbej;�� . 4;;: Effluent Tee FlIta�pr$sent?.❑ Yes o. If yes, was It gleaned? ❑ Ye- . �,.•r•�1 . r6�; o�ditl �(:. 'ii'" I� �r�, •�. Q +r.° �Cort`of.3 i� ,r •'r,'+: r' 1�11!:':N..(� y .$t .� - �. ;::�4; j' �•..�%i.,;�,1,,>��r,;�3�I:��;r';Y;g,;�,�r(;:i!;."'���vYr.•,:':���.St'�'.; ... .. .. �• Jrl l�."�4r.11� i 1,��'�',ti1,.i�'f'f�!'��,;�� '. , _ � :! .'..i, ':1•'+!i.hilt T.�YN:J'��Ot%;:,1:� !, t ,''�, a•,• P.Limped By;.., Or :[IL.;,r. •��•1`w'rtt:r`:w�•'�i%. Amar\u!,i�,rJ,1'iqr i},s, J+S•rr� . r .,... ,,,.. .i:.:'�;., '•,.�,'.,.i•'. :11;ri'fr'1 r!I '.GI+ '(•-1 .irll�'i�1 Y•(rl,f+;•' ••i,r, ,j,, Vehlde Ucen#e Number �5� �1/4y.,��1s• k�5 ' .vYY:X;. 4SLS ;cr �/ : •� /,//y/�///� .r.'� �'j"a,f'i'!�j'1,r.��'�ir:'l•ly rr. •'V`>r�J 14'' �v / / • Nii �r .� y.' .,•,. UD i{ r,y.l f; �. i/.r}./rlilfl.,..... • ' �; +� +'•O lam`' e Contents yvere posed: . ' ..I'••.::'y 1.' ..I�i,.a.1,.7•14.;J? 'i'��'t� :;,•x '71 1; .,• ,•, ..: .•'t: i{�, .fi•�a:',7Ji,•F� r "•r,'"�t'M.I��rr,'1!♦.ii' ' �:�;' '"�::�•�.:,�°�',;:,,.�:3;r;.'•:+: ,SlpnatureolHauie w ' t: Uate. htfpa/wwtiv.mass.gov/daa/wafer/approvajs t5forms,htm# ...... � •,>;: •:. ,. . ., ,. Ins pact , tJf011T14.dot7! 08/Q3 " tu System Pnpin9 Record Pale 1 t / i' V - " monwealth of ass.'c usetts � _ ° Com . it °/Town';off•NORTH ANDOVER MAS AC T v System Pumping Record TOWN CJr NORTH ANDOVER . Form 4 HEALTH DEPARTMENT DEP,has provided this form for use by local Boards of Health. The System Pumping Record must local Board of Health or other approving be submitted to the pp 9 authority. A. Facility Information Important: when fining out .1 System Location: forms on the computer,use only the tab key Address to move your cursor-do not City/Town State Zip Code Use the return key.. 2. . System Owner: MC 1)4n Name 5�. 5"a.? leen AOJD Address(if different from to tion) CitylTown State Zip Code Telephone Number B. Pumping Record - i z o64SJ ;,,, • 1. Date of Pumping 2. Quantity Pumped: eons Date 3. Type of system: ElCesspool(s) Septic Tank ❑ Tight Tank ❑'Other(describe): 4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System:` 6. Sy em Pumped By: - - - - Name ,VehicleOrd License Number . • 5�. �;. i�ccc:Q, ��-. ac� J Ana Company 7. . Location where contents were disposed: X4Cccnc� , � Signature of Hauler . Date http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect t5forrn4.doc•06/03 System Pumping Record•Page 1 of 1 TO OF NORTH ANDOVISP, JAN 0 6 2005 U^I I SY M PUMPINQ UCOftL SYSTEM OWNER dt ADDRE S SYSTEM LOGATIQN -7 DATE OF PUMPINQ,_,. �- l _QUANTITY PUMPED; Sa c Tank: NO YES P� , NA rVRE ON SERVICE: ROUTINE„ �M RUIrNC'1' ObSBRVA't'IUNS: GOOD CONDITIUN�PULL'f'U WVER �y AV ORWE BAFFLES 1N PLACE. ROOTMUMS SOLIDS ..._.. FLOODED LWH]qD RUNBACK SOLID CARRYOYER_.,__OnfER EXPLAIN System Pumpod by _ ... ...... (./.G... ' rvice-) . .. . �`. . ,Qraa�r� rrra. VUMMENTS. �:VN PEN'I'S fKANSt'EKRBp I't� ,,..� I cj� i .g 1jr 12 Bo ' s TOWN OF`NO$TH ANDOVER w '`SYSTEM PUMPING RECORD DATE C• IDD 3 " - ...�— �. SYSTEM OWNER&ADDRESS SYSTEM LOCATION MC DON.a)61 DATE OF PUMPING QUANTITY PUMPED CESSPOOL NO�_YES 77777 SEPTIC TANK NO YES NATURE OF SERVICE;:,RO[JTINE EMERGENCY OBSERVATIONS: / e GOOD CONDITION FULL TO COVER HEAVY GREASE ,T BAFFLES IN LACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLID CARRYOVERT 0 HER EXPLAIN , SYSTEM PUMPED BY �I COMMENTS: CONTENTS TRANSFERRED TO )e U v/x TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: I LO SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) Lo DATE OF PUMPING: / - U I QUANTITY PUMPED aoo GALLONS CESSPOOL: NO . YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) i II' SYSTEM PUMPED BY: i COMMENTS: CONTENTS TRANSFERRED TO: JUbr6 Alvwver 12.4 I- •, STIIMT's SEPTIC TANK SERVICE ��G Nlo,n Sf 47 RAILROAD STREET Na f4h A BRADFORD, Ih 01835 Won v I L,f- )G1-0614 978-372-7471 L,e- MONTH OF ®c(a ber �96co M0NTHLY REPORT FOR TOWN OF DATE ADDRESS ADDRESS GALLONS 00 '3 ern Lyes )--5/— l c� 6 e-13 q lU 156 MAO St -� reel . a� 53 Alcilr!oo I U JWN OF NORTH ANDOVER TOWN OF/jANDOVER BOARD OF HFALTH SEPTIC SYSTEM SERVICING DEC 9199s REPORT { Date:_ 3L-�9-�= - Homeowner:_ (.IJwJ�C� Pumper Street :_ -7s�a-� -, Address:—/14,6 Phone �}, _ Phone Nature of S-arvice: Routine Emergency Observations: Good Condition Full to Cover Baffles in Place Leachfield Runback Excessive Solids Heavy Grease Roots Other (Explain) Description of Work: Comments :: Town of North Andover, MA TOWN OF NORTH ANDOVER/ Wate:rshed Septic System BOARD OF HEALTH servicing Report Date:. Mr, I lQ--(q,/,g Homeowner: Re;c,�, (.0 Pumper Street S(N-1 I �. , Address: Phone Phone Nature of Service: Routine Emergency Observations: Good Condition Full to Cover _ Baffles in Place Leachfield Runback ] Excessive Solids Heavy .Grease Roots Other (Explain) Descr:_pt.ion of Work : Comments: s Town of North Andover, MA Watershed SeRtic Sys tc-m NORTH EP� F H Servicing I:eport IOW gpPR00F Date. ` N Homeowner:_ � � Pt roper :_I -4 Lpol—I AIV Street _ Ac dress: Phone _ �Q��- p`� (� PI one Nature of Service: Routine Emergency _ Observations: Good Condition Full to Cover Baffles in Place Leachfield RunbEck Excessive SolidE 1�U0 Heavy Grease Nd Roots Ka Other (Explain) Description of Work: Comments : L� (, ,-66R�sO Prey Q F6)wtj O oJEELc_. 5s - 5CHIc SY sTE,, PS►cO ,�PPi�ov��v D,4rt� 1JPRvIN6 /urrjoj'�ily -- 1 P(AtJ DESS &A-)6 R Full') P T- U15APP�v�� D _ CoArO.05 ��E c��17,%vl ��till a►?r� R 4SoNS = 17&-P4 fT 2`7-1-7 u,.5,-ed �5 DwC _ StPrt('- SYSTEM J SI;a U,,4TIOAJ x4V4Tto� 1-k)S V4-rC El P45S 0 F�4it� �>J5P6-1-10A) PIPE Fft�O&A How ry T/J0t� F-,l ?W5 `0 f=/JIL ,dPFROOED Q7/3TC 1-(-72 f _ APPMOJING AOTHoi?�Ty 60/ 0IJAC- InJSt .i Ipn�s ���-,a►-�Y) D1�C1 P�Kdv i� D,a TC" RE/J50 tis �f APP►3ovVJ6 f 4 t ' v\ r I � , r, S r ' INTER AGENCY REFERRAL Q Report from Date: _ Community Agency From: To: Tel. No. : Tel, No. : Attention Patient Age Address Date of next clinic; app't. Ho sp. BID„ Content of Report to Hospital: Division of Tuberculosis, MDPH PH-TM-211-2/2/62 Q�d 6A 05; copp M(l 26L �( .1SZf 1�✓u ��M JL5 02 ef In Mar - vi I V�j LJ -,P-LIS Page 2 : Tom Neve stated that in a R-3 Zoning District a cluster development was not allowed. Changes in the Bylaw since 1985 regarding contiguous building area, upland and a zoning freeze on property' as to use . The common driveways will be 15 feet wide with a 6 . foot wide. island with post and rail fence between. Four common driveways accessing 11 dwellings. Paul Hedstrom stated that the standards of the Special Permit have to be met as well as the safety issues being addressed. Tom Neve stated that the driveways have been placed 125 feet to 200 feet apart, all are straight and with grades of 5% normal curvature . A water looped system around the property, hydrants, sprinklers in each home, a sewer system from Route 114 . Paul Hedstrom stated that due to the freeze on the property that the Board has to live up to the Bylaw obligation but factorally the Board can control, minimize and reduce the number of dwelling units accessed of common`. driveways . George Perna asked why the applicant has not submitted a subdivision plan originally. Tom Neve stated that he had a choice. Tom . stated that he would like to set up a workshop to make modifications. A motion was made by John Burke to take the matter under advisement and continue the public hearing. The motion was seconded by George Perna and voted unanimous by those present. On January 7 , 1988 the Planning Board held a meeting in the Town Hall Selectmen' s Meeting Room. The meeting was called to order at 7 : 40 p. m. by Vice-Chairman, George Perna. Also present and voting were John Simons, Clerk and Erich Nitzsche . John Burke arrived at 7 : 45 p. m. Paul Hedstrom was absent. Ben Osgood presented the Board with the proposed driveways . George Perna questioned the applicant about a possible cluster as an alternative and/or subdivision. Ben Osgood stated that due to limited land area and the Towns new CBA Requirements , he could not subdivide the property and obtain 11 lots . Cluster is not currently allowed in R-3 Zoning District. Erich Nitzsche questioned the design of 11 lots on 1 driveway. The Board asked for a cluster development plan, a scale drawing of the 1 driveway proposal, asked for the easement documents, and water and sewer design. A motion was made by Erich Nitzsche to continue the public hearing to February 4 , 1988. There was no second. John Simons made a motion to continue the public hearing until January 21-, 1988. The motion was seconded by Erich Nitzsche and voted unanimous by those present. The Planning Board held a regular meeting on Thursday evening, January 21,1988 in the Town Hall , Selectmen ' s Meeting Room. The meeting was called to order at 8 : 25 p. m. by the Chairman, Paul Hedstrom. Also present were John Simons, Clerk and John Burke . George Perna and Erich Nitzsche were absent. Because there was not quorum, the Planning Board could not hear the application on the Chestnut Street, Common Driveways. V � V "444--) 1� Gslr M Rec� utsflzj-)- S07 i �5 S�,r1`o c,4r C017-ier- 1 r I how 5C 1 ", J Page -4- Order of Conditions Lots 7 and 11 Chestnut Street & Turnpike DEQE X1242-447 14. The NACC does not agree with the applicant's delineation of the wetland resource areas at the site, particularly at the area of the crossing. Accordingly the wetlands shall be redelineated and revised plans sub- mitted to NACC for review under Condition 1119, prior to the start of construction. Since a breakdown by type of the resource areas affected by the proposed crossing has not been provided, the NACC has assumed that all of the resource areas affected are bordering vegetated wetland areas and has evaluated this project accordingly. PERFORMANCE/DESIGN STANDARDS/CIIANGES: 15. The NACC finds that intensive use of the upland areas and buffer zone proposed on this site may cause alteration of the wetland resource areas during the construction activities, particularly the housing unit construc- tion. In order to prevent any alteration of wetland resource areas beyond those proposed in the Notice of Intent and approved herein, a ten (10) foot no-cut zone and a twenty-five (25) foot no-construction zone shall be established from the edge of the bordering wetland resource areas. These zones shall be shown on the plans discussed in Condition 1121 below. 16. No earthen embankment in the buffer zone shall have a slope steeper than 2: 1. Any slopes of steeper grade shall be rip-rapped to provide permanent stabilization. 17 . Prior to the start of construction, a detailed Construction Sequence Schedule and Erosion Control Plan shall be submitted to .the NACC fc.ir review and approval. Said sequence or schedule shall integrate the erosion control measures in the construction program. 18. No further Notices of Intent or Requests for Determination shall be required of this project if it conforms to the requirements of this Order of Conditions. Any changes shall be handled as specified in Condition 1119 below. 19• Any changes in the submitted plans, Notice of Intent, or resulting from the aforementioned Conditions must be submitted to the NACC for approval prior to implementation. if the NACC finds, by majority vote, said changes to be significant and/or to deviate from the original plans, Notice of Intent, or this Order of Condition , to such an extent that the interests of the Act and Bylaw cannot be protected by this Order of Conditions and would best be served by the issuance of additional Conditions, then the NACC will call for another public hearing within 21 days, at the expense of the applicant, in order to take testimony from all interested parties. Within 21 days of the close of said public hearing, the NACC will issue an amended or new Order of Conditions. GILBERT REA JOB 44 Rea St. SHEET NO. • OF NO. ANDOVER, MA 01845 Phone 682-9864 CALCULATED BY DATE CHECKED BY DATE SCALE ............. ........... .............. ............. ............ . ................. ................. ............ .............. . .............. ............. ..................................................... ......................... ............. ........................................ ........................ .............. ...................................................................... ........................................................................... .......... .................................... . ................ .............................................................. .........................- ............. .............. .......................... .......... ............... ................................... .............................. .................................................................................. ..................................................... ............... ............... ............ ...................... ....................... ............... ................ ................. ................. ............ ............ ................ ................ ...................... ............... ........... ...... ............ ................ ..................... .............................-........... ............. .......... ................................... ................ ...........I ........................... ............................. .................................. ...................................... ........................ .......... 01.1........... ............. ......................... ................... ........... ........ ... ...................... ........... ............ ............. .......................................... ........................ ............ ......... ............. ........ .......... ............................-..................... ................... ............................................- ............ ...................... .......... ............. ......... .................. ............ ................- .......... ............. ... ...... .....-.................. ................. ............ .................. ............. ............. .......... ..... ..... ............. .............. ............. . ................ .......................... ............. ......................... ................-.......... ............................................ ...... ............- ........... ................................................... ............... ........... .............................. .......... ................................................................. ..................................................................... .............. ...................... .......................... .................................................... ............ ............. .............. .............. .......... ........................ ......................... ........................ ............ .............. .......... .......... ................. ..................... ... .......................................... .......... ........................... ................................................................................ .............. ............. ................ .. ......... ............ ........ --------------- .............. ............... .......................... ........... ................. ..................................... ............ ............................. .................... .................................... ...... .......... 0.1.11111.11............ .................................... ........................ .......................... ............. ................................ ...... .... ..... ............. ........... ......... .................. ................... ...................... ....................................................-..... ............. ............... ........................... ............ 49PI,j0F% I ................. ................ ....................... .............. I av-k ............ .............. .... ....... .......... ........................... ................. ...................... ............................ ........... ....................... ....... . ........ ............ ............ ..................... ..................................... ............................ .............. Li ........................................... ............. ............. ............................................. ........... .............. ........... PRODUCT 204-1Ees Inc..Groton,Mass.01471.