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HomeMy WebLinkAboutMiscellaneous - 612 SALEM STREET 4/30/2018 612 SALEM STREET 2101065 �"0000.0 — � _. � � - — - - ' .�. r e North Andover Board of Assessors Public Access , Page 1 of 1 +' S NOR,N North Andover Board of Assessors CHUstt1 6 roperty Record Card 22�Click Seal To ReA/X FY:2009 Community:North Andover PHOTO Click on Photo to Enlarge Search for Parc Search for Sale. J S - Summary _= Residence S Detached Structu Condo 612 SALEM STREET Commercial Location: 612 SALEM STREET Owner Name: BELLIVEAU,MARC S. BELLIVEAU,ALLISON D. Owner Address: 612 SALEM STREET City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 5-5 Land Area: 0.86 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 4072 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 839,700 873,600 Building Value: 645,300 679,200 Land Value: 194,400 194,400 Market Land Value: 194,400 Chapter Land Value: LATEST SALE Sale Price: 900,000 Sale Date: 05/17/2006 Arms Length Sale Code: Y-YES-VALID Grantor: PAUL J.ST.HILAIRE Cert Doc: Book: 10188 Page: 0284 http://csc-ma.us/PROPAPP/display.do?linkld=1461788&town=NandoverPubAcc 1/12/2009 North Andover Board of Assessors Public Access ,. ; Page 1 of 1 t r NORTH North: Andover Board of Assessors +Ow-no CN„ Sroperty Record Card Click Seal To Return Parcel ID :210/065.0-0011-0000.0 FY:2009 Community:North Andover SKETCH PHOTO Click on Sketch to Enlarge Click on Photo to Enlarge Search for Parcels Fb ' s Search for Sales r Summary ' Residence _I<= Detached Structure Condo 612 SALEM STREET Commercial Location: 612 SALEM STREET Owner Name: BELLIVEAU,MARC S. BELLIVEAU,ALLISON D. Owner Address: 612 SALEM STREET City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood:5-5 Land Area: 0.86 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 4072 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 839,700 873,600 Building Value: 645,300 679,200 Land Value: 194,400 194,400 Market and Value: 194,400 Chapter Land Value: LATEST SALE Sale Price: 900,000 Sale Date: 05/17/2006 Arms Length Sale Code: Y-YES-VALID Grantor: PAUL J.ST.HILAIRE Cert Doc: Book: 10188 Page: 0284 http://csc-ma.us/PROPAPP/display.do?linkld=1461788&town=NandoverPubAcc 1/12/2009 Residential Property Record Card �? PARCEL ID:210/065.0-0011-0000.0 MAP:065.0 BLOCK:0011 LOT:0000.0 PARCEL ADDRESS:612 SALEM STREET FY:2009 PARCEL INFORMATION Use Code: 101 Sale Price 900,000 Book:__ 10188 Road Type: T y Inspect Date. 05/16/2006 Tax Class: T Sale Date: 05/17/06 0284 -Rd Condition: P Meas Date: 09/06/2005 Owner: ._- ._ _ _Page: _ _ _ _ ... BELLIVEAU,MARC S. Tot Fin Area 4072__ Sale Type_ P Cert/Doc: _ _ _ Traffic M _Entranced _ X Tot Land Area:-0.86 Sale Valid: Y Water. Collect Id SGC BELLIVEAU,ALLISON D. - _ _ - .- _ -_ - _ _ _. - _ _. Grantor: PAUL J.ST.HILAIRE Sewer: Inspect�Reas: �M Address: - - -- - -- - - - --- - -- -- - •- •- ---- ----. _ _- _ 612 SALEM STREET Exempt-B/L% / Resid-B/L% 100/100 Comm-B/LP/o Indust-B/L% / Open Sp-B/L% / NORTH ANDOVER MA 01845 RESIDENCE INFORMATION LAND INFORMATION Style: CL Tot Rooms: 10 Main Fn Area: 2052 Attic _ _ -- -- NBHD CODE: 5 NBHD CLASS: 5 ZONE: - - Se Type Code 'Method S -Ft Acres Influ-Y/N Value Class Story Height: 2.50 Bedrooms: 4 Up Fn Area: 202.0 Bsmt Area: 2004 _9 YP. _ -_ - -37375 Roof: H Full Baths: 2 Add Fn Area:- - Fn Bsmt Area: 1 P 101 S 37375 0.858 194,366 V - Ext WaIL•^ FB -Half Baths: I Unfin Area: Bsmt Grade: DETACHED STRUCTURE INFORMATION Masonry Trim: Ext Bath Fix: 2 Tot Fin Area: 4072 - -- - Str Unit Msr-1 Msr-2 E-YR-BIt Grade Con-d%Good P/F/E/R Cost Class Foundation: CN Bath Qual: L RCNLD: 644.790 SE S 80 0.00 1990 A A w X50//45 500 v 1 Kitch Qual: L EffYr Built: 2005 Mkt Adj: Heat Type: FA Ext Kitch Year Built: 2005 Sound Value: VALUATION INFORMATION Fuel Type: G _ Grade VE_ Cost Bldg: 644,800 Current Total: 839,700 Bldg: 645,300 Land: 194,400 MktLnd: 194,400 Fireplace: 2 Bsmt Gar Cap: 3 Condition: E Aft Str Val 1: Prior Total: 873,600 Bldg: 679,200 Land: 194,400 MktLnd: 194,400 Central AC: Y Bsmt Gar SF: 8.36 Pct Complete: 100 Att Str Va12: Att Gar SF: %Good P/F/E/R: ///100 SKETCH PHOTO r t W: t / �i j.. i_. r � dt a FM 12 22 FU/FM/B 40 _ 34 2004Sq.R 16 FW 3 3 = 16 Sq.R 16 Sq.R 612 SALEM STREET Parcel ID:210/065.0-0011-0000.0 as of 1/12/09 Page 1 of 1 612 SALEM STREET 065.0-0011 Complaint Detail Report Printed On:Wed Jan 14,2009 Complaint#: CT-2009-000013 Status: lin discovery GIS#: 8793 Violator: BELLIVEAU,MARC S • ,4oRrti Address: 612 SALEM STREET Map: 065.0 Address: 612 Salem Street Date Recvd.: Jan-13-2009 ITime Recvd.: 11:56 AM Block: 0011 NORTH ANDOVER,MA 018 Category: Dempster Lot: Type: Residential 10 E x p GeoTMS Module: Board of Health District: Trade: Recorded By: Pamela DelleChiaie Zoning: R3 Structure:SINGLE FAMIL DWELLING SS�1i Fit1�¢ Description Complaint: Received a complaint through the North Andover Police Department regarding dumpsters in yard. Possibly acting as a transfer station for a business. NAPD asked the Health Dept.to follow-up.--p.d. Comments: Callers Date Time Name Phone Best Time To Reach Recorded By Response Jan-13-2009 11:56 AM NAPD (978)683-3168 Q Pamela De1leChiaie Follow-Up by Health Inspector Actions Taken GeoTMS Module Status Date Time Response Type Action Taken Comments k Board of Health REFE n GeoTMS®2009 Des Lauriers Municipal Solutions, Inc. Page 1 of 1 612 SALEM STREET JS-2005-0157 Proiect Detail Report Printed On:Mon Aug 30,2004 Project Name: GIS#: 3887 Project No: JS-2005-0157 Owner of Record SMITH,EDWIN N LT&EDITH B Map: 065.0 Date Submitted: Aug-18-2004 612 SALEM STREET Block: 0011 Status: Open NORTH ANDOVER,MA 01845 Lot: Work Category: Work Location: 612 SALEM STREET Zoning: Proposed Use: District: land Use: 101 Proposed Use Detail Subdivision Description DEMOLITION Comments: of Work: Department Status GeoTMS Module: Status File No. Comments: LCDate: Board of Health GREEN FLAG BHJ-2004-0120 To be on sewer. Septic tank of old house must be properly abandoned: Crushed and filled with sand. Building,Electrical&Mechanical Permits GREEN FLAG BEM-2005-0132 Permit History Type: Permit No: Issue Date Status Work Category Contractor Project No: Description of Work: Building BP-2005-0131 Jul-29-2004 OPEN Demolition JS-2005-0157 DEMOLITION Form U Signoff-construct BHP-2004-0610 Aug-09-2004 SIGNED OFF JS-2005-0157 Raze Dwelling GeoTMS®2004 Des Lauriers Municipal Solutions,Inc. Page I of 1 i FORM U - t`O RELEASE FORM INSTRUCTIONS: This form is used tb. J rift' 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 or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT S. � 1���—�i. PHONE Yl S LOCATION: Assessor's Map Number PARCEL I SUBDIVISION LOT (S) STREET A 1 c ST. NUMBER C� OFFICIAL USE ONLY ***** RE MENDATIONS O OWN AGENTS: zc CONSERVATION ADMINIST)IATOR DATE APPROVED (� DATE REJECTED COMMENTS 0 ?-tere— TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS /;OOD INS CTOR-HEAL DATE APPROVED DATE REJECTED TI NSPECTO LTH DATE APPROVED DATE REJECTED CO(M'MENTSr �f=c� �,,c_ rrz-. �W��.'- `'' P7o-f,,C__ PUBLIC WORKS -SEWERMATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm �j /YCif i1 . ls1mifrom[Li Official Use Only \Q� 77 Permit No. &0j { ! BOARD OF FIRE PREV NTION REGULATIONS 527 CMR 12:00 Occupancy&Fee Checked APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00 (Please Print in ink or type all information) Die - o To the Inspector of Wires: Town of North Andover The undersigned applies for a permit to perform the electrical work described below. LocationC7I sr^c e S (Street&Number Owner or Tenant n t � Owners Address 1 1 lA (`C !r 'e r, r mac' �' MA g) D Is this permit in conjunction with a building permit Yes ❑ No ❑ (Check Appropriate Box) �2 y�r10 Purpose of Building tNC 6(' �w Existing Service �7 Amps Voits Overhead ❑ Urxigmd ❑ Na of Meters New Amps_!! k 2. � Volts Overhead ❑ Undgmd I No.of Meters Number of Feeders and Ampacity r�( Location and Nature of Proposed Electrical Work - /J(2 Total No.of Lighting Outlets No.of Hot fuse No.of Transformers KVA Above ❑ In ❑ 0 No.of Lighting Fixtures Swimming Pool gmd ❑ gmd ❑ Generators KVA No.of Emergency Lighting No.of Receptacles Outlets No.of Oil Burners Battery Units No.of Switch Outlets No of Gas f3umers FIRE ALARMS:No of Zone Total No.of Detection and No.of Ranges No of Air Gond Tons Initiating Devices Heat Totaf'-- Total .of Diposal No. Pumps Tons KW No.of Sounding Devices of Dishwashers Area HeatingNO.I of Self Contained, KW DebectiorySounding Devices D.of D Devices KVY. 0 Municipal ❑ Other s Heating Local Connection No.of No.of Low Voltage of Water Heaters KW Signs Bailases Wirify Hydro Massage Tuds No.of Pkotors Total HP HER: i URANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws ve ent Liability Insurance Policy incli.Oirpleted Operations Coverage or its substantial equival YES NO = submi ` valid proof of same to the Office,Y - NO = If you have checked YES please indicate the verage by checking the appropriate box BOND = OTHER = ( ease Specify) (Expiration Date)' imated Value of-Electrical Work$ rk to Start fi 7— C1.c-` Inspection Date Resquested Rough'!W C_A Final ned under the Penalties of perjury:l � C ` / q -/7 M NAME L )) LIC.NO. / ! I A nsee26/1 a r (_C u)rye It L/_ Signature LIC.NO. ress a` ��3/2.�2 ,/!�Lc. i t man. Bus.Tel No. Alt Tel.No. ER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance—coverage or its substantial 3 equivalent as required by Massachusetts eral Laws.And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) ::D I Telephone No. PERMITTEEi (Signature of Owner or Agent) $ i t j i? aA� Y 6069 Date.. ....7^ /` ...�a.� . .... ......... 1 HORTM TOWN OF NORTH ANDOVER ' PERMIT FOR WIRING ,ssACMUS� c This certifies that...,.:.....�..... .. tihas permission to perform ........ _ --{- .......................................... wiring in the building of f—....�X� ..:.. ......:.:..................................................... at....41,1?.......... .. .................... ,North Andover,Mass. Fee... .. ..... Lic.No m` . ,, . ! - � s. .. - ?-!-f !�-- ......... " r ELECTRICAL INSPEG r R - Check # r/�`. D ffiZ fiffOFPEUX34FW PemdtNa O BOMOFFtREpMVMIiDl1►R6MLATiWM7(1 M,atq tkcupaetep a<Few Checked ?-A5�--� APPLICATTONFOR PERMIT TSO PERFORMELE CAL WORK ALL WORK TO vE PERFORM®IN AccORDANCB wrrH THE MASSACHUSnS ELECTRICAL coD 27 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date E Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number) Cv / 2 f a-� owner aTen" S.-Y'- Owner's Address Is this permit in conjunction with a building permit Yes© No a (Check Appropriate Boa) Purpose of Building 9�S/ A/ Utility Authorization No. Existing Service Amps ....L.Vold Overhead Underground No.of Metas _ New Senda Ampa�/ VoW Overhead Underground 1:3 No.of Meters Number of Feeders and Ampacity Locadon and Nature of Proposed Electrical Work � a r A la r Nil No.of Ughft Oudad No.of Hot Tobe Na of 7Ystst WOW Total Na of Ligbdng Fres Swhwni g Pool' Above Below KVA KVA No.of Receptacle Oudsu No.of OB Bu mn Na of EROWIMMp LiOding Baltary Units Na of Switab Oudeu No.ofGo Barmn No.of Rams No.of Air Cont Total FIRE ALARMS No.of zeas. Tear No,of asposek No.of Had Tote! Taal Na of Datecdan aed Tata KW faideftDaviow No.of Dishwa ben Spece Ana Haft KW Na of Sanding Devtas Na of Self Coatainvil No.d Dryer Hosting Devices Kw �Devices Other No.Of Wats Heaters KW Na of Na of Coeaeedom sign bob No.Hydro MomV Tabs Me of Motors Told HP rYr�rRrr• �S V o-Gi r . �ee r A4,1 fr` 1r�saataeCUtea�Ptrorsitbt�ea�c)viare��IbfasdastmCCimesallawa Ihtn rzarmtLirti�laaonaePbic,YidrdrBCl i� airsrte�fWe�aralea Ing ►� �p IhneshrftdvWpiWdf9 abheCfikmY�9 IyauhatededmdYB4,pira d the bar mmm, Btm 13 t7um 1:3 rleese** I WadcbSktltepa�ionDaeRec}r�ed Raigh E�msiDdValLeofPhttraiWbdc S STigndurrder�ie�af Foid FBtMNAME 19AI >` -F /Y Limmm Yys C L ka0 jLe;oa,Gee r AQ SU/h v a• S�,asae d/�u�� ..� � Lio=M =?off 4/ 7 Z2 Bu*=TMNn 47,?-G Yo?- 4 V7'1 ehtawi v�7 /'7i ��� S G/V Ayry✓�e--e f�l/� AtTMNa OWI iWSIlVS MANCEWAMR;IamawaedrrnheLmwdmmd Iheir nme=u*a*aieWWgrftssrajaedbYMeesadseeltC xalLa+tt ardthtt mysierrtzm dispesnit�vrtitafiraquiemat (Please check one) Ownat a Agent Telephone No. PERWr FEE s � Town of North Andover ttoRTFI 0 Office ®f the Planning Department 0 - - - Z- . If- Community Development and Services Divisi®n 27 Charles StreetC North Andover, Massachusetts 01845 �SSacea+,SEt http://www.tow-nofnorthandover.com Planning Director. iwoods@townofnorLha-iidover.com P (978) 688-9535 J.Justin Woods F (978)6,k&9542 SENT USPS VIA CERTIFIED MAIL RETURN RECEIPT REQUESTED # 11033 0510 CW0 Mq 053b NJ 0- February 26, 2003 C3 CD nCD r-Tj -T: Robert Mancusi c/o Timothy J. Schiavoni,Esq. NJ 70 Bailey Boulevard Haverhill, MA 01830 RE: Robert Mancusi Form A Application dated October 9,2002 and stamped received by the Town Clerk on February 13,2003,is hereby Approved. Plan Titled "Robert Mancusi&Edith B. Smith," prepared by Christianson:& Sergi, professional engineers and land surveyors, 160 Summer Street,Haverhill,MA 01830. The Plan is dated October 9,2002 and stamped received by the Planning Department on February 13,2003. Dear Mr. Mancusi: At their regularly scheduled meeting of February 18, 2003, your above-referenced Form A Application was presented to the North Andover Planning Board. The Board determined that the Planning Director could approve the Form A application as the plan appears to comply with the provisions of MGL Chapter 41, Section 81.P and with the provisions of the of the Town of North Andover,Massachusetts Planning Board Rules and Regulations Governing the Subdivision of Land dated November, 2000, last Amended December 2002 (North Andover Subdivision Rules&Regulations), pending resolution of one question for the surveyor regarding the contiguous buildable area(CBA)calculations for the proposed Lot 11-2. On February 21, 2003,1 spoke with Mike Bouffard at Christianson& Sergi and received satisfactory answers regarding the calculations. In accordance with the Planning Board's decision on February 18, 2003,1 hereby approve the Form A application. The next Planning Board meeting is March 11, 2003, at which the mylar will be endorsed. You are hereby notified that should you disagree with this decision,you have the right,under MGL Chapter 41, Sections P&1313,to appeal to this decision within twenty days after the date this decision has been filed with the Town Clerk BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 612 Salem Street Lot 11-2 R. Mancusi/E. Smith Form A Approval February 26, 2003 Page 2 of 2 Please feel free to contact me if you have any questions. SVfinwoods tor cc: Christianson& Sergi, 160 Summer Street, Haverhill, MA 01830 Members,North Andover Planning Board Joyce Bradshaw, Town Clerk Conservation Administrator Director of Public Works Health Administrator Building Inspector Police Chief Fire Chief Atmos Assessor , BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEAL I'H 688-9540 PLANNING 688-9535 y f' Edwin Smith f 1 fi.Salem St. APPLICATION FOR SEWAGE DISPOSAL INSTALLATION HEALTH DEPARTP..+ENT--NORTH AIMOVER, MASS. I hereby make application for a permit for a sewage disposal installation at _ Salem St. . I will install this system in accordance with all the laws of the Commonwealth of Massachusetts and regulations of the Board of Health of the Torn of North Andover. Further$ I will construct the house sewer of bell and spigot pipes, the minimum diameter being 4 inches$ and will maintain a minimum grade of if until 10 feet preceding the septic tanks, where the grade shall not exceed 2%. I will install a concrete septic tank of 750 gals in size. A manhole (s) permitting easy cleaning will be provided with removable cover (s) of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with open jointed bell and spigot Ackron pipe at least 4 inches in diameter and laid in a series of trenches$ the bottom of which will provide a minimum of 110 linen, --y (square) feet of effective absorption area. The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling the trench$ 2 inches of gravel or stone 1/8« to IN' (dia.) will be placed over the course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single tile line will exceed 100 feet in length and in any case, two lines of the will be installed. A minimum of 6 feet will, be maintained between the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No part of the in— stallation will be less than 100 feet from any private water supply: 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. I further ggree not to cover any portion of this installation until«,roved by,the inspection officer,, as provided below$ and to incorporate any additional requirements that may be attached to the permit. Plot Plans must be submitted with application. DATE . r. ' C Signatur6 of Applicant I hereby issue the above permit for the Board of Health of the Town of North Andover, Massachusetts. DATE /. � 9.S T �u��--- Si nature of Health Agent I have inspected the uncovered system indicated above and find everything done as described. DATE L2A ,� Signature df_�Ispecting Officer Pbreolation Test 5 min. Garbage Grinder 1 J .✓J July 19, 1958 Mary Miss M Sheridan R. N. Health Agent Board of Health North Andover, Mass. Dear Miss Sheridan: An examination was made as requested in order to determine the suitability of the soil for the subsurface disposal of sewage on the proposed Salem Street building site of Mr. Edwin N. Smith. The subsoil in the area was of a sandy clay content and a 5-minute percolation test was conducted. The land in general is high. It is recommended that a 750 gallon concrete septic tank be installed together with 140 lineal feet of drain pipe. Very truly yours, William J. iscoll w BOARD OF HEALTH TOWN OF NORTH ANDOVER, MASS. 7 ra. I ti ? ISO n+s m gr ♦ A4 f J. 'D�sn to La how, ?tofu-4t,Co„`4, !iGl"Yr4.-rA PJ K- (q 0 { s°___ Y 1, NAVE . C.'Z� �. DATE 2, ADDRESS �.�.� . :1� . LOT N0. . TEL. '7 .�.�.d 3. NO. OF BEDROOMS DEN NO. . . . 4. GARBAGE GRIMER, 9 N0. 5, SHOW DIIIE+NSIONS OF HOUSE y `3 6 6, SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES 7, SHOW DI1,1ENSIONS OF LOT 8, SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL g, NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM 10. SHOW LOCATION OF BROOKSO STREAMS, DITCHES, LEDGE OUTCROP, ETC. 11, SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY. y.vG.l.N !��/I-li ✓t+4�+-c L a 1 TOWN OF NORTH ANDOVER� J ��X �r l� SYSTEM PUMPING RECORD DATE 7 SYSTEM OWNER&ADDRESS SYSTEM LOCATION --�� i Al� G. s� DATE OF PUMPING ��®20 QUANTITY PUMPED J�D D CESSPOOL NO /YES�_ /SEPTIC TANK NO YES—I,/ NATURE OF SERVICE: ROUTINE_ EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN LACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLID CARRYOVER OTHER EXPLAIN - - SYSTEM PUMPED BY � 2 Jell COMMENTS: .f CONTENTS TRANSFERRED TO \' COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS + a DEPARTMENT OF ENVIRONMENTAL PROTECTION of rh TITLE 5 -- OFFICIAL INSPECTION FORM—NOT FOR VOL . T-- T ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A ,, CERTIFICATION Property Address:1 sa liom Owner's Name Owner's Address: / Date of Inspection: 41'7,144 Name of Inspector: (please print)o(/Y)2, /, SQ Company Name: lY-QVP/e ,�.,�qha �rulce, Mailing Address: Jj pj)!��gn M0 . Telephone Number: q7,9- ,'3 - 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 ails Inspector's Signature: A GI�LL1 Date: f 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. Title 5 Inspection Form 6/15/2000 page l '�W ... .. i1„_ .Z-,. i,. ,.,.,_a,N,..... ..... ... .... .;y,..�.y,...-:..._, _.,. � - ,..:�,. ry +�,,,.».-.:...._ ,..� .yi..... .. .,. , -_,_i,,.�. r-_.. —, ., �:r+..:.-, ',. .,.t e •i t ,w .. Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A //-- CERTIFICATION(continued) Property Address: (I��o2. 'SaaJ/ew S7" p//?-agm wo_g 1,ma. Owner: Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: S 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: T 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 r _ 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 �d t ND explain: 2 Page 3 of I 1 • OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: SQ/eP9 -"ST Owner: is la 5 Date of Inspection: NSU 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 syitem is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the Analysisjmust be attached to this form. 3. Other: 3 Page 4 of 11 F .� OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: CSJ f�• )���'h� (; Owner: (' Date of Inspection: 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 :-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 I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for 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.] �u (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"to4ach 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. 4 Page 5 of 11 • OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 69Mqj . S77 D i/G Owner: S Date of Inspection: L-17 q769 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 J 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: Yes no 7 v 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)[3 10 CMR 15.302(3)(b)] 5 Page 6 of 11 • • OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: /_.� Al Owner: 4ymrw U ` Date of Inspection: 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): 021 Number of current residents: Does residence have a garbage grinder(yes or no): � Is laundry on a separate sewage system(yes or no):_ [if yes separate inspection required] Laundry system inspected-(yes or no):,y Seasonal use:(yes or no):iLu Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): Nb Last date of occupancy: COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 9 Was system pumped asp f the inspection(yes or no):e S If yes,volume pumped:f irad gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM g , _Septic tank,distribution box,soil abso:ptim 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: 3 Were sewage odors detected when arriving at the site(yes or no):�4 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEMINFORMATION-(continued) Property Address: & /02- S4L L S owner: /� a /1l/��I/� ,i?) . Date of Inspection: 1-{/q/o BUILDING SEWER(locate on site plan) Depth below grade: 3 U Materials of construction: L�egt iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.):. . Al . , I b z T-'�3 6 o SEPTIC TANK 111—Nlocate on site plan) Depth below grade: Material of construction: Z-- '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: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 3 ` Scum thickness: /it „ Distance from top of scum to top of outlet tee or baffle_ Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: O M S / f';15- Comments 'i-Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRA��(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of l 1 • OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: e } sT• to t nl I V)yr 1Z Owner• a S Date of Inspection: r 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: k (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:�1 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.): y; PUMP CHAMBER: N (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: (0 /2 >0 1L10n2 LT- q, N�> C/N/Atielz :rnG . Owner: / Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type A � . . leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: a _ 44 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.): (/ 6 h/u e-14n a l 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 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.): 9 Page 10 of 11 . ` OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEMINFORMATION(continued) Property Address: 61,1;21 Q) Owner: )131)62,! Date of Inspection: 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. i 0 - �� 6 Qa- 3d 6 f��L9 10 Vage 11 of 11 • OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C n SYSTEM INFORMATION(continued) Property Address: 1,gls9,. gakiy -0,7-- N 7-' Owner:Maw U S Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells / Estimated depth to `ground water r feet Please indicate(check)all methods 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 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: !3v 5 A KjS "4 Pc r'{ / J/ G Z Gy--/o 6 ' ,c/G /'0/AT%a J-/ I1