Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Miscellaneous - 667 FOREST STREET 4/30/2018 (2)
��� ���CS4� U� i \ �� �--_ ,. i North Andover Board of Assessors Public Access Page 1 of 1 ybRYi, TQw,n Of lgo*p�.L,,i Jy—cm Ort T� o •,1'O �4o -Assessmss, h � Property Record Card Return to the Home page click on logo Parcel ID: 210/105.D-0020-0000.0 Community: North Andover SKETCH PHOTO New Search Click on Sketch to Enlarge Click on Photo to Enlar e Sales Summary - Residence Detached Structure Condo - T Commercial Comparable Sales _ o>>aor2oor 667 FOREST STREET Location: 667 FOREST STREET Owner Name: PALLADINO,JOSEPH A BEVERLY A PALLADINO Owner Address: 667 FOREST STREET City: NORTH ANDOVER State:MA ZIP: 01845 Neighborhood:6-6 Land Area: 1.1 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 3273 sgft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 562,200 516,900 Building Value: 330,500 306,500 Land Value: 231,700 210,400 Market Land Value: 231,700 Chapter Land Value: LATEST SALE Sale Price: 0 Sale Date: 12/31/1976 Arms Length Sale Code:N-NO-OTHER Grantor: Cert Doc: Book:01304 Page: 0794 http://csc-ma.us/NandoverPubAcc/jsp/Home.jsp?Page=3&Linkld=990626 10/12/2007 Commonwealth of Massachusetts RECEIVED City/Town of APR 0 9 2013 a System Pumping Record i rOSNN NI�Mg :AN s Form 4 ALmmi o�A�t,T�EN r DEP has provided this form for us&by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A..Facility Information 1. System Location: Left/Right front of hous eft Right ar f hous , Left/right side of house, Left/ Right side of building, Left/Right front of bui Ing, Left/Right rear of building, Under deck Address G&17 1.1 City/Town State Zip Code 2. System Owner. V& CA �v Name Address(if different from location) City/Town Stat dip Code Telephone Number B. Pumping Record _ 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company , 7. Location w ere contents were disposed: Ca L Lowell Waste Water "f—4 Sign t e Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts RECEIVED City/Town of System Pumping Record NOV 13 2008 Form 4 TOWN OF NORTH ANDOVER L4!4H LTH DEPARTMENT DEP has provided this form for use by local Boards of H sed, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: Left front<j!Tr&h left side Right front, right rear, right side of house. forms on the computer, use only the tab key Address, ,f J to move your cursor-do not City/Town State Zip Code use the return key. 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) _ eptic Tank Tight Tank r] Other(describe): 4. Effluent Tee Filter present? Yes p—Pd6" If yes, was it cleaned? El Yes [ No 5. Condition of System: 6. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises,Inc Company 7. Location where contents were disposed: .L. '.1 Lowell Waste Water 7M J- A igna ure of H u r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 pORT1� O �tba® eg q�r� HLE � �• it it "sr Aea �} �• o�A t««eu"w"wee,7• � PUBLIC HEALTH DEPARTMENT (ommunity Development Division (FICA O(' C090)J.-I r�AYCE As of October 12, 2007 g its is to certify that the individua(su6surface d4osa[sy1stem received a S VS(AC70R'Y•IjVSTEC9Y0jrNrof the: Replacement of Distribution 0oa( Oye Codd Bateson At: i 667 Forest Street Wap 105.0 (Parce(20 %orth,udover, qv q 01845 Tfie Issuance of this certifi'cate shall not 6e construed as a guarantee that the system wilt function satisfactorily. i fr /��tw lusan T'. awyer6C* Yfealth Director 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com tAORTlf 0 �iLe� $6�'ly® 0 71 1E 2. 0 too CHU OSA toewC�ea.M.w,v'S' PUBLIC HEALTH DEPARTMENT Community Development Division ('12TI 'I�AT� �' C� �� AYCE As of: October 12, 2007 This is to cert that the indviduaCsu6surface dtsposafsy tem received a SA`IIS,FA0T01RT 1-(VS(ECg70Y of the: Replacement of Distribution Bo,C Bye Todd Bateson Ate 667 Forest ,Street W ap 105.(D• Parcel20 XorthAndover, VA 01845 The Issuance of this certfcate shall not be construed as a guarantee that the system will function satisfactoritry. �f Asan 1Y.: awyer 6ficYfeaCth Director 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.com TOWN OF NORTH ANDOVER NORTH Office of COMMUNITY DEVE .OPMENT AND SERVICES a HEALTH DEPARTMENT 1600 OSGOOD STREET; Building 2-36 *", . •� NORTH ANDOVER,MASSACHUSETTS 01845 �'Ss;;CHU Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director X78.688.8476—FAX D-BOX ❑ Installed on stable stone base ❑ Inlet tee (if pumped or >0.08'/foot) + Q� Hydraulic cement around inlet & outlets ® Observed even distribution G � [v Speed levelers provided (not required) ��G 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 ❑ 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 Of top, ,� Commonwealth of Massachusetts Map-Block-Lot 10----0020 ----------------------- Board of Health „ a Permit No a •' BHP-2007-0263 •�e North Andover ----------------------- : •--.�'�. P.1. FEE �"SACH vs�� F.I. $125.00 ----------------------- Disposal Works Construction Permit Permission is hereby granted Todd-Bateson to(Replace D-Box)an Individual Sewage Di: at No 667 FOREST STREET as shown on the application for Disposal Wort _ September 10,2007 -----------------------------I Issued O-- Sep-10-2007 ealth pt ►?os�,�sy Map-Block-Lot Comm �� '•� pec � / / 105.D-0020 ----------------------- CMU s � s Certifil �fss� gE< THIS IS TO CERTIFY,That —bx) by Todd Bates-on- ------- - --------------- ----------------------------------------------------------------------------------------------------- Installer at No 667 FOREST STREET 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-2007-026 Dated September 10,200.7 ------------------26 ---Se - - Printed On: Sep-P Board of Health f ''b*r'" Commonwealth of Massachusetts Map-Block-Lot Of 105.D-0020- p ----__ Board of Health Permit No a s BHP-2007-0263 North Andover ----------------------- °? P.I. FEE 1SSAcMt F.I. $125.00 ----------------------- Disposal Works Construction Permit Permission is hereby granted Todd-Bateson- ----- ---------------------------------------------------------------------------------------------- to(Replace D-Box)an Individual Sewage Disposal System. at No 667 FOREST STREET ---------------------------------------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP-2007-026 Dated September 10,2007 -- ------------------------------ Issued On: Sep-10-2007 Board of Health e MQRT+aMap-Block-Lot .a 3�p4�yiaa oo Commonwealth of Massachusetts 105.D-0020- o A Board of Health ------------------ North Andover �cMuyE,,•ACWU Certificate of Compliance � �' THIS IS TO CERTIFY That the Individual Sewage Disposal System (Replace D-Box) by Todd Bateson ------------------------------------------------------------------ -------------------------------- - Installer at No 667 FOREST STREET __ has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the i application for Disposal Works Construction Permit No. BHP-2007-026 Dated...September 10,2007 ------------------------ Printed On: Sep-10-2007 Board of Health AORTN q s .• O . •e tib F 9 Town of North Andover HEALTH DEPARTMENT �CW CHECK#: DATE: / LOCATION: � � T ✓/ H/O NAME: CONTRACTOR NAME: k Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ `r ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ;F ❑ Recreational Camp $ ❑ Sun tanning $ - ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ a ❑ Well Construction $ SEPTIC S,,sem: ❑ Septic-Soil Testing $ a- ❑ Septic-Design Approval ���( C) $ CSS he Dis Disposal Works Constructip $ / ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5Inspector $ ❑ Title 5 Report $ b ❑ Other:(Indicate) $ 2587 Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer �gHTiy App_ lication for Septic Disposal System `A Construction- Permit - TOWN OF TODAY'S DATE R,. MA 01845 $ 250.00—Full Repair NORTH ANDOVE $125.00-Component Important: Application is hereby made for a permit to: When filling out forms on the ❑ COr1StrUCt a new On-Site sewage dISpOSaI System* computer,use ❑ Repair or replace an existing on-site sewage disposaE7"o,VVt,4 ��EiVE(� only the tab key to move your epair or replace an existing system component cursor-do not 10 2007 kee the return A. Facility Information ,L yC(r (,e.g/ � p pRT�ANp pV Address or Lot# — City/Town 2.-*TYPE OF SEPTIC SYSTEM*: ( �G4 ❑ Pump &Gravity(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) City/Town State Zip Code Telephone Number 3. Installer Information rye ------ Name P '. !I� Nameryt� EN'fEP�I�9S��, YNdbr'. Address 111 Arglila E3 �J �d — Aj_. Andover, MA 0181.0 City/Town State Zip Code — Telephone Number(Cell Phone#if possible please) 4. 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 w u Application for Septic Disposal Svstem _ y`` •oop Construction Permit - TOWN OF TODAY'S DATE 1 �k ? • ORTH ANDOVE R, 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 Andover and not to place the system in operation until a Certificate of Compliance has been issu this Board of Health. Name Date Applicar Approved By- ( oard of Health Representative) - /y^c7-7 Ne Date Application Disapproved for the following reasons: r Office Use Only: 1. Fee Attached? Yes No 2. Project Manager Obligation Form Attached? Yes o� 3. Pump System? If so,Attach co�of Electrical Permit es No 4. Foundation As-Built?(new construction ronly): Yes No (Same scale as approwd plan) 5. Floor Plans?(new construction only): Yes_ No ' ,SEPTIC SYSTEM INSTALLAR PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: (address of septic system) For plans by n (EngIZ Relative to the application of �` zw i�� (Installer's name) and dated // 7_ Dated 'l D '® o av s ate With revisions date (Last remised 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 glans 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 Title 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or my com.�any. a. Bottom of Bed—Generally,this is the first(15)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: healthdegt@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 s er to complete the installation of the system identified m the attached application for installation. I furth 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 tanly D-Box,pipes, stone, veno 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: (Toda),'s Date) ame—Print) z e—Signe TO: NORTH ANDOVER, MASS Acj- G 19 BOARD OF HEALTH FROM: DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection T is to certify that I have ins p ted the construction of the said disposal system at 6 G 7 h a R E S 7— —57— North Andover, Mass. SITE LOCATIO The grades and cons Ion are as specified in my plans and specifications dated eg. P = o ", riitarian fat N d C/) 011tln1Qq9ad9 0. f � �'ij Hd3SOf a©, 1 �I 1 S O 8.M� SIVA.e' b ZO GcJALL \ o N 4- BEt�edo�r 36' Ac+JEGG/�c/C� \ \ � � IGS 6 c \1 a QST ,ems ti° •i� �x _� � D s ,e �c./o,C'T.s' A,c/vovE,2 /Y/ASS. � \,� �• >-,G� � -' �• ,TGu•EP// LT F,4,eB4l.4Z 0, eS '1 y/LL/11-4 J 2oAZ) T-EL. 4-4933 OF �AS� V" TEST AREA ,CAGY sr.2EE'r 2� G _ 2ND 1 e • � tt���---z—/�s"'b''�'' �'"_ __......_,__ �_ _._._.,......�., .._._..�T� �41� �}l'�.-jT3WC?}I.. Cw'3V�P4 f obx�,�e ;,. st1 �{-"�'�=P�g�Q�AT�C?CJdCIs►JttE!?5^rc[:r �. }Cr`W-ks 1w 1 C. usHeO t 0F PPtON IbE-D -NO T1Otom! � 31 r 2 w leo JANK t � 3 1w 'r t� a mid, MAY Z( , 1973 M!ZT - # i 5«71' SAaIA i c' G1&I AL � TtLC, Septic System Information 667 FOREST STREET Printed On:Monday, September 10, 20 System ID: BHS-2007-0105 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: No No Soil Type: Depth: Laundry: No No Inspections: Inspected: Expires: Inspector: Status: 09/04/2007 Neil J. Bateson Passes Comments: Title 5 GeoTMSO 2007 Des Lauriers Municipal Solutions, Inc. Page 1 of 1 Of HORT#f ,,tip fj .. • p9 n Town of North Andover �f HEALTH DEPARTMENT 7; ,SSACMUSE4 CHECK#: JV%U DATE: LOCATION: H/0 NAME: o-c /Grp ✓� 4 CONTRALTO " AME:✓�a-tjD� Tyne of Permit or License:(Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type. $ ❑ Funeral Directors $ p F ❑ 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 -nspector $ ` Q Title 5 Report $ �Q ❑ Other:(Indicate) $ 2586 Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer SATESON ENTERPRISES INC. ��C�9 �® '� � �' `- :,, 111 Argilla Road "+� t- """" � Andover, Massachusetts 01810SEP .I 0 2007 Lr e +vnr USA First-Class TOWN OF NORTH ANDOVER ( n HEAL-0-1 DEF ARTMENT A-e, se7 ��� lli„,,,lIlllLiffillid,lt,,,tf l:I„,pill Ill Ili l,i„I,I1,,,,lll BATESON ENTERPRISES INC. ;�s D� ;SEX—ESSSE 111 Argilla Road �`�A '��-8 �' r Andover, Massachusetts 01810 SEP 1 0 2007 USA First-Class aA�sox TOWN OF NORTH ANDOVER HEA!TH DEPARTMENT "Cule� t oo C �'-�a f+0•:=•N-%'csc�e► 111„r t„I I I,I I I 1,i l l I,11,i I I IJ-:11 I I J I I III J i I I I I I I I]If I fill! e r ♦ • � C�6 Zi ED COMMONWEALTH OF MASSACHUSETTS SEP 5 2007 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS r d DEPARTMENT OF ENVIRONMENTAL PROTECTSON NORTH AND EM OVER F �M s+ C_ TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property hAddress:_667 Forest Street _ _North Andover_ Owner's Name: Joseph Palladino _ Owner's Address:_667 Forest Street_ _North Andover,MA 01845_ Date of Inspection:_9/4/2007 Name of Inspector: Neil J.Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address:_111 Argilla Road_ _Andover,MA 01810_ Telephone Number:_(978)475-4786_ 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 AFsh. 1 Inspector's Signature: Date: 9/4/2007_ 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:Washer Machine&Well Backwash System. ****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. r� Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_667 Forest Street _North Andover_ Owner:-Palladino_ Date of Inspection:_9/4/2007_ Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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: Washing machine needs to be tied back into septic system. B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain._ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 667 Forest Street_ _North Andover — Owner:_Palladino Date of Inspection: 9/4/2007 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 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. _ from The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more o 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:_667 Forest Street_ _North Andover— Owner:_Palladino Date of Inspection: 9/4/2007_ 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 clomed 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'/Z day flow. _No7 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 H 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:_667 Forest Street_ _North Andover_ Owner:_Palladino Date of Inspection: 9/4/2007 Check if the following have been done.You must indicate`des"or"no"as to each of the following: Yes No Wo-tank _ Pumping information was provided by the owner,occupant,or Board of Health No tank for washer&well backwash. 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? N/A ` 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? _ _ 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? No tank for washer&well backwash. _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 _N/A_ _ Existing information. _Yes_ _ Determined in the field(if any of the failure criteria related to Part Cis 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:_667 Forest Street_ _North Andover– Owner:_Palladino Date of Inspection: 9/4/2007_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_N/A_ Number of bedrooms(actual):_5_ DESIGN flow based on 310 CMR 15.203 N/A Number of current residents:_2 Does residence have a garbage grinder(yes or no):_No Is laundry on a separate sewage system(yes or no): Yes_ Laundry system inspected(yes or no): _Yes_ Seasonal use: (yes or no):_No_ Water meter reading:_On well water_ Sump pump(yes or no):_No Last date of occupancy:_Current_ COMMERCIALIMUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,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: Was P pumped as system um ed art of the inspection(yes or no):_ y If yes,volume pumped: gallons--How was quantity pumped determined?_ Reason for pumping: _ TYPE OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool_Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval X Other(describe): Leach pipe for washer machine&well backwash_ Approximate age of all components,date installed(if known)and source of information Unknown_ 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:_667 Forest Street _North Andover_ Owner:_Palladino Date of Inspection: 9/4/2007 BUILDING SEWER_X_ (locate on site plan) Depth below grade:_24"_ Materials of construction: _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.) _1.5"PVC thru wall.1.5"PVC in house. No leaks visible SEPTIC TANK: Depth below grade: Material of construction:,concrete,metal_fiberglass__polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no)::(attach a copy of certificate) Dimensions: Sludge depth Distance from top of sludge to bottom of outlet tee or baffle: 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: How were dimensions determined: Comments ( pumping onrecommendations,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:_ 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.): O 01 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_667 Forest Street_ _North Andover - Owner:_Palladino Date of Inspection: 9/4/2007 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX Depth below grade _ Depth of liquid level above outlet invert:__ solids over,an evidence of (note if box is level and distribution to outlets equal,an evidence of so ds c y Comments( o q Y an'Y leakage into or out of box,etc.)__ 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:_667 Forest Street_ _North Andover Owner:_Palladino_ Date of Inspection:_9/4/2007 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 trench,number,length:—1 trenches 35'long_ leaching field,number,dimensions: _ overflow cesspool,number: innovative/alternative system Typetname 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.1.5"PVC pipe thru foundation to 4"corrugated pipe,35'long 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 Property Address:_667 Forest Street_ _North Andover— Owner:_Palladino Date of Inspection: 9/4/2007_ 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 O Well Head Driveway To Wed 88'Approx. C D Garage House A B Deck Bulk Sunroom Head Septic �- �5' ► Tank A to Tank=17'2" A to D-Box=59'9" Washer Machine& Well Backwash Line B to Tank=5096" B to D-Box=53'3" C to Well Head=59' D-Box D to Well Head=57'6" i 40' 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_667 Forest Street_ _North Andover– Owner:_Palladino_ Date of inspection:_ _ SITE EXAM Slope_Yes_ Surface water_No_ Check cellar _Dry_ Shallow wells_No_ Estimated depth to ground water_>6'_ Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed:— Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain:__ Checked with local excavators,installers-(attach documentation) X Accessed USGS database-explain: _Essex County Soil Map_ You must describe how you established the high ground water elevation:_Essex County Soil Map,Sheet#37, Canton Soil,Water>6'Deep 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: 667 Forest Street, North Andover Owner: Palladino Date of Inspection: 9/4/2007 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. Neil J. Bateson Bateson Enterprises,Inc. f RECEIVED COMMONWEALTH OF MASSACHUSETTS SEP 5 2007 EXECUTIVE OFFICE OF ENVIRONMENT ARM-RS)RTH ANDOVER u a HEALTH DEPARTMENT d DEPARTMENT OF ENVIRONMENTAL PROTECTION C,1-,:� fo, c%v—fIn SVB TITLE 5 �� G OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_667 Forest Street _North Andover Owner's Name:Joseph Palladino _ Owner's Address:_667 Forest Street_ _North Andover,MA 01845_ Date of Inspection:_9/4/2007 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 ail l� Inspector's Signature: Date: _9/4/2007_ 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: 667 Forest Street _North Andover — Owner:-Palladino_ Date of Inspection:_9/4/2007_ 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 replacement. 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): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_667 Forest Street _North Andover — Owner: Palladino Date of Inspection: 9/4/2007_ C. Further Evaluation is Required by the Board of Health: Conditions exist which require fin-ther 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 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 I 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:_667 Forest Street_ _North Andover— Owner:_Palladino_ Date of Inspection:_9/4/2007_ 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 —No7 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'/z 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:_667 Forest Street_ _North Andover_ Owner:_Palladino_ Date of Inspection:_9/4/2007 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? N/A _ 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 _N/A_ _ 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:_667 Forest Street _North Andover_ Owner:_Palladino Date of Inspection: 9/4/2007_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_N/A_ Number of bedrooms(actual):_5_ DESIGN flow based on 310 CMR 15.203_N/A_ Number of current residents: Does residence have a garbage grinder(yes or no):–No_ Is laundry on a separate sewage system(yes or no): Yes_ Laundry system inspected(yes or no): _Yes_ Seasonal use: (yes or no):_No_ Water meter reading:_On well water_ Sump pump(yes or no):–Nom- Last No_Last date of occupancy:_Current_ COMMERCIAL/INDUSTRIAL 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 four years ago,owner_ Was system pumped as part of the inspection(yes or no):_No_ If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: 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_Original,owner 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:_667 Forest Street _North Andover_ Owner:_Palladino Date of Inspection: 9/4/2007 BUILDING SEWER_X_ (locate on site plan) Depth below grade:—36"_ 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.) _3"Cast iron thru wall.3"PVC in house. No leaks visible SEPTIC TANK: X Depth below grade: 24"_ 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:_7'z 5 x 4' Sludge depth:_5"_ Distance from top of sludge to bottom of outlet tee or baffle: 27"_ Scum thickness:_0_ Distance from top of scum to top of outlet tee or baffle:- 6"-Distance from bottom of scum to bottom of outlet tee or baffle: 10"_ 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 baffle ok.Outlet bate corroded on top.Liquid level at outlet invert.No evidence of leakage.Center cover on septic tank has riser 2"deep._ 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:_667 Forest Street_ _North Andover— Owner:_Palladino Date of Inspection: 9/4/2007 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX X Depth below grade 244'1— Depth of liquid level above outlet invert:_-1"_ Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.)_D-box level&distribution not equal.Evidence of carryover.Evidence of leakage,liquid below outlets._ 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:_667 Forest Street_ _North Andover_ Owner:_Palladino_ Date of Inspection:_9/4/2007_ 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 trench,number,length:—4 trenches 40'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 ok.Vegetation ok.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 Property Address:_667 Forest Street_ _North Andover Owner:_Palladino Date of Inspection: 9/4/2007 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 O Well Head Driveway C To Wel D 88'Approz. Garage House A B Deck Bulk Sunroom Head � Septic -359 Tank A to Tank=17'2" A to D-Boz=59'9" B to Tank=50'6" B to D-Boz=53'3" C to Well Head=59' D-Boz D to Well Head=5796" i 40' Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_667 Forest Street_ _North Andover— Owner:_Palladino_ Date of Inspection:_9/4/2007_ SITE EXAM Slope_Yes_ Surface water_No_ Check cellar _Dry_ Shallow wells_No_ Estimated depth to ground water_>6'_ Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain:__ Checked with local excavators,installers-(attach documentation) X_Accessed USGS database-explain: Essex County Soil Map_ You must describe how you established the high ground water elevation:_Essex County Soil Map,Sheet#37, Canton Soil,Water>6'Deep 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: 667 Forest Street, North Andover Owner: Palladino Date of Inspection: 9/4/200' 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. Neil J. Ba eson Bateson Enterprises, Inc. Address2��s-7- fV7 � Title of File Page of Date File Open: Date file closed: Doc Document/Action Title Date of Refer to other Purpose of Docume nt/Action and nates: action Document/ document/ Num. Action Department Board of Appeals — Board of Health — Planniing Board — Conservation Commission — Building Department Sh 71 TOWN OFNO$TH ANDOVER SYSTEM PUMPING RECORD _..--- DATEAV:i_l AW3 SYSTEM OWNER&ADDRESS SYSTEM LOCATION fialladlo a l��'7 FresT6T �Ao< /U anrd�ve�. )Val DATE OF PUMPING_ / ✓`© + Z QUANTITY PUMPED �5 OJ CESSPOOL NO �YIES SEPTIC TANK NO YES NATURE OF SERVICE;;,RQ.UTINE ' EMERGENCY OBSERVATIONS: GOOD CONDITION-" FULL TO COVER HEAVY GREASE BAFFLES IN LACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS - 'FLOODED SOLID CARRYOVER OTHER EXPLAIN SYSTEM PUMPED BY C COMMENTS; CONTENTS TRANSFERRED TO Y �� ". NORTH Application for Septic Disposal System D ' r -Obi*�.•y'�ti 3�•�°'• ' °°c TODAY'S DATE Construction Permit - TOWN OF ORTH ANDOVER, MA 01845 $ 250.00—Full Repair �►;S•�...�'� $125.00-Component S�CHU 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 ❑Zp 'r or replace an existing on-site sewage disposal system* only the tab key b— �x to move your r orreplace an existing system component—What? cursor-do not use the return A. Facility Information _ key. - �I Address or Lot# Cityrrown SEP 2 6 2008 2.-*TYPE OF SEPTIC SYSTEM*: ❑ Pump ❑ Gravity(choose one) TOWN OF NORTH ANDOVER ***If pump system,attach copy of electrical permit to applicatio_&***_TH°EFARz rv=t_NT ❑ 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) City/Town State Zip Code Telephone Number 3. Installer Information Name Narr0X 15y,6��T99 ENTERPRISE.. Address rgifla ROEd -- Andover, MA 098.10 Cityrrown State Zip Code Telephone Number(Cell Phone#if possible please) 4. Designer Information Name Name of Company Address Cityrrown State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 1 ,,.RTI, Application for Septic Disposal System cA Construction Permit — TOWN OF TODAY'S DATE ORTH ANDOVER, MA 01845 $250.00-Full Repair SSS4C0 $125.00-Component 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 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 And r, and not to place the system in operation until a Certificate of Compliance has been is by this Board of Health. Na Date Application Approved By: (Board of Health Representative) Name Date Application Disapproved for the following reasons: For Office Use Only: I Fee Attached. Yes No 2. Project Manager Obligation Form Attached. Yes No 3. Pump Svstem?:Ifso,Attach copv ofElecuical Permit Yes No 4. FoundationAs-Built. (new construction ronly): Yes No (Same scale as approved plan) 5. Floor Plans?(new construction only): Yes No Application for Disposal System Construction Permit•Page 2 of 2 i SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: — y (Address of septic system) For plans by f n ieer) Relative to the application of o ��q T�s'as� (Installer's name) And dated ngui date) Dated �—';4 !> �'r�'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 beim 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 Title 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(1s) 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: healthdent_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 of Health staff or consultant. d. Installation of tank,D-Box,pipes, stone, ven;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 �prrved plans No instructions by the homeowner,general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: (Today's Date) ame— not (Name—Signed)