HomeMy WebLinkAboutMiscellaneous - 66 SPRING HILL ROAD 4/30/2018 (2) i
5P KI MG H l L. T�qb
i `�
North Andover Board of Assessors Public Access Page 1 of 1
� P
E1r
,10RT►1 North Andover Board of Assessors
O�w•�ao.��ti0
3?�a;a ...e.•. O
It � Y
� wowws.o✓•' •C�
'SSACHU roperty Record Card
Click Seal To Return Parcel ID :210/107.A-0235-0000.0 FY:2010 Community:North Andover
SKETCH PHOTO
Click on Sketch to Enlarge Click on Photo to Enlarge
Search for Parcels
Search for Sales
Summary
a
Residence •�����
Detached Structure
Condo 66 SPRING HILL ROAD '• •
Commercial
Location: 66 SPRING HILL ROAD
Owner Name: CISSEL TRS,PAUL W&JUDY A
CISSEL FAMILY REALTY TRUST
Owner Address: 66 SPRING HILL ROAD
City: NORTH ANDOVER State: MA Zip: 01845
Neighborhood: 7-7 Land Area: 1.00 acres
Use Code: 101-SNGL-FAM-RES Total Finished Area: 5421 sgft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 892,800 949,600
Building Value: 667,200 724,800
Land Value: 225,600 224,800
Market Land Value: 225,600
Chapter Land Value:
LATEST SALE
Sale Price: 1 Sale 08/14/2001
Date:
Arms Length Sale F-NO-CONVNIENT Grantor: PAUL CISSEL
Code:
Cert Doc: Book: 06310 Page: 0283
http://csc-ma.us/PROPAPP/display.do?linkId=1519540&town=NandoverPubAcc 6/17/2010
4 '
Ct MORT:,y 7 ,1 5 O
Town of North Andover
HEALTH DEPARTMENT
�SSwcNust� Ili
EC : O DATE: IL
LOCATION: Y f�
H/O NAME:
CONTRACTOR NAME: I
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 $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
Title 5 Report $ .�V..
❑ Other:(Indicate) $
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer
a
RECEIVED
Commonwealth of Massachusetts r
----
JUL 082015 no
Title 5 Official Inspection Form
TOWN OF NORTH ANDOVER
Subsurface Sewage Disposal System Form -Not for Voluntary AssessmenLTH DEPARTMENT �� 0
Property Addr
C`SSe�1
ON ner Owner's Name
information is Oc-- h �v�� I 6 t y
required for every V�.� �($�
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Mportant:When
filling out A. General Information
on the computer,
use only the tab 1. Inspector.
key to move your
cursor-do not
use the return
key. Name of Insp or
t3nf�r Ze�,:S Ste_ `C_ Oc t z�c
Cony Name
y Hze� Q�
Company Address
City/Town State Zip Code
UO3 2sa9- 00!:�
Telephone Number License Number
B. Certification
I certify that 1 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 approvedsystem inspector pursuant to..Section 15.340 of
Title,,_'5 (310 CMR 15.000). The system:
LamPasses ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
Inspector Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.."
'This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t51ns-3/13
TItle50ffldal Iru pectlm Form Subsurface Savage Disposal System-Page 1017
r
f r
a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Add��r,e
Ow ner
information is Owner's Name
required for every — (►�1 %l l / / I
page. City/Town State� Zi Code 1p J
P Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
0/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 orexfiltration 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):
l-9ns•3/13
Title 5 Of ficial Ins pec t on Form Subsurface Sewage Disposal System•Page 2 of 17
s
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal`System Form -Not for Voluntary Assessments
Property Address
. .-''Job C e�1
Owner O,vner's Name
information Is
required for every. ,1.--.Q m 0
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑;; pump Cham ber.pumps/alarms not operational. System will,pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break..out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due t6a 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 mannerwhich 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
Lore•313 - Title 50fticlal ire
pactlon Form subsurface SavaOe Disposal SWtem•Peg e 3of 17 �
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
G(D �A� \� 4ZC�
Property Address
S c-c S
Cw ner Cw ner's Name
information is V RS 0C—
required for every Jy`1 V J
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fall unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
❑ l� Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ L9 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
t5 m•3/13 Title 5OfAdd ImpecUon Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
-- Title 5 Official - Inspecti 'n,,Form.=
Subsurface`Sewa'ge Disposal System Form -Not for VoluntaryAssessments
1 (ZO
Property Address
Z\'A U C
ON ner Owner's Name
information Is (�'��
required for every.....,... . . ..- GZ�.O� Q.�'. 4
page. (ityRown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ 10 Required pumping more than 4 times in the last,.year NOT due to clogged or
f obstructed pipe(s). Number of times pumped:
❑ E 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.
❑ l� 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•wateranalysls, 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'llow 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
„desiign,fiow 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 Dr'
Yes No
❑ ❑ the system is within 400 feet of a surface'drinking water supply
❑ ❑ the system is within 200 feet of, tributary to`a surface drinking water supply
.the system is located..in a nitroge.n.sensiti.ve area (Interim Wellhead Protection
Area– IWPA)or a mapped Zone II of a public water supply well
if yo'u 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.
t51ns•'all - -. TI1e50ffIdel Ins .
pectlon Farm Subsurface Sevege Disposal System•Page Sot 17
Commonwealth of Massachusetts
EMM�W Title 5 Official Inspection. Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
(I,(,, S \A�
Property Address
C��el
Ow ner Owner's Name
information is n_
required for every Q 0 V
page. City/rown 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
❑ L� 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)
�f ❑ Was the facility or dwelling inspected for signs of sewage back up?
I� ❑ Was the site inspected for signs of break out?
IJ ❑ 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?
d ❑ 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): Number of bedrooms (actual): Lt
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): �Q7
tSins•3113 .. Title 5 offldal Inspecbon Fam Subsurface Sewage Disposal System-Pape 6 of 17
Commonwealth of Massachusetts .`:.:`F' ' . ' `•''`:-''�'' ' ,; k.
Title 5 O#ficl{Inspection ;F6rmr � � ' ±'
Subsurface'Se"virage'Disposai System,For rri`'=NoYforVi�luritary•Asse§sments
Property Address
_ .. _._. . ._ S.... 4 y.
Owner Owner's Name "
information Is ✓1 l
required for every ' 1,"• �i't.���fit'... MA, `:6-Ll ._�_.... ....b' )..j..
4 g'Y.......... . y.i — �7
page. ....... ..._ ._'City _,,..
_ State , Zip,Code. _, -.._".Date of Irispbction •
D. System Information
Description:
Nurriber"of current residents:
Does residence have a garbage grinder? ' ' ❑ Yes ❑�No
Is laundry on a separate sewage system? (Include laundry system.inspeption,;; t ❑ Yes 03--`No
Information In this report.)
"Laundry system inspected? ❑ Yes ❑ No
Seasonal use? " ❑ Yes No
'Water'meter'readings, if available.(last 2 years usage (gpd)):
_ Detail: . . .
qvT
Sump pump? ❑ Yes B"'No
Last date of occupancy: 4
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
-"'Desigri'flovii(based on 310 CMR 15.203): Gallons per day(gpd)
Ba§is'of design'flow(seats/personsysq: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-iiieter readings;'if'aVailable:
cslr�•sn a •, ,^ '.
Title 6 ornael tri '
paetlon Forrrc 3J bsuiace Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official; Insp•ection:,Form�)
Subsurface;Sewage,Disposal.System Form -Not for Vol untary.Assessrnents
G S(' �nS
-Property Address J :.
V \ �e
Cw ner-._... . _ . ._..
. _Ow War's Name.._... /� / , /
information is 0-Q 6U'e-„ m� a R (
required for every �
page. City/Town-,-,-' State Zip Code Date of Inspection
M System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
owe
Source of information: 03-
Was system pumped as part of the inspection? L7 Yes ❑ No
If yes, volume pumped:. 1000
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System: _.. .
L� 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) y
_❑ . Innovative/Altemative.technology; Attach,a,.copy.ofthe 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 3113 _. _ Title 5Offldal Inspection Form Subsurface Seymge Disposal System•Pape 8 o 17.
Commonwealth of Massachusetts -
- - Title 5 Official'� Inspection; Form
Subsurface""Sewage Disposal System Form=Not'forVoluntary Assessments,--'—''.
Property Addr
ON ner Owner's Name
Information is ,p
required for every. .. - -n-apdoy-p—C I`�1�.. b,�yS 6-VS7I
page... _. ..... ... ._.City/Town State Zip Code. Date of Inspection
D. System Information (cont.)
in, �..
Approximate age of all components, date installed (if known)and source of information:
.010(!��',n�l s�,-3-k.m
v ,
Were-sewage odors detected when arriving at the site? ❑ Yes Er-'No
Building Sewer (locate on site plan):'
Depth below grade: feet
" Material of construction:
Eq'oast iron [E 46 PVC
❑.,other.(explain);;.
Distance from private water supply well or suction line:'
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
i..l ai �:rc, WG in C�o�Q S1 �e Gn 17Gv U� %nk1
Septic Tank(locate on site plan): -
Depth below grade:
feet
Material of construction:
2 concrete ❑ metal ❑ fiberglass ❑,polyethylene ❑ other(explain)
Iftank'is-metal; list age:
years
""Is"age confirmed by a Certificate'of Compliance? (attach a copy of cetificate
) r:.` ' ❑ Yes ❑ No
_ Dimensions:
_... .._.._. .Sludge depth:;.
t9rm•313 .. _ ,. .,
Tile 50PoGA Ins pectlm Farm;Substrface Sevege Disposal Syttem•Pape got 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
R0
Rope Address
a,v ner \
informCw ners Nameation is _
(� /�cw. /�
required for every 1 � � aoy � l�,, 6 f�1�S �— I
page. aty/,Town State Zip Code Date of Inspection
M System Information (cont.) ., ;..
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness 5
Distance from top of scum to top of outlet tee or baffle
.. . ..Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? _ .1p YY�eASuk<e
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 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.pum ping: Date
t5ins•&73 TIOeS Official Ins
pecUon Farm:Subsurface Savage Dispersal Swam•Pie 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for VoluntaryAssessments
Property Address
v (A
ON ner Owner's Name J
Information Is M
required for every n-'CL ��/Q C 1" ��
page. City/Town State Zip Code Date of'hspection
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 worldng 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
L4ns-3113 .
TItle50f}Idal Ire peetlon Farm:Su bstrface SevpeDlaposel Swam-Page 11 d 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Ow ner Owner's Name
information is
required for every ` ao V�C
page. Qty/Town State Zip Code Date of Inspection
D. System Information (Cont.)
Distribution Box (if present must be opened)(locate on site plan): y e S
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
1I0ar -J&4 b 4 V\") Snmc
Pump Chamber (locate on site plan):
Pumps in working order: ❑ Yes ❑ No'
Alarms in working order: ❑ Yes ❑ No'
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
' If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required): yeS
If SAS not located, explain why:
Ons•3/13
TItle50fOclal Inspection Form:Subsurface Savage Olsposal System-Pape 12 of 17
4N_ Commonwealth of Massachusetts J A
Title 5 Offitfhlp; In 0' 'e"Cition",',F-b"-iWi� .
Subsurfa6e`Sewage Disposal Form,=-Not'for.Voldntiary,Assb`isrh'e'nts-
.... .......
..............
Property Address
Owner Owner's Name
information Is
re _ d-_.,0 ::
quIred forevery._
page. r lTbWh�,j
....... State zip.Po(jq 'ki
!;�ate of spection
D. System Information (cont.)
Type:
leaching pits number:`"
.......... .❑ leaching chambers number
leaching-galleries number. ................--
--leaching trenches "number, length: -
ED leaching fields :':`number, dirh'ehsf6ns!:,`1 x 1-/0
El overflow cesspool number.
innovative/alternative system
technology:
tomm-eh'ts (note conditioh,of soil, signs of hydraulic'failure,'Ie'VeI'6f'Nnd1h','1`damp soil, condition of
9
vegetation, etc.):
i)el-Y DF rSpfcTrG-r\
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 El Yes ❑ No
t5im-3113 Tree 5 Official ins pactlan Form Subsulace Sevage Dispceal System-Page 13af 17
Commonwealth of Massachusetts
Title 5 Official Inspection form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
C) cv, H-� 1 2�
Property'Address
Owner Owner's Name
ation
equirred forievery 0'1A, S r`b— �•—
►S
page. .,Qty/Tow.n, .. o—�
State Zip Code Date of Inspection
M System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic.failure, level of ponding, condition of vegetation,
etc.):'
t5ins-3113
- TI1e601flda1 lns pectlan Form Subsurface Sevepe Dlspoed System-Page 14 d 17
Commonwealth of Massachusetts
- Title 5 Official" Inspection -Form
Subsurface Sewage Disposal System Form -Not forVbitlntary Assessments
Property Address
Cw ner Owner's Name
information is I '. �V�7► . 1�`t S.._ �.�_J...
required for every ^
page Crtyrrown 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
GAoq? kjo u-g c
. . . .., .. .. pub` ?a(c�:., a
_ C ` aGl
t51ra•3113 Title 5 Oftidal Ins pectlan Farm Subsurface Sewage Olsposal system•Page 15 of 17
I
Commonwealth of Massachusetts
Title 5 Offiicial•,Inspections-F.orm
Subsurface.Sewage Disposal.System.Form -Not.for Voluntary Assessments
-Property Address —�
C�
Ow ner Oro ner's Name Q( �
information is (S—
required for every Cil
page. Cityffowri State 72ip Code Date of Inspection
D._System Information(cont.)
Site'&a;i-.
Check Slope
[ "'Surface water
C�9�Check cellar
Ltd'/Shallow wells
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
l� 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:
You must describe how you established the high ground water elevation:
SPS I
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins,3113 : ` ..1 Tides official ImpscBon Form Subsurface Sevage Disposal System-Page 16 d 17
Commonwealth of Massachusetts
t ,
Title_:5 Official Inspection .Form
Subsurface-.Sewage Disposal System Form Not for Voluntary Assessments
Pro
party Address
(JCQ C CCS 2j
ON ner ON ner's Name, _
information Is T) a,� ���C- d1�C
required for every I' (�
page. C+ty/Town State Zip Code Date of Inspection
E..Report.Completeness Checklist
LTJ inspection Summary: A, B, C, D, or E checked .
1/Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
EY""System Information—Estimated depth to high groundwater
[ir sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ns•3/13 tltleSOf9dal IrispecUonForm Subst6fece Savage Disposal SAtem-Pegs 17 d 17
• 06/30/2015 18:47 9782088697 CHARLES CARROLL PAGE 01/01
SEPTIC
&DRAIN ' S ` %
BORACZEKSERVICE1�7,
• THE PROFESSIONAL .EXPERTS IN THE SEPTIC & DRAIN INDUSTRY •
,-"( PLEASE PAY FROM THIS BILL-
Customer Name: 7 CHISHOLM ROAD
' KINGSTON,NH 03848
Service Location: (603)329-6005•(978)374-$$03
J
Phone: (978)921-5353•(978)465-2121 •(603)772-2759
7 / 77 — ,1o7 www,boraczakieptic.com
Contact:
BlllingAddress: SCRV{CANCI THE ENTIRE NORTH SFIOft'i'
+ CERTIFIED TI1 r'LE V INSPECTORS
City: SAME DA y EMERGENCY SERVICE
Date of Service:
Nature of Service Spacial Instructions ❑Completed
Lf-- J z- 7EFReg.Maint. ❑Incomplete!Reason
p Reg, ❑Emergency Per: D Schedule: .r r r ( f�c✓ir.tw,- Ou
❑NIC � Day nNight A M bu{ i•urs i=� �o�n � "P
5 1� 0(w , ��S r 0- 0r
Services Rendemd ❑Car WashCEJ
Vacuum Pumping D Dump Charges Observations Drain Cleaning ���
Septic Tank. minimum 5 tons of sand ,['Good Condition ❑Main Line
13 Drywall $�/ton+9%fuel
'[I Laach 0 0 Pit I overflow surcharge.Any amount over Leach field Runback Toilet Bowl
D D-Box 5 tons will be billed, Riding High 0 athtuub 1 Shower
Sink
❑pump Chamber (liquid I®vel) ❑Bath
$ _ ❑Full to Cover 0 Vanity
D Grease Trap ❑Yearly Profile Fee
C3 Catch Basin ❑Excessive Solids Floor Drain
D Portable Toilet ❑Boraczek Charges Top!Bottom D Yard Drain
D
1]Other $ 4 hour minimum Use Powdered Soap ❑Vent .
City:_, $ 1 hour travel 11 Heavy
Grease Cl Water Jotting
Size: _ — ❑Roots ❑Other
❑Suggest Electric Rootering A footage:
1000 1500 0 Van Called '1,
0 Under 1000 gallons D gaUons ❑ gallons ❑other
❑2000 gallons 0 3000 gallons Q 4004 gallons
0 5000 gallons n 6000 gallons ❑other
Miscellaneous
a'
0 Digging Charge _ __ D Backhoe 11 Inspecdori
❑Location ft,l in. ❑Kubota hm. ❑Title V Inspection
D Service Call ❑Consultation Reason:
❑Labor [I Estimate ❑Pump Repair
D Waiting Time ❑System Installation D Repair
(,7 Portable Toilet Rental ❑System Treatment
-Digging Charge Is Per Driver's Discretion ❑same ❑Rejuvenation
Description of Work a� . /l f, r ./•r,r1
RecommendationsA g, �- r/^ erms of Paymen'fi -C.O.D. PARTS
Vacuum Pumping Draih Cleaning Payment Re ulred Pon Sanrlce
D Cash TAX
Yr. Month Yr. Month NB!theck -
❑Credit (j (:
DISCOUNT
Terms & Conditions �-�-
1.Not responsible for damage beyond the curb line. 3. 1.5%per month will be charged to accounts past due. TOy/#L /
2,All complaints shall be reported within 48 hours. 4.The purchaser agrees to pay all Cost of collection, 0<��
I the undersigned agreeI term and conditiibns.
r'r.'
Customer Signature Serviceman_ Serviceman ✓"fir'
DEP has provided this fomt for use by local 8pards of health;;olher forms may be uwa, but
infamtlon must be suostantlally the ams ai that provided
local Board of Health bo determine the form they u4e.The this form,caoebi€t,;t> ,
M8 i"ocal hoard of tieagll or other proving au PumPbV Record must 60 suti")qt
accordance wain t1 days firm the l<
with 310 CMR 15.351. m
RECEIVED
A. Facility Information JUL
a:;knit I'. System Location: TOWN CF''' , ;H ANDOVER
HEAT , �'�I'KRTMEI,I'
r' . System owner:
u,....a.rFP ��� SVN'iCCY �1 W`...4„•.�u....__. ,.
•wdrm of ditmg hm WaWw' +uar-r .v:....._...........r... ..
VaylIan Std• r .._
S. Pumping Record
� l7ae of Pumping �� /�- t S- ,
P 9 �� 2. quantity pumped: CX1U
3 Type of system: ❑.Cesspooi(s) ,� Septic Tank ❑ Tight Tank
13 other(describe):
4,. Effluent Tee Mer Present? (a Yes trNo If yam,was it caned?
5. Condition of System:
Systecm Pumped By:
t�rre 1
Companp T'
Dation where contents were disposed:
6L-SD
"M of Hawn
SOWNO of ftwWMq Feaft Date ._._ _�•
Of HORT:,h 1 V 1
O 9
• Town of North Andover
HEALTH DEPARTMENT
CHU
CHECK#: S DATE:
LOCATION: c�
H/O NAME:
CONTRACTOR NAME:
Type of Permit or License:(Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type: $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
Zitle
Inspector $
5 Report $
❑ Other. (Indicate) $
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer
a
Commonwealth of Massachusetts
. Title 5 Official Inspection Form � 1�
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ��� — 7 2010
66 Spring Hill Road TOWN OF NORTH ANDOVER
Property Address HEALTH DEPARTMENT
Judy Cissel
Owner Owner's Name
information is
required for North Andover MA 01845 6/21/2010
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: 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
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
❑ Needs Further Evaluation by the Local Approving Authority
d J �
6/21/2010
Insp rs ignature V Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 66 Spring Hill Road
Property Address
Judy Cissel
Owner Owner's Name
information is
required for North Andover MA 01845 6/21/2010
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
After permit from B.O.H., install new outlet tee with gas baffle in septic tank and install new d-box.
inspection from B.O.H., septic system now passes Title 5 Inspection.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts Fents
I'V E
Title 5 Official Inspection Form2010
Subsurface Sewage Disposal System Form-Not for Voluntary AssessORTH ANDOVER66 S Tin Hill Road
Property Address
Judy Cissel
Owner Owner's Name
information is
required for North Andover MA 01845 6/8/2010
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. General Information
When filling out
forms on the
computer,use 1. Inspector:
only thetab key
to move your Neil J. Bateson
cursor-do.not Name of Inspector
use the return
key. Bateson Enterprises Inc.
Company Name
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
❑ Needs Further Evaluation by the Local Approving Authority
6/8/2010
Insp "tignature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
a . Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M �r 66 Spring Hill Road
Property Address
Judy Cissel
Owner Owner's Name
information is
required for North Andover MA 01845 6/8/2010
every page. Cityrrown 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-09108 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
66 Spring Hill Road
Property Address
Judy Cissel
Owner Owner's Name
information is
required for North Andover MA 01845 6/8/2010
every page. Citylrown 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 N F1 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 Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
66 Spring Hill Road
Property Address
Judy Cissel
Owner Owner's Name
information is
required for North Andover MA 01845 6/8/2010
every page. Cityrrown 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:
Outlet tee inseptic tank&d-box needs to be replaced.
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
66 Spring Hill Road
Property Address
Judy Cissel
Owner Owner's Name
information is
required for North Andover MA 01845 6/8/2010
every page. Citylrown 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—IW-�A)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 Tittle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
66 Spring Hill Road
Property Address
Judy Cissel
Owner Owner's Name
information is
required for North Andover MA 01845 6/8/2010
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system 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):r_ 4 Number of bedrooms(actual): - 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 600
t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth'&Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
66 Spring Hill Road
Property Address
Judy Cissel
Owner Owner's Name
information is
required for North Andover MA 01845 6/8/2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 3
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available it e able(last 2 years usage d
9 (gp )) Yes
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
66 Spring Hill Road
Property Address
Judy Cissel
Owner Owner's Name
information is
required for North Andover MA 01845 6/8/2010
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: Pumped 2008, owner
Was system pumped as part of the inspection? ❑ Yes No
If yes,volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Altemative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of tFfe I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-09/08 Title 5 Official Inspection Forth: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
66 Spring Hill Road
Property Address
Judy Cissel
Owner Owner's Name
information is
required for North Andover MA 01845 6/8/2010
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
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
1.5
Depth below grade:
feet
Material of construction:
® cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
4"Cast iron thru wall, 3" PVC in house, no leaks visible
Septic Tank(locate on site plan):
Depth below grade: 0.5
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: = years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
10'x5'x4'
Sludge depth:
2"
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
66 Spring Hill Road
Property Address
Judy Cissel
Owner Owner's Name
information is
required for North Andover MA `= 01845 6/8/2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
26"
Scum thickness
4"
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle
15"
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 off, needs to be replaced. Depth of liquid at outlet invert. 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
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 66 Spring Hill Road
Property Address
Judy Cissel
Owner Owner's Name
information is
required for North Andover MA 01845 6/8/2010
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, j
liquid levels as related to outlet invert, evidence of leakage, etc.):
I
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
66 Spring Hill Road
Property Address
Judy Cissel
Owner Owner's Name
information is
required for North Andover MA 01845 6/8/2010
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&distibution equal. Evidence of leakage, bad corrosion holes, D-box needs to be
replaced. Evidence of carryover, outlet tee off in septic tank.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
66 Spring Hill Road
Property Address
Judy Cissel
Owner Owner's Name
information is
required for North Andover MA 01845 6/8/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 3 trenches 40'
long
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil ok. Vegetation ok. No sign of ponding to surface.
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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
66 Spring Hill Road
Property Address _
Judy Cissel
Owner Owner's Name
information is
required for North Andover MA 01845 6/8/2010
every page. cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction: —
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
66 Spring Hill Road
Property Address
Judy Cissel
Owner Owner's Name
information is
required for North Andover MA 01845 6/8/2010
,
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
S LC.eev�
p�,<-�y�
R
3
I °°
S-epi a
0
_ D t l Ila
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
't 66 Spring Hill Road
Property Address
Judy Cissel
Owner Owners Name
information is
required for North Andover MA 01845 6/8/2010
every page. City/Town 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: >4feet
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: 7/12/1985
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
Design plan
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
As per test pit data on design plan.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-09/06 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
66 Spring Hill Road
Property Address
Judy Cissel
Owner Owner's Name
information is
required for North Andover MA 01845 6/8/2010
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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Summary Record Card generated on 6/2/201011:17:36 AM by Karen Hanlon Page 1
Town of North Andover
Tax Map # 210-107.A-0235-0000.0
Parcel Id 18060
66 SPRING HILL ROAD
CISSEL, PAUL & JUDY
66 SPRING HILL ROAD
N. ANDOVER, MA
01845
Class 101 Single Family Property Type 1 Residential
Size Total 1 Acres
FY 2010
UB Mailing Index
Name/Address Type Loan Number Active/Inact. From Until
CISSEL,PAUL&JUDY Payor
66 SPRING HILL ROAD
N.ANDOVER,MA
01845
UB Account Maint.
Account No Cycle Occupant Name Active/Inactive
Bldg Id. 14261.0-66 SPRING HILL ROAD Last Billing Date 3/2/2010
2100257 02 Cycle 02 Active
UB Services Maint.
Account No.2100257
Service Code Rate Charge Multiplier/Users
MISCFEE ADMIN FEE 1 1 9.18 1/
WTR WATER 01 ALL METER SIZE 159.25 /1
UB Meter Maintenance
Account No.2100257
Serial No Status Location Brand Type Size YTD Cons
36184646 a Active ERT HH b Badger w Water 1 1 0
Date Reading Code Consumption Posted Date Variance
5/4/2010 68 a Actual 33 -26%
2/1/2010 35 a Actual 35 3/11/2010 -100%
11/21/2009 0 n New Meter 0 3/11/2010 -100%
11/21/2009 5233 r Replacement 0 3/11/2010 -100%
11/21/2009 5233 a Actual 83 12/11/2009 40%
8/4/2009 5150 a Actual 50 9/11/2009 0%
5/4/2009 5100 a Actual 40 6/16/2009 0%
2/2/2009 5060 a Actual 30 3/16/2009 -22%
11/5/2008 5030 aActual 40 12/10/2008 -63%
8/4/2008 4990 a Actual 110 9/12/2008 157%
5/2/2008 4880 a Actual 40 6/18/2008 7%
2/4/2008 4840 a Actual 40 3/14/2008 -68%
11/2/2007 4800 a Actual 120 1/15/2008 132%
8/3/2007 4680 a Actual 50 9/14/2007 -23%
5/7/2007 4630 m Manual estimate 50 6/26/2007 72%
MSG
2/28/2007 4580 m Manual estimate 50 3/23/2007 -370/c
11/3/2006 4530 a Actual 50 12/22/2006 98%
Trouble Code:03
8/21/2006 4480 a Actual 30 9/13/2006 -40%
Trouble Code:03
5/25/2006 4450 a Actual 60 6/20/2006 360/c
Trouble Code:03
2/8/2006 4390 a Actual 40 3/13/2006 -680/c
Trouble Code:03
11/4/2005 4350 a Actual 110 12/14/2005 1360/c
V `q .
Commonwealth of Massachusetts
City/Town of
System Pumping Record �V
Form 4 JUN 3 U Zoll
N
DEP has provided this form for use by local Boards of Health. Other s ma be used, but th.
information must be,substantially the same as that provided here. B o D C with your
local Board of Health tQ determine the form they use. The System P miffed to
the local Board of Health o€other approving authority.
A. Facility Information
1. System Location: Left side 91,pnuse,Right side of house, Left front of house, Right front of house,
Left rear of hous Riaht r_ar of h Left rear of building. Right rear of building.
Address 6/_
Citylrown /� State Zip Code
2. System Owner.
Name (�
Address(if different from location)
City/Town State Zip Code
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. Condi 'pryof System-
6.
yst�
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location here contents were disposed:
.L.S. Low ste Vyater
Signature ofMule Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
NORTH
O�IfLco ,6�4r�
�? et;�' 6 OL
IcILE COPY o tto
Co
AQcDCHED
itM!
SSACHUS����
PUBLIC HEALTH DEPARTMENT
(ommunity Development Division
CERTIFIC.ATE OF C0914<1',GI. ONCE
1-L
As of:
June 30, 2010
This is to cert that the individual subsurface disposal system received a
SAT ISFAC`7O1RT lYSIT EMOX of the:
!Rfp&cement of a Component:
Ustri6ution Box and Outlet Tee
Foran On Site SewageDisposaCSystem
By.
ToddBateson
At:
66,)pnyg mid Woad
flap-10T.A; Parcel 235
90rthAndover, 9 A 01845
The Issuance of this certificate shall not 6e construed as a guarantee that the system will
function satisfactorily.
n T Sawyer,
(Pu6lic Yfealth Oirector
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
tkORTFf
{r OFt1�ec q+
cop� r 6 OL
1O ti +'
AK
OQA C OC MICNCwKM`y1'
SSACHUS���y
PUBLIC HEALTH DEPARTMENT
Community Development Division
CERTIFIC��I'E O F C09Y('GI. A jrVCE
As of:
June 3 0, 2010
This is to cert that the individualsu6surface disposalsystem received a
SATIS-ACT0 T1-AVS(PECg70jYof the:
ft&cement of a Component:
Oistri6ution Box and Outlet Tee
Tor an On Site Sewage (D sposalSystem
By.
ToddBateson
At:
66 Sprit M-INZoad
Map-107..X; Parcel 235
Xorth.Andover, 9WA 01845
The Issuance of this certificate shaff not 6e construed as a guarantee that the system wdf
function satisfactorily.
n T Sawyer, kS
(Pu6fic Yfealth(Director
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 918.688.8476 Web www.townofnorthandover.com
TOWN OF NORTH ANDOVER 4 NORTH
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT M
1600 OSGOOD STREET;Building 2-36
NORTH ANDOVER,MASSACHUSETTS 01845SAC�gs
`S�CHUS
Susan Y.Sawyer,REHS/RS 978.688.9540—Phone
Public Health Director 978.688.8476—FAX
D-BOX
❑ Installed on stable stone base
Inlet tee (if pumped or >0.08'/foot)
� 0
Hydraulic cement around inlet & outlets
Observed even distribution
Speed levelers provided (not required)
Comments:
a
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
❑ 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
40R Th Commonwealth of Massachusetts Map-Block-Lot
"."41 107.A0235
p Board of Health Perm-----------
Permit No
North Andover BHP-2010-0618
F 3
P.I. FEE
• a, _:r:t.. � '
3 $125.00
�S �cMu�ti F.I.
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Todd-Bateson
to(Repair-D-BOX&OUTLET TEE)an Individual Sewage Disposal System.
at No 66 L
--------------SPRING--------HILROAD------------------------------------------------------------------------------------------------------------------------------------
as shown on the application for Disposal Works Construction Permit No. BHP-2010-061 Dated June 16,2010
------------------------ -----------------------------
---------- - - - :fteON------------------
Issued On:Jun-16-2010 of Health
at 'Ao o¢" Commonwealth of Massachusetts Map-Block-Lot
or ,•.� " aA 107.A0235
Board of Health -----------------------
North Andover
; `��•-"°��'" ; CERTIFICATE OF COMPLIANCE
ACM
THIS IS TO CERTIFY,That the Individual Sewage Disposal System (Repair-D-BOX&OUTLET T
by Todd Bateson
-------------------------------------------------------------------------------------------------------------------------------------------------------------
Installer
at No 66 SPRING HILL ROAD
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-2010-061 Dated___June--16,_20-10
Printed On: Jun-17-2010
----------------- -- -----------------
- -- - --- - - ----------------------------------------------- Board of Health
• MORTH '4 ` 5049
? a v 00 1.
0,• ,
� 9
r . Town of North Andover
' HEALTH DEPARTMENT
,SSACHU`+t1
CHECK �
/ DATE:
LOCATION: w
H/O NAME:
CONTRACT NAME: a�C
Type of Permit or License: (Check box)
❑ Animal- $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type:
❑ Funeral Directors $
❑ Massage Establishment $ t
❑ Massage Practice $ j
r }•
❑ Offal(Septic)Hauler $ .
❑ Recreational Camp $I `
❑ Sun tanning A
t l
❑ Swimming Pool $
❑ Tobacco $
❑ Trash lSolid Waste Hauler $ `
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing /1 $
❑ Septic-Design Approval
0-- eptic Disposal Works Construction(DWC) $ Jf.
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
❑ Title 5 Report $
❑ Other:(Indicate) $
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer
9l0 �
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Addrsss: G . �,P�'�1 �y LG �'o 9 Date of Inspection
SEPTIC TANK-
(lo"on site plan)
Depth below grade:
Material of construction: 6nc1ete metalFRP other(explain)
Dimensions: IS H /d x _3 G
Sludge depth:' ....?
Distance from top of sludge to.bottom of outlet tee or baffle: 02
Scum,thickness: D
Distance from top of scum to top of outlet tee or baffle: l
Distance from bottom of scum to bottom of outlet tee or baffle: c)Q
Comments;
(recommendation for pumping, condition ofinlet and outlet tees^or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.) �1)i1 p i'(j j O/`
GREASE TRAP. .
(locate on site plan)
Depthbelow,gradei
Material of construction: concrete metal_FRP 'other(explain)
Dimensions:
Scum.thiclmess:
Distance from top,of scum to top of outlet tee or baffle:
Distance froia bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation_to outl, :;;pert, structural integrity,
......... .
1.
evidence of leakage,etc.)
(revised 11/03/95) 6
j
ot`NORTIrw Adplication for Septic Disposal System
.� •-°: °� a
-Construction Permit — TOWN OF TODArS GATE
* �' • ORTH ANDOVER MA 01845 $250.00-Full Repair
tis•,„•� $125.00-Component
Important: Application is hereby made for a permit to:
When filfing 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 2 epair or replace an existing system component-What? t)—Lq u -0--dam.f/,g Te.
cursor-do not
use the return
key. A. Facility Information
Nrlt Pj Rq
OCEIV121
Q Address or Lot#
Cityrrown e , I-
;
TOWN OF NORTH ANDOVER
2.-*TYPE OF SEPTIC SYSTEM*: HEALTH DEPARTMENT
❑Pump ravity(choose one)
***If pump system,attach copy of electrical permit to application***
Conventional System(pipe and stone system)
❑ Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system.
❑Pressure Distribution S.A.S.(No D-Box)(Attach Draft Maintenance Agreement)
❑Pressure Dosed(D-Box Present)S.A.S.
2. Owner Information_Name
Address(if different from above)
Nb �
CftyFown State
Zip Code
T° ' 6�3--Fsa 1
Telephone Number
3. Installer Information l
�or14A T,eSpN BATMN
Name A Name of Co any ILIA ROAD
/I / r9,'�/,g 'fix , MA01810
Address
-� /414_
City/Town State
Zip Code
C/V �/s-Jt7d3
Telephone Number(Cell Phone#if possible please)
4. Designer Information
Name Name of Company
Address
City/Town State Zip Code
Telephone Number(Best#fo Reach)
Application for Disposal System Construction Permit-Page 1 of 2
i
N° TN Applicatidn for Septic Disposal System
°p Construction Permit — TOOF TODAY'S DATE
W1�I
� � w
ORTH ANDOVER, MA 01845 $ 250.00-Full Repair
$125.00 -Component
�SgACHUSES
PAGE 2OF2
A. Facility Information continued....
5. Type of Building: esidential Dwelling or[]Commercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of theafore-described
on-site sewage disposal system in accordance with the provisions of Title 5 of the
Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of
North Andover, and not to place the system in operation until a Certificate of Compliance has
beenissue this Board of Health.
Nam
Date
Application Wroved By: ( rd of Health Representative)
Name i Date
plication Disapproved for the following reasons:
For Office Use Only:
I Fee Attached. Yes v No
2. Project Manager Obligation Form Attached. Yes 61 No
3. Pump System? Ifso;Attach copv ofElectrical Permit YesL. No
4. Foundation As-Built. (new construction ronly). Yes
(Same scale as approved plan)
5. Floor Plans?(new construction only): Yes
Application for Disposal System Construction Permit•Page 2 of 2
s
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
(, S r; MW W . P., A4,
(Address of septic system t For plans by
� ] (Engineer)
Relative to the application of n
(Installer's name) And dated
rtgin 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 apnrr owed 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 beinglevied against me and/or
my company
a. Bottom of Bed—Generally,this is the first(1') inspection unless.there is a retaining wall,which
should be doiie.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:healthdeptQtownofnorthandover.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 ample 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 dans. No instructions by the homeowner,general contractor, or an other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer: (Today's Date)
(Name—Print) — .
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
De artment of °���°P� p�°�6
Environmental Protection
on �
1MI �m F.Weld rudy Coxe
s.crstey
Argea Paul Ceiluccl
LL Gwamor David B. Struhs
Commkokx*(
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A _
p / ,NCERTIFICATION
Property Addresw �lji Ci ' Address of Owner.
Date of Inspection: (If different)
Name of Inspector. Benjamin C. , Osgood Jr.
Company Name,Address and Telephone Number. New England Engineering Services, Inc.
33 Walker Road, North Andover, Ma 01845
CERTIFICATION STATEMENT Tel. 508-686-1768 Fax, 508-685-1099
I certify that I have personally inspected the sewage disposal system a"his address and that the information reported below is true, accurate
and'complete as of the time of inspection. -The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
_Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: /�� Date: 7
The System Inspector shall submi copy of this ins on report"to the Approving Authority within thirty (30),days of completing this
inspection. If the system is'a shared system or bas 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 Department of Environmental Protection.
.The original should be sent to the system owner and copies sent to the buyer, if applicable and.the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15;303.
Any failure criteria not evaluated are indicated below.
B]"SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair, passes
inspection.
Indicate yea, no, or not determined(Y, N, or ND). Describe basis of determination in all instances, If"not determined", explain why not)
The septic tank is metal, cracked, structurally unsound,shows substantial infiltration or exfiltration,.or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
by the Board of Health.
(revised 11/03/95) . 1
One Winter Street • Boston, Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
JPrimed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.A.,
CERTIFICATION (continued)
Property Add. i� �V��/ 1J`t'/L Z t�lY 1p�. I CSGIJ'P '
Date of Inspection: /�J�/�l'�
Bl SYSTEM CONDITIONALLY PASSES (continued).
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obgtructed•_pipe(s)
or due to a broken;settled or uneven distribution baa,.The pystem will pass inspection if(with approval of the Board of
Health):. .
broken 1pipe(s)are replaced
obstruction is removed'
distribution box is levelled or replaced .
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Beard of Health):.
broken pipe(s) are replaced
obstruction is removed
CI 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 the
public health,'safety and the environment. -
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINE_ S THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of a.surface water,
Y Cesspool or privy is within.'60 feet of a bordering vegetated wetland or a salt marsh.
1:2) SYSTEM WILL FAIL UNLESS THE BOARD.:OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT
The system hag A-septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water su ly.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well:
- The system•has aseptic tank and soil absorption system and is.within 50 feet of a private water supply well.
The system.has a peptic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well,unless a well water analysis 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.
3) OTHER
(revised 11/03/95) 2
�IPo As $'ty ;fit•.,,, ..
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (oontinued)
Property Address: L/C
Owner. lj� �� /Tf�i`
Date of hwpeotioa::
DI,.SYSTEM FAILS:.
"I have determined that the system violates one or more of the following failure criteria as defined in 310.CMR 15.303. The basis for
this determination is"identified below. The Board of Health should be contacted to determine what will be necessary to correct the
failure.
_ Backup of sewage into facility or system component due to an 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E1'LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 god or greater(Large System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
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 suPP).S'
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone Il of a public
water supply well)
The owner or'o operator of such
pe" any system shall bring the mend Estill into full compliance with t
a5'� facility p he groundwater treatmentro
P fin"
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information..
(rev ised fll/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Aadresx 11
Date of Impeotiotu
Check,if the.following Have been done:
illmpiag•information was requested of the owner,occupant,and Board of Health. .
None of the system components have been pumped for at least two weeks and the system has been:receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
As built plana have been obtained and examined. Note if they.are not available with NIA.
f' The'facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow
v'The site was usapected for signs of breakout.
T'
vAll system components,excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered,.pt red,.opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on existing information or
/�aPPT��by non-intrusive methods.
The facility.owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub.
Surface Disposal System.
(revised 11/03/95) 4
s,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATI,ON
Property Addreae
:Owner.
Date of Inspeotion: .
ksmEIVTIAiy
` FLOW CONDITIONS
I� .
rDegign flow: �to� .
Ntiinber of bedrooms:
Number of current residents:
Garbage grinder(yes or no):
Lauadry connected to system or no):
seasonal use(yep or no): /7d
Water meter readings if available:_ %Ju,h �<.g f(� —� ii/GS
Lest date.of occupancy:
COMMERCIAL/INDU9TRIAI�
Type of establishment:
Design flow' Gallons/day. .,
Grease trap present: (yes or'no)
Industrial Waste Holding.Tank:present. (yes',or no)
Non-sanitarywaste discharged to the Title 5 system: (yea or no)
Water meter readings, if available: `—
Last date of occupancy:
THER:
(Describe)
L ast'date of occupancy:
i
: . GENERAL INFORMATION
PUMPING RECORDS and source of informs ' n:
,�C9�GN
system pumped as part ofinspection: (yes or n) Aj
If yes, volume pumped: ealllons
Reason for pumping
TYPE F SYSTEM
Septic.tank/distribution box/soil absorption system
<.
Single cesspool
_ Overflow cesspool
Privy.,
shared system(yes or.no) (if yes, attach previous inspection records, if any)
Other(explain) .
y
APPROXIMATE AGE of all components, date installed(if known)and source of information; i
/�iLyS
Sewage odors detected when arriving at the site: (yes or no) 2(/
.(revised 11/03/95)
6 '
Q
000
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
r of rty Address: �op, //Uo P 0401,e `,
Date of Inspection:_
TIGHT OR HOLDIN(I TANK
(locate on site plan).
Depth below grade:
Material of construction:,_concrete_metal_FRP other explain)
'<c
Dimensions:
Capacity: gallons
Design flow:- gallons/day
Alarm level:•
Comments:
(Condition of inlettee;condition of alarm and float switches'etc.)
DISTRIBUTION BOX-,
(locate on site plan) .
Depth of liquid level above outlet invert: O
Comments:
(note if level and distribution is equal, evidence ol solids carryover, evidence of leakage into or out of box, etc.)
e4 7171,
PUMP CHAMBER:-
(locate
HAMBER(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump.chamber,condition of pumps and.appurtenances,etc.)
(revised 11/03/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C'
SYSTEM INFORMATION(continued)
Property Address: .l0(? l"�if2!�r/7� G C f°(o6r0; NQ A4 cP0fil , IA"9- `Date.of Inspection:
SOIL ABSORPTION SYSTEM (SAS):_
(locate on site plan, if possible;excavation notregwrequired, may be approximated by non-intrusive methods}
If ngtdetermiped to be present,explain:
Type:
leaching pita, number.
F: leaching chambers, number_
leaching galleries, number-
leaching
umberleaching trenches, number,length;
leaching fields, number, dimensions:
overflow cesspool,number:
Comments: ( ote condition of axil s' of hydraylic failure, level of ponding,,conditio of vegetation etcJ
8��.1C., �./r1r �v!L u� J/9 /1•,2t� �i�
CESSPOOLS: .
(locateon 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(cesspool must be pumped as part of inspection)
Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
PRIVY:_
(locate on siteP lan)
Materials of construction:
Dimensions:
Depth'of solids:
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.)
(revised 11/03/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM,,.
PART C
SYSTEM INFORMATION(ooatinuod)
4 (. -
z Perty Addrvw&- G
pOwaer, ��GfJi L/ P/jj
DS!ta of Int+ tion:
s SIM.'I'CH OF SEWAGE DISPOSAL SYSTEM:
k : include'ties to atrleast two'permanent references landmarks'or benchmarks
.>.., .locate all we11a within 100' .
, � r
Qe9
i ?n kec�
' - -
r
i
l
_
7
3�ZU �'oanl
.�
yy
DEPTH TO:GROUNDWATER
Depth topwndwater .� { feet.'.
JJ 1
meEhod of determination or approximation: C'S•h •�;A 7 c �,V Ju 1l0<r% CO(�' S% J �' 't a P 0
-
(revised 11%03/95) 9
u
-rte
tioF�TH A�v►�vEl�, M,a. Ppc- ,�6-tl4E�-"
W,�Er{ Sc7 Ply - rbwf l o WELL A��oucD lYJT'L -
SS � �� SEI�T'IG SYS 1�,c� `��►�.�,)
4PPI�Ov6V �ArC� 1JPR UI1J6 Augioi;�1Ty
CaiJPITI O,J5
�F�6PP>�VED pgTE
R�4SoNS =
D l 3ti SCPr(-�-' SYSTEM W Si%O U-A-T I OAA
,—r--YG/3V4Tco,&J 1JSPt�-6TIOAJ V4rC Q FA15S F41L
�wAL I;US(�Ecrlo�
pPPI�dVEJ� Q/JTC AP1�Mool1lj6 AUTHORS 7/
,d�i�IT�O�AL I,�J5F6c (oo5 (I1=4oy)
DISA PPRvvF,D D,a rC
RASO NS
FINAL APPRpvaL
BOARD OF HEALTH
No.Andover, Mass .
SUBSURFACE DISPOSAL DESIGN CHECK SST
LOT # (GSYS(fILL
APPROM - DATE �'- - DISAPPROVED DATE _
Providdds /�J�' Reasons
it I
Title V FAIL, OK
Reg 2.5 The submitted plan must show as a minimums
a) the lot to be served-area,dimensions lot #,abutters
b location and log deep observation hoies-distance to ties
c location and results percolation tests-distance to ties
d design calculations & calculations showing required leaching area
(e) location and dimensions of system-including reserve area
f) existing and proposed contours
(g) location any wet areas within 1001 of sewage disposal system or
disclaimer-check wetlands mapping
(h) surface and subsurface drains within 1001 of sewage disposal
system or disclaimer
(i) location any drainage easements xithir 1001 of sewage disposal
systems or disclaimer-Planning Board fres
(3) known sources of water supply within F101 of sewage disposal o .
system or disclaimer
(k) location of any proposed well to serve. lot-1001 from leaching facility
(1) location of water lines on property-10 from leaching facility
(m) location of benchmark
(n) driveways
(o) garbage disposals
(p) no.PVC to be used in construction
(q) profile of system-elevations of basement, plumb,Npip e, septic tank,
distribution box inlets and outlets, distribution field piping and
Other 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) capac t es- 50% of flow, water table, tees, depth of tees,
access, pumping
(b) cleanout
(c) 3.01 Brom cellar wall or inground swinmsi.ng pool
(d) 251 from subsurface drains
Reg 10.2 Distribution Boxes
(a) slope grea—t—er—UZ 0.08
Reg 10.4 b) s►ut�