Loading...
HomeMy WebLinkAboutMiscellaneous - 547 WINTER STREET 4/30/2018 (2):1t North Andover Board of Assessors Public Access s riORYy Return to the Home page click on logo New Search Sales Summary Residence Detached Structure Condo Commercial Comparable Sales Town of ISTorth Andover Boewd of Assessors Parcel ID: 210/104.A-0093-0000.0 SKETCH Click on Sketch to Enlarge Page 1 of 1 Property _ Record Card Community: North Andover PHOTO Click on Photo to Enlarge Location: 547 WINTER STREET Owner Name: GILL,JEAN M Owner Address: 547 WINTER STREET City: NORTH ANDOVER State: MA ZIP: 01845 Neighborhood: 6 - 6 Land Area: 1.02 acres Use Code: 101 - SNGL-FAM-RES Total Finished Area: 2581 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 576,000 528,700 Building Value: 345,000 318,600 Land Value: 231,000 210,100 Market Land Value: 231,000 Chapter Land Value: LATESTSALE Sale Price: 524,500 Sale Date: 06/03/2002 Arms Length Sale Code: Y -YES -VALID Grantor: PRUDENTIAL SERVICE L Cert Doc: Book: 6878 Page: 0084 http://csc-ma.us/NandoverPubAcc/J*sp/Home jsp?Page=3&Linkld=989947 5/18/2007 f MORTN , O �.... •.••YO ! Ft �!.r •,. 09 • . Town of North Andover .: .. HEALTH DEPARTMENT S�CNUS! CHECK #: 1 LOCATION: H/O NAME CONTRACT 7083 Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWQ $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ?� Title 5 Report $ ❑ Other. (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer _=1ME Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. ISI Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 547 Winter Street Property Address Jean Mauck Owner's Name North Andover Citylrown MA 01845 State Zip Code 4/10/2015 Date of Inspection Inspection results must be submitted on this form. Inspection forms may iReGaUM any way. Please see completeness checklist at the end of the form. OR 21 2015 A. General Information TOWN OF D pARTM NVTER 1. Inspector: Neil J. Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover MA Cityrrown State 978-4754786 S115 Telephone Number License Number B. Certification 01810 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑Nine Further valuation by the Local Approving Authority 1 IN t 4/10/2015 Insp ct r Asignature 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 547 Winter Street Property Address Jean Mauck Owner Owner's Name information is required for North Andover MA 01845 4/10/2015 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): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 547 Winter Street Property Address Jean Mauck Owner's Name North Andover MA 01845 4/10/2015 Cityfrown 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 ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 - El 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 547 Winter Street Property Address Jean Mauck Owner's Name North Andover MA 01845 4/10/2015 City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or. more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17 Owner information is required for every page. Commonwealth of Massachusetts `title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 547 Winter Street Property Address Jean Mauck Owner's Name North Andover Cityrrown B. Certification (cont.) Yes No MA 01845 4/10/2015 State Zip Code Date of Inspection ❑ ® 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 the system is within 200 feet of a tributary to a surface drinking water supply 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 Area — IWPA) or a mapped Zone II of a public water supply well 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r` 547 Winter Street Property Address Jean Mauck Owner Owner's Name information is required for North Andover MA 01845 4/10/2015 every page. Cityfrown 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): A i Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): . t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 Commonwealth of Massachusetts JD 019 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u,p 547 Winter Street D. System Information Description: Number of current residents: 01845 4/10/2015 Zip Code Date of Inspection Does residence have a garbage grinder? Property Address Yes Jean Mauck Owner Owner's Name information is required for North Andover MA every page. Cityrrown State D. System Information Description: Number of current residents: 01845 4/10/2015 Zip Code Date of Inspection Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) , ❑ Yes ❑ No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage 9 ( Y 9 (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 Forth: Subsurface Sewage Disposal System • Page 7 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 547 Winter Street Property Address Jean Mauck Owner's Name North Andover City/Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: MA 01845 State Zip Code Date General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: 4/10/2015 Date of Inspection Pumped Jan. 2015, owner gallons 701M. -FM ® 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 • M3 Title 5 official 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 ,•��` 547 Winter Street D. System Information (cont.) 4/10/2015 Date of Inspection Approximate age of all components, date installed (if known) and source of information: Tank & Trenches are 30 years old. D -Box is 8 years old. 12/17/1985, as built plan & info at B.O.H. Were sewage odors detected when arriving at the site? ❑ Yes Z No Building Sewer (locate on site plan): Depth below grade: Material of construction: ® cast iron ® 40 PVC ❑ other (explain): 1.8 feet Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" Cast iron through wall & 3" PVC in house, no leaks visible. Septic Tank (locate on site plan): Depth below grade: .8 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x 5'x 4' Sludge depth: 0" t5ins • 3113 Title 5 official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Property Address Jean Mauck Owner Owner's Name information is required for North Andover MA 01845 every page. Cityrrown State Zip Code D. System Information (cont.) 4/10/2015 Date of Inspection Approximate age of all components, date installed (if known) and source of information: Tank & Trenches are 30 years old. D -Box is 8 years old. 12/17/1985, as built plan & info at B.O.H. Were sewage odors detected when arriving at the site? ❑ Yes Z No Building Sewer (locate on site plan): Depth below grade: Material of construction: ® cast iron ® 40 PVC ❑ other (explain): 1.8 feet Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" Cast iron through wall & 3" PVC in house, no leaks visible. Septic Tank (locate on site plan): Depth below grade: .8 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x 5'x 4' Sludge depth: 0" t5ins • 3113 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 .'' 547 Winter Street Property Address Jean Mauck Owner information is required for every page. t5ins • 3113 Owners Name North Andover Cityfrown D. System Information (cont.) MA 01845 State Zia Cod Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 33" 1„ 8° 14" 4/10/2015 Date of Inspection 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 tee ok. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): 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 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 547 Winter Street Property Address Jean Mauck Owner Owner's Name information is required for North Andover MA 01845 4/10/2015 every page. Citylrown 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 Dimensions: Capacity: Design Flow: Alarm present: Alarm level: ❑ fiberglass ❑ polyethylene ❑ other (explain): gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 547 Winter Street Property Address Jean Mauck Owner's Name North Andover MA 01845 4/10/2015 City/Town 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, has flow levelers. No evidence of leakage. Evidence of light 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.): * 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: t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 547 Winter Street Property Address Jean Mauck Owner information is required for every page. t5ins - 3/13' Owner's Name North Andover City/Town State D. System Information (cont.) leaching pits leaching chambers leaching galleries leaching trenches leaching fields overflow cesspool innovative/alternative system 01845 4/10/2015 Zip Code Date of Inspection number: number: number: number, length: number, dimensions: number: 3 trenches 42' long Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface Cesspools (cesspool must be pumped as part of 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 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17 Owner information is required for every page. Commonwealth of Massachusetts Yitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 547 Winter Street Property Address Jean Mauck Owner's Name North Andover City/Town MA 01845 State Zip Code 4/10/2015 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 547 Winter Street Property Address Jean Mauck Owner's Name North Andover MA 01845 4/10/2015 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 D --fox. 3S t5ins • 3/13 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 547 Winter Street Property Address Jean Mauck Owner's Name North Andover Cityrrown D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: MA 01845 State Zip Code 4 feet 4/10/2015 Date of Inspection 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: May 1983 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Design plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: As per test pit data on design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins - 3/13 Title 5 Official Inspection Forth: 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 547 Winter Street Property Address Jean Mauck Owner Owner's Name information is required for North Andover MA 01845 every page. Cityfrown State Zip Code E. Report Completeness Checklist 4/10/2015 Date of Inspection 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 t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 Summary Record Card generated on 4/7/2015 1:02:32 PM by Karen Hanlon Town of North Andover Tax Map # 210-104.A•0093-0000.0 Parcel Id 16320 547 WINTER STREET CHRIS HILLS 547 WINTER STREET NORTH ANDOVER MA 01845 Page 1 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.02 Acres FY 2015 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until CHRIS HILLS Owner 547 WINTER STREET NORTH ANDOVER MA 01845 MAUCK, CHRIS & GILL,JEAN Payor Inactive 10/5/2007 547 WINTER STREET NORTH ANDOVER, MA 01845 TENANT MOVING IN. OWNER NOW LIVES AT 1012 PINE RIDGE RD, RICHMOND, VA 23226 CELL 978-273-4408 JOE O'BRIEN Previous Customer Inactive 10/13/2012 547 WINTER STREET NORTH ANDOVER, MA 01845 TENANT UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 18022.0 - 547 WINTER STREET Last Billing Date 1/7/2015 3180051 03 Cycle 03 Active. UB Services Maint. Account No. 3180051 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 l/ WTR WATER 01 ALL METER SIZE 142.60 /1 UB Meter Maintenance Account No. 3180051 Serial No Status Location Brand Type Size YTD Cons 18739618 a Active 00 ERT HH METE METE w Water 0.63 0.63 677 Date Reading Code Consumption Posted Date Variance 3/18/2015 1113 a Actual 42 27% 12/15/2014 1071 aActual 32 1/15/2015 -27% 9/16/2014 1039 a Actual 47 10/15/2014 71% 6/12/2014 992 a Actual 26 7/16/2014 12% 3/13/2014 966 aActual 23 4/11/2014 -3% 12/13/2013 943 aActual 24 1/17/2014 0% 9/13/2013 919 a Actual 24 10/15/2013 3% 6/14/2013 895 a Actual 22 7/24/2013 -14% 3/20/2013 873 a Actual 29 4/22/2013 16% 12/13/2012 844 aActual 15 1/9/2013 40% 10/16/2012 829 f Final Bill 5 10/16/2012 -14% 9/19/2012 824 a Actual - 20 10/15/2012 -35% 6/18/2012 804 a Actual 30 7/16/2012 6% 3/20/2012 774 a Actual 29 4/14/2012 -4% 12/19/2011 745 aActual 31 1/17/2012 25% 9/16/2011 714 a Actual 25 10/13/2011 -21% 6/13/2011 689 a Actual 30 7/20/2011 32% 3/15/2011 659 a Actual 23 4/13/2011 -10% 12/14/2010 636 aActual 25 1/12/2011 -17% 9/16/2010 611 a Actual 32 10/15/2010 32% Commonwealth of Massachusetts o City/Town of . System Pimping- Record :... 4, 2015 Form 4 TN DEP has provided this form for use=by local Boards of Health. Other forms may be'used, but the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Locatio L / Rig ont of hou , Left/ Right rear of house, Left/ right side of house, Left/ Right side of bui Ing, Left / Ig n of building, Left / Right rear of building, Under deck Address CityfTown State Zip Code 2. System Owner. ^� Name' Address (i different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ Date Cesspool(s) ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 8 No owl , 6. System P*ped By: 7. State Zi d Telephone Number l� — 2. Qua. tity Pumped Septic Tank Gallons —? ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No Neil. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company contents were disposed: �a Ups t5form4.doo- 06/03 System Pumping Record • Page 1 of 1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFF DEPARTMENT OF ENVIRONMENTAL TITLE 5 RE JUN 15 2007 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 547 Winter Street_ —North Andover_ Owner's Name: _Chris Mauck _ Owner's Address: _547 Winter Street _ _ North Andover, MA 01845_ Date of Inspection: _5/22/2007 Name of Inspector: Neil J Bateson Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, MA 01810 Telephone Number: _( 978 ) 475-4786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority j %ls Inspector's Signature: Date: _5/22/2007_ /V C7 The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments: After permit from B.OJI., install new D -box with riser, inspection from B.O.H., septic system now passes Title 5 Inspection. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. _EL�/A�iI C» S Top PDaWDAT"io C.Y. ► U,\/ co t" ouU-b p.v,C )kj\/ Iu D -Box p,v. c. wv ov i p -Box (1--,/P• 5� j b or Li u5 (T -1/P.) 1 T1 v- ,•����:�- wv cam I+ 1 ZD. ADS �'r "'b4' 440, "+ x ST. 15bo 6A �$ ;EPTI a TAW 1 C. j-i-7o.zo' �&jIUTI 5P STfZE51' T- C `reY, `NA'r 1 Nps 1 Q SN5 TIF—�'.D TN IF- I i�.1 ST �i1J..AT Com" TSE- D1S-POSAi - AT' LOT b W I kilEP ST A.I QZT Cpt��,��CTic�� l��_ ii..!• CoMPUAA W(TIA PLAW-S � SPE CI111RTI0Qc- pmPtkl4 8Y H HAcl. 5wG1.QF'5-Zl (� SEf-u1 GI1s DXT5-I): 10-9-198)q AS BUILT PLAN OF SUBSURFACE DISPOSAL SYSTEM LOCATED IN _�IJoR)nA �lul:)oVE:R 1 MhSs, AS PREPARED FOR �• C • � � � � � Wt of 4j4.. l"z4�. DATE: p C �-�l "� , I ~i ►) 9 S5 ° ROBERT c SCALE: 1",`.40"$ aft r. MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS 0 PLANNERS 66 PARK STREET 0 ANDOVER, MASSACHUSETTS 01810 0 TEL. (617) 473-3355, 373-5721 E1-= 101, of ,1- 100,'1 UD,lfq r coo - '�7 QD,Z "+ x ST. 15bo 6A �$ ;EPTI a TAW 1 C. j-i-7o.zo' �&jIUTI 5P STfZE51' T- C `reY, `NA'r 1 Nps 1 Q SN5 TIF—�'.D TN IF- I i�.1 ST �i1J..AT Com" TSE- D1S-POSAi - AT' LOT b W I kilEP ST A.I QZT Cpt��,��CTic�� l��_ ii..!• CoMPUAA W(TIA PLAW-S � SPE CI111RTI0Qc- pmPtkl4 8Y H HAcl. 5wG1.QF'5-Zl (� SEf-u1 GI1s DXT5-I): 10-9-198)q AS BUILT PLAN OF SUBSURFACE DISPOSAL SYSTEM LOCATED IN _�IJoR)nA �lul:)oVE:R 1 MhSs, AS PREPARED FOR �• C • � � � � � Wt of 4j4.. l"z4�. DATE: p C �-�l "� , I ~i ►) 9 S5 ° ROBERT c SCALE: 1",`.40"$ aft r. MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS 0 PLANNERS 66 PARK STREET 0 ANDOVER, MASSACHUSETTS 01810 0 TEL. (617) 473-3355, 373-5721 z r 73 a A V r i t 4 • ti N M Q M M 00 O O "t 3 j �i � w z cn, C * O 2 m � w h a Of MORT1j , r N � is �. •• Oc Town of North Andover :. HEALTH DEPARTMENT ,sSACNUSt� CHECK #: 3/ DATE: -���l LOCATION: H/O NAME: G,,4111S / w/c CONTRACTOR NAME: e -41 �/�,-e&%�, rw Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type. $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title inspector $ .® Title 5 Report $ ,e ❑ Other: (Indicate) $ 2439 Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer f COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: _547 Winter Street_ —North Andover_ Owner's Name: _Chris Mauck _ Owner's Address: _547 Winter Street _ _ North Andover, MA 01845_ Date of Inspection: 5/11/2007 Name of Inspector: Neil J Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, MA 01810 Telephone Number: _( 978 ) 475-4786_ 1VE,D 0� MAY 2 2 2007 -rOVVN OF NORTH DEPARTM ANDOVER T CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: Passes X Conditionally Passes Needs Further Evaluation by the Local Approving Authority ail T Inspector's Signature: Date: _5/11/2007 The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments: ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. f Pago 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _547 Winter Street_ _ North Andover— Owner: _ Mauck _ Date of Inspection: _5/11/2007 _ Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: X One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. D -box needs replaced. N The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: N Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain: N The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _547 Winter Street_ _ North Andover — Owner: _Maack _ Date of Inspection: _5/11/2007 _ C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance y "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Pago 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _547 Winter Street — North Andover — Owner: _Mauck_ Date of Inspection: 5/11/2007 _ D. System Failure Criteria applicable to all systems: You must indicate `yes" or "no" to each of the following for all inspections: _ No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool No Liquid depth in cesspool is less than 6" below invert or available volume is `/z day flow. —No7 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ No Any portion of the SAS, cesspool or privy is below high ground water elevation. _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] _No_ (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 ITd• You must indicate either "yes" or `no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: _547 Winter Stmt_ _ North Andover _ Owner: Mauck_ Date of In- spection: 5/11/2007_ Check if the following have been done. You must indicate `)r&' or `no" as to each of the following: Yes No Yes _ Pumping information was provided by the owner, occupant, or Board of Health No Were any of the system components pumped out in the previous two weeks ? Yes_ — Has the system received normal flows in the previous two week period ? No Have large volumes of water been introduced to the system recently or as part of this inspection ? Yes _ Were as built plans of the system obtained and examined? Yes_ — Was the facility or dwelling inspected for signs of sewage back up ? Yes_ _ Was the site inspected for signs of break out ? Yes _ Were all system components, excluding the SAS, located on site ? _Yes_ _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? _Yes_ _ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes No _Yes_ , Existing information. _Yes_ _ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: _547 Winter Street _ North Andover– Owner: _Mauck_ Date of Inspection: _5/11/2007 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): _4_ Number of bedrooms (actual): _4_ DESIGN flow based on 310 CMR 15.203 _600 Number of current residents: _3 Does residence have a garbage grinder (yes or no): Yes_ Is laundry on a separate sewage system (yes or no): No _ Laundry system inspected (yes or no): _ Seasonal use: (yes or no): _No_ Water meter reading: Yes_ Sump pump (yes or no): _No Last date of occupancy: _ Current _ COAUM ERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): _gpd Basis of design flow (seats/persons/sqft,etc.): _ Grease trap present (yes or no): Industrial waste holding tank present (yes or no): Non -sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: — Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: Pumped 2001, owner _ Was system pumped as part of the inspection (yes or no): Yes_ If yes, volume pumped: _1500_ gallons -- How was quantity pumped determined? _Measured tank_ Reason for pumping: _Inspect tank & tees_ TYPE OF SYSTEM X_ Septic tank, distribution box, soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank _ Attach a copy of the DEP approval Other (describe): Approximate age of all components, date installed (if known) and source of information _22 Years old, 12/17/1985, as built plan, _ Were sewage odors detected when arriving at the site (yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _547 Winter Street _ North Andover _ Owner: _Mauck_ Date of Inspection: 5/11/2007 BUILDING SEWER _ X _ (locate on site plan) Depth below grade: _22" Materials of construction: _X_ cast iron _X_ 40 PVC _other Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.) _ 4" cast iron thra wall. 3" PVC in house no leaks visible. i3W0ceK\,EM 1 Depth below grade: _10" _ Material of construction: X concrete _ metal _fiberglass _polyethylene _other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): — (attach a copy of certificate) Dimensions: _10'x 5' x 4' Sludge depth5"_ Distance from top of sludge to bottom of outlet tee or baffle: 27" _ Scum thickness: _7"_ Distance from top of scum to top of outlet tee or baffle: - 811 -Distance from bottom of scum to bottom of outlet tee or baffle: 13" _ 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 _ Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of septic tank leaking. _ GREASE TRAP: _(locate on site plan) Depth below grade: _ Material of construction: _concrete _metal _fiberglass polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _547 Winter Street_ _ North Andover — Owner: _Mauck_ Date of Inspection: _5/11/2007 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX _X ( locate on site plan ) Depth below grade 24"_ 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.) _P -Box level & distribution equal. D -box badly corroded, needs replaced. Evidence of carryover. _ PUMP CHAMBER: _ (locate on site plan) Pump in working order (yes or no): Alarm in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _547 Winter Street _ _ North Andover — Owner: _Mauck_ Date of Inspection: _5/11/2007 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: X leaching trench, number, length: —3 trenches 42' long_ leaching field, number, dimensions: overflow cesspool, number: innovative/altemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): —Soil ok. Vegetation ok. No sign of ponding to surface. CESSPOOLS: Number and configuration: _ Depth — top of liquid to inlet invert: Depth of sludge layer: _ Depth of scum layer: _ Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: _547 Winter Street _ _ North Andover — Owner: _Maack _ Date of Inspection: _5/11/2007_ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building Ato2=16'8" A to D -Boz = 25' Bto1=38'7" Bto2=32' B to D -Boz = 35' Page, l l of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _547 Winter Street _ _ North Andover_ Owner: _Mauck_ Date of Inspection: 5/11/2007 _ SITE EXAM Slope _ No _ Surface water No _ Check cellar _ Dry _ Shallow wells _ No _ Estimated depth to ground water _ 4' _ Please indicate (check) all methods used to determine the high ground water elevation: X Obtained from system design plans on record - If checked, date of design plan reviewed: _10/9/1984 Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: _ Checked with local excavators, installers- (attach documentation) _ Accessed USGS database -explain: _ You must describe how you established the high ground water elevation: As per design plan_ Summary Record Card generated on 5/16/20.07 1:55:45#PM by Elaine Barclay Page 1 • Town of North Andover Tax Map # 210-104.A-0093-0000.0 547 WINTER STREET MAUCK, CHRIS & GILL,JEAN 547 WINTER STREET NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 1.02 Acres FY 2007 US Mailing Index Name/Address Type Loan Number MAUCK, CHRIS & GILL,JEAN Payor 547 WINTER STREET NORTH ANDOVER, MA 01845 US Account Maint. Active/Inact. From Account No Cycle Occupant Name Bldg Id. 18022.0 - 547 WINTER STREET Last Billing Date 4/2/2007 3180051 03 Cycle 03 US Services Maint. METE METE w Water Service Code Posted Date Rate MISCFEE ADMIN FEE 15 0.635/8 WTR WATER 10/20/2006 01 ALL METER SIZE US Meter Maintenance 10 4/17/2006 Serial No Status 1/17/2006 Location 18739618 a Active 0 00 Date Reading Code 3/16/2007 289 a Actual 12/13/2006 267 a Actual 9/19/2006 252 a Actual 6/21/2006 215 a Actual 3/23/2006 193 a Actual 1/3/2006 183 a Actual 9/26/2005 168 a Actual 6/8/2005 155 m Manual estimate ACTUAL IS 120 3/18/2005 155 a Actual OVEREST BILLS, LET READ GET BACK TO 155 12/16/2004 155 m Manual estimate ERT # INCORRECT. CHANGED ON 1/5/05 9/28/2004 125 m Manual estimate 6/15/2004 85 m Manual estimate 4/23/2004 65 m Manual estimate 12/26/2003 45 n New Meter Active/Inactive Active Charge Multiplier/Users 7.82 1/ 71.53 /1 Brand Type METE METE w Water Consumption Posted Date 22 4/16/2007 15 1/19/2007 37 10/20/2006 22 7/10/2006 10 4/17/2006 15 1/17/2006 13 10/14/2005 0 7/15/2005 4/5/2005 30 1/14/2005 40 10/8/2004 20 7/30/2004 20 5/17/2004 0 12/26/2003 Size 0.63 0.63 Until YTD Cons 0 Variance 34% -57% 68% 93% -16% 28% -100% -100% -100% 0% Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating -Water& Sewer Lines -Septic Systems & Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 547 Winter Street, North Andover Owner: Mauck Date of Inspection: 5/11/2007 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Neil J. B eson Bateson Enterprises, Inc. . Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. 00 f CommonvVealth of Massachusetts City/Town of System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. Syst m Location: ,4ddress Cityrrown 2. System Owner: rfalk-) GIGV Address (if different from location) Ste Zip Code Cityrrown State 4p Code Telephone Number B. Pumping Record _5— 11 -6-2 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s)peptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑-WO� If yes, was it cleaned? ❑ Yes ❑ No 5. Conditioof System: 6. Systerp P, mped By: Name 7. t5form4.doc- 06103 Company contents wer spy . <, , Vehicle License Number Gp'7 Date System Pumping Record • Page 1 of 1 "tM, • Commonwealth of Massachusetts Map -Block -Lot 104.A- 0093 - Board of Health Permit No • BHP -2007-0124 North Andover ----------------------- *� P.I. FEE �SSACNust< F.I. $125.00 ----------------------- Disposal Works Construction Permit Permission is hereby granted Todd Bateson -------------- --------------------------------------------------------------------------------- to (Repair -D -BOX ONLY) an Individual Sewage Disposal System. at No 547 WINTER STREET as shown on the application for Disposal Works Construction Permit No. BHP -2007-012 Dated May 18, 2007 r ------------------ Issued On: May -18-2007 r f e th t --------------------------------------------------------------------------------- Bo Commonwealth of Massachusetts Map -Block -Lot 104.A- 0093 - a Board of Health ----------------------- North Andover �.*•p••,.e•r Certificate of Compliance SACHUS THIS IS TO CERTIFY,That the Individual Sewage Disposal System (Repair -D -BOX ONLY) by...Todd Bateson- -- ---------------------- -- ------------------------------------- ---------------------------- - -- -- ------------ ------ -- -- -- -- -- -- --- Installer at No 547 WINTER STREET ---------------------------------------------------------------------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. 13HP-20077012 Dated _ _ _ MAY 18,_ 2007 ----------------------------------------------------------------- Printed On: May -18-2007 Board of Health IL NORTq 0.41`w •1y0 � e F 9 Town of North Andover '�,'••.,,,, :. HEALTH DEPARTMENT �sS�cwuS°s CHECK #: DATE: t)�elrl LOCATION: H/O NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic Design Approval $ ✓) 70,�Septic Disposal Works Construction (DWC) $ � (1 ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other: (Indicate) $ 2435 Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Important: Aanlication is herebv made for a permit to: M TODAY'S DATE $ 250.00 — Full Repair $125.00 - Component When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer, use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key to move your P<epair or replace an existing system component cursor - do not use the return key. A. Facility Information 1 ne Address or Lot # City/Town d _ v ✓_t g- 2.- *TYPE OF SEPTIC SYSTEM*: ❑ Pump Gravity (choose one) ***If pump system, attach copy of electrical permit to application*** ❑ Conventional System (pipe and stone system) ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D -Box Present) S.A.S. 2. Owner Information /q z- Gk►-' S 1,444c Name Address (if different from above) City/Town 3. Installer -Information 1 f a � �a-T,�Sd`✓ 4. ate Zip Code Telephone Number Name Name 16nMum- _ ( iii A r cad --- Address d Andover, MA 01810 City/Town State Zip Code - Telephone Number (Cell Phone # if possible please) Name Name of Company Address City/Town State Zip Code--- ---- -- - - - Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 !� c PAGE 2 OF 2 A. Facility Information continued.... 5. Type of Building: residential Dwelling or []Commercial B. Agreement TODAY'S DATE $ 250.00 — Full Repair $125.00 - Component The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andove nd not to place the system in operation until a Certificate of Compliance has been Issuefirby4his Board of Health. Name Date Appli Approved By: and of Health Representative) N Date Application Disapproved for the following reasons: .For Office Use Only: 1. Fee Attached? Yes 2. Project Manager Obligation Form Attached? Yes_ 3. Pump System? If so, Attach copy offlectrical Permit Yes_ 4. Foundation As -Built? (new construction ronly): (Same scale as approved plan) 5. Floor Plans? (new construction only): Yes_ Yes No No No No No ".I % SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: &y°7 wt ti14./- sY (Address of septic system) n n For plans by Relative to the application of f.�5�,✓ (Installer's name) And dated Dated S - / �— a o ay s ate With revisioi I understand the following obligations for management of this project: 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner, contractor, project manager, or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or MY compan_ a. Bottom of Bed — Generally, this is the first`(Is� inspection unless there is a retaining wall, which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection — Engineer must first do their inspection for elevations, ties, etc. As -built of verbal OK (or e-mail to: healthdeptatownofnorthandover com) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system, all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade — Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation) and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board of Healtb staff or consultant. d. Installation of tank, D -Box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer. I understand that_I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: �% ,Q ���yJ (Today's Date) S-- l *�Ta 7 (Name —Print) PUBLIC HEALTH DEPARTMENT Community Development Division CE1�7IFICA7E oFCo9bt�1'GIA9VCYE As of: May 20, 2007 This is to cert that the individual su6surface ATosal system received a SAT1rSTAC`701RTIXsPEM0Yof the.- Septic he. Septic System Repair — 1D-Oo,-� Only 0y. 2odd oateson At: 547 Winter Street Porth Andover, MA 01845 The Issuance of this certificate shall not 6e construed as a guarantee that the system will function satisfactorily. Susal Sawyer, RUTS, Tu6Cc Yfealth Director 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com NORTh 0 ,�t►.eo �6'9ti • 00 gyp_ cx.uc�uw'cw . �• PUBLIC HEALTH DEPARTMENT fommunity Development Division CER71F7CA7E OF C0�44PU,4NM As o£ May 20, 2007 This is to cert that the individuarsu6surface disposaCsystem received a SA9TSTACTORT-TXS(EM0Yof the: Septic System Repair — 4o,-� Only By. ToddBateson At: 547 Winter Street North Andover, AVIA 01845 'The Issuance of this certfcate shall not be construed as a guarantee that the system will function satisfactoriC . SusaXT Sawyer,E-9I Tu6fic Yfeafth Director 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com '(1u. 16 ;iY 0. (� y Ki cOU�uC�wK■ _ 1. PUBLIC HEALTH DEPARTMENT Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION n ,� ADDRESS: MAP: LOT: ," % �C%64 Xzw, Z`` INSTALLER: q/�f c�e✓�L DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading Monolithic construction ❑ Water tightness of tank has been achieved (Visual or Vacuum Test or Water held for 24hrs) ❑ Inlet tee installed, centered under access port ❑ Outlet tee (gas baffle or effluent filter) installed, centered under access port 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com µORTh O�ttLtO 06',,{•� O �+ r- 70 it�'>f' * * 7 eye PUBLIC HEALTH DEPARTMENT (ommunity Development Division ❑ 24" inch cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ Combo Tank installed. Size: ❑ 1000 gallon Pump Chamber installed H-10 loading Monolithic 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 ❑ 24" inch cover to within 6" of final grade installed over pump access port ❑ Water tightness of tank has been achieved Visual testing ❑ Hydraulic cement around inlet & outlet Comments: DISTRIBUTION -BOX Installed on stable stone base Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets Observed even distribution v Speed leveae s provided (not required) Comments: l 2 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.towoofnorthandover.com r' tAORT#1 q O �t�eo 06 �O !O p O •AKI */ PUBLIC HEALTH DEPARTMENT Community Development Division SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to 6 in into C soil ❑ layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Retaining wall (boulder / concrete / timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel -less Chambers) ❑ Brand and Model of Chamber Infiltrator Quick 4 ❑ Number of chambers per row 9 ❑ Number of rows (trenches) 3 ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan Comments: CONTROL PANEL Comments: ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: ❑ Rated for exterior if placed outside ❑ Alarm signal located inside 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com TFC O _ ''� tOGIKMtwKM , 7' PUBLIC HEALTH DEPARTMENT fommunity Development Division SYSTEM ELEVATIONS 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 fox 978.688.8476 Web www.townofnorthandoyer.com INVERT INFIELD PLAN INVERT ELEV. Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 INV Lateral 1 TOP Lateral 2 INV Lateral 2 TOP Lateral 3 INV Lateral 3 TOP Lateral 4 INV Lateral 4 TOP 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 fox 978.688.8476 Web www.townofnorthandoyer.com /Q-tt6lD ' �?Ms'6 OCL `0 y tyo� • t M T \°qA coc�iw�i:ncw v'�' �.a_°R�Too PUBLIC HEALTH DEPARTMENT (ommunity Development Division CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback ' Suction line 222(2) Z 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws 5 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Tank SAS Sewer ❑ Property line 10 10 -- ❑ Cellar wall 10 20 -- ❑ Inground pool 10 20 -- ❑ Slab foundation 10 10 -- ❑ Deck, on footings, etc 5 10 -- ❑ Waterline 10 10 101 ❑ Private drinking well 75 1002 50 ❑ Irrigation well 75 100 ❑ Surface Water 25 50 ❑ Bordering Vegetated Wetland , Salt Marsh, Inland / Coastal Banka 75 100 ❑ Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ❑ Trib. to surface water supply 325 325 ❑ Public well 400 400 ❑ Interim Wellhead Prot. Area ❑ Reservoirs 400 400 ❑ Drains (wat. supply/trib.) 50 100 ❑ Drains (intercept g.w.) 25 50 ❑ Drains (Other) Foundation 10 (5) 20 (10) ❑ Drywells 20 25 ' Suction line 222(2) Z 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws 5 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com �LN CommonvVealth of Massachusetts City/Town of System Pumping Record Form 4 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key mnm DEP has provided this form for use by local Boards of Health. Other fo information must be substantially the same as that provided here. Befor i local Board of Health to determine the form they use. The System Pumpi the local Board of Health or other approving authority. A. Facility Information 1. Syst�m Loc Address ':.) 1 c J "C City/Town �j ` St e 2. System Owner: Name Address (if different from location) City/Town !E—C—EIVED MAY 2 2 2007 y� be ,; ,b It 'ER Ris{ cin; thk your rrtu be submitted to Zip Code StateV7 7ip Code ��t (0� Telephone Number B. Pumping Record U `6 J 1. Date of Pumping Date 2. Quantity Pumped 3. Type of system: ❑ Cesspool(s) ©tic Tank ❑ Other (describe): Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes ❑-X6­� If yes, was it cleaned? ❑ Yes ❑ No 5. ConditiorLof System: t4euaj� 1 v� L 6. Systerp P4imped By: Name Company 7. Locatio where contents we sposed: t5forrn4.doc• 06/03 1 t. Vehicle License Number Date System. Pumping Record • Page 1 of 1 , 0 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: _547 Winter Street_ North Andover_ Owner's Name: _Eli Kalil Owner's Address: _547 Winter Street_ _North Andover, Ma. 01845_ Date of Inspection: 4/12/2001_ Name of Inspector: Neil J. Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, Ma. 01810_ Telephone Number: _( 978 ) 475-4786 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: _X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fa' Inspector's Signature: Date: _4/12/2001_ The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. i q' APR 2 6 2001 Page 2 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _547 Winter Street_ _North Andover_ Owner: Kalil Date of Inspection: 4/12/2001 Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND explain: Page 3 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _547 Winter Street_ _North Andover— Owner: Kalil Date of Inspection: 4/12/2001_ C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well's*. Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _547 Winter Street_ North Andover Owner: Kalil Date of Inspection: 4/12/2001_ D. System Failure Criteria applicable to all systems: You must indicate `yes" or "no" to each of the following for all inspections: Yes No _ _No_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ _No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _No_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ _No_ Liquid depth in cesspool is less than 6" below invert or available volume is less than V2 day flow No Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ _No_ Any portion of the SAS, cesspool or privy is below high ground water elevation. _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _No_ Any portion of a cesspool or privy is within a Zone I of a public well. _ _No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ _No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No_ (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either "yes" or "no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no — the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone 11 of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: _547 Winter Street_ North Andover_ Owner: Kalil Date of Inspection: _4/12/2001_ Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No Yes _ Pumping information was provided by the owner, occupant, or Board of Health _No Were any of the system components pumped out in the previous two weeks ? _Yes _ Has the system received normal flows in the previous two week period ? No Have large volumes of water been introduced to the system recently or as part of this inspection ? Yes _ Were as built plans of the system obtained and examined? (If they were not available note as N/A) Yes _ Was the facility or dwelling inspected for signs of sewage back up ? Yes _ Was the site inspected for signs of break out ? Yes _ Were all system components, excluding the SAS, located on site ? _Yes_ _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? _Yes_ _ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no Yes _ Existing information. For example, a plan at the Board of Health. _No_ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 1.5.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: _547 Winter Street North Andover Owner: Kalil Date of Inspection: _4/12/2001_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): _4_ Number of bedrooms (actual): _4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x 9 of bedrooms): _600 Number of current residents: Does residence have a garbage grinder (yes or no): No_ Is laundry on a separate sewage system (yes or no): _No_ [if yes separate inspection required] Laundry system inspected (yes or no): ____ Seasonal use: (yes or no): _No Water meter readings: Jan. 00 to Jan 01= 9800 Ft' X 7.5 = 73,500 Gals. / 365Days =201 Gals./ Day Sump pump (yes or no): _No_ Last date of occupancy: _ Current COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgft,etc.): Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): _ Non -sanitary waste discharged to the Title 5 system (yes or no): _ Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: _Pumped last April, owner_ Was system pumped as part of the inspection (yes or no): Yes_ If yes, volume pumped: _1500 gallons -- How was quantity pumped determined? _Measured tank _ Reason for pumping: _Inspect tank & tees._ TYPE OF SYSTEM X Septic tank, distribution box, soil absorption system _ Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) T Innovative/Alternative technology. Attach a copy of the current operation. and maintenance contract (to be obtained from system owner) _ Tight tank — Attach a copy of the DEP approval Other (describe): Approximate age of all components, date installed (if known) and source of information: _16 Years old. 12/17/1985 As built plan. _ Were sewage odors detected when arriving at the site (yes or no): _No Page 7 of l l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _547 Winter Street_ _North Andover— Owner: Kalil Date of Inspection: 4/12/2001_ BUILDING SEWER (locate on site plan) X Depth below grade: 22" Materials of construction: —X—cast iron _X_40 PVC _other (explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): _4" Cast iron thru wall to septic tank. 3" PVC in house. No leaks. SEPTIC TANK: X locate on site plan) Depth below grade: Material of construction: —X—concrete _metal _fiberglass polyethylene �other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) Dimensions: _10' x 5' x 4'_ Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 24" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: _8" Distance from bottom of scum to bottom of outlet tee or baffle: _18" How were dimensions determined: Subtract scum & sludge depth to tee length. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumped septic tank. Inlet & outlet tees ok. Depth of liquid at outlet invert. No evidence of leakage. _ GREASE TRAP: (locate on site plan) Depth below grade: _ Material of construction: concrete metal _fiberglass _polyethylene _other (explain): — — Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _547 Winter Street_ _North Andover— Owner: Kalil Date of Inspection: 4/12/2001_ TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: _0_ Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): _D -box level & distribution equal. No evidence of leakage. Evidence of carryover, pumped d -box to clean. _ PUMP CHAMBER: (locate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): M Page 9 of l l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 547 Winter Street_ ^_ North Andover_ Owner: Kalil Date of Inspection: 4/12/2001_ SOIL ABSORPTION SYSTEM (SAS): _X (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: X leaching trenches, number, length: 3 trenches 42' long _ leaching fields, number, dimensions: overflow cesspool, number: innovativelalternative system Typetname of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): _Soil ok. Vegetation ok. No sign of ponding to surface. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site pian) Number and configuration: Depth — top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _547 Winter Street_ North Andover_ Owner: Kalil_ Date of Inspection: 4/12/2001_ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Ato1=13'10" Ato2=16'8" A to D -Box = 25' Bto1=38'7" Bto2=32' B to D -Box = 35' Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _547 Winter Street_ North Andover— Owner: Kalil Date of Inspection: 4/12/2001_ SITE EXAM Slope Surface water Check cellar Shal low wells Estimated depth to ground water _4 feet Please indicate (check) all methods used to determine the high ground water elevation: X Obtained from system design pians on record - If checked, date of design plan reviewed: _10/9/1984_ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked with local excavators, installers- (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: As per design plan. Tel: (978) 475-4786 Fax: (978) 475-5451 BATE S ON ENTERPRISES, INC. Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 547 Winter Street, North Andover Owner: Kalil Date of Inspection: 4/12/2001 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Neil J. B eson Bateson Enterprises, Inc. TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: L4 SYS 5-q (example: left front of house) t -42" 0-r- �%ajs-p- �a�` bUANTITY PUMPED DATE OF PUMPING: t- f GALLONS CESSPOOL: NO -' YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) CONTENTS TRANSFERRED TO: Commonwealth of Massachusetts Massachusetts System Pumping Record System Owner System Location UA �� Date of Pumping: �`� �� Quantity Pumped: ` ���gallons Cesspool: No Yes L:J Septic Tank: No Yes �— System Pumped by: vdt`¢4ea 50&'7paa License # Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: -, a SOIL PROFILE & PERCOLATION TEST DATA North Andover, Mass. Street No W Lot No Loc/Subdiv. Pland Owner Investigator 1AIFI 2..11'tP�G,1[_ Observer K, -I -TL- SOIL PROFILE DATES l..kev 2.Elev 3. Eley 4.Elev 63 � 0 2 1 2 3 n Benchmark Elevation In MU 5 6 7 8 9 10 DATES 0 1 2 3 4 5 6 7 8 9 L0 3 Location Datum PERCOJ,ATION TEST to KW) ►nlSNt 0 1 2 3 4 5 6 7 8 9 10 Ti,es Pto 8Test Pit Number1 N3� 2 3 Start Saturation Soak -Minutes Start e Drop of 3" -Time Drop of 6" -Time M4ns.lst 3" drop Mins.2nd " Drop Percolation Board of Health North W_bVerZHasa. APYiiVy M 9AT1 OK SEPTIC SISTEKD. INSTAIS.ATICK CHECK LISf LOT ` U) ST r r DISAPPr1AQATIri Ob PAIL easunst 1. Distance To: a. Wetlands b. Drains c.. Well 2. Water Line Location 3. No PPC Pipe 4. Septic Tank a. _Tees -_Length & To Clean Out Covers b. Cement Pipe to Tank On Both Sides of Tank 5. Distribution Box a. Covers _& Box - No Cracks b. All Lines Flowing Equal Amolmts / c. No Back Flow 6.- Leach Field or Trench a. Dimensions b. Stone Depth c. Capped Ends d. Clean Double Washed Stone 7. Leach Pits a. Dinansions b. Stone Depth c. Splash Pads d. Tees e. Cenant Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. No Garbage Disposal i. - `—�. -Final Grading Inspection 10. Barricading Covered System 11. As Built Snbmitted a. Lot Location b. Dimensions of System c. Location Kith Regard -to Pere Test d. Elevations e. Water Table 011 Board of Health NortY.`mdover, Mas s APPROVED DATE 12 - Provided: Title -T -- Reg 2.5 Y SUBSURFACE DI5POSAL DESIGN CHECK LIST DISAPPROVED DATE Reasons: i-oo LOT til) C�,To� I1_ The submitted plan must show as a minimum; a) the lot to be served -area ,dimerssions lot #,abutters b location and log deep observation hoes -distance to ties c location and results percolation tests -distance to ties d 'design calculations & calculations showing required leaching area e) looation and dimensions of 'system -including reserve area f) existing and proposed contours g) location any wet areas Athin 100, of sewage disposal system or ._. disclaimer -check wetlands mapping h) .:surface and subsurface drains within 100+ of sewage disposal system or,disclaimer . i) location ar'y &-ainage easement:; within 1001 of sewage disposal Systems or, disclaimer -Planning Board files J) kno�= sources of water supply within 2001 of sewage disposal system or disclaimer Q location of anF proposed well to serve lot -100, from leaching facility 1) location of water lines on property -10, from leaching facility m) location of benchmark n) driveways 06 o) garbage disposals p) no PVC to be used in construction q) profile of system -elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and Other elevations -rY maximum ground water elevation in -ax -ea. -sewage disposal system S) plan mast be prepared by a Professional Ragineer or other professional authorized by law to prepare such plans Reg 6 ( Septic Tanks (a) capacities -15D% of flow, water table, tees, depth of tees, access, pumping (b) cleanout (c) 101 from cellar wall or inground sv4 amd.ng pool (dy-25+---front subsurface drains Reg 10.2 Distribution Boxes Reg 10.4(b� sump slope greater 0.08 shin Check List FAIL' I OK P L6=hjM Pits Leaching pits are preferred where the installation is possible a) calculations of leaching area-mdnimam 500 eq ft b) spacing . c) surface drainage 2% d) cover material 'a) V xV A" splash pad f) tee at elbow g) no bends in pipe from d -box to pipe Leaching Fields a) ngreater t 20 minutes/inch b) area•ffi.ni=z 900 s4 ft c) construction of yield ,d) surface drainage 2 % ,e) 201 from cellar wall or i.nground swimming pool Leachi�n �Weenches ;a) calculauons—orIeaching area -mitt 500 eq ft ;b) spacing -4 ft min 6 ft with reserve between ,c) dimensions A construction A stone ;f) surface drainage 2% Downhill -Sloe — ,a) slope y xo be shown) (b) y/x Z 150 = (to be shown) EMS (a) aPval (b) stand=by power so i C►u►uu►►Il�r�Mllll of Alawr►ttbusell� . 1 MWOU1113 TOWS! C ^:"9T ANDOVER/ A 11LVi llll'--1 ► $ MAY 0 1996 ' !�S'llilill"Uit'i18—5j'ileiii"Lueillo ! LA � Q11dnlll), Putttpedt Dow ar 1►ut►►piny /lD)9I ; �'ttq�uuit Vel h'1► 1'tl ► ' Q; ► Llresise Nt Cunlenls.Unt►sle►►rd lilt Dnle Commonwealth of Massachusetts City/Town of RECEIVED System Pumping RecordIki Form 4 AUG 0 6 2012 S� TOWN OF NORTH ANQpuFQ DEP has provided this form for use by local Boards of Health. Othe d>►hstmrel]Dbl&�l e information must be substantially the same as that provided here. Before using I k 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. t5form4.doc• 06103 A. Facility Information 1. System Locati: I�g,Left ig hous Left / Right rear of house, Left / right side of house, Left / Right side of bu / Right front of building, Left / Right rear of building, Under deck Address , --t r 1-7 City/Town `"� 2. System Owner. Name Address (if different from location) City/Town V' -k Z -'c S)�- State How�v 0--'Aq� 4 Zip Code State �l Zip t �C.ode 236 lL� Telephone Number —1 �L B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No 5. Condition of S ls� �� A 1 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Locatio contents were disposed: G.L S. Lowell Waste Water It If yes, was it cleaned? ❑ Yes ❑ No F5821 Vehicle License Number Date System Pumping Record . Page 1 of 1