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HomeMy WebLinkAboutMiscellaneous - 67 CRICKET LANE 4/30/2018 67 CRICKET LANE 210/107.A-0217-0000.0 \ s -v 4 I f I North Andover Board of Assessors Public Access Page 1 of 1 e � ,koRYy TovmOf North th Aii<tover. °�•"' ,"o ]Ekoard of Assessors R � cwu ems' Property Return to the Home page click on logo Record Card Parcel ID: 210/107.A-0217-0000.0 Community:North Andover SKETCH PHOTO New Search Click on Sketch to Enlarge Click on Photo to Enlarge Sales r?-r •;�1., Summary o= Residence Detached Structure Condo Commercial Comparable Sales 6711 CRICKET LANE °• Location: 67 CRICKET LANE Owner Name: MARKOWSKY,WARREN A ROBIN J MARKOWSKY Owner Address: 67 CRICKET LANE City:NORTH ANDOVER State:MA ZIP: 01845 Neighborhood: 7-7 Land Area: 1.03 acres Use Code: 101 -SNGL-FAM-RES Total Finished Area:2640 sgft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR I Total Value: 635,800 663,400 Building Value: 410,800 426,600 j Land Value: 225,000 236,800 Market Land Value:225,000 Chapter Land Value: LATEST SALE Sale Price: 420,500 Sale Date:05/08/2000 Arms Length Sale Code: Y-YES-VALID Grantor:WALNUT RIDGE Cert Doc: Book:05744 Page:0276 http://csc-ma.us/NandoverPubAcc/jsp/Home.jsp?Page=3&Linkld=1181906 1/17/ I -C\- Commonwealth of MassachusettsFREVED City/Town of System Pumping Record �Form 4 Mpp``Ar�99p(0*\�1tERl EIV] ill iyl DEP has provided this form'for use by local Boards of Health.Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/Right front of ho y g use Rlghq�ar b ouf0 se�eft/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address City/Town 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 i< 2. entity Pumped: Date Gallons 3. Type of system: E] ,Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes M/No If es was it cleaned? yes, El Yes ❑ No 5. Condition of System: o r I/"lG 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Loca i ere contents were disposed: G.L"S.P Lowell Waste Water Sign toWHaule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of RECEIVED a System Pumping Record Form 4 NOV 13 2008 TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of 4aIthF-QthJdff&ffi9hTd*Tbe 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, left rear, left side of house. Right fron rig t rea right sid of Ouse forms on the computer,use only the tab key Address /� �r to move your (� l cursor-do not use the return City/Town State Zip Code key. 2. System Owner: Name �- - Address(if different from location) City/Town State ip F 7-6 Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: 0 Cesspool(s) — eptic Tank Tight Tank Other(describe): 4. Effluent Tee Filter present? Q Yes LSO If yes, was it cleaned? Yes No 5. Condition of Sem: 6. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatio ere contents were disposed: L.s, Lowell Waste Water J- tignaluke of H u r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of _ System Pumping Record Form 4 ON 14 NO DEP has provided this form for use by local Boards of Health. Ot r orms m e the information must be substantially the same as that provided here l ck with your local Board of Health to determine the form they use. The Syste submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left front of house, right front of house, side of , right side of house, Left rear of house, right rear of house, left side of building, right rear of building, under deck. C"'t�--.. Lv�\ /��4AV\ City/Town State Zip Code 2. System Owner: Name Address(if different from location) City/Town State� � � �C-� �p Gede 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 2 No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of ,ystem: f 6. ed System P B Pumped p Y Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. L n ere contents were disposed: ed. G.L.S.D ell Wa ater Signat e H ler Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of AECEIVE System Pumping Record Form 4 DEC $81011 M y• DEP has provided this form for use by local Boards of Health. Other fo r� Rt3 information must be substantially the same as that provided here. Bef 'r ith your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/Right front of house, Left/Right rear of ho Le^ g ;e of h , Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address �7 Lv\, Citylrown State Zip Code 2. System Owner: Name Address(if different from location) Cityrrown State /I —,6,,,,6Zip Code Telephone Number �t 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 ion of System: � 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Lo ' n ere contents were disposed: G.L,S.Q Lowell Waste Water SignAtufe cfHauleU Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts = City/Town of RECkVEF System Pumping.Record Form 4 NO'S r 1014 CVvnj�Uh NOW ANDOVER DEP has provided this form for use,by local Boards of Health. iRI ARr+P1 tamed, ut the information must be substantially the same as that provided h using. isrm;check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/Right front of house, Left/Right rear of hous L ft/ deo house Left/ Right side of building, Left/Right front of building, Left/Right rear of bui dingy, Under de Address Cityrrown State Zip Code 2. System Owner. Name Address(if different from location) Cityfrown State , ip ode t Telephone Number ✓ B. Pumping Record 1. Date of Pumping 2. Qua Pum ed: Date P Gallons 3. Type of system: ElCesspool(s) Septic Tank El Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yeas Ly'Na If yes, was it cleaned? ❑ Yes ❑ No; ' 5. Condition 6: system Pumped By.- Nell. y:Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Comparry 7. Locat' ere contents were disposed: G•�-s'• Lowell Waste Water Sig Houle Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 M tkOR Ty �� SEED I 676 0 O ' t6 'P JE ��SSgcHUSe��� PUBLIC HEALTH DEPARTMENT Community Development Division Date: February 6, 2008 Warren and Robin Markowsky 67 Cricket Lane North Andover, MA 01845 Re: ' Building application for addition Dear: Mr. and Mrs. Markowsky, Your application for the addition has been reviewed by the Health Department. The application was originally denied in written form on, January 15, 2008 due to increased flow that would require a septic system upgrade or another option that was listed. A subsequent application was received on January 31, 2008, indicating that the 3-season room would not be insulated and therefore should not be counted as a room. The result of this change implied that there was no increase in flow. This second application was found deficient for the following reason as shown in italicized red: 1. ❑ Missing information 2. X Passing Title 5 inspection of septic system required per local N. Andover regulations 3. ❑ Location of structure not acceptable Unknown at this time 4. ❑ Undersized s ed septic system Unknown at this time To address the problem(s): If#1 is checked, please supply: a. Floor plan of existing and proposed addition—all rooms b. Certified plot plan showing house, septic system and proposed project in scale (you may pick up an as-built septic plan at the Health Office and draw in the addition) If#2 is checked: a. Have the septic system inspected by a certified Title 5 inspector to determine whether it is operating properly: (inspector list attached) OR b. Tie-in to municipal sewer 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorth and oversom H#3 is checked: a. Relocate the project 1r#4 is checked: Options a. Provide additional information proving that the existing septic system meets current capacity requirements. Please consult a professional engineer or registered sanitarian to determine the flow capacity of the septic system. b. Hire a professional engineer to design a new septic system that meets State Regulations c. Request approval of a deed restriction agreeing to always be a bedroom home. i. Submit a request in writing to the Board of Health identifying why the need to upgrade the septic system is a severe hardship, ii. Attend a BOH meeting to address the board iii. If approved, record the deed restriction at the registry of deeds In addition to the passing Title V Inspection, the Health Dept, is also requesting a written acknowledgment. The letter will establish that the enclosure is not going to be utilized as living space and that if this area is converted in the future the owner is aware that the old septic system will have to be replaced with a system fully compliant with the MA DEP and NA Board of Health Regulations. Once a passing Title V inspection, and the signed document are received, the building permit will be approved by the Health Office. Thank you. Sincerely, 11-1,,-Susw1 Sawyer, Pu is Heal irector Cc: Building Department File 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com t%OR Til Q� S,ED �/1✓ OL yyO T ? _K lb O cxwic.a:wc- 1- 9 ��SSgcHus'spy PUBLIC HEALTH DEPARTMENT Community Development Division Date: February 8,2008 Warren and Robin Markowsky 67 Cricket Lane North Andover, MA 01845 Re: Building application for porch addition and repair Dear: Mr. and Mrs. Markowsky, .The building application dated January 31, 2008, to repair the existing porch and add a deck, at 67 Cricket Lane has been approved. Note that this correspondence dated February 8, 2008 supersedes the previous denial letter sent to you regarding the second building permit application. Per a phone discussion between Robin Markowsky and Susan Sawyer held on February 8, 2008 the new application does not include the enclosure of the screened porch; rather it is a repair of the existing structure and the addition of a large deck. Please be advised that the septic system servicing this property is at maximum capacity. Future increase in the footprint of this building will require a Title V inspection; however, to increase the number of rooms in this home in the future will require a fully compliant septic system upgrade. An increase in room number does include the conversion of the screened in porch to a three-season room. Thank you for your cooperation in this matter Sincerely, ; S`us Sawyer, ublic Health Di or Cc: Building Department File 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.towoofnorthandover.com Dan GObeil Lorne Improvement 80 Munroe Street Haverhill, MA 01.830 (508) 451-0493 C.S. 063220 CONTRACT RSG, 132182 CUSTOMER :Robin & Warren Markowsky DATE: January 26,2008 67 Cricket Ln. North Andover 01845 978-6876869 PLAN: Add on to screen room & build deck THE JOIE WILL INCLUDE THE FOLLOWING: PRICE • Add approximately 6' on.to existing screen room, making it 12'x20'. • Create an opening on left side for one Storm door, and two screened in o enin s. • Create three symmetrical openings in rear for three screened in openings. • Create opening on right side for two screened o enin s. • Vault ceiling leaving existing roof line and add two "Velux"manual skylights. • Apply tongue& groove pine to entire area. • Electrical: Switches and outlets to code and install ceiling fan. Fan to be provided by homeowner. $550.00 • Painting and staining to be done by others. TOTAL MATERIAL AND LABOR $17,348.00 • Build aI2'x28' deck with a 24'x12' pyramid off of that. • Stairs will go down a few steps to a landing then proceed towards driveway. Back steps will be 4' to 6' wide with no rails. • Full Skirt around entire deck with trim. • Price for Reserve Rail and Pro-Cell decking style deck. TOTAL MATERIAL AND LABOR $20,639.00 Payments will be scheduled in quarter increments throeh different hases of'ob. • DUMPSTER AND PERMIT FEES INCLUDED • Anything above and beyond said work will be done on a time and material basis at a rate of$45.00 an hour. Payments will be in quarter increments TOTAL MATERIAL AND LABOR: through different phases of job 38537.00 ACCEPTED & AGREED TO BV: Robin Markowsky Daniel Gobeil DATE: DATE: o ,,ORTH q O T�eD '6w �O it io OCMI[IM WKw V �i9 q�RATiD wPt��� SSACHUS� PUBLIC HEALTH DEPARTMENT Community Development Division Date: December 18,2007 Warren and Robin Markowsky 67 Cricket Lane North Andover,MA 01845 Re: Building application for addition Dear: Mr. and Mrs. Markowsky, Your application for the addition has been reviewed by the Health Department. The application was denied on, December 18, 2007, for the following reason as shown in italicized red: 1. X llissing information 2. X Passing Title 5 inspection of septic system required per local N. Andover regulations 3. ❑ Location of structure not acceptable Unknown at this time 4. ❑ Undersized septic system Unknown at this time To address the problema If#1 is checked, please supply: a. Floor plan of existing and proposed addition—all rooms b. Certified plot plan showing house, septic system and proposed project in scale (you may pick up an as-built septic plan at the Health Office and draw in the addition) If#2 is checked: a. Have the septic system inspected by a certified Title 5 inspector to determine whether it is operating properly: (inspector list attached) OR b. Tie-in to municipal sewer If#3 is checked: a. Relocate the project If#4 is checked: Options 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.com 4 a. Provide additional information proving that the existing septic system meets current capacity requirements. Please consult a professional engineer or registered sanitarian to determine the flow capacity of the septic system. b, Hire a professional engineer to design a new septic system that meets State Regulations c. Request approval of a deed restriction agreeing to always be a=bedroom home. i, Submit a request in writing to the Board of Health identifying why the need to upgrade the septic system is a severe hardship. ii. Attend a BOH meeting to address the board j iii. If approved, record the deed restriction at the registry of deeds Once the floor plan is reviewed, a determination will be made whether a septic upgrade is required. It is recommended that you complete tasks I.a and 2.a prior to the hiring the septic inspector. This way you will know that if the system passes its inspection there will be no additional issues. Please feel free to call the Health Office at 978-688-9540 with any questions you may have. Sincerely, Susan Sawyer, Public Health Director Cc: Building Department File 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com 5 y t&ORTH ✓ 0 ,�5�-E� 16��0 a OL O A O cu.uiwwrt. 1 9 ��SSAC HUS���� PUBLIC HEALTH DEPARTMENT Community Development Division Date: January 15,2007 Warren and Robin Markowsky 67 Cricket Lane North Andover,MA 01845 Re: Building application for addition Dear Mr. and Mrs. Markowsky, Thank you for submitting the requested information in regards to your building application to close in the screened room and add a porch to your property listed above. Your application for the addition has been reviewed by the Health Department, however, it was unfortunately denied on January 15, 2008, for the following reasons. As detailed in the previous denial, the review of the house floor plans, submitted by you, indicate that the home has greater than the nine(9)rooms (not including bathrooms and hallways)that it was originally approved for and is therefore currently in non-compliance with the State Environmental Code regarding subsurface disposal systems. The Health Dept. file shows no previous approval or agreements regarding the number of rooms; however please know that the code also does not penalize homeowners for past actions. The purview of this office is to bring systems into compliance as these conditions come to our attention as in your case. The enclosure of the porch as described in the proposal submitted by Dan Gobeil Home Improvement describes in detail the enclosure of the screen room. This enclosure is by definition and increase in flow. See attached section of the MA DEP regulations.310.15.204 An increase in flow cannot be allowed other than as listed in the regulation. Mr. Neil Bateson came to our office to review materials to do a Title V inspection on your property. We informed him that to do the inspection at this point is not prudent and suggest he hold on the inspection until further notice. As of right now a full septic system upgrade would be required to move forward in this project. If you choose to do a new septic system, the place to begin would be with an engineer who specializes in septic systems. We would be happy to walk you through the process if you plan to take action in this direction. 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com In addition to not needing the Title V Inspection, it is also unnecessary to complete the original tasks requested. These items were noted in the previous letter, "Once the floor plan is reviewed, a determination will be made whether a septic upgrade is required. It is recommended that you complete tasks La and 2.a prior to the hiring the septic inspector." If you disagree with the findings of this review in regards to the number of rooms being greater than 9, please contact this office and we could arrange a walk through of your home. Also see section 15.412 and the complete code for variance information if you consider enforcement of this regulation to be manifestly unjust and you wish to come before the board to ask that a deed restriction be considered. You must prove and supply all previously requested information(see previous denial letter)and request to be on a Board of Health agenda to address this consideration. Sincerely, S Sawyer, REHS/RS blic Health Director Cc: Building Department File 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 fax 978.688.8476 Web www.townofnorthandover.com i 310 CMR: DEPARTMENT OF ENVIRONMENTAL PROTECTION .'.S 15.204: Increases in Design Flow to System F No person shall increase the actual or design flow to any cesspool or to any other system above the existing approved capacity,or change the type of establishment of a facility served by a cesspool, ded first. Upgrades to accept increased design flow shall be unless the cesspool or system is upgra performed in full compliance with the requirements applicable to new construction unless a variance is allowed pursuant to 310 CMR 15.414. For purposes of 310 CMR 15.204,the approved design flow fi shall be the flow listed in the most recent Disposal Works Construction Permit. 15.211: Minimum Setback Distances $; (1) All systems must conform to the minimum setback distance for septic tanks,holding tanks,pump r, chambers,treatment units and soil absorption systems,including reserve area,measured in feet and ', as set forth below. Where more than one setback applies,all setback requirements shall be satisfied. ry Septic Tank Soil Absorption System Holding Tank Pump Chamber }t Treatment Unit Grease Traps Property Line 10[5] 10[5] sx ' Cellar or Crawl Space Wall, Swimming Pool(inground),foundation drain 10 20 Slab Foundation 10 10 e� Water Supply Line(pressure) 10[1] 10[1] yf Surface Waters(except wetlands) 25 50 "* Bordering Vegetated Wetland(BVW), Salt Marshes,Inland and Coastal Banks 25 50 k" Surface Water Supply- Reservoirs and Impoundments 400 400 Tributaries to Surface Water Supplies 200 200 Wetlands bordering Surface Water Supply or Tributary thereto 100 100 Certified Vernal Pools 50 100[2] Private Water Supply Well or Suction Line 50 100 y c ; Public Water Supply Well (2) (2) Irrigation Well 10 25 Open,Surface or Subsurface Drains which discharge to Surface Water Supplies or tributaries thereto 50 100 a" Other Open,Surface or Subsurface Drains ='' (excluding foundation drains)which intercept seasonal high groundwater a table[3] 25 50 %� Other Open,Surface or Subsurface Drains ,wt (excluding foundation drains) 5 10 Leaching Catch Basins& ti Dry Wells 10 25 ° Downhill Slope not applicable 15[4] 5 [1) Disposal facilities shall be at least 18 inches below water supply lines. Wherever sewer ' lines must cross water supply lines,both pipes shall be constructed of class 150 pressure pipe and shall be pressure tested to assure watertightness. [2] The required setback shall be 50 feet where the applicant has provided hydrogeologic data acceptable to the Approving Authority demonstrating that the location of the soil absorption system is hydraulically downgradient of the vernal pool.Surface topography alone is not determinative. 14 4/21/06 310 CMR-512 ' r Se. k I 310 CMR: DEPARTMENT OF ENVIRONMENTAL PROTECTION u � 15,412: continued w, (c) With the exception of those watersheds(Ware,Quabbin and Wachusett)to which the provisions of 350 CMR 11.00 (MDC Watershed Protection regulations) apply, local '• moi£ Approving Authorities may,after consultation with the local water supplier,issue variances for the siting of systems within the setbacks to surface water supplies or to tributaries to surface water supplies and may exempt tributaries consistent with the standards and procedures of 350 CMR 11.00 without Department approval provided that no such variance or exemption shall result in the siting of a septic tank or soil absorption system within 200 , feet of said surface water supplies or 100 feet of said tributaries,or siring of a septic tank within 25 feet or a soil absorption system within 50 feet of any surface water. Copies of all such variances for uses and exemptions of tributaries shall be submitted to the Department by the local Approving Authority within 30 days of issuance. 15.413: Conditioning of Variances (1) The local Approving Authority or the Department may issue variances subject to such Y conditions, including, but not limited to, monitoring and reporting requirements, deed recordation requirements,financial assurances or other qualifications on the use of the system, as it deems necessary to protect public health, safety, welfare and the environment. Any conditions shall be expressed in writing in allowing the variance. (2) Any denial of a variance by the local Approving Authority or the Department may direct the applicant to upgrade an existing system consistent with the requirements and standards of 310 CMR 15.404 and 15.405. Failure to do so may be the subject of enforcement action by the local Approving Authority or the Department. 15.414: Variances for Increased Flow to Existing System Local approving authorities and the Department may vary the application of any provisions c {' of 310 CMR 15.000 with respect to any particular case involving increased flow to an existing system only when in the opinion of both the Department (except as provided in 310 CMR 15.412(4))and the local Approving Authority all of the following conditions are met. A showing by the person requesting a variance that the proposed variance would satisfy the maximum feasible compliance provisions as set forth in 310 CMR 15.404 and 15.405 shall not presumptively entitle such person to a variance. k (1) The person requesting a variance has established that strict enforcement of the provision of i' 310 CMR 15.000 from which a variance is'sought would be manifestly unjust,considering all the relevant facts and circumstances of the individual case including, at a minimum, the following: a the owners of any such stem for which permit applications were after March 31 , 1995 shall be deemed to have had knowledge that full compliance with the requirements applicable to new construction is preferred; (b) the costs of full compliance with the requirements applicable to new construction shall be compared to the costs of compliance with a variance;and (c) whether an upgrade in full compliance with 310 CMR 15.000 is feasible without increased flow. ! .(2) The system cannot be brought into full compliance through any of the following: ! I (a) an upgraded system which is in full compliance with 310 CMR 15.100 through 15.293; (b) an alternative system which has been approved for such use pursuant to 310 CMR 15.284remedial use),), 1528 5 (piloting), 15.286 (provisional approval), or 15.288 (certification for general use); (c) a shared system which has been approved for such use pursuant to 310 CMR 15.290 and 15.291;or (d) connection to a sewer system. (3) The upgraded system with the increased flow provides better protection of public health and safety and the environment than the existing system with no increase in flow. Increased flows not in compliance with 310 CMR 15.000 will rarely pOvide better protection than existing flows to a system designed and constructed in compliance-Kith the 1978 Code or 310 CMR 15.000, but are more likely to constitute improvements over nonconforming or failed systems. 9/22/06 (Effective 4/21/06)-corrected 310 CMR-566 i i .0000,L, A � a -- f myyl A t 1 , o f It f }rI� 1 I _ C Y �) i S I 6ESr NCE !E-©r�D:5f PROCFG.< 1.21(1'2' V 1 j i i ©AJ s 'EE XT x G `�`` �, 6OV4 T rO4 I Z`X I4' SCC C CJA - C- PVC 6 7-10AI � I 4'f C3 (4007711 jis cz sof F s ,5gmPst)Ai Pos t 5 14' i V 1 P C*x COMMONWEALTH OF MASSACHUSETTS r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS o DEPARTMENT OF ENviRoNMENTAL PROTECTION ONE WINTER STREET,BOSTON,MA 02109 617-292-5500 r V ARGEO PAUL CELLUCCI TRUDY CORE Governor Secretary ARGEO PAUL CELLUCCI - DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address:67 Cricket Lane, North Andover Name of owner: Walnut Ridge Development LLC Address of Owner:Same Date of Inspection:3/29/00 Name of Inspector:Richard A. Briscoe I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: R.A. Briscoe,'lnc. Mailing Address: 61 Garrison St., Groveland, MA 01834 Telephone Number:[9781372-2200 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 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 Furth Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: ,3 -.3t. OG The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 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. NOTES AND COMMENTS t1my 31 r (revised 9/2/98) Page 1 of 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:67 Cricket Lane, North Andover Owner: Walnut Ridge Development LLC Date of Inspection: 3/29/00 INSPECTION SUMMARY: Check A,B, C, or D: A.SYSTEM PASSES: have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B.SYSTEM CONDITIONALLY PASSES: A14 One or more system components as described in the"Conditional Pass"section needs to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,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,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the septic tank is replaced with a conforming septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is leveled 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 Board of Health): broken pipe(s)are replaced obstruction is removed '.l (revised 9/2/98) Page 2 of 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 67 Cricket Lane, North Andover owner: Walnut Ridge Development LLC Date of Inspection: 3/29/00 C.FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: 414 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 DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)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 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 PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS 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. Method used to determine distance (approximation not valid) 3) OTHER •1 (revised 9/2/98) Page 3 of 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 67 Cricket Lane, North Andover owner: Walnut Ridge Development LLC Date of Inspection: 3/29/00 D.SYSTEM FAILS: *14 You must indicate"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described 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. Yes No 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 dogged 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. E.LARGE SYSTEM FAILS: PA You must indicate"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd 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: 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 11 of a public water supply well. The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. (revised 9/2/98) Page 4 of 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 67 Cricket Lane, North Andover Owner: Walnut Ridge Development LLC Date of Inspection: 3/29/00 Check if the following have been done: You must indicate either"Yes"or"No"as to each of the following: Yes No _ Pumping information was requested of the owner,occupant,and Board of Health. X _ 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 plans have been obtained and examined.Note if they are not available with The facility or dwelling was inspected for signs of sewage back-up. 4L _ The system does not receive non-sanitary or industrial waste flow —, _ The site was inspected for signs of breakout. _ All system components,excluding the Soil Absorption System,have been located on the site. _ The septic tank manholes were uncovered,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: ,X _ Existing Information. Ex.Pian at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)] _ The facility owner and occupants,(if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal System. .f (revised 9/2198) Page 5 of 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 67 Cricket Lane, North Andover owner: Walnut Ridge Development LLC Date of Inspection: 3/29/00 FLOW CONDITIONS RESIDENTIAL: Design flow: ASV Q.p.d./bedroom. Number of bedrooms(design)---!t Number of bedrooms(actual) ±, Total DESIGN flow: 0-0 W40 Number of current residents: 2 Garbage grinder(yes or no):- Laundry(separate syatem)(ycs or no):_Ao If yes,separate inspection required. Laundry system Inspected(yes or no):_Ao Seasonal use(yes or no):_M Water meter readings,if available(last two year's usage(gpd): Sump Pump(yes or no) /0 Last date of occupancy:_(,VIA7,0 COMMERCIALANDUSTRIAL: . Type of establishment: Design flow: gallons/day (Based on 15.203) Basis of design flow: 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 vailable: Last date of occupancy OTHER:(Describe) Last date of occupancy:_ GENERAL INFORMATION PUMPING RECORDS and source of information: /ff 7 System pumped as part of inspection:(yes or no) LW If yes,volume pumped gallons Reason for pumping: TYPE QF SYSTEM A Septic tank/distribution boxisoil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract. Tight Tank Copy of DEP Approval Other �- APPROXIMATE AGE of all components,date installed(if known)and source of information: J Sewage odors detected when arriving at the site:(yes or no) (revised 9/2/98) Page 6 of 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 67 Cricket Lane, North Andover Owner: Walnut Ridge Development LLC Date of Inspection: 3/29/00 BUILDING SEWER: (Locate on site plan) Depth below grade:_ Material of construction:_cast iron 40 PVC_other(explain) Distance from rivate water supply well or suction line Diameter Comments: (condition of joints,venting,evidence of leakage,etc.) SEPTIC TANK: S (locate on site plan) Depth below grade: Material of construction: ncrete_metal_Fiberglass_Po lyethylene_other(explain) If tank is metal,list age=Is age certified by Certificate of Compliance—(Yes/No) Dimensions:000 G Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: I.3 Scum thickness: , 3 Distance from top of scum to top of outlet tee or baffle_ Distance from bottom of scum to bottom of outlet tee or baffle: !.2 How dimensions were determined: Qofx -A4 Comments: �ACIVS /ti/��*C�t, (recommendation for pumping,cond on of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,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: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage etc.) 'l (revised 9/2/98) Page 7 of 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 67 Cricket Lane, North Andover Owner: Walnut Ridge Development LLC Date of Inspection: 3/29/00 TIGHT OR HOLDING TANK:Ad(Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: Material of constructlon:_concrete_metal_Fiberglass_Polyethylene other(explain) Dimensions: Capacity: aallons Design flow: aallons/day Alarm present: Alarm level: Alarm in working order_Yes;_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert:_ Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.) PUMP CHAMBER: ,W (locate on site plan) Pumps in working order:(Yes or No)_ Alamo in working order:(Yes or No)_ Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) (revised 9/2/98) Page 8 of 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 67 Cricket Lane, North Andover Owner: Walnut Ridge Development LLC Date of Inspection: 3/29/00 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not located,explain: Type: leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Altemative system: Name of Technology: Comments: (note condition of soll,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) CESSPOOLS: (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(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:__AP (locate on site plan) Materials of construction: Dimensions: Depth of solids:_i„_ Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) (revised 9/2/98) Page 9 of 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 67 Cricket Lane, North Andover Owner: Walnut Ridge Development LLC Date of Inspection: 3/29/00 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent references landmarks or benchmarks locate all wells within 100'(locate where public water supply comes Into house) revised 9/2/98 Page 10 of 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 67 Cricket Lane, North Andover Owner: Walnut Ridge Development LLC Date of Inspection: 3/29/00 NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow: Moderate: Deep: SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 6 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record Observation of Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators,installers Use USGS Data Describe In your own words how you established the High Groundwater Elevation. (Must be completed) a/V O/�v (revised 9/2/98) Page 11 of 12 h R. A. BRISCOE, INC. 61 GARRISON ST. GROVELAND,MA 01834 TEL.(978)372-2200 FAX(978)372-2450 SEPTIC SYSTEMS.DESIGNED, BUILT, REPAIRED AND PUMPED Title V Inspections Title V Inspection Report 3/29/00 Property Address: 67 Cricket Lane, North Andover Owner. Walnut Ridge Development LLC Date of Inspection: 3/29/00 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. R. A. Briscoe •D !D Page 12 of 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 67 Cricket Lane, North Andover Owner: Amy J.Channen Date of Inspection: 8/23/97 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100'(locate where public water supply comes into house) A � 0 C D 7A4-/,c nisi bov 7X Zy 4rej C - 17- 0 _..1 4 _ 0 _ 3Z. 6 O S2 D r (revised WOW) Page 9 of 11 f • T(.}*.: COMMONWEALTH OF MASSACHUSETTS r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS 0DEPARTMENT OF ENVIRONMENTAL PROTECTION 2 o � ONE WINTER STREET,BOSTON,MA 02109 617-292-5500 WILLIAM F.WELD TRUDY COXE Govemor Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address:67 Cricket Lane, North Andover Owner: Amy J. Channen Date of Inspection:8/23/97 Address of Owner:Same Name of Inspector: Richard A. Briscoe (if different) I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: R. A. Briscoe. Inc. Mailing Address: 61 Garrison St., Groveland, MA 01834 Telephone Number: [5081372-2200 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 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: _k-P-as ses _Conditionally Passes _Needs Further Evaluation By the Local Approving Authority _Fails Inspector's Signature: Date: Z 3. 97 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 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]SYSTSES: V IIhhave 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. COMMENTS: B]SYSTEM CONDITIONALLY PASSES: One or more system components as described in the"Conditional Pass"section needs to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,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,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 11 r ti SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:67 Cricket Lane, North Andover Owner: Amy J. Channen Date of Inspection: 8/23/97 B]SYSTEM CONDITIONALLY PASSES(continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled 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 Board of Health): broken pipe(s)are replaced obstruction is removed Cl 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 DETERMINES 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 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS 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. Method used to determine distance (approximation not valid) 3) OTHER (revised 04/25/97) Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 67 Cricket Lane, North Andover Owner: Amy J. Channen Date of Inspection: 8/23/97 D]SYSTEM FAILS: You must indicate"Yes"or"No"as to each of the following: 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. Yes No 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 clogg5ed 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. E]LARGE SYSTEM FAILS: You must indicate"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd 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: 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. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00.Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 67 Cricket Lane, North Andover Owner: Amy J. Channen Date of Inspection: 8/23/97 Check if the following have been done: You must indicate either"Yes"or"No"as to each of the following: Yes No V _ Pumping information was requested of the owner,occupant,and Board of Health. V _ 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 plans have been obtained and examined.Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow The site was inspected for signs of breakout. All system components,excluding the Soil Absorption System,have been located on the site. _ The septic tank manholes were uncovered,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: _ The facility owner and occupants,(if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing Information. Ex.Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)] (revised 04/25/97) Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 67 Cricket Lane, North Andover Owner: Amy J. Channen Date of Inspection: 8/23/97 FLOW CONDITIONS RESIDENTIAL: Design flow: LOp.d./bedroom for S.A.S. Number of bedrooms:_y Number of current residents. Garbage grinder(yes or no): �� Laundry connected to system(yes or no)jes Seasonal use(yes or no): 9)p 7'(Z v v Water meter readings,if available(last two(2)year usage(gpd): l0/5700 /y f' � Z y 610,((( Sump Pump(yes or no)--Ajo Last date of occupancy::C.(,Jlol Lcij COMM ERCIAL/INDUSTRIAL: Type of establishment: Design flow: gallons/day 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 vailabie: Last date of occupancy OTHER:(Describe) Last date of occupancy:_ GENERAL INFORMATION PUMPING RECORDS and source of information: -D System pumped as part of inspection:(yes or no) /(/0 /.�¢/ eSC�✓ 2 rd Co/a�S If yes,volume pumped gallons 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) VA Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components,date installed(if known)and source of information: �7 O 3 ,lftJ Sewage odors detected when arriving at the site:(yes or no)—4 1A (revised 04/25/97) Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 67 Cricket Lane, North Andover Owner: Amy J. Channen Date of Inspection: 8/23/97 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction:_cast iron_40 PVC�ther(explain) Distance from private water supply well or suction line Diameter . Comments: (condition of joints,venting,evidence of leakage,etc.) SEPTIC TANK:- (locate on site plan) I Depth below grade: Material of construction: 1oncrete_metal_Fiberglass_Polyethylene other(explain) If tank is metal,list age_is age certified by Certificate of Compliance_(Yes/No) Dimensions: 4061) 4'A c Sludge depth: — Distance from top of sludge to bottom of outlet tee or baffler Scum thickness:_ Distance from to of scum to top of outlet tee or baffle:` Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: Q-'Ck Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) GREASE TRAP: IVO (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: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet Invert,structural integrity, evidence of leakage etc.) (revised 04/25/97) Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 67 Cricket Lane, North Andover Owner: Amy J. Channen Date of Inspection: 8/23/97 TIGHT OR HOLDING TANK:—h-oTank must be pumped prior to,or 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 level: Alarm in working order_Yes;_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX:�p7 (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.) - PUMP CHAMBER--W (locate on site plan) Pumps in working order:(Yes or No)_ Alarms in working order:(Yes or No)_ Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) (revised 04/25/97) Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 67 Cricket Lane, North Andover Owner: Amy J. Channen Date of Inspection: 8/23/97 SOIL ABSORPTION SYSTEM(SAS).— (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number: u J length:leaching fields,number,dimensions: overflow cesspool,number: Altemative system: Name of Technology: Comments:(note condition of soil,signs of hydraulic failur ,level of ponding,condition of vegetation,etc.) 4jQ lJryVo i Dr .aec�_�u7' CESSPOOLS:_ (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(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 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.) (revised 04/25/97) Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 67 Cricket Lane, North Andover Owner: Amy J. Channen Date of Inspection: 8/23/97 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100'(locate where public water supply comes into house) o � C D TA4-k ois/ 7x z y _../ 4 - - 3Z. 6 S2-0 (revised 04/25/97) Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 67 Cricket Lane, North Andover Owner: Amy J. Channen Date of Inspection: 8/23/97 r Depth to Groundwater 6 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site(Abutting property,observation hole,basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators,installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) (revised 04/25/97) Page 10 of 11 R. A. BRISCOE, INC. 61 GARRISON ST. GROVELAND,MA 01834 TEL.(508)372-2200 FAX(508)372-2450 SEPTIC SYSTEMS.DESIGNED,BUILT,REPAIRED AND PUMPED Title V Inspections Title V Inspection Report 8/23/97 Property Address: 67 Cricket Lane, North Andover Owner. Amy J. Channen Date of Inspection: 8/23/97 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. kA. Briscoe Page 11 of 11 M1' +I E �.. f r .."t, l Ii. �?r ttf I:.t, Ir'-�1raaP" t :aN ft St";Y t ? ,:t t f;f } fh-" I' ���-+-{ 'i 'r kIr t t wti�r `r ;,,P rI M& ° std f:e e Mrd I'r - s�,`, .e q Ir.�,i, r'r.�i z�`� ", J h I•�4. 1 a rtf,�s''yY�gtt' µ�?tq�`��ftxttx?n tri `ti erh t rs ',' - - ,� M� i�Y T J2 v � it!Y t') f y! y_ e e 71. -n Sp7 't,eS i +Y .t-��' "�C der 15 t q � 1. 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