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Home My WebLink AboutMiscellaneous - 66 EQUESTRIAN DRIVE 4/30/2018 (2) Egg QUESfR1AN DRIVE Je L 2101105 .0 II I 1 I i i North Andover Board of Assessors Public Access Page 1 of 1 f. Is 0 _ 3 Parcel ID: 2i0/105.D-0141-0000.0 Community: North Andover SKETCH PHOTO Click on Sketch to Enlarge No Picture Available Location: 66 EQUESTRIAN DRIVE Owner Name: NICHOLS,KAREN SAWYER Owner Address: 66 EQUESTRIAN DRIVE City: NORTH ANDOVER State: MA ZIP: 01845 Neighborhood: 7 - 7 Land Area: 1.72 acres Use Code: 101 - SNGL-FAM-RES Total Finished Area: 2880 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 605,700 567,300 Building Value: 387,100 364,800 Land Value: 218,600 202,500 Market Land Value: 218,600 Chapter Land Value: LATESTSALE Sale Price: 100 Sale Date: 07/10/2002 Arms Length Sale Code: A-NO-FAMILY Grantor: NICHOLS,MARK W Cert Doc: Book: 06937 Page: 0100 http://csc-ma.us/NandoverPubAcc/j sp/Home.j sp?Page=3&Linkld=808503 9/8/2006 Residential Property Record Card PARCEL ID:210/105.D-0141-0000.0 MAP:105.D BLOCK:0141 LOT:0000.0 PARCEL ADDRESS:66 EQUESTRIAN DRIVE PARCEL INFORMATION Use-Code: 101 Sale Price: 100 Book: 06937 Road Type: T Inspect Date: 06/17/2002 Tax Class: T Sale Date: 07/10/2002 Page: 0100 Rd Condition: P Meas Date: 06/17/2002 Owner: Tot Fin Area: 2880 Sale Type: P Cert/Doc: Traffic: M Entrance: X NICHOLS, KAREN SAWYER Tot Land Area: 1.72 Sale Valid: A Water: Collect Id: RRC Address: Grantor: NICHOLS,MARK W Sewer: Inspect Reas: C 66 EQUESTRIAN DRIVE NORTH ANDOVER MA 01845 Exempt-B/L% / Resid-B/L% 100/100 Comm-B/LOM Indust-B/L% 0/0 Open Sp-B/L% 0/0 RESIDENCE INFORMATION LAND INFORMATION Style: CL Tot Rooms: 7 Main Fn Area: 1704 Attic: NBHD CODE: 7 NBHD CLASS: 7 ZONE: R1 Story Height: 2 Bedrooms: 4 Up Fn Area: 1176 Bsmt Area: 1704 Seg Type Code Method Sq-Ft Acres Influ-Y/N Value Class Roof: G Full Baths: 2 Add Fn Area: Fn Bsmt Area: 1 P 101 S 43560 1 215,186 Ext Wall: FB Half Baths: 1 Unfin Area: Bsmt Grade: 2 R 101 A 0.72 3,384 Masonry Trim: Ext Bath Fix: Tot Fin Area: 2880 DETACHED STRUCTURE INFORMATION Foundation: CN Bath Qual: T RCNLD: 334163 Str Unit Msr-1 Msr-2 E-YR-BIt Grade Cond%Good P/F/E/R Cost Class Kitch Qual: T Eff Yr Built: 1987 Mkt Adj: 1.1 PC S 648 1988 A A 50///50 19,500 Heat Type: HW Ext Kitch: Year Built: 1985 Sound Value: Fuel Type: O Grade: GV Cost Bldg: 367,600 VALUATION INFORMATION Fireplace: 1 Bsmt Gar Cap: Condition: G Att Str Val 1: Current Total: 605,700 Bldg: 387,100 Land: 218,600 MktLnd: 218,600 Central AC: N Bsmt Gar SF: Pct Complete: Att Str Va12: Prior Total: 567,300 Bldg: 364,800 Land: 202,500 MktLnd: 202,500 Att Gar SF: %Good P/F/E/R: /100/100/93 Porch Tyne Porch Area Porch Grade Factor W 340 SKETCH PHOTO 4 1 No Pictu re 10 4 A4 42 i 528 Sq.Ft. 1704 Sq.PL176 Sq.R. AML 24 28 28 A v al" I Eno- b I 22424 Parcel ID:210/105.D-0141-0000.0 as of 9/8/06 Page 1 of 1 i mss- . .._..�....�_ � 4 I l 1 � h � �C Ase)6 Lo f / is v NORTH O�tii.ao ,6'��r •e OOH O O tet.airiwrt1. 4A0 ��SSACHU� PUBLIC HEALTH DEPARTMENT Community Development Division )Date: February 6,2008 Address: 66 equestrian Re: Building application for 3-season room Dear: Mr;Marcinelli, Your application for the 3-season room has been reviewed by the Health Department. The application was denied on, February 6, 2008, for the following reason as shown in red: 1. X Missing information 2. ❑ Passing Title 5 inspection of septic system required per local N. Andover regulations 3. ❑ Location of structure not acceptable 4. ❑ Undersized septic system To ad real ft p,robjg ): H#1 is checked, please supply: a. Floor pian of existing and proposed addition—all rooms b. Certified plot plan showing house, septic system and proposed project in scale(you may pick up an as-built septic pian at the Health Office H#2 is checked: a. Have the septic system inspected by a certified Title 5 inspector to determine whether it is operating properly: (inspector list attached)OR a. Tie-in to municipal sewer H#3 is checked: a. Relocate the project If#4 is checked: Options 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.towoofnorthandover.com I a. Provide additional information proving that the existing septic system meets current capacity requirements. Please consult a professional engineer or registered sanitarian to determine the flow capacity of the septic system. b. Hire a professional engineer to design a new septic system that meets State Regulations c. Request approval of a deed restriction agreeing to always be a bedroom home. i. Submit a request in writing to the Board.of Health identifying why the need to upgrade the septic system is a severe hardship. ii. Attend a BOH meeting to address the board iii. If approved, record the deed restriction at the registry of deeds Please feel free to call the Health Office at 978-688-9540 with any questions you may have. Sincerely, ,.. ` Susan Sawyer, Public Heal irector Cc: Building Department File 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Commonwealth of Massachusetts RECEIVED City/Town of System Pumping Record SEP 2 5 2006 Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Th stem-Pumping Recor must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When tilling out 1. System L atio fomes the computer,use only the tab key Address to move your cursor- not / use thereturn urn City/Town State Zip Code key. 2. System Owner. (V Name Address(if different from location) Cdyfrown State Zi ,ode Telephone Number .B. Pumping Record 1. Date.of Pumping nate 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) 0,86p-tic ank. ❑ Tight.Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes D_No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: -- 6. System Ppeda Name Vehicle License Number Company -- . 7. Location vAere contents a osed:. Signatu o a ler Date hftp://www.mass.go,v/dep/`Wat r/approvalt/t5forms.htm#inspect t5form4.doc•06103 System Pumping Record•Page 1 of 1 Of NORTH �t�ec r6,9�0 OL O '�' O cOtmtMwKw y^� T ��ssgc►+us�� PUBLIC HEALTH DEPARTMENT Community Development Division %CcFR I EICAcIE O F CO-MID GI DACE As of: September 19, 2006 Thais is to cert that the individuaCsubsurface dzsposaCsystem received a: (Distribution (Bol( replacement by Todd oateson At: 66 Equestrian Drive North Andover, MA 01845 The Issuance of this certi/icate shaff not 6e construed as a guarantee that the system wiff function satisfactorify. us `Y. Sawyer, 12VTSIgU Pu6fic.7feafth Director 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 fox 978.688.8476 Web www.townofnorthandover.com t4ORTFi 6116 OL O 16 y� T ` �.9 q°Awteo�Pa,�(5 SSACHUS� PUBLIC HEALTH DEPARTMENT Community Development Division C'E1��II FICA�I'E OE CO�V1�1'�IAXCE As of: September 19, 2006 This is to cert that the individuafsubsurface disposaf system received a: 1Distfi6ution (Bo,-� replacement 6y Todd Bateson At: 66 Equestrian lD ive North Andover, W3 01845 The Issuance of this certjCicate shaff not 6e construed as a guarantee that the system wiff function satisfactorify. us `Y Sawyer, 12Efs/ ' Pu6fic Yfeafth Director 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com a 66 EQUESTRIAN DRIVE BHP-2006-0233 0.4 ORTN North Andover ° DWC Component Repair - D-Box Only > - Fee Permit - D-Box Inspection ss,CNSt� Item Status Violation Critical Urgency Project Address: 66-EQUESTRIAN DRIVE Inspector: Michele Grant Date of Inspection: Tuesday, Sep 19, 2006 Date of re-inspection: Permit Number: BH_P-2006-0253 Status: FULL COMPLY North Andover Board of Health 1600 OSGOOD STREET BUILDING 20;SUITE 2-36 NORTH ANDOVER MA 01845(978)688-9540 healthdept@townofnorthandover.com GeoTMSO 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 21,2006 ) Page I of I TOWN OF NORTH ANDOVER NOR*h Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT p 1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 NORTH ANDOVER, MASSACHUSETTS 01845 �'"53�C,,U tag Susan Y. Sawyer, REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: �p `��'1MAP: LOT: INSTALLER: ]at2-5 DESIGNER: / PLAN DATE: BOH APPROVAL DATE ON PLAN: ../ INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: I SITE CONDITIONS ❑Existing septic tank properly abandoned ❑Internal plumbing all to one building sewer ❑Topography not appreciably altered Comments: SEPTIC TANK ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading Monolithic construction ❑ Water tightness of tank has been achieved (Visual or Vacuum Test or Water held for 24hrs) ❑ Inlet tee installed, centered under access port ❑ Outlet tee (gas baffle or effluent filter) installed, centered under access port ❑ 24" inch cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present ❑ Hydraulic cement around inlet & outlet Wastewater System Documentation—Feb 2006 Page 1 of 6 J TOWN OF NORTH ANDOVER E gORTH 4 Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 NORTH ANDOVER, MASSACHUSETTS 01845 'Ss,;�H„St`' Susan Y. Sawyer, REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ Combo Tank installed. Size: ❑ 1000 gallon Pump Chamber installed H-10 loading Monolithic construction) ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ 24" inch cover to within 6" of final grade installed over pump access port ❑ Water tightness of tank has been achieved Visual testing ❑ Hydraulic cement around inlet & outlet Comments: ADVANCED TREATMENT TECHNOLOGY ❑ Type of treatment device: ❑ Installed per manufacturers requirements ❑ All components working in accordance with manufacturer's requirements Comments: Wastewater System Documentation—Feb 2006 Page 2 of 6 TOWN OF NORTH ANDOVER t NORTH Office of COMMUNITY DEVELOPMENT AND SERVICES �?�' � �'`° 0 HEALTH DEPARTMENT 1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 NORTH ANDOVER, MASSACHUSETTS 01845e ^GNUS Susan Y. Sawyer, REHS/RS 978.688.9540—Phone Pub ' irector 978.688.8476—FAX D-BOX Installed on stable stone base Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets M�Ibserved even distribution peed levelers provided (not required) Comments: SOIL ABSORPTION SYSTEM ❑ Bottom of SAS excavated down to soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 3/4-1 Y2" double washed stone installed ❑ 1/8-1/2" (peastone) double washed stone installed 0 Laterals installed and ends connected to header ❑ Laterals vented if impervious material above ❑ Orifices @ 5 & 7 o'clock positions ❑ Gravel-less disposal systems: type, number and location as per plan ❑ Elevations of laterals installed as on approved plan ❑ 40 Mil HDPE barrier installed ❑ Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: Wastewater System Documentation—Feb 2006 Page 3 of 6 TOWN OF NORTH ANDOVER NORTh Office of COMMUNITY DEVELOPMENT AND SERVICES o ,a.o 0 HEALTH DEPARTMENT p 1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 ►�, . ,'�i NORTH ANDOVER, MASSACHUSETTS 01845 �9Ss�cNos``� Susan Y. Sawyer, REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX PRESSURE DISTRIBUTION ❑ -- inch manifold ❑ laterals installed with end sweeps size: material: ❑ Squirt test ft in height ❑ Equal distribution to all laterals ❑ orifice size inch as per plan Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: ❑ Rated for exterior if placed outside Comments: Wastewater System Documentation—Feb 2006 Page 4 of 6 ' TOWN OF NORTH ANDOVER E NORTH Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT " ; p 1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 `►"4 .`r„' NORTH ANDOVER, MASSACHUSETTS 01845 �9Ss"""°etty .1CMUS Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback Tank SAS Sewer ❑ Property line 10 10 -- ❑ Cellar wall 10 20 -- ❑ Inground pool 10 20 -- ❑ Slab foundation 10 10 -- ❑ Deck, on footings, etc 5 10 -- ❑ Waterline 10 10 101 ❑ Private drinking well 75 1002 50 ❑ Irrigation well 75 100 ❑ Surface Water 25 50 ❑ Bordering Vegetated Wetland , Salt Marsh, Inland/Coastal Banka 75 100 ❑ Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ❑ Trib. to surface water supply 325 325 ❑ Public well 400 400 ❑ Interim Wellhead Prot. Area ❑ Reservoirs 400 400 ❑ Drains(wat. supply/trib.) 50 100 ❑ Drains(intercept g.w.) 25 50 ❑ Drains(Other)Foundation 10(5) 20(10) ❑ Drywells 20 25 Suction line 222(2) 2 10 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54,and 10.30,respectively,pursuant to 15.211(3),also by NA wetland bylaws Wastewater System Documentation—Feb 2006 Page 5 of 6 TOWN OF NORTH ANDOVER °f NORTH Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 NORTH ANDOVER, MASSACHUSETTS 01845 Susan Y. Sawyer, REHS/RS 978.688.9540—Phone Public Health Director 978.688.8476—FAX SYSTEM ELEVATIONS INVERT ON DESIGN PLAN FIELD INVERT ELEV. Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 HIGH Lateral 1 LOW Lateral 2 HIGH Lateral 2 LOW Lateral 3 HIGH Lateral 3 LOW Lateral 4 HIGH Lateral 4 LOW Lateral 5 HIGH Lateral 5 LOW Wastewater System Documentation—Feb 2006 Page 6 of 6 Septic System Information 66 EQUESTRIAN DRIVE 1 , Printed On: Wednesday,November 08 System ID: BHS-2002-0602 General System Information Latest Permit Information Calcaluted Design Flow: Test Pits Septic Tank Disposal Trench Design Flow: One Two Capacity: Number.- Design umber.Design Flow Provided: Minutes per inch: Width: Width: Total Flow. Depth: Length: Length: Seasonal: No No Depth to Water: Diameter: Leaching: Grinder. Yes No Soil Type: Depth: Laundry: No No Haulin ilPumpinq Listing QuantityR Tvpe System Tyoe Pumped Pumped By Transferred To Disposed At Date Pumped (gallons) Routine Septic Tank Bateson Ent GLSD 10/14/2005 1500 Routine Septic Tank Bateson Ent GLSD 09/19/2006 1500 Comments: normal level in tank ` Inspections: Inspected: Expires: Inspector. Status: 09/20/2006 Neil J.Bateson Passes Comments: TITLE 5 08/31/2006 Neil J. Bateson Conditionally Passes Comments: Title 5 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Page 1 of 1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a DEPARTMENT OF ENVIRONMENTAL PROTECTION d �e TITLE S OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 66 Equestrian Drive RECEIVED _North Andover_ Owner's Name:_Mark Nichols OCT 2 4 2006 Owner's Address:_66 Equestrian Drive —North Andover,MA 01845_ Date of Inspection:9/20/2006_ T�HEALLTH DEPARTMENTWN OF NORTH R Name of Inspector:_Neil J.Bateson Company Name: Bateson Enterprises Inc._ Mailing Address:_111 Argilla Road_ _Andover,MA 01810 Telephone Number:_(978)4754786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority S Inspector's Signature: VVDate: _9/20/2006_ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments:After permit from 13.0.1L,install new d-box,inspection from B.O.11,septic system now passes Title 5 Inspection. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Septic System Information 66 EQUESTRIAN DRIVE 4 Printed On: Thursday,September 21, System ID: BHS-2002-0602 General System Information Latest Permit Information Calcaluted Design Flow: Test Pits Septic Tank Disposal Trench Design Flow: One Two Capacity: Number: Design Flow Provided: Minutes per inch: Width: Width: Total Flow: Depth: Length: Length: Seasonal: No No Depth to Water: Diameter: Leaching: Grinder: Yes No Soil Type: Depth: Laundry: No No Hauling/Pumping Listing Quantity Tvpe System Type Pumped Pumped By Transferred To Disposed At Date Pumped allons Routine Septic Tank Bateson Ent GLSD 10/14/2005 1500 Inspections: Inspected: Expires: Inspector: Status: 08/31/2006 Neil J. Bateson Conditionally Passes Comments: Title 5 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Page 1 of 1 E • Ot,NORT��y . O Town of North Andover ��'•�.; o:: �' HEALTH DEPARTMENT ,SSwCHUstt �y CHECK#: c�7 LOCATION: l��i �IrQS�fi'i4/l',,l/�t°, H/O NAME: CONTRACTOR NAME;./�'�'/iC Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ TrashlSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ El-'`fitlet5 Report -��d� $ ❑ Other. (Indicate) $ 799 Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer COMMONWEALTH OF MASSACHUSETTS fD EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a d DEPARTMENT OF ENVIRONMENTAL PROTECTION l A F \v TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS v SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A r` CERTIFICATION Property Address: 66 Equestrian Drive RECEIbD /North _ Andover_ Owner's Name:_Mark Nichols SEP 1 Owner's Address: 66 Equestrian Drive 4 2006 _North Andover,MA 01845_ TOWN OF NORTH ANDOVER Date of Inspection:8/31/2006_ HEALTH DEPgRTNENT Name of Inspector: Neil J.Bateson_ Company Name: Bateson Enterprises Inc.— Mailing Address:_111 Argilla Road_ _Andover,MA 01810 Telephone Number:_(978)4754786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes _X Conditionally Passes Needs Further Evaluation by the Local Approving Authority /,� ails c Inspector's Signature: Date: 8/31/2006_ 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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_66 Equestrian Drive_ _North Andover— Owner:_Nichols_ Date of Inspection:_8/31/2006_ Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: X One or more system components as described in the "Conditional Pass"section need to be replaced or repaired The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain .D-box needs replaced N The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: N Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: N The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): brokenPiPO are replaced e s laced 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: 66 Equestrian Drive- -North Andover — Owner:_Nichols_ Date of Inspection:_8/31/2006_ C. Further Evaluation is Required by the Board of Health: further evaluation b the Board of Health in order to determine if the system Conditions exist which require fu y y 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 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: 66 Equestrian Drive_ _North Andover_ Owner:_Nichols_ Date of Inspection:_8/31/2006_ D. System Failure Criteria applicable to all systems: You must indicate"yes"or`no"to each of the following for all inspections: No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool No Liquid depth in cesspool is less than 6"below invert or available volume is 1/2 day flow. _No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ No Any portion of the SAS,cesspool or privy is below high ground water elevation. _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] _No_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:_66 Equestrian Drive_ _North Andover_ Owner:_Nichols_ Date of Inspection:_8/31/2006_ Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Yes — Pumping information was provided by the owner,occupant,or Board of Health No Were any of the system components pumped out in the previous two weeks? Yes_ ` Has the system received normal flows in the previous two week period? No Have large volumes of water been introduced to the system recently or as part of this inspection? _Yes — Were as built plans of the system obtained and examined? Yes_ _ Was the facility or dwelling inspected for signs of sewage back up? Yes _ Was the site inspected for signs of break out? _Yes_ _ Were all system components,excluding the SAS,located on site? _Yes _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _Yes_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No _Yes_ , Existing information. _Yes_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_66 Equestrian Drive- - North Andover – Owner:_Nichols_ Date of Inspection:_8/31/2006_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual):_4_ M_ DESIGN flow based on 310 CR 15.203_600_ Number of current residents:_3 Does residence have a garbage grinder(yes or no): Yes_ Is laundry on a separate sewage system(yes or no): No_ Laundry system inspected(yes or no): Seasonal use: (yes or no):_No_ Water meter reading: Yes_ Sump pump(yes or no): No Last date of occupancy:_Current 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:_Pumped last year,owner_ Was system pumped as part of the inspection(yes or no): Yes_ If yes,volume pumped:_1500 gallons--How was quantity pumped determined?_Measured tank_ Reason for pumping: _Inspect tank&tees_ TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool_Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe):_ Approximate age of all components,date installed(if known)and source of information:_21Years old. 12/12/1985 As built plan_ Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 66 Equestrian Drive_ _North Andover_ Owner:_Nichols_ Date of Inspection:_8/31/2006_ BUILDING SEWER_X_ (locate on site plan) Depth below grade: 24"_ Materials of construction: _X_cast iron _X_40 PVC other Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.) _4"cast iron thru wall,3"PVC in house, no leaks. SEPTIC TANKS: X Depth below grade:_12"_ Material of construction:_X concrete—metal—fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions:_10'x 5'x 4' Sludge depth:—3"_ Distance from top of sludge to bottom of outlet tee or baffle: 24"_ Scum thickness:_4"_ Distance from top of scum to top of outlet tee or baffle:- 811-Distance from bottom of scum to bottom of outlet tee or baffle: 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 _Pumped septic tank.Inlet tee ok.Outlet tee ok.Depth of liquid at outlet invert.No evidence of septic tank leaking in or out._ GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete metal fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_66 Equestrian Drive- - North Andover_ Owner:_Nichols_ Date of Inspection:_8/31/2006_ 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 4polyethylene 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 BOXS:_X Depth below grade _30"_ 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-boa level&distribution equal.Evidence of leakage.Evidence of carryover D-box needs replaced,heavy corrosion holes_ PUMP CHAMBER:_(locate on site plan) Pump in working order(yes or no):_ Alarm in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_66 Equestrian Drive_ _North Andover— Owner:_Nichols_ Date of Inspection:_8/31/2006_ SOIL ABSORPTION SYSTEM(SAS):_X (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number: _X leaching trenches,number,length: 2 trenches 45'long_ leaching field,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 oL Vegetation oL No sign of ponding to surface._ CESSPOOLS: Number and configuration:_ Depth—top of liquid to inlet invert:_ Depth of sludge layer:_ Depth of scum layer:_ Dimensions of cesspool: Materials of construction: _ Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_66 Equestrian Drive_ _North Andover — Owner:_Nichols_ Date of Inspection: 813112006_ 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 Driveway House Water Meter A Porch B 1 Septic Tank 2 AtoI=22' Ato2=26'1" A to D-Box=30' Bto1=26'5" B to 2=27' D_ B to D-Box=30'4" Box Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) i Property YAddress: 66 Equestrian Drive _ _North Andover — Owner:_Nichols_ Date of Inspection: 8/31/206_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water_ 4'_ Please indicate(check)all methods used to determine the high ground water elevation: X Obtained from system design plans on record-If checked,date of design plan reviewed:_5/28/1985_ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain:_ Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: _ You must describe how you established the high ground water elevation:_As per design plan_ - Tel: (978)475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating-Water.& Sewer Lines-Septic Systems&Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 66 Equestrian Drive, North Andover Owner: Nichols Date of Inspection: 8/31/2006 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. A Neil J. B teson Bateson Enterprises, Inc. (!011lll! IIy1► Jill of�1'�115$R4 J;usetl8 ` Mass (.1111.mAis uecord Feil (��vller System L UCallon p _N Alp pf l�llllliltllS l d �v �� QuahWy Pumped: [c�gallons 1'esspofil: No I. Yes L-1 Septic Took: No U Yes es &ylnl 1311lllped Ny: '� �,OaK, 4 License # Ipplllpflif lranslerrrod I" ®realer Lawreole eanitary QNtkfpl ; aip;_ Jnspeclor: TOWN OF SYSTEM PUMPING RECORD l DATE: k(D o), 03 SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example: left front of house) �'CYJ5 �oa ot DATE OF PUMPING: QUANTITY PUMPED : OCA 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: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste i' TOWN OF ► `" ` SYSTEM PUMPING RECORD -- . - - DATE: 0 OCT 2 4 2005 TO`: :Y SYSTEM OWNER & ADDRESS SYSTEM LOCATION 01 (example:left front of house) 't;�-q DATE OF PUMPING: G ` QUANTITY PUMPED : G �U GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YESy 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: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste P' Board of Health North AndoverZHaae. SEPTIC SISTER INSTAI.LATICK CHECK LIST LOT PpriOVED DATE DISAPPR �9X AVATJO OK EAU V1 j ea Inst FAIL ' OK 1. Distance To; a. Wetlands b. Drains c.. Well 2. Nater Line Location - 3. No PPC Pipe 4. Septic Tank a. Tees -_Length & To Clean Out Covers b. Cement Pipe to Tank Cu Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines.Flowing Equal- Amounts C. No Back Flow 6. Leach Field or Trench a. Dimensions b. Stone Depth c: Capped Inds d. Clean Double Washed Stone 7. Leach Pits a. Dimensions b. Stone Depth c. Splash Pads d. Tess e. Cement Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. No Garbage Disposal 9. Final Grading Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System c. Location with Regard-to Pere Test d. Elevations e: Water Table BOARD OF HEALTH No.Andover , Mass . _ SUBSURFACE DISPOSAL DESIGN CHECK LIST LOT # 1 APPROVED DATE 7�, - 1) DISAPPROVED DATE!_ Provided: Reasons: Title V FAIL 09 Reg 2.5 The submitted plan must show as a minim='. a) the lot to be served-area,dimensions lot #,abutters b localocation and resultson and lodeeppercollaobservtion tests-distance tion eto ties to s c d design calculations & calculations E'uming required leaching area (e) location and dimensions of system-in ,luding reserve area f) existing and proposed contours (g) location any wet areas within 100' o.' sewage disposal system or disclaimer-check wetlands mapping (h) surface and subsurface drains within 100' of sewage disposal system or disclaimer (i) location any drainage easements within 100' of sesage disposal system or disclaimer-Planning Boa •d )iles (3) known sources of water supply wi�,hin '100, of sewage disposal n system or disclaimer (k) location of any, proposed well to sere- lot-1001 from leaching facilit (1) location of water lines on property-101 from leaching facility (m) location of benchmark (n) driveways ., (o) garbage disposals (p) no PVC to be used in construction (q) profile of system-el evations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and Otter elevations (r) maximum ground water elevation in area sewage disposal system (s) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Reg 6 Septic Tanks (a) capacities-150% of flow, water tab1E , tees, depth of tees, access, pumping (b) cleanout (c) 10 1, from cellar wall or inground swi ming pool (d) 251 from subsurface drains Reg 10.2 Distribution Boxes (a) s ope greater than 0.08 Reglo.4 = stuff Commonwealth of Massachusetts City/Town of RECBiVBD System Pumping Record Form 4 c:w 2014 J 1�1 N Up NUR I M ANDOVER DEP has provided this form for use;by local Boards of Health. Othe fbF �f �y e information must be substantially the same as that provided here. B foresingis 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,/Righ �ofhou , Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address City/Town V State Tp Code 2. System Owner. H Ci Name' Address(d dMerent from location) Citylrown State pCal Telephone Number t,. B.'Pumping Record 1. Date of Pumping P g Date 2. Quantity Pumped: -- . Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yeas No If yes, was it cleaned? ❑ Yes ❑ No; ' 5. Condition o, f p�Sy�temV: J�f _ 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. LoCatinnwhere contents were disposed: L .S. Lowell Waste Water ; �-� =-I'Y Sig a Haule Date t5form4.doc-06/03 System Pumping Record•Page 1 of 1 r: Commonwealth of Massachusetts Map-Block-Lot •.,�o°R 105.D-0141 - ° p Board of Health Permit No ` North - Andover BHP-2006-0253 ---------------------- P.I. FEE cwustt F.I. $125.00 Disposal Works Construction Permit Permission is hereby granted ------------------------------------- to(Repair-D-BOX REPLACEMENT ONLY)an Individual Sewage Disposal System. at No 66 EQUESTRIAN DRIVE - - ---- ------- ------------- - ---------------------------------- -- - - -------------------------------- _- --- --------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP-2006-025 Dated September 08,2006 --------------------------------- -- ------------ Issued On: Sep-08-2006 Board of Health Commonwealth of Massachusetts Map-Block-Lot er .+' •'• °oM 105.D-0141 - Board of Health ----------------------- 901-4 ----------------- North Andover 'TS CHUStCertificate of Compliance THIS IS TO CERTIFY That the Individual Sewage Disposal System (Repair-D-BOX REPLACEME by ---------------------------- ----------- Installer at No 66 EQUESTRIAN DRIVE --------- - - ------------------- -- ----------------- has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. BHP-2006-025 Dated September 08,2006 Printed On: Sep-08-2006 --------------- --------------------- ------ ------ Board of Health I of 40RT" • 0 Town of North Andover HEALTH DEPARTMENT fr► Q` swCHU f CHECK#: LOCATION: H/O NAME: ✓�/� � CONTRACTOR NAME: �--''r ��- J � Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type. $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ Ij Septic Disposal Works Construction(DWC) $� � ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) $ -�P lf'� Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer ,tni9"'" , Application for Septic Disposal System _ TODAY'S DATE AConstruction Permit - TOVN OF M�•A ;.:. y• NORTH ANDOVER, MA 01845 it $125.0 -Component Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer, use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key to move your GJ-Ke-pair or replace an existing system component cursor-do not use the return A. Facility Information key.raD Address or Lot# �rjs— 0 City/Town _ ----- — 2.- *TYPE OF SEPTIC SYSTEM*: SEP - 6 2006 ❑ Pump ravity (choose one) TOWROI * QRTH ANDOVER If pump system, attach copy of electrical permit to a 1pliCWiJ0n1 uEPARTMENT ❑ Conventional System (pipe and stone system) ❑ Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D-Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D-Box Present)S.A.S. 2. Owner Info matin Name Address(if different from above) City/Town State Zip Code Telephone Number 3. Inst ler Information Name � ` ` — � �� ^ , Name of Company -— — - Address Ole to City/Town Stat Zi Code Telephone Number(Cell Phone#if possible please) a. Designer Information Name Name of Company Address City/Town State Zip Code -------- - ----------... ..--- Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 Application for Septic Disposal System o °,Construction Permit - TOWN OF TO DATE NORTH ANDOVER, MA 01845 $ 250.00-Full Repair " $125.00 -Component PAGE 2 OF 2 A. Facility Information continued.... 5. 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 Andov , d not to place the system in operation until a Certificate of Compliance has been issu b this oard of Health. Name Date i Application proved By: ( and of Health Representative) Nam Date t� A plication Disapproved for the following reasons: For Office Use Only: 1. Fee Attached? Yes No 2. Project Manager Obligation Form Attached? Yes v No 3. Pump System? If so,Attach copy of Electrical Permit Yes_ No 4. Foundation As-Built?(new construction ronly): Yes_ �I Ia No (Same scale as approved plan) l V 5. Floor Plans?(new construction only): Yes_ No Application for Disposal System Construction Permit-Page 2 of 2 , SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: ('address of septic sy m) For plans by (Engineer) Relative to the application of 0'� _e 5o/y (Installer's name) And dated ngina ate Dated o ay s ate With revisions dated (Last 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 plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner, contractor,project manager, or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection,without completion of the items in accordance with Tide 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or my company. a. Bottom of Bed—Generally, this is the first'(V5 inspection unless there is a retaining wall,which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection—Engineer must first do their inspection for elevations, ties, etc. As-built of verbal OK (or e-mail to: healthdept@townofnorthandover.com) from the engineer must be submitted to the Board of Health,after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system,all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade—Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation)and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover. significant fines to all persons involved are also possible 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board ofHealth staff or consultant. d. Installation of tank,D-Box,pipes, stone, vent,pump chamber, retaining wall and other components. 6. As the installer. I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner,general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: (To Date) 31—c-,C (Name—Print)rint (Name— e Ir Commonwealth of Massachusetts City/Town of a System Pumping Record � � Form 4 M DEP has provided this form for use by local Boards of He Ith. Oth r I � ed, but the information must be substantially the same as that provid dT irm, check with your local Board of Health to determine the form they use. ThepIng ecord 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 hous Le o h use right rear of house, left side of building, right rear of building, under deck. Cityrrown State Zip Code 2. System Owner: Name Address(if different from location) CitylTown State- t r7J ip o r Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 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: Aj 6)� (0J,-)(2A 6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Location here contents were disposed: L.S.D. Owell Wa a Water Signat f auler Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1