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HomeMy WebLinkAboutMiscellaneous - 65 CEDAR LANE 4/30/2018/ 65 CEDAR LANE ` 210/106.A-0144-0000.0 \` K r!1 lay � r � ►.. • : _ �1✓1 JI � �� + Ll �� f � k, Lir • 6 PLLVIEw eaac , Aja . eE-At,,P'A vla,yr. 00, 00 s1+ oJ4� Ar FA r c :.ELL. �K a � , jJAIl IJ "R-U'L6HA)i4C -Ar FGLErr C% Town of North Andover NORTH OFFICE OF 3�°,.t"" 16 �tioL COMMUNITY DEVELOPMENT AND SERVICES ° 30 School Street « ' North Andover. Massachusetts 01845 WILLIAM J. SCOTT North Director June 3, 1997 Mr. Stephen Stabile 65 Cedar Lane North Andover, MA 01845 RE: Unidentified observation in we ands @ 65 Cedar Lane. Dear Mr. Stabile: On May 30, 1997, 1 visited your property, per your request to inspect "something floating in the wetlands". I observed a mocha colored substance throughout the entire wetland. I walked the wetland line trying to come to some sort of conclusion. I did not believe that it was a siltation runoff, nor did I smell a distinct odor. I reiterated my observation to Sandra Starr, Health Administrator, and she assured me that sewerage is black in color. I then asked Susan Ford, Health Inspector, to inspect the property for any additional possibilities. -On June 2, 1997, Susan inspected the property and could not identify the substance in question. Since Susan and I inspected your property, both of us have encountered similiar phenomenon in other wetlands in North Andover. We believe, through our inspections, that the unidentified observation may be an algae bloom at its preliminary stage. However, neither the North Andover Conservation Department, nor the Board of Health, are certain or confident of these findings. I would advise you to contact Christopher Bresnahan, Environmental Engineer, at the Department of Environmental Protection, 10 Commerce Way, Woburn, MA 01801; (617) 932-7684. If you have any additional questions, comments, or concerns, feel free to contact Susan Ford, Health Inspector, Michael D. Howard, Conservation Administrator, or myself, at 688-9530. Thank you for your anticipated cooperation. Sincerely, Richelle Martin Conservation Associate I CONSERVATION.688-9530 BEALTH 688-9540 P1_ NNINQ.688-9535. cc: Michael D. Howard, Conservation Administrator Susan Ford, Health Inspector Sandra Starr, Health Administrator File f NORT J Sl y_ 3728 O 4 •e� 0 0 -"` - �� 0 Town of North Andover `�,'•,,,,, HEALTH DEPARTMENT ,SSACNUSf� CHECK#: DATE: 1 U a LOCATION: AND o ( � }� �(1'> �1 . r H/O NAME: CONTRACTOReNAMEc....10, -�/"� Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Foodl Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Ti Inspector $ ® Title 5 Report $ ©r ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer W Cc , mdhwealth of Massa-chusetts Title 5 Official Inspection Form RE F-INEID Subsurface Sewage Disposal System F \i-Not for Voluntary Assessments oo$ 2 M ,.•''r 66 Cedar Lane �0 SEC Property AddressRTH AN es �Ep� F N EN? R James Hardwick �E TO 0TH FN'TM Owner Owner's Name information is North Andover �EC OA 01845 DHA 8008 required for N every page. Cityrrown v t ,iO�P I S State Zip Code Date of Ins on O TOWN OF NORTH NDOVER D RTMENT Inspection results mu ubmitted on this form. Inspection f many way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Neil J. Bateson cursor-do not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name Q 111 Argilla Road Company Address Andover Ma 01810 City/Town State Zip Code 978-475-4786 SI15 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 I ❑ Needs Further Evaluation by the Local Approving Authority - I,r, 11/4/2008 Ins ct is SignaW Date J 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. I t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 v Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 66 Cedar Lane Property Address James Hardwick Owner Owner's Name information is required for North Andover MA 01845 11/4/2008 every page. City/Town state Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 a Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 66 Cedar Lane Property Address James Hardwick Owner Owner's Name information is required for North Andover MA 01845 11/4/2008 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 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r M ,•''r 66 Cedar Lane Property Address James Hardwick Owner Owner's Name information is required for North Andover MA 01845 11/4/2008 every 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 coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 r Commonwealth of Massachusetts 1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 66 Cedar Lane Property Address James Hardwick Owner Owner's Name information is required for North Andover MA 01845 11/4/2008 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection ion Forth: Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 66 Cedar Lane Property Address James Hardwick Owner Owner's Name information is required for North Andover MA 01845 11/4/2008 every page. City1rown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins•09108 Title 5 Official Inspection Form:Subsurface SewagDisposaI System•Page 6of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 66 Cedar Lane Property Address James Hardwick Owner owner's Name information is required for North Andover MA 01845 11/4/2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 t i 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? ❑ Yes ® No Water meter readings, if available last 2 ears usage On well water 9 ( Y 9 (gpd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Forth: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 �M 66 Cedar Lane Property Address James Hardwick Owner Owner's Name information is required for North Andover MA 01845 11/4/2008 every page. Citylrown 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: Unknown 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: to 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 66 Cedar Lane Property Address James Hardwick Owner Owner's Name information is required for North Andover MA 01845 11/4/2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed(if known)and source of information: Original to house Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): 100 Distance from private water supply well or suction line: feet Comments(on condition of joints, venting,evidence of leakage, etc.): 4" PVC thru wall to septic tank, 3" PVC in house no leaks visible Septic Tank(locate on site plan): Depth below grade: 1 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 7'x5'x4' Dimensions: Sludge depth: 8" t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 66 Cedar Lane Property Address James Hardwick Owner Owner's Name information is required for North Andover MA 01845 11/4/2008 every page. City/Town 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 15" Scum thickness 12" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 91, 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 tee ok. Outlet tee corroded on top. Depth of liquid at inveert. No evidence of leakage 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 66 Cedar Lane Property Address James Hardwick Owner Owner's Name information is required for North Andover MA 01845 11/4/2008 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ 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•09108 Idle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts 9-3 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 66 Cedar Lane Property Address James Hardwick Owner Owner's Name information is North Andover MA 01845 11/4/2008 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box,etc.): D-Box level&distribution equal. Evidence of leakage Evidence of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): i Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 66 Cedar Lane Property Address James Hardwick Owner Owner's Name information is required for North Andover MA 01845 11/4/2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil Ok. Vegetaion ok. No sign of ponding to surface. Camera inside of leach pits thru outlets in d- box, pit#2 flooded, Pit#1 dry. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts i W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 66 Cedar Lane Property Address James Hardwick Owner Owner's Name information is required for North Andover MA 01845 11/4/2008 every page. City/Town 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.): I 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•09108 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Pape 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 66 Cedar Lane Property Address James Hardwick Owner Owner's Name information is North Andover MA 01845 11/4/2008 required for every 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 permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately _ .... V3 hi -� a a�a�a r we t5ins•09/08 Title 5 Offidat tnspedion Forth:Subsurtaoe Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 66 Cedar Lane Property Address James Hardwick Owner Owners Name information is required for North Andover MA 01845 11/4/2008 every page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: Essex Countya it Sol Map You must describe how you established the high ground water elevation: Essex County Soil Map, Sheet#36, Canton nSoil, Water>6'deep Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 66 Cedar Lane Property Address James Hardwick Owner Owner's Name information is required for North Andover MA 01845 11/4/2008 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts City/Town of System Pumping Record REdEI'VED s y` Form 4 JAN - 4 2012 DEP has provided this form for use by local Boards of Health. Other fo information must be substantially the same as that provided here. BefoZe4biM9� y)t?4%):gAT�jVJjth your local Board of Health to determine the form they use. The System Pum itted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/Right front of hous . Ig rear of hou , Left/right side of house, Left/ Right side of building, Left/Right front of tui Ing, em Ig rear of building, Under deck Address /, 5— GVH �� City/Town tIL�J, State Zip Code 2. System Owner: ��t^q v J I (e- Name Address(d different from location) City/Town State q Zi C de Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quanti umped: Gallons I 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ YesNo If yes,was it cleaned? E] Yes ❑ No 5. Conditipf System: ')��� 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locat' a contents were disposed: G.L S. Lowell Waste Water SignAtufe I Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 65 CEDAR LANE 2101106.A-0144-0000.0 1/ i Cunningham Lindsey U.S.,Inc. AA P.O.Box 703689 Ci U.r nin a,I27 Dallas,TX 75370-3689 ' Telephone(888)738-8714 Facsimile(214)488-6766 Lends p A CLCAT@CL-NA.COM March 25, 2015 NORTH ANDOVER TOWN BUILDING COMMISSIONER North Andover Town Hall 120 Main Street North Andover, MA 01845 Claim Number: A033567527 Policy Number: 30706400004 Company Name: ARBELLA INSURANCE GROUP Date of Loss: 02/10/2015 Insured: STEPHEN STABILE Property Location: 65 CEDAR LN, NORTH ANDOVER, MA 01845 To Whom It May Concern: Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss and claim number. Commonwealth of Massachusett - - - City/Town of p System Pumping- Record ori L r�J14 Form 4 . �+ Ta- �s u;,,;;x�r�ANDOVER HEALTH DEPARI EN- DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using.this form,check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility. Information 1. System Location: Left/Right front of house, Left/Right rear of house,aalprigh ide of hou , Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under ec Address /1_� � � �, I Cityfrown (O State Z,p Code 2. System Owner. Name Vl Address(if different from location) City/Town StateP� 4 4z::pde ` Q' L I of Telephone Number ; 1 B. Pumping Record f — i - � 4 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) ErSeptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes L<J No If yes, was it cleaned? ❑ Yes ❑ No; 5. Condon of s m: 6. System Pumped By. Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location re contents were disposed: L S'. Lowell Waste Water �-4- KaA Signitule 9t Haule Date t5fomu4.doe-06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts RECEME City/Town of System Pumping Record SEP 2 7 2007 r` Form 4 TCHEALWN FH DEFA�No TH AND 'JENI DEP has provided this form for use by local Boards of Health. Other fo used, but the information must be substantially the same as that provided here. Before using this orm, check with your local Board of Health to determine the form they use. The System Pumping Record be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. Systw Location: forms on the � i� �o_� computer, use only the tab key Addres to move your cursor-do not Citylrown State Zip Code use the return key. 2. System Owner: Name Address(if different from location) CityfTown State Zip Code Telep on�i a Number B. Pumping Record 1. Date of Pumping qDate �2. Quantity Pumped: Gabns 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: \0�� 6. System Pumped By; tkj Name Vehicle License Number Company 7. Locatere contents wE disposed: X��ek (?_'(3 f/,67;? Signature of Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 i Commonwealth ofassachusetts n r /� � RECEIVED V ' _Ayt a b v_er / , Massachusetts OCT 19 2004 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT System P v pingRecord System Owner System Location Date of Pumping: C} (`3 Quantity Pumped: Q ti-b gallons Cesspool: No [ Yes [] Septic Tank: No [] Yes [ System Pumped by: 64&"w License# Contents transferred to: Greater Lawrence Sanitary District Date: 3 Inspector: i TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD CCT 2 5 2001 DATE: SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: �'� QUANTITY PUMPED GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: COMMENTS: CONTENTS TRANSFERRED TO: "� � Address Title of Fide Page of Date File Open: Date file Closed: Doc Document/Action Title Date of action Refer to other Purpose of DocuMent/Action and notes Document/ document/ Num. Action De artment ---- Board of Appeads — Board of Health — Planning Board _ Conservatiion Com" � — �ssion Building Department �'— DESIGNER IS CERTIFICATION This is to certify that the subsurface sewage disposal system installed at C tbrk LgNF a Subdivision .bot No. , Town Lot No. and Town I%p No, has been installed in strict accordance with the plans and specifications approved by the AWOmmm Board of Health. This certification includes the location, grades and mate a s f all components of the system. '4w-�g e Note: This must be delivered to the 3ea1' � Board of Health within 48 hours following the approving inspect iron. '.` -' 4 " dia. Cast Iron 'Ir. d Qrangeburg or Lqusv.s El II- 1/8 " ^t/8 " to 3/8" Stone Feundation "!a I l --! s�,►. . 12 Max G aQQ� D' (� Cast �`;�� df� N or Iron � Tees ° r f.cel c;4 41 3/4�� to 1 t/2'lp\\ i Stone 1,000 Gal. Septic Tank — Concrete Seepage Pit Dist. Box 6" Sand � u PROFILE Water Table (Vor A1409.� -- � not to scale �{ Test Data Owner : Soil Lag � 't Date (4 -74) -- -�--Y-_ Presoak _ 12- to 9' Location Rate 2 ;��,, /I�. { C Et Flow 400 day../bAy Seepage Area ,Jo, ,�!m60uei?. Sheet c N Commonwealth of Massachusetts i �. RECEIVED City/Town of System Pumping Record Z5 ro» Form 4 TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. Othe e information must be substantial) the same as that provided here. Before using y p ng this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left front of house, right front of house, left side of house, right side of house, Left rear of house, right rear of house, left side of building, right rear of building, under deck. City/Town State Zip Code 2. System Owner: Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record �5 — N-- l( 1. Date of PumpingD 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? E] Yes 2"No It yes, was it cleaned? ❑ Yes ❑ No 5. Conditipri of System: 6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Location where contents were disposed: L.S.D. Wwd Waste Watim i Signature f ul r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1