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Miscellaneous - 55 LOST POND LANE 4/30/2018
4 I � �� a � Q � � � � -� o, _-. __ -- ._ _� _ - - - � o�0000-�aao-a�vo�io�a - ------ ---- - - _— - __ ___ �'aa - n - .h•.+ a I '�'+s'YJ z— ` �� jk�Ye'y�„i-�f�� � t .t�yi. `,. `"' ,.. rt -i " t ..i F �k�-R..•,.o-•ty�,�r^� i f a., fH�x{L'" y '''i o-<7 n' u f t.4•. t vf ,t `t�� c: z y�c-�*ti y � �•�` Y�;�Si'. �nk�1+��)jr�t+i^� .e MAP # " LOT: # PARCEL # STREET - '4' -. � O.ONSTRUCTI ON_APPROVAL. HAS PLAN REVIEW FEE BEEN PAID? YES NO PLAN APPROVAL: DATE /s0 i APP. BY- DESIGNER: //� //� PLAN DATE.- CONDITIONS WATER SUPPLY: TOWN WELL WELL PERMIT DRILLER WELL TESTS: CHEMICAL DAIS APPROVED BACTERIA I DA I E (IPPRUVED .BACTERIA II DATE APPROVED COMMENTS: FORM U APPROVAL: APPROVAL 1'0 ISSUE YES NO 7 DATE ISSUED l BY CONDITIONS: FINAL APPROVAL: . ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NU ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE:0/3. 7._. „-BY - `-,., _ ' .,;;• • ._ �EPTI�SY&Z�M_�.NSIfl�.l,.8_Z.IQN • t IS THE' INSTALLER LICENSED? r + �..�i YES NO TYPE. OF CONSTRUCTION: 7 =' NEW REPA I R <, NEW CONSTRUCTION:',.. CERTIFIED PLOT PLAN REVIEW NO CONDITIONS OF:.APPROVAL YES NO (FROM FORM U. *. ! _ ES NO ..-ISSUANCE OF DWC PERMIT DWC PERMIT N0. r'. . ` INSTALLER: BEGIN INSPECTION0: EXCAVATION INSPECTION: NEEDED: BY ,'• „ ._, CONSTRUCTION INSPECTIONS NEEDED: AS BUILT PLAN SATISFACTORY: YES: L: DATE: BY Q APPROVAL TO BACKFILL. " FINAL . GRADING APPROVAL: DATE1;!l LW_q_& BY - ;''.II'• DATE: �3E3Y FINAL CONSTRUCTION APPROVAL: North Andover Board of Assessors Public Access Page 1 of 1 pORTot North Andover Board of Assessors rOt�t� o ,e''ryG t S^�M�Se Property Record Card Parcel ID :210/104.B-0221-0000.0 FY:2012 Community:North Andover Click on Sketch to Enlarge Click on Photo to Enlarge it 55 L-13 LOST POND LANE Location: 55 LOST POND LANE _ Owner Name: KIM,SEUNG YEON&SUN SUK Owner Address: 55 LOST POND LANE City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood:7-7 Land Area: 1.16 acres Use Code: 101-SNGL-FAM-RES ,:Total Finished Area: 2094 sqft :. 0 Total Value: 485,100 485,100 Building Value: 258,200 258,200 Land Value: 226,900 226,900 Market Land Value: 226,900 Chapter Land Value: Sale Price: 625,000 Sale Date: _05/31/2005 Arms Length Sale Code: Y-YES-VALID Grantor: SALTAM Cert Doc: T _ Book: 9537 'Page: 323 http://csc-ma.us/ isp ay. o? > Id=1894661&town=NandoverPubAcc 8/1/2012 North Andover Board of Assessors Public Access Page 1 of 1 E NORTH Idorfh Andover Board of Assessors Of 4e�H O Or F 9 MATCHING PARCELS ,SSNGHUS�t Click on a column title to sort data by that column 15 items found,displaying all items.1 Fiscal Year Pa reel ID St.No. Street Owner Name 2012 210/104.13-0024-0000.0 OOPEN2 LOST POND LANE TOWN OF NORTH ANDOVER, CONSERVATION COMMISSION 2012 '210/104.B-0015-0000.0 OFRT X LOST POND LANE TOWN OF NORTH ANDOVER, • ' CONSERVATION COMMISSION 2012 210/104.13-0012-0000.0 50 LOST POND LANE PRASHANT,MANGESH SHANBHAG, SANCHETI,PRLYANKA 2012 210/104.13-0221-0000.0 55 LOST POND LANE KIM,SEUNG YEON&SUN SUK, 2012 1210/104.13-0220-0000.0 67 LOST POND LANE HARKINS,LAURA A, 2012 210/104.13-021 0-0000.0 70 LOST POND LANE BARTLETT,MICHAEL&CATHARINE, 2012 1210/I04.13-0219-0000.0� 75 LOST POND LANE, I 2012 210/104.13-0211-0000.0 80 LOST POND LANE LAFOND,GARY, 2012 210/104.B-0218-0000.0 83 LOST POND LANE MADDEN REALTY TRUST,DANIEL T.& ANNE M.MADDEN TRUSTEE i 2012 1210/104.B-0217-0000.0 89 LOST POND LANE DOOLEY,JUDITH M&KEVIN F, 2012 210/104.13-0212-0000.0 90 LOST POND LANE KALKAT,KULJIT KAUR,KALKAT, TARLOCHAN SINGH ;210/104.13-0213-0000.0 96 LOST POND LANE 2012 WOLMERING,PAUL J,JACQUELINE A JACOBS I'I 2012 1210/104.13-0216-0000.0 97 LOST POND LANE DAUBRESSE,GARY,DAUBRESSE, _LOUISE 2012 (210/104.13-0214-0000.0 102 LOST POND LANE TETRAULT,THOMAS M,CHRISTINE A TETRAULT 2012 210/104.13-0215-0000.0 103 LOST POND LANE BIELICKI,CARLOS B,SUSAN M BIELICKI 15 items found,displaying all items.1 I http://csc-ma.us/PROPAPP/newSearch.do?town=NandoverPubAcc&from=NewSearch 8/1/2012 Commonwealth of Massachusetts Title 5 Official Inspection Form �ECEIvE Subsurface Sewage Disposal System Form-Not for Voluntary Assessmen s AuG M 55 Lost Pond Road MAIN OF NORTH ANDOVER Property Address HEALTH DEPARTMEPIT Seung Kim Owner Owner's Name information is required for North Andover MA 01845 8/7/2012 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: When filling out A. General Information forms on the computer, use 1. Inspector: only the tab key to move your Neil James Bateson cursor-do not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name 111 Argilla Road , Company Address ((— Andover MA 01810 I ,cin Citylrown State Zip Code 978-475-4786 S115 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Neectp Further Evaluation by the Local Approving Authority r , 8/7/2012 Inspect is ignatu. 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. F ****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•11110 Title 5 Official Inspection Forth:Subsurface.Sewage Disposal System•Page 1 of 17 r Commonwealth of Massachusetts R. Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M s 55 Lost Pond Road Property Address Seung Kim Owner Owner's Name information is required for North Andover MA 01845 8/7/2012 every page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: After permit from B.O.H., pump septic tank , replace outlet pipe to d-box&d-box, inspection from B.O.H., septic system now passes Title 5 Inspection B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 17 Po Y • 9 Commonwealth of Massaciusetts . Title 5 Official Inspection Form z Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 55 Lost Pond Road Property Address Seung Yeon Kim ,d Owner Owner's Name information is required for every North Andover MA 01845 7/17/2012 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, RECEIVED use only the tab 1. Inspector: key to move your cursor-do not Neil James Bateson �� use the return Name of Inspector key. Bateson Enterprises Inc. TOWN OF NORTH ANDOVER fC=11 Company Name 111 Argilla Road Company Address Andover MA 01810 City(rown State Zip Code 978-475-4786 SI-15 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 7/17/2012 Inspectors IS ignature 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M ,•''y 55 Lost Pond Road Property Address Seung Yeon Kim Owner Owner's Name information is required for every North Andover MA 01845 7/17/2012 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 i 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 exMtration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ® N ❑ ND (Explain below): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 55 Lost Pond Road Property Address Seung Yeon Kim Owner Owner's Name information is North Andover MA 01845 7/17/2012 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): C) Further{Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.30.3(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 55 Lost Pond Road Property Address Seung Yeon Kim Owner Owner's Name information is required for every North Andover MA 01845 7/17/2012 page. 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: Outlet pipe to d-box&d-box needs to be replaced. 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 ElDischarge or ponding of effluent to the surface of the ground or surface waters ED due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or cloggedP SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins-11/10 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 55 Lost Pond Road Property Address Seung Yeon Kim Owner Owner's Name information is required for every North Andover MA 01845 7/17/2012 page. City(rown State Zip Code Date of Inspection B. Certification (cont.) Yes No ElN Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑. ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ 0 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 El El the system is located in a nitrogen sensitive area(Interim Wellhead Protection Asea—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 55 Lost Pond Road Property Address Seung Yeon Kim Owner Owners Name information is required for every North Andover MA 01845 7/17/2012 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recent) art of El ® this inspection? y y or as P El ® Were as built plan of the system obtained and examined? (If they were not available note a N/ inspected for signs of sewage back u . Was the facility or dwelling ® ❑ tY P 9 9 P ® ❑ 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): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 55 Lost Pond Road Property Address Seung Yeon Kim Owner Owner's Name information is required for every North Andover MA 01845 7/17/2012 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: II Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? El Yes ® No Water meter readings, if available last 2 ears usage d ): Yes 9 . ( Y 9 (gp ) Detail: Sump pump? El ® No Current Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(-based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft.;etc.): Grease trap present? _ ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 55 Lost Pond Road Property Address Seung Yeon Kim Owner Owner's Name information is required for every North Andover MA 01845 7/17/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped 2010,owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 55 Lost Pond Road Property Address Seung Yeon Kim Owner Owner's Name information is required for every North Andover MA 01845 7/17/2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 16 years old, 11/18/1996, construction permit date, no as built plan, info at B.O.H. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1.6 Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): 4" PVC thru wall, 3" PVC in house, no leaks visible Septic Tank(locate on site plan): .6 Depth below grade: 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 10'x5'x4' Dimensions: 4" Sludge depth: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 i i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 55 Lost Pond Road Property Address Seung Yeon Kim Owner Owner's Name information is required for every North Andover MA 01845 7/17/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 23" 411 Scum thickness 8e Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 17" 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 cover broken, replaced. Inlet tee ok. outlet cover broken replaced. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Outlet pipe to d-box pitched wrong, needs to be replaced Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 II Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 55 Lost Pond Road Property Address Seung Yeon Kim Owner Owner's Name information is required for every North Andover MA 01845 7/17/2012 page. Cityrrown 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.): i I Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts v W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 55 Lost Pond Road Property Address Seung Yeon Kim Owner Owner's Name information is required for every North Andover MA 01845 7/17/2012 page. 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 cover broken,replaged. D-box level &distribution equal. No evidence of leakage. Evidence of carryover. D-box has corrosion holes, needs to be replaced. . 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 55 Lost Pond Road Property Address Seung Yeon Kim Owner Owner's Name information is North Andover MA 01845 7/17/2012 required for every i page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2 trenches 38' ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface. I Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 55 Lost Pond Road Property Address Seung Yeon Kim Owner Owner's Name information is North Andover MA 01845 7/17/2012 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 55 Lost Pond Road Property Address Seung Yeon Kim Owner Owner's Name information is required for every North Andover MA 01845 7/17/2012 page. City/Town 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 »ermanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate I where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately ��-t1S�� (JSrovev_.J e DEp_ S °O`?>O?C ;56'I I , t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 y Summary Record Card generated on 7/10/2012 2:46:41 PM by Maureen McAuley Page 1 Town of North Andover Tax Map # 210-104.6-0221-0000.0 Parcel Id 16540 55 LOST POND LANE SEUNG YEON KIM 5.5 LOST POND LANE NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.16 Acres FY 2012 UB Mailing Index Name/Address Type Loan Number Activellnact. From Until SEUNG YEON KIM Owner 55 LOST POND LANE NORTH ANDOVER,MA 01845 HYMAN,JANET. Previous Customer Inactive 4/30/2004 55 LOST POND LANE NORTH ANDOVER,MA 01845 LORRAINE SALTAMARTINI Previous Customer Inactive 5/31/2005 55 LOST POND LANE NORTH ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 18004.0-55 LOST POND LANE Last Billing Date 7/9/2012 3180033 03 Cycle 03 Active UB Services Maint. Account No.3180033 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 57.00 /1 UB Meter Maintenance Account No.3180033 Serial No Status Location Brand Type Size YTD Cons 13242725 a Active 00 METE METE w Water 0.63 0.63 407 Date Reading Code Consumption Posted Date Variance 6/18/2012 829 a Actual 15 7/16/2012 28% 3/20/2012 814 a Actual 12 4/14/2012 -32% 12/19/2011 802 a Actual 18 1/17/2012 14% 9/16/2011 784 a Actual 16 10/13/2011 -16% 6/13/2011 768 a Actual 18 7/20/2011 12% 3/15/2011 750 a Actual 16 4/13/2011 0% 12/15/2010 734 a Actual 16 1/12/2011 -80% 9/16/2010 718 a Actual 83 10/15/2010 253% 6/14/2010 635 a Actual 22 7/15/2010 24% 3/18/2010 613 a Actual 19 4/14/2010 -18% 12/14/2009 594 a Actual 22 1/12/2010 -29% 9/16/2009 572 a Actual 34 10/15/2009 13% 6/10/2009 538 a Actual 26 7/20/2009 56% 3/17/2009 512 a Actual 18 4/29/2009 -12% 12/15/2008 494 a Actual 20 1/20/2009 -43% 9/16/2008 474 a Actual 38 10/10/2008 144% 6/10/2008 436 •a Actual 14 7/16/2008 8% 3/14/2008 422 a Actual 13 4/11/2008 7% 12/17/2007 409 a Actual 13 1/22/2008 -81% 9/14/2007 396 a Actual 64 10/12/2007 320% 6/20/2007 332 a Actual 17 7/20/2007 18% 3/16/2007 315 a Actual 14 4/16/2007 -15% 12/13/2006 301 a Actual 15 1/19/2007 -57% Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 55 Lost Pond Road Property Address Seung Yeon Kim Owner Owner's Name information is required for every North Andover MA 01845 7/17/2012 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells >4 Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record, If checked, date of design plan reviewed: 4/25/1995 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 design plan test pit info. Water 5' below trenches. Before filing this Inspection Report,please see Report Completeness Checklist on next page. 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 55 Lost Pond Road Property Address Seung Yeon Kim Owner Owner's Name information is required for every North Andover MA 01845 7/17/2012 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 I PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CeniYicate of Compliance As of.• Aupust T, 2012 This is to cert that a SA SIS TA CTO RT INSTECION Was completed for the: ftfacement andInstalration of an 91-20 Distri'6ution Box and Bui�n� sewer-pipe Tor an On Site Wastewater osa(S-yst�em 0y: 2odd Bateson at: 55 Lost ('ondGane Parcel ID : 210/104.B-0221-0000.0 jrNortFiAndove s WA 01845 The Issuance of this certificate shaft not 6e construed as a guarantee that the On Site Sewage 1Disposaf System wiff function satisfactorily. usan . Sawyer, REYWIR5 Pu6Crc YfeaCth Director 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com c • S�gTGED 7�6 • i • 7, t` �ReTED A � North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFOR TION ADDRESS: -�'� 0 5T" v✓��IIAP: LOT: INSTALLER: DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN; INSPECTIONS v� TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ gallon tank has been installed loading ❑ Monolithic tank construction ❑ Watertightness of tank has been achieved by testing ElInlet tee installed, centered under access port E ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of final grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ gallon Pump Chamber installed ❑ loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX Installed on stable stone base H-20 D-Box Inlet tee (if pumped or >0.08'/foot) [� Hydraulic cement around inlet & outlets /❑� Observed even distribution Speed levelers provided (not required) Comments: rMOR7gAApplication for Septic Dis osal SvstGm O.((►�•1� b, TODAY'S DATE t Construction Permit=T+OWN O s $250.00-;Full Repair, w01845 . * ,. VER~ 11�IA 25.00-.Com orient ,ANDt� �� p SSAC/Wg Important: Application Is hereby made for a Permit to: When filling out U 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 Bl�epair or replace an existing system component-What? - cursor-do not use the return A. e=acility Information VQ Address or Lot# JUL ri 1(112 Cityrrown AID "Vka— 1't7W 2.-*TYPE OF SEPTIC SYSTEM*: OF`�' iI��aus� HI Al,Ylt r� errnrtrrT [�Pump Q�G-mvity(choose one) ***If pump system,attach copy of electrical permit to application*** onventional System(pipe and stone system) ❑infiltrator or Blodiffuser(gavel-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 S0- Lt AJ q r\ v� Name 1�- �S �e 5 / �dar� �!✓ Address(if different from above) AZo Ckyfrown State Zip Code Telephone Number 3. Installer Information Name Name of Comjd any IS ES, Address INC.111 ARGILLA ROAD ANDOVER M104 si o � Cky/rown State Zip Code Telephone Number(Gell Phone#ifpossible please) 4. Gesiciner Information Name Name of Company Address Citylrown State Zip Code Telephone Number(Best#foReach) Application for Disposal System Construction Permit•Pap 1.of 2, ;MUs :Ta,ti, ,Application..for Septic Disposal System . 3 . DATE pConstruction -Permit '- TOWN. OF TODAY'S $.250.00-Full Repair ORTH ANDOVER MA 01845 $125.00.-Component ,SSICHU`+ PAGE 2OF2 A. Facilityinformation continued.... S. Type-of Building: esidential Dwelling or[]Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover,and not to place the system in operation until a Certificate of Compliance has been issued bj4A Board of Health. Name Date Application Aroved By oard of Health Representa ive) Name Date App' atio Dlsaoproved,.for the following reasons: For Office Use Only: 1 Fee Attached. Yesv „ _. No 2, ProjectllTariager Obligation Form Attaehed? Yes No 3,: Pump 3 sv tem? Ifst Attach copy ofElecmical Permit:. Yes No 4. FoundatlonAs Built. (new construction ronly). Yes_ No (Same scale as approved plan) — 5. FloorPlans?(new construction only). .Yes_ No i Application for pisposal SYstern 10dn*uct!oh Permit Page 2 02 RP fIX RO ECT MANAGEMENT OBLIGATIONS SEPTIC SYSTEM nvsTAla�E J s the North Andover licensed installer for the construction for�the septic system for.the property.a A t For plans by (Address of septic system) 4(ERelative to the.application of ��' ��� And dated(installer's name) eDatedWith revisions (1bday's ate (L st revised date) I understand the following obligations for management of this project: 1. As the installer,I am.obligated to obtain all permits and Board of Health approved plans prior to ;performing any work on a site. I must have the approved�ilans and the hermit on site when anv work is beim_ 2. As the installer,.I.must call for any and altinspections. If homeowner,contractor,project manager,or any ted with m company schedules an inspection and the system is not ready,then other.pexsonnotassoda, y p y item three shall.b e.applicable. 3. As the installer,I am-required to.have the necessary work completed pnot.to the applicable inspections as indicated below I uttdet stand that re uestinZ an inspection,without completion,of the items in.accordance with Title 5 and tihe Boatel of pleaith Retiulations tnay xesu7tin a 50.00-fine beinir.levied agatnst:me-and or my mpaT . a:. Bo'tfom of Bed:=Generali ,this is the:first:l' ins ectton unless.there is:i retainin wall,which y ( . p . . g should be doiieArst. Thelastaller must request the iiispecti6n but does not have to be presernt. b. Final-Construction.Inspection—Engineer must first:do their inspection for elevations;ties,etc. As-built of-Verbal OK(or a-mail to:healtl dept�townoffi thandover.com):from the engineer must be submitted to.the.Board of.Health,afte#`whicli:installer.caUs for an inspection time. Installer must be present for this.inspection. With a pump system,all electrical w::oik:mustbe ready and able to cause,putrip.to work and!alarm.to f inedon.. c. Final�Gtade Installer must request�inspection.when o grading is complete._..Installer does not have to be on=site. 4. As-the installer,I understand that only I tuy 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 firth understand that work d"ones others utilicensed-to install septic systems in North Andover can constitute reasons for denial-of the systern andlor--revocation or suspension of my lieense:to operate in.the Tovvn.of North And"over signYficant fines to alliersons involved:are alio possible 5.. As the:installer,,T understand that'l must be onsite during the.performance.of the following construction_ steps: a. Determination that.theproperelevation of the'excavation has been reached b. Inspection ofthe sand and stone to be used. c. Fimal inspection by Board ofHealth staffor consultant. d Installation..of tank,D Box pipes,stone, vent,primp cbam�uer,retaining waif and other components. 6. As the installer,I understand that lam.solely responsible for the installation.of the.system as per the approved lilans No instructions by the homeowrier,general.contractor_-or a=..other persons shall absolve me Qf uiis obligation. Undersigned Licensed Septic.Installer. Croday';s Date) o cQ-tQ2So�/ . ame,– ..rintj601 — ''t THOMAS E. NEVE ASSOCIATES, INC. Engineers • Land Surveyors • Land Use Planners 447 Boston Street US #1 TOPSHELD, MASSACHUSETTS 01983 DATE ",Z5 JOB NO. (508) 887-8586 J ATTENTION FAX (508) 887.3480 Gj AAJ�4�P� �rC P.i2�2. TO p*"d Q %r RE: LO 2 -ta� �joarc.� C)V- "SALTS t_l� ort.�cz-1 -�N�v 0�1 A F MT ,R WE ARE SENDING YOU `Attached ❑ Under separate cover via the followin . ❑ Shop drawings 5t-Prints ❑ Plans ❑ Samples Specifications ❑ Copy of letter ❑ Change order ❑ COPIES DATE NO. DESCRIPTION �'• l2lto-$ -A ac L s�e-ry `-� A S AN%-[PC>-f t:tS R59S 'L wA L-LT 8 tA�1t Fb►-��D 1 � ?{ZfQ�O 8 L 'Ck�onµ�� E NEVE ASSouttG3. Q�vt 12"tto-t3 %7L-PA-1 ar %_a� iat.�b p, P2o F05.6o rjA ,11-r G� DILt�t A� S�E�CFr�t. � 31Zg l� �-.�t t t_osT �b►-b t�p,.,c. ���t�atn,Ep CJ-c -t5 E-N�+assor�,a-cE�. THESE ARE TRANSMITTED as checked below: ❑ For approval ❑ Approved as submitted Resubmit CO copies for approval ❑ For your use ❑ Approved as noted ❑ Submit copies for distribution > ❑ As requested ❑ Returned for corrections ❑ Return corrected prints ❑ For review and comment ❑ EJ FORBIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS oV-4�"W- SA'At>-f: 3 coP►ES oP "-r"'E.- ¢�v�SE,o S`tS'TE�nn L_o S-t Po•-s p h_- VtiaE, $o-r%A C7E S t C»-1S QEF�Et.'-r r-�-stv-4cv c" Ja►LAAC_-4 30� I9_1.15Co. Pt_EA�.+� NtrtE t��A'C <_CT a SAS $E �1 DESK-,1J��p "TO A -Tk4V_G£. $E�tCooM S71i lE t�t NC•a A V IV W tt.L_ P�GV J t 1ZE A IR;Z. r4-mr-f WAIN I.OcA" iQ Art_p►J Cl- -tb�f. ►�'f oar 'C>-t f� PrC o PEe-r{ P L.E to 5E Ftp 4 -NA '�"� yE�st G" cF t_r_ r t3 GoMPt_t�S vJtTk-1 `-rovt� t QuE�S 5-f Pr1'E�p BCrrAA PvT' ovQ r �I,JC� p,.,qp t►J�{pz7yL tF I-fou iso t c� k_�5%.rp.-cj -Co C_At_L... -TV}-t-A-"tC- COPY TO RECYCLED PAPER: t- ��Contents:40%Pre-Consumer-10%Post-Consumer SI H enclosures are not as noted,kindly notify us at once. r Li 'T` r. . ..:r`� .. _ ..r,r ,,;t',^ �� �3v.':t-„�:�> t .�-, �r.w.�r 7�'-^ `) 3 ; .i'i.��. .. :;3, • .-_�1-.-? :x'„ + moi,i .. .•� ,r...ilrT- r -•`7, +.:.t'.Y..i ':,, _�. .f.. f; a ..�. �;_i' }'7�: .:1• ,,is .iE .. "� M. f.'r'�T-t`• G' L.J•.. ••(:'.-•? y art. _ �. J _ .'!`�fc:'?:� - ,;-'?.. s ,..�: _ �.1% r.'T Y�"I" '?x,__ •`k•"e 1 'iF:-i.=;c..i , _. `! M ?' t , 'a. .! t:7 T 7 ^'" r.`ay. ;� _..7`s �'..:c::.-) r �7 •'7 .� i-."'.) �.. ,.`-t -_)d- •"��' .I - .!' r yn. .. .. t'""• :I( `I' �:.� ./ r �.14,•u r-t 1. .�I,... n`'d 4 .•/ 3'... r'7 _�_- �')... w.��`1Fi�>t' �f TF_T'f.. i:Lt. �;o •. •j` L: .. 'F r '?•, r.� .y i. + #..r. - '. .., ,# _.a 71, ::' tet. r'", 1. ,�`.".... e _ , ...I•` 'i '��%""!e 'f 't• rr � 1 ''.i r"s'� "x ?„.. ,r>n r, -�'i _tar , ....I ,r r ? _�t'_ r`'•. J..�+ ..•1: c_� f:-i t-; ._ _''j-.'.'�.'.7.5'.'l+j ....: _ � j.:•`r r..✓ _��:_ '-i! !'7.... l .,l'yt,•.t rd Town of North AndoverNORTH ,ti OFFICE OF 3?ot•�,�.o 1 COMMUNITY DEVELOPMENT AND SERVICES p 146 Main Street North Andover, Massachusetts 01845 "SSACNUSt 508 688-9533 December 12 , 1995 Thomas Neve Neve Associates 447 Old Boston Road Topsfield, MA 01983 Re: Lot #13 Lost Pond Lane Dear Tom: This is to inform you that the proposed plans for the site referenced above have been disapproved for the following reasons: 1) Benchmark not within 75 feet of system. 2) Pick one code. a) Under 1978 code there must be 25 feet of fill around system and 4 feet to groundwater. b) Under 1995 code you can use 15 feet and 3 to 1 but there must be 5 feet to groundwater. No Further Review If you have any questions, please do not hesitate to call the Board of Health Office at the number below. Sincerely, Sandra Starr, R.S. Health Administrator SS/cjp BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Julie Parrino D.Robert Nicetta Michael Howard Sandra Starr Kathleen Bradley Colwell NORTH ANDOVER BOARD OF HEALTH DESIGN REVIEW REPORT FEE: ali"�D PERMIT ## 7'9,3- DATE RECEIVED 110 ( 3, APPLICANT MAP PARCEL ADDRESS LOT # 11-13 ENG. STREET Z 657 ADDRESS PLAN DATE !/0 • Qom, /r/9j- REV. DATE CONDITIONS OF APPROVAL APPROVED DISAPPROVED h� REASONS FOR DISAPPROVAL: ilJ©T jdj/ r-i51 1A) S YSTE Al C0b,6: , A. UAvb � lg78 CbD� T c, BUST �'t-- A� -r ate' �8. ZJN D 45-e d-O M- '166) GAeL) U 5`�7 /6 07" M 0 5 j �Tv r E'er T TO t INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. fills out this section***************** APPLICANT: :,� (, c. �� Phone LOCATION: Assessor' s Map Number /d 7 Parcel ���T°���� 1Y Z5,175 subdivision Lot(s) 1 J Street t� `5 J f v. �' St. Number ial Use only************************ RECOMMENDATIONS OF TOWN AGENTS: Date Approved JFcnservati�onAdministrator Date Rejected _:Comments - Date Approved Town Planner Date Rejected Comments Date Approved Food Inspector-Health Date Rejected / i��✓ //� i Date Approved c/ .eptic�.Inspector-Health Date Rejected Comments . Public Works - sewer/water connections driveway permit Fire Department Received by Building Inspector Date N T H Town of 4Andover S�2 0 No. w��L_AKE Ol' dower, Mass., 16116 19 * A. COC HICHEWICK �SD'4ATED P`P� "♦� BOARD OF HEALTH PERMIT T DFood/Kitchen Septic System /jt " Q BUDDING INSPECTOR THIS CERTIFIES THATl�- G e--....................... ...... has permission to erect........................................ buildings on �S �- ..5..� 10�..D.......i ndation to be occupied as........................................1j /.� ........ ../ .:............:................................................ Chimney �fj l�P provided that the person accepting this permit shall in every respect Confor to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBIWG_IFSP CTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. ug incl PERMIT EXPIRES IN 6 MONTHS iELEC TRI AL SPECTO UNLESS CONSTRUCTION ST S / 1 77 ...... ...... ... ........ ........................................... Service B LDING INSPECTOR Final Occupancy Permit :Required to Occupy Building GAS INSPECTOR Dis la a Cons icuous Place on the Premises Do Not Remove Rough P Y in P Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burne , - Street Smoke Det. PLAN REVIEW CHECKLIST ADDRESS Z6,7-1,3 Z05T ENGINEER GENERAL 3 COPIES t--' STAMP LOCUS Z-� NORTH ARROW SCALE -� CONTOURS PROFILE (/ SECTION // BENCHMARK SOIL & PERCS ELEVATIONS WETS. DISCLAIMER WELLS & WETS ?4— DRIVEWAY (Elev) WATER LINE FDN DRAIN SCH40y TESTS CURRENT? 1gR4 SOIL EVAL SEPTIC TANK MIN 150OG �/� . 17 INVERT DROP GARB. GRINDER_Z_(+200% EDF) 25 ' TO CELLARZ,' MANHOLE ELEV GW # COMPS. D-BOX SIZE # LINES FIRST 2 ' LEVEL STATEMENT INLET - OUTLET JAS-,-3,3 -.W (2" OR . 17 FT) TEE REQ'D? LEACHING MIN 660 GPD& RESERVE AREA ',-1�4 ' FROM PRIMARY? 2% SLOPE 100 ' TO WETLANDS L- 100 ' TO WELLS 'J 4 ' TO S.H.GW. ' (5 > /IN) 35 ' TO FND & INTRCPTR DRAINS i/ X325 ' TO SURFACE H2O'SUPP 4 ' PERM. SOIL BELOW FACILITY ✓ MIN 12" COVERS FILL?��5 ' if above natural elev; 10 ' if below) BREAKOUT MET? TRENCHES MIN 660 gpd4 SLOPE (min .005 or 6"/100 ' ) SI"'D�EWALL DIST. 3X EFF. W OR D (MIN 6 ' ) JZ RESERVE BETWEEN TRENCHES?C- IN FILL? C'0'0�MUST BE 10 ' MIN. d/ 4" PEA STONE?_LZ-VENT? (>3 ' COVER; LINES >501 ) BOT JO 4- + SIDE vat X LDNG 1 77 = TOT (L x W x #) (DxLx2x#) (G/ft2) )(9 Copyright © 1995 by S.L. Starr F Town of North Andover, Massachusetts Form No.s f NORTH BOARD OF HEALTH 19(� F DESIGN APPROVAL FOR is CH SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant .J(1 - Test No. Site Location �� C3 �n Y Reference Plans and Specs— - �(1x.V�� 6_1Z�/l-� ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. CHAIRMAN,BOARD OF HEALTH Fee Site System Permit No. 9 C15 Town of North Andover, Massachusetts Form No. 1 NORTIy � BOARD OF HEALTH �OPi�'(LED '646�� _19— APPLICATION FOR SITE TESTING/INSPECTION �9SSoyA, Applicant ; 10 _.t tl.{ NAME ADDRESS TELEPHONE Site Locations–d" ' .f..�„ �, ,� .! �7 r5 Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee _ Test No. S.S. Permit NO. D.W.C. NO. C.C. Date Plbg. Permit No. e NEW ENGLAND ENGINEERING SERVICES INC . TCS 80-.1 March3, ••2 4 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover,MA 01845 RE: TITLE V REPORT: 55 Lost Pond Road,North Andover, MA i Dear Sir or Madam: Enclosed is a copy of the Title V report for the above referenced property. The system PASSED our inspection. If there are any questions please call me at my office, 686-1768. Sincerely Benjamin C. Osgoo , Jr. 60 BEECHWOOD DRIVE-NORTH ANDOVER, MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTALAFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 5s )-os7- Pa v� Po Oo all-e A,,,n ever- Mr4 < Owner's Name: _ Q A.0 GT N AAA AA/ ��{ Owner's Address: � � E o s r Po D ac, �f,Vd?+ OF Q 0,F NEA`4T11 BOP. 0 C) -nom rk AJ o OV 4a /4 3 Date of Inspection: 1-M �ti 20�� MAR Name of Inspector:(please print) Beni amin C. Osgood, Jr. ° tee . CompanyName:New England Engineering Services Inc. • ""` MailingAddress:60 Beechwood Drive. North Andover. A 01845 Telephone Number: 978-686-1768 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:. 'Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails �t n Inspector's Signature: �: C. (Jr 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. 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. s Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: has i dI P-ml /A&/D 6,.j e, rvtA- Owner: -T-41v E i H /n 140 Date of Inspection:___ 3I3(a! Inspection Summary: Check A,B,C,D'or E/ALWAYS complete all of Section D A. .System Passes: —ZI 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: AIJ 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. NDexP lain: 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): brokeni s laced P P�)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address•_ S J,cs7 Owner:_ N l-iivl�4�i Date of Inspection: 3(,0y C. Further Evaluation is Required by the Board of Health: N� 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(l)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface.water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: A j r,o,ear ,vi/4 Owner: --5-VjM6`t' M 6 A/ Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate`des"or"nor 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 -t�' 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'/z day flow L.- 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. r Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well, Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.[This system passes if the well water analysis, performed at a DEP certified laboratory,for 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.] A10- (Ye mo)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15303,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 onsidered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 You must. 'cate either`W or`no"to each of the following: (The following teria apply to large systems in addition to the criteria a e yes no the system is in 400 feet of a surface dr' g water supply I / — the system is within 2'00..feet - tributary to a surface drinking water supply — _ the system is 199atedd in a nitrogep sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 f-a public water supply N`ell If you ha�ve�an�s'veered"yes"to anquestion in Seti E the Y q csystem is considered a significant threat,or answered in Section D above the large system has failed. owner or operator of any large system considered a significant threat underSection E or failed under Section hall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regi al 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: Sy /.--sT Owner: sQNie H Y M Jkh 1 Date of Inspection:_z)�� 3�1 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? _ _Z-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 constructiondimensions,depth of liquid,depth of sludge and depth of scum? e� Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Y�o Existing information.For example,a plan at the Board of Health. — �Determined in the field if an of the i ( y e fa hire 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: S S <-osT Owner: TSAmET R,-?mA/V Date of Inspection: C> .j FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: Z Does residence have a garbage grinder(yes or no): D Is laundry on a separate sewage system(yes or no):N� [if yes separate inspection required] Laundry system inspected(yes or no):- Seasonal use:(yes or no): Ivo Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): vo Last date of o )ancy:w i,r e rrC-----._...-..--- COMIM"CIALA NDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgketc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged tothe 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: 1 ea K TE z- C:)—N Et- Was system pumped as part ofthe inspection(yes or no): Ifyes,volume pumped:Fes' �lions-How was quantity Y P umP� de termined? Reason forpumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: ueCAa-s Were sewage odors detected when arriving at the site(yes or 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: _6C5– �U�fZi}t /'wy��cOL Owner• nfi Am ET I lim AAA Date of Inspection: ?1.31 c>y BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron 4440 PVC other(explain): Distance from private water supply well or suction line: A/A Comments(on condition of joints,venting,evidence of leakage,eta): ,.j Bf�E,��E,yr SEPTIC TANK;_(locate on site plan) Depth below grade: 9 Material of construction: a/concxete_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: 1560 &yqL�toav s Sludge depth:_ 4 z' Distance from top of sludge to bottom of outlet tee or baffle: 3z. Scum thickness: -4 Z Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 15� How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc:): LCAV,wtt: I,.$ 02 ou-r- GREASE TRAPzVfi-(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: <S; LosT -Po u b 2 o /V- 2111 A )r>cJJC 2 nn i4 Owner: : AN t�-T Date of Inspection: 3 13 L a' TIGHT or HOLDING TANK: &I ft (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: gallonstday Alarm present(yes or no): Alar level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): zc>l tN 1 7,7 /&N9 r jb/L PUMP CHAMBER: 104- (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 5S Lis po«o P q 0 km A- Po,,,ca- Owner: 'i' AXEj RYMA111 Date of Inspection; SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: Z L-�aJ_3 leaching fields,number,.dimensions: overflow cesspool,number: innovativetalternative system Typelname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Jai O F G!C�� f Gc�Kt "VD r2tit AL ./V0 -?0 AJ r'ahA �- U 2 "u-si Atiy�(TI J ✓ CESSPOOLS:/yam_(cesspool must be pumped as part of inspectionxlocate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scam 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.): �I Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: S,!�- 1.�sa�V D jZ9 Owner: Date of Inspection: 3� � 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. Vtoosj i l f Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 5.5- L as r P,>N o 0-i) /Volum ANp6ve2 Owner: E-,- K y ivu A n/ Date of Inspection: ?,1 `o,4 SITE EXAM Slope Surface water r7 on Check cellar ivo s, Pl p,27 Shallow wells N O u r Estimated depth to ground water (, feet Please indicate(deck)all mdhods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting propertylobservation hole within ISO 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: - ; reE,- t6.14 G-it0'v a c vA--IVe- i Form No.3 Town of North Andover, Massachusetts : BOARD OF HEALTH LORTI-f 1 Ot „ O ya.BOO i O 9 •° <« =�� ''� ` DISPOSAL WORKS CONSTRUCTION PERMIT SSACHUSE TELEPHONE Applicant ADDRESS NAME1 Site Location I Repair Ran Individual Soil Absorption • ( ) � • Permission is hereby granted to Construct ( or S.S. No. Sewage Disposal System as shown on the Design App CHAIRMAN,BOARD OF HEALTH H 6 j D.W.C. No. Fee APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE:T�gb CURRENT INSTALLER'S LICENSE# LOCATION: Ze 7 S % " LICENSED INSTALLER: SIGNATURE: ��% ----- TELEPHONE# K2- 2122 T� CHECK ONE: REPAIR: NEW CONSTRUCTION: V IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. Adminis rative Use Only $75.00 Fee Attached? Yes , No Foundation_ As-Built? Yes—,,/- No Approval Date: /�.[���� f