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Miscellaneous - 67 VEST WAY 4/30/2018 (2)
` _ � o Feb 19 04 04:24p NOTICE OF VARIANCE/DEED RESTRICTION p.2 Pursuant to 310 CMR 15.00 Title 5, and as a condition of the North Andover Board of Health Disposal Works Construction Permit # Zlg2 dated notice is hereby given that real estate located at North Andover, Massachusetts, as described a deed from Kris and Linda Bierbaum to John M. Pallone and Donna J, Pallone dated 9/1/1998 and recorded in the Essex County Registry of Deeds in Book 2799 and Page 270 is the subject of a variance from the Town of North Andover Minimum Requirements for the Subsurface Disposal of Sanitary Sewage A1.05 and C9.01(4). Said variance limits the maximum number of bedrooms at this dwelling to four bedrooms. This variance is within the jurisdiction of the North Andover Board of Health. Signed and sealed this_ // day of we�2003 COMMONWEALTH OF MASSACHUSETTS Essex, ss. 2003 Then personally appeared the above-named John Pallone and Donna Pallone acknowledged the foregoing instrument to be their free act and deed, before me, notary public i� Date-Approved., I = r ' = Bacteria _II , Date Approved Plumbing Sign Off Wiring Sign off: Form "U" ApprovalAApproval to Issue YES NO 4 Date Issued f 6y #_....: Conditions -`1 FinalApproval" s Y . All Permits Paid =`- YES NO Well Construction Approial? YES - NO Septic System` onstrwction Approval. _" YES NO,. Certifications YES NO .Other? -.YES NO Any Variance Needed �. '�'ES NO `� TO Y 0 So FINAL BOARD OF HEALTH APPROVAL: DATE: APPROVED BY: r-- ..:..nSEPTIC s�(sTE INSTALLATION _ .:CONDITIONS: - 11%rT/�G� A-) Is the installer licensed YES N_0 - A x -- :;T,ype of Construction« EW` REPAIR z L. m. New.Construction - ;Cert�fiedP�lot_ PfanRev�ew''Yf h -- Yf� NO ` 4_ Floor Plan Review= r *' Contlit�ons ofwApp�oval from Forrn U. --Y-ES _ NOy a :� _- . z Issuance,of.' DW. permit 1 _ .YESNO .,DWCY,Perrr`iit'Paid� r /f y� _ . YES N0 , DWC Permit# _ z Installer =:: Begin�'Inspection .- � � ��. I_ YES NO 4 — — wry r ,Excavation Inspection. Needed _� w _ �.:. K :."t7 '„'4.r-T•:. .z.:.:.,r,TxS. �'ka.rs, .e-, _ ;,x,.,}:•.-.ter. #' £� a," w err ii� L 1 .t 74 Passed - By`�� s x Construction Inspect*on - a Needetl� '.f.: �.. xaaww°s3 �R�"'F" gyp'" '�• �..'S_ - _. ��r- - i F - -As Built Plan;Satisfactory - YES 7777777 .Approval of Backfill Dateii Final�Geadin9'AppfbVal Date: Final Construction Approval: Date: By Certificate of Compliance: Approval Date: _ A Of 'r 4 E '5,+6 eiueA*c¢ �2yo7►L S`KTeH . S1 is A REcow VP f5+9 La YtQ A WV F.LE vomoLl ;pF -r*4 ew yT u46 tires GOHPOf•16rJ rti. . I DMEL KOCR�A� N0.37752 �►�IL.�' PLAN OF SLjBSU-RFACE DISPOSAL SYSTEM ,. LOCATED IN UD 2T I� A N 7(N E 12..G7 �(E�i'� AS PREPARED FOR DATE: c9 - 19 •00 —rNI I oci 0 SCALE: l''= d`i0' _rL 1 69Z MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS 0 LAND SURVEYORS * PLANNERS 66 PARK STREET • ANDOVER. mASSACNUSETTS 01810 or TEL 1617) 475-3555, 373-5721 �1 Oviner information is nxluired for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. RQm t5ins - 03/13 Commonwealth of Massachusetts Title 5 Official Inspection Form 6v lllp rm Subsurface // Sewage Disposal -System Form - Not for Voluntary Assessments! -165 His 6 7 �'S� Ljq C oioyQr, TOWN OF NORTH ANDOVER State p Code Date of inspection Inspection results must be submitted on this form. Inspection forms may not be altered In any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector. NA Ile r� Name of Inspector Company Name aj Company Address �—, I 6,1) City/Toyun 9 4 4� 4 Teleph ne Number B. Certification State Zip Code _____� License Number 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 CHAR 15.000). The system: (Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Ins i's Slgnature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared syst em or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. """This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. TrJ8 5 OffidW k"Pw*M FWM Subsuftm B DbposW gysfam • page 1 d 17 Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments S 7 es (,v Property Address Owner's Name City/Town State Zip Code B. Certification (cont.) Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: Z"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: G B) System Conditionally Passes: (-e— One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the lowing statyements. If "not determined, " please explain. The septic tank is metal and over 20 years old' or the se c tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or filtration or tank failure is imminent. System will pass inspection if the existing tank is replaced h a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspectio ' it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank i ess than 20 years old is available. ❑ Y ❑ N 0 ND (Explain below): Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 2 of 17 Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 6 -� ps -� (�Ja Property Address Cityrrown B. Certification (cont.) B) System Conditionally Passes (cont.); State Zip Code Date of Inspection ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND ( xplain below): 11 obstruction is removed El El ❑ (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ Y`—' ND (Explain below): ❑ The System required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if Ith approval of the Board of Health): ❑ broken Z'removed eplaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruct ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health de mines in accordance with 310 CMR 15.303(1)(b) that the system is not function' g in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within feet of a surface water ❑ Cesspool or privy is wi in 50 feet of a bordering vegetated wetland or a salt march t5ins - 03/13 Title 5 Official Inspection Form Subsurface sewage Disposal System •Pepe 3 of 17 Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 6 �? Property Address Owner's Name City/Town o. %►eruyication kcont.) State Zip Code Date of Inspection 2. System will fail unless the Board of Health (and Public Water Supplier, if any) deterimes 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, suppl ❑ The system has a septic tank and SAS and the SAS is within a Zo 1 of a public water supply. ❑ The system has aseptic tank and SAS and the SAS is with' 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SA 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 anal s, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presen of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no oth ailure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑N; ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow t5ins • 03113 Title 5 Official Inspection Fonn Subsurface Sewage Disposal System Page 4 of 17 Owner Information is required for every page. t5ins - 03/13 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i 6 - 1 Ve5-f Property Address Owner's Name City/Town B. Certification (cont.) Yes No ❑ Fir ❑ Cv)' AE State Zip Code Date of Inspection Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: Any portion of the SAS, Cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] L� This system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. / Yes No ❑ ❑ the system is within 400 feet of a ace drinkiing water supply ❑ ❑ the system is within 200 fe f a tributary to a surface drinking water supply ❑ ❑ the system is locate ' a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA or apped Zone II of a public water supply well If you have answered "yes" to question in Section E the system is condidered a significant threat, or answered "yes" in Secti above the large system has failed. The owner or operator of any large system considered a s' ificant threat under Section E or failed under Section D shall upgrade the system in accords with 310 CMR 15.304. The system owner should contact the appropriate regional officej he Department. Title 5 Ofticial Inspection Form Subsurface Sewage Disposal System - page 5 of 17 a - Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Foran Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V00s± Property Address Owner's Name City/Town C Checklist State Zip Code Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No 0' ❑ a ❑ 21 ❑ IDI ❑ Pumping information was provided by the owner, occupant, or Board of Health Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? This size and location of the Soil Absorption System (SAS) on the site has been determined based on: IJ ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 7 J` Q 6P) [Sins - 03/13 Title 5 Official Inspection Form Subsurface Sewage otsposal System • Page 6 of 17 Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner's Name City/Town D. System Information Description: state Zip Code Date of Inspection Number of current residents: Does residence have a garbage grinder? J 5 t roe U5 e 0 Yes ❑ No Is laundry on a separate sewage system? [if as separate in tion reauiredl El Yes LTJ Ne Laundry system inspected? J� ❑ Yes ❑ No Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions:. Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft.,etc.): Grease trap present? Industrial waste holding tank present? f ie Non -sanitary waste discharged to the Titjd5 system? Water meter readings, if available: ❑ Yes 1� No Gallons per day (gpd) ❑ Yes ❑ No Crr vj- - ,Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No TWO 5 Offldel Inspection Farm Subsurface Sewage Disposal system • Page 7 of 17 A Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e Property Address j Owner's Name City/Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: State Zip Code General Information Date Date of Inspection Source of information: ' L ._ qua i°Y Was system pumped as part of the inspection? ❑ Yes IJ No If yes, volume pumped: How was quantity pumped determined? 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) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5iris • 03113 71tle 5 Official Inspection Form Subsurface Sewage Disposal System - Page 8 of 17 Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner's Name Citylrown u. System Information (cont.) State Zip Code Date of Inspection Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: ❑ Yes 0 No L-� feet ❑ cast iron 12 40 PVC ❑ other (explain) AJ Distance from private water supply well or suction line: Am/ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: Material of construction: 1 concrete ❑ metal If tank is metal, list age: feet ❑ fiberglass / ❑ polyethylene ❑ other (explain) _-4-- years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: / Sludge depth t5ins • 03/13 11tl6 5 Official Inspection Form Subsurface Sewage Disposal System • Page 9 of 17 Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y6� Address ame Cityrrown D. System Information (cont.) Septic Tank (cont.) State zip Code Date of Inspection 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? l.D 71UUd6e 1A a Q - Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): a..MMUM ►.A.MM111111 MA11111111s, " • : i Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ Dimensions: Scum thickness Distance from top of scum to to ,o /outlet tee or baffle Distance from bottom of s71r' o bottom of outlet tee or baffle Date of last pumping: feet ❑ polyethylene ❑ other (explain) t5ins - 03113 Date TWe 5 Offldal Inspecuon Forth Subsurface Sewage Olsposal System • page 10 of 17 11 iL Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Address Owner's Name Gity/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee orb a condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ poly ylene ❑ other (explain) Dimensions: Capacity: Design Flow: Alarm present: Alarm level: Date of last pumping: Comments (condition of gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date and float switches, etc.): Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5irts • 03113 Title 5 Official Inspection Form Subsurface Sewage Disposal System • page 11 of 17 a r Owner Information is required for every page. t5ins • 03113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System form - Not for Voluntary Assessments offt2�:)-Q y Property Address Owner's Name Citylrown State D. System Information (cont.) Zip Code Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): 3 6 1A I Pump Chamber (locate on site plan): Pumps in working order: Q Yes ❑ No Alarms in working order: Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excav3§6'n"not required): If SAS not located, explain why: Title 5 Ofndal Inspection Form Subsurface Sewage Disposal System • Page 12 of 17 Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Address Owner's City/Town D. System Information (cont.) state Zip Code Date of Inspection Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of itechnology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cesspools (cesspool must be pumped as part of inspection) 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 on site plan): ❑ Yes ❑ No Title 5 Official Inspection Form Subsurface Sewage DISposal system • page 13 of 17 a Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner's Name City/Town D. System Information (cont.) State Zip Code Date 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 etc.): level of ponding, condition of vegetation, 15ins • 03113 Title 5 Official lnspedlon Form Subsurface Sewage olsposel SystemI Pap 14 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Vest Warr Owner's Name. North Andover Cityrrown MA 01845 State Zip Code Date of InSDectl Li. system Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately _ (:�q �► !L4 le[i a c4'6 C-'� D- - v7,R'3 1! t5ins • 11/10 Title 5 Oficial Inspection Forth: Subsurface Sewage Disposal System • page 15 or 17 lip. Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Address Gity/Town D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water / ❑ Check cellar ✓ ❑ Shallow wells Estimated depth to high ground water: State Zip Code Date of Inspection Te—et Please indicate all methods used to determine the high ground water elevation: u1 Obtained from system design plans on record If checked, date of design plan reviewed: ae ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USG$ database - explain: You must describe how you established the high ground water elevation: I Y Before filling this Inspection Report, please see Report Completeness Checklist on next page. l I Title 5 official Form Subsurface Sewaae I tsin:: - 03!73 System • Pa" 16 0! 17 1 Commonwealth of Massachusetts Title 5 OfficialInspecti' on Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments kq��tr Property Address Owner Owner's Name Information is requinad for every page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist 2- Inspection Summary: A, B, C, D, or E checked +� Inspection Summary D (System Failure Criteria Applicable to All Systems) completed System Information - Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 15ins - 03/13 71tle 5 Official Inspection Form Subsurface sewage Disposal System • Page 17 of 17 Summary Record Card generated on 7118/2016 2:15:55 PM by Karen Hanlon r' Town of North Andover " Tax Map # 210-1043-0162-0000.0 Parcel Id 16484 67 VEST WAY GLEN & PATRICIA SCHMIDT 67 VEST WAY NORTH ANDOVER MA 01845 Page 1 Class 101 Single Family Property Type 1 Residential Zonin92 1 Residential Zoning3 1 Residential Size Total 1.03 Acres FY 2016 UB Mailina Index Name/Address GLEN & PATRICIA SCHMIDT 67 VEST WAY NORTH ANDOVER MA 01845 PALLONE, JOHN 67 VEST WAY N. ANDOVER, MA 01845 UB Account Maint. Account No Cycle Bldg Id. 17812.0 - 67 VEST WAY 3170477 03 Cycle 03 UB Services Maint. Account No. 3170477 Service Code MISCFEEADMIN FEE WTR,'.WATER 4t Brand UB Meter Maintenance Account No. 3170477 ERT HH Serlai No Status w Water 0.63 0.63 36185549' a Active Code Date Reading 6/13/2016 1246 3/11/2016 1199 12/10/2015 1184 9/9/2015 1153 6/10/2015 1068 3/12/2015 1044 12/12/2014 1030 9/10/2014 1005 6/9/2014 908 3/11/2014 879 12/12/2013 865 9/12/2013 848 6/11/2013 772 3/14/2013 725 12/12/2012 713 11/14/2012 710 9/12/2012 685 6/12/2012 561 3/13/2012 517 12/12/2011 492 9/13/2011 447 6/7/2011 283 3/7/2011 259 12/8/2010 235 9/9/2010 211 6/8/2010 56 Type Loan Number Owner Previous Customer Active/lnact. From Inactive 11/16/2012 Occupant Name ActivelInactive Last Billing Date 4/14/2016 Active Rate Charge Multiplier/Users 0.635/8 7.82 1/ 01 ALL METER SIZE 57,00 /1 Until Location Brand Type Size YTD Cons ERT HH b Badger w Water 0.63 0.63 1191 Code Consumption Posted Date Variance a Actual 47 207% a Actual 15 4/2212016 -52% a Actual 31 1/20/2016 -64% a Actual 85 10/16/2015 250% a Actual 24 7/24/2015 71% a Actual 14 4/28/2015 -42% a Actual 25 1/15/2015 -74% a Actual 97 10/15/2014 224% a Actual 29 7/16/2014 105% a Actual 14 4/11/2014 -16% a Actual 17. 1/17/2014 -77% a Actual 76 10/15/2013 55% a Actual 47 7/24/2013 305% a Actual 12 4/22/2013 22% a Actual 3 1/9/2013 -73% f Final Bill 25 11/14/2012 -71% a Actual 124 10/15/2012 179% a Actual 44 7/16/2012 78% a Actual 25 4/14/2012 -46% a Actual 45 1/17/2012 -70% a Actual 164 10/13/2011 541% a Actual 24 7/20/2011 -3% a Actual 24 4/13/2011 1 % a Actual 24 1/12/2011 -84% a Actual 155 10/15/2010 552% a Actual 23 7/15/2010 -9% Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Q rcmen Commonwealth of Massachusetts Title 5 Official Inspection' Form Subsurface Sewage Disposal System Form - Not for Voluntary. Asses: 67 Vest Way Property Address John Pallone Owner's Name North Andover MA City/Town 01,0M 01845 Zip Code r. 141 nts i Gw T I OFNO HEALTH DEPARTME 9/11/2012 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Neil James Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover MA 01810 City/Town 978-475-4786 Telephone Number B. Certification State S115 License Number Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9/11/2012 inspector's Signat a Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the gondiitions of use at that time. This inspection does not address how the system will perform (l the fviture under the same or different conditions of use. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Vest Way Property Address John Pallone Owner's Name North Andover MA 01845 9/11/2012 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y 0 N ❑ ND (Explain below): t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Commonwealth of Massachusetts g . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 67 Vest Way Owner information is required for every page. Property Address John Pallone Owner's Name North Andover MA 01845 9/11/2012 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y. ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N F1 ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Vest Way Property Address John Pallone Owner's Name North Andover MA 01845 9/11/2012 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Vest Way Property Address John Pallone Owner Owner's Name information is required for North Andover MA 01845 9/11/2012 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or"less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200.feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a Nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If yob' have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins - 11/10 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts u v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 67 Vest Way Property Address John Pallone Owner Owner's Name information is required for North Andover MA 01845 every page. City/Town State Zip Code C. Checklist 9/11/2012 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 ' Commonwealth of Massachusetts ❑ No ❑ Title 5 Official Inspection Form ❑ No a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ❑ No 67 Vest Way Property Address John Pallone Owner Owner's Name information is required for North Andover MA 01845 9/11/2012 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Yes Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes ® No Current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M ,' 67 Vest Way Property Address John Pallone Owner Owner's Name information is required for North Andover MA 01845 9/11/2012 every page. Cityrrown D. System Information (cont.) Last date of occupancy/use: Other (describe below): State Zip Code General Information Date Date of Inspection Pumping Records: Source of information: Pumped Nov. 2009, owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Measure tank Reason for pumping: Inspect tank & tees 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) and a copy of latest inspection of the UA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 67 Vest Way Property Address John Pallone Owner information is required for every page. Owner's Name North Andover Citylrown MA 01845 9/11/2012, State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 12 years old, 9/19/2000, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 1.6 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" PVC to septic tank. Unable to see piping in house, finished cellar. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 9 feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 10' x 5' x 4' Sludge depth: 3" ❑ Yes ❑ No t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 67 Vest Way Property Address John Pallone Owner information is required for every page. t5ins • 11/10 Owner's Name North Andover Cityrrown MA 01845 State Zip Code 9/11/2012 Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 25" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts o- W Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 67 Vest Way Property Address John Pallone Owner information is required for every page. Owner's Name North Andover MA 01845 9/11/2012 City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: Design Flow: gallons gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ❑ Yes ❑ No " Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Vest Way Property Address John Pallone Owner's Name North Andover Cityrrown D. System Information (cont.) MA 01845 9/11/2012 State Zip Code Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert D Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D -box level & distribution equal. No evidence of leakage. Evidence of light carryover, pumped d -box to clean. D -box has riser, cover 1" deep. Pump Chamber (locate on site plan): Pumps in working order: ® Yes ❑ No Alarms in working order: ® Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump ok. Alarm ok, has both audible & visual. Power wire for hot tub runs over metal actress cover for Gump tank. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer _ t . Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System . Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Vest Way Property Address John Pallone Owner Owner's Name information is required for North Andover MA 01845 9/11/2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching.chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: x 50' leach fifelel d ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer _ t . Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System . Page 13 of 17 —vim= Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Vest Way Property Address John Pallone Owner's Name North Andover MA 01845 9/11/2012 City[Town State Zip Code Date of Inspection D. System* Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Vest Way Property Address John Pallone Owner's Name. North Andover MA 01845 9/11/2012 City/Town State Zip Code Date of Inspection D. System Information (cont.) . Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Vest Way Property Address John Pallone Owner's Name North Andover MA 01845 9/11/2012 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 4 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 8/25/1999 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Design plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Test pit data on design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 67 Vest Way Property Address John Pallone Owner information is required for every page. Owner's Name North Andover MA 01845 9/11/2012 Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins - 11/10 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 ,C-\ Commonwealth of Massachusetts City/Town of o System Pumping Record Form 4 DEP has provided this form 'for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. `Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left / Right front of house, Left / Right rear of house, Left / ' side of house eft / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address Citylrown State 2. System Owner. Name Address (if different from location) Citylrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): q — It — f<a, — 2. Quantity Pumped Septic Tank Zip Code State Zip Code 6c s 3-36 3a - Telephone Number Date Cesspool(s) ls� Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes 3<o If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: -4a�,�, a d -b)r- Neil Bateson F5821 Name Vehicle License Number Bateson,Enterprises Inc Company 7. Location where contents were disposed: G.L,S.p Lowell Waste Water t5form4.doc• 06/03 Date System Pumping Record • Page 1 of 1 Summary Record Card generated �n 9/4/2012 1:20:14 PM by Maureen McAuley Page 1 Town of North Andover Tax Map # 210-1043-0162-0000.0 Parcel Id 16484 67 VEST WAY PALLONE, JOHN 67 VEST WAY N. ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.03 Acres FY 2013 UB Mailina Index Name/Address PALLONE, JOHN 67 VEST WAY N. ANDOVER, MA 01845 UB Account Maint. Account No Cycle Bldg Id. 17812.0 - 67 VEST WAY 3170477 03 Cycle 03 UB Services Maint. Account No. 3170477 Service Code MISCFEE ADMIN FEE WTR WATER UB Meter Maintenance Account No. 3170477 Serial No Status 36185549 a Active Date 6/12/2012 3/13/2012 12/12/2011 9/13/2011 6/7/2011 3/7/2011 12/8/2010 9/9/2010 6/8/2010 3/10/2010 12/11/2009 11/12/2009 9/8/2009 6/9/2009 3/16/2009 12/8/2008 9/8/2008 6/6/2008 3/10/2008 12/12/2007 9/6/2007 6/20/2007 3/15/2007 12/13/2006 9/13/2006 Trouble Code:03 6/19/2006 3/9/2006 Trouble Code:03 12/22/2005 Type Loan Number Active/Inact. From Payor Occupant Name Active/Inactive Last Billing Date 7/9/2012 Active Rate Charge Multiplier/Users 0.635/8 7.82 1/ 01 ALL METER SIZE 209.20 /1 Until 4760 a Actual 40 1/17/2006 -60% Location Brand Type Size YTD Cons ERT HH b Badger w Water 0.63 0.63 553 Reading Code Consumption Posted Date Variance 561 a Actual 44 7/16/2012 78% 517 a Actual 25 4/14/2012 -46% 492 a Actual 45 1/17/2012 -70% 447 a Actual 164 10/13/2011 541% 283 a Actual 24 7/20/2011 -3% 259 a Actual 24 4/13/2011 1 % 235 a Actual 24 1/12/2011 -84% 211 a Actual 155 10/15/2010 552% 56 a Actual 23 7/15/2010 -9% 33 a Actual 25 4/14/2010 2% 8 a Actual 8 1/12/2010 0% 0 n New Meter 0 1/12/2010 0% 5842 a Actual 410 10/15/2009 425% 5432 a Actual 73 7/20/2009 368% 5359 a Actual 18 4/29/2009 -73% 5341 a Actual 61 1/20/2009 -49% 5280 a Actual 124 10/10/2008 90% 5156 a Actual 61 7/16/2008 286% 5095 a Actual 16 4/11/2008 -75% 5079 a Actual 69 1/22/2008 -47% 5010 a Actual 105 10/12/2007 444% 4905 a Actual 24 7/20/2007 63% 4881 m Manual estimate 14 4/16/2007 -1% 4867 •a Actual 14 1/19/2007 -78% 4853 a Actual 61 - 10/20/2006 262% 4792 "a Actual 20 7/10/2006 26% •4772 a Actual 12 4/17/2006 -64% 4760 a Actual 40 1/17/2006 -60% i Town of North Andover Office of the Health Department Community Development and Services Division 27 Charles Street North Andover, Massachusetts 01845 Heidi Griffin Acting Public Health Director TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE February 19, 2004 This is to certify that the individual subsurface disposal system constructed ( ) repaired (X) by Mike Reilly at 67 Vest Way North Andover, MA 01845 t%ORT{fOlt ` h A 9SSACHU`+ES Telephone (978) 688-9540 Fax(978)688-9542 has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorrilj,r ? il Chairman, North Andover Board. of Health BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 m TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION Tndersigned hereby certify that the Sewage Disposal System ( ) constructed; ( 7epaired: by I,I I I! E 1 1,Imo` located at lig% T was installed in conformance with the North Andover Board of Health approved plan, System Design Permit # dated , with an approved design flow of� gallons per day. The materials used were in conformance with those specified on the approved plan; the system was installed in accordance with the provisions of 310 CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on the As -built which has been submitted to the Board of Health. Bed inspection date: 4% ` 10 awtoo Final inspection date: _5.10 I dt `O Q�Put Q�_ _R? Q.4," - Engineer Representative Engineer Represents ive Installer: ' _ Lic.#: Date: _%Z Design Engineer: Date:. q" —D fp 1� INSPECTION CHECKLIST FOR SEPTIC SYSTEMS Yes A. Bottom of Bed 1. Excavation to proper depth 2. With trenches, sides of excavation are beneath B horizon 3. Edge of excavation specified distance from foundation, etc. Comments: B. Retaining Wall 1. Wall height and width as specified 2. Waterproofed 3. Wall minimum 10' to leaching facility 4. Wall meets specifications of plan Comments: NO Initia 7���� C. Building Sewer 1. Pipe diameter minimum 4" 2. Schedule 40 pipe 3. Watertight joints - 4. Inlet to tank cemented / 5. Slope minimum 0.01 or 1/8" per foot minimum 6. Pipe properly set on compact firm base 7. Pipe laid on continuous grade in straight line 8. Cleanouts precede all change in alignment and grade 9. Manholes at any 90° change 10. 10' minimum offset to water line Comments: D. Septic Tank 1. Level 2. 1,500 gal minimum 3. Gas baffle present on outlet 4. Manhole to grade_ 5. Manholes over center and each tee 6. 3-20" manholes 7. Inlet tee minimum 12" under invert 8. Outlet tee minimum 14" under invert 9. Outlet line cemented 1/ 10. Air space 3" above tees 11. 2" - 3" drop from inlet to outlet 12. Pipe set 13. Compact base with 6" of crushed stone under tank 14. Tank is watertight Comments: E. Pump Chamber 1. If separate from tank, compact base with 6" of 3/4" stone underneath 2. Minimum 2" pipe to d -box if gravity system 3. 20" access manhole 4. Tank level 5. Watertight 6. Tank size agrees with plan specification 7. Manhole to grade 8. Check valve and bleeder hole present 9.. Alarm in building on separate circuit 10. Alarm functions 11. Manual operating switch 12. Pump delivers liquid to d -box Comments: F. Distribution Box 1. D -box level 2. Minimum 0.1T' (2") drop from inlet to outlet 3. Minimum 6" sump 4. Outlet pipes show equal distribution 5. Compact base with 6" of stone beneath box 6. Box is watertight 7. All lines cemented with hydraulic cement 8. Schedule 40 pipe Comments: G. Soil Absorption system 1. All stone double -washed - %" - 1 ''/i" - pea stone 1 Yes NO Bucket test done? _} 2. Minimum 2". of pea stone above distribution lines 3. Minimum 6" stone beneath pipe 4. Distribution lines capped or connected together 5. Grading meets 3:1 slope 6. Minimum of 9" of fill graded over system 7. Toe of slope stops minimum 5' from edge of property; if not, then swale. Comments: H. Leach Trenches 1. Minimum 2 trenches 2. Length of trenches agree with plan. (Max. length 100') 3. Width of trenches agree with plan - Minimum 2'; maximum - 4'. 4. Vent present if <50 feet or specified Distance between trenches minimum 4' and maximum of 6' VMinimum distance between trenches 10' 7. Pipe slope minimum 0.005 or 6" per 100' 8. Depth of trenches below outlet invert minimum of 6". aL1 Yes NO 9. Pipes set on stable base. Comments: 1. Leach Field 1. Maximum length of field 100' 2. Pipe slope minimum 0.005 or 6" per 100' 3. Separation between pipe 6' maximum 4. Pipes connected at end 5. Separation between adjacent fields 10' minimum 6. Pipes set on stable base 7. Maximum 4' separation from edge of field to first line 8. Minimum two distribution lines 9. Maximum perc rate 20 mpi Comments: I Leaching Pits 1. Minimum inlet pipe 4" 2. Pits of concrete 3. Sidewall between 12" and 48" wide 4. Access manholes on each pit 5. Pipes cemented with hydraulic cement Comments: K. Final Grade 1. Slope over soil absorption system minimum 0.02 2. All system components covered by at least 9" soil 3. Cover soil free of stones larger than 6" 4. Grading slopes away from dwelling 5. No areas over system that may pond o 2 LL ce w CL z _O P: U D Y H z O Y ce 3 J Q O a cn I -q i Q J w** / C +*OVER �YW I O H ..O Q tv O N _ Q w a L O Z � � < U 3 c O a O H ..O Q O N _ Q w a L O Z � � < U 3 c O co L. a � � U L � a L a O Q �Q N U Q L � VI '� c C O O U O C O c N ro "� a`o � a� L a> _ t ro N to O a c (1 O Q �J C ro L 3 a � U- fi APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERI IIT DATE: � / 'g -cc CURRENT L`iSTALLER' S LICENSE LOCATION: (,--) V -r,-> t'::,4 LICENSED LN'STALLER: - , p Cs.e_ � \ \\4 = -- c--- SIGNATURE: TELEPHONEm S�i q 47 ,.-% az?. CHT- CK 0NE: REPAIR: NEW CONSTRUCTION: IF NEW CONSTL?CTION, PLEASE ATTACH F0UNDATION AS -BUILT. 575.00 Fee Attached? Foundation As -Built? Administrative Use Only Yes No Yes N o Floor Plans? Yes No Approval Date: 7 % d JUL ! $ INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property atrelative to the application of P, Q p.k dated )— j.0,-agon for plans by �o�� i_�-)OQg5914 dated 9—t 67C3) with revisions dated LpC n t I understand and agree to the following obligations for management of this project: 1. As the installer I am obligated to call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item two shall be applicable . 2. 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 my company. a) Bottom of Bed — generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final Inspection — Engineer must first do their inspection for elevations, ties, etc. As -built or verbal OK from engineer must be submitted to BOH, after which installer calls for inspection time. Installer must be present for this inspection. With 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. Does not have to be on site. 1•; 3. As the installer I understand that persons or companies not associated with my company may not perform the work required by my company to complete the installation of the system identified in the attached application for installation. I further understand that work 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 in the Town of North Andover plus significant fines to all persons involved. 4. 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. d) Installation of tank, D -box, pipes, stone, vent, pump chamber, retaining wall and other components. 5. 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 Date: AUG -18-2003 11:13 GLSD 508 685 7790 x.02102 i,, 8/18/03 Analysis of material from F.P. Reilly sample dated 8/15/03 The material in question came from the distribution outlet of a failed septic system. The material was diluted with lab pure water and examined with a microscope set at 400x phase contrast. The sample contained silica particles (sand), sludge particles, a few pieces of cellulose (plant cells), a few microscopic worms and a large population of bacteria. There is no indication that this material is out of the scope of "normal" septic tank contents. F TO: Brian LaGrasse North Andover Board of Healt 27�Charles Street North Andover, MA 01845 -SUBJECT Sediment Analysis FROM: SHAHEEN, PALLONE A ASSOC., P.C. CERTIFIED PUBLIC ACCOUNTANTS 861 TURNPIKE STREET NORTH ANDOVER, MA 01845 PHONE: (978) 686-7200 FAX: (978) 686-4314 FOLD DATE Auaust 21, 2003 — _ As wP discussed on the phone, enclosed is the information I received from Greater Lawrence Sanitary District regarding the samples taken from my house. Please call me if you have any questions. V. o L AUG2a r SIGNED hn M. Pallone (0495) Jun 02 05 01:31p Tue jun 03 16.2S:06 2001 9iO3eet t 11 -P -0Z Y & 6GoS OC rwitcL go. : 01.166.111, owl eg go. :w/y. "Mle w0• : 40. 11 &'Movion . VA So11 peeetiptim. . SepTIC 600 OeaaTRe : ASN' CF:OTLG'�1CM. Lr10A4RORY TEST OATA Fa:_Mt.e - 3.030613 b"th : N/A FAVVatiau VA Zest Oreo : 6-3-03 l40*te8 0y . OW/M Test wetwd . AM ChLCKed by >:C )ego : 1 p.2 FIM CIYVS SET T 11 t - Java ODeaLAgr "eight vap"lative ft%==L [enh ,t pilllmcarm Retain" ro:y.t petaLaed Fint+r .spo. too _ ._..-.-- ------ ...., x.107 f.'i5'--...o_� 0.00 100 i�� rf �' g7 110 -0.079 2.00 6.00 i-00 ' 020 0.013 6.GS 23.39 30.00 91 s. see 0.0 17 0.43 5e-00 66.00 C50 O.Ota 6.10 67.30 LILS.30 _ 9_010 0-23 21.00 L59.70 53 646 2]0_60 2! :LAO 0-006 0.15 T1 .S0 0.002 0.07 50.10 296-70 ! 6700 p 30_90 )25.00 rap Total w• of Seeple . 325.8 laze weistc 0 Moirr.ue ear a ONS 0.6127 060 = 0.310* USO 0.2463 019 0.LS70 M. Dis : 0.0702 olO.: O.o7Se sell mumili atina A61P Glmw 6ya001 P/A AVM Gaup Pace 1y/A AA KX Grasp S_aa0ol a A-3 (0: AASTILC GsaOP VaM Fine Ca+r a _gip - t r3 6�.i. IFI &;.... ' �,�.� c 6•d dZ*:TO EO to Inc Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES WILLIAM J. SCOTT Director (978) 688-9531 October 4, 1999 William Dufresne Merrimack Engineering 66 Park Street Andover, MA 01810 27 Charles Street North Andover, Massachusetts 01845 RE: 67 Vest Way, North Andover Dear Mr. Dufresne: This is to inform you that the proposed plans for the repair of the septic system located at 67 Vest Way, North Andover, have deficiencies which must be addressed before plans can be approved. These deficiencies are as follows: .r Sty.,, ie •�� O F 9. Fax(978)688-9542 1. A geo-membrane has been proposed instead of a poured concrete retaining wall. (NA 9.02) 2. Missing statement that existing septic tank must be excavated and removed from the site. (3 10 CMR 15.354(3)(c)) Please be advised that all plan resubmittals require a $60.00 fee. If you have any questions, feel free to contact the Health Department at 978-688-9540. Sincerely, Sandra Starr, R.S. Health Administrator Cc: J. Pallone File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Sep -29-99 07:58A Paul D. Turbide, PE/PLS September 29, 1999 Sandra Starr North Andover Board of Health Administrator Office of Community Development and Services 30 School St. North Andover, MA 01845 RE: Title V review for 67 Vest Road Dear Sandra, 508-465-0313 P.02 I find that the design plans dated Sept 16, 1999 adequately address the regulations. However, I make the following minor comments and corrections that should be made. ❑ An impervious barrier of geo-membrane is proposed. The North Andover regulations could be interpreted as requiring a concrete retaining wall. If this were so, then the proposed impervious barrier would require a local variance, I find that the use of the geo-membrane should be adequate for this design. o There should be a statement that the existing septic tank must be excavated and removed from the site. 310 CMR 15.354(3)(c) If you have any questions or comments please feel free to contact me. Sincerely Carlton A. Brown, PE/PLS Vest67.doc f� PORT ENGINEERING Civil Engineers & Land Surveyors One Harris Street Wewburyport, MA 01950 (978)465-8594 �7MV�71C PLAN SUBMITTAL FORM LOCATION: VC5-r j -44-Y' NEW PLANS: $125.00/Plan REVISED PLANS: YES $ 60.00/Plan SITE EVALUATION FORMS INCLUDED: NO DATE: DESIGN ENGINEER: _Pd4jZ�l2`��af DATE TO CONSULTANT: *If you want your plans expedited, please submit four plans and included a stamped envelope with the correct amount of postage to mail plans to Port Engineering. When the submission is all in place, route to the Health Secretary. I < i i EAS _ (1 SEP 2 i999 ----4� Lpc�`l��lp�J a 67N160- 4�0'0t FORM - U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all -necessary approval / permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. APPLICANT JoN� �a�N� �cq,C,Ce�,�� PHONE 146_,' ASSESSORS MAP NUMBER 10q— LOT NUMBER SUBDIVISION ©IL2 LOT NUMBER STREET V c�"i w STREET NUMBER (-7 OFFICIAL USE ONLY RECOMMENDATIONS OF TOWN AGENTS DATE APPROVED CONSERVATION ADMINISTRATOR DAVE REJECTED CON RENTS DATE APPROVED R DATE REJECTED COMMENTS DATE APPROVED FOOD INSPECTOR - HEALTH DATE REJECTED DATE APPROVED SEPTIC INSPECTOR - HEALTH DATE REJECTED COMMENTS �. .PUBLIC WORKS - SEWER / WATER CONNECTIONS AAI 14 t, 7 DRIVEWAY PE P- VIP - i�W 7 - Ze -ori U(Z-0 Z -0 d 17T_ DATE APPROVED FIRE DEPAR DATE REJECTED COMIyfENTS RECEIVED BY BUILDING INSPECTOR DATE ►%r 19 Com!. 4 9 w z °0° z o °o A L ¢ W ti d Q d w 3 ¢ 3 cn E-' � C4 M W W , > w r- o � a U bD 7 c O F- W 4C w epi o "= W L p U ,y Q ti 3 U coo 3GtnQ o ami z y ti is O U p W � Q CID 0 A C 2 O U W'O a O. p a C N <�°„ p 8 0 = v 'ca 00 0 C O U ca . _ Q N O U G N t U R L 3 a 3 a W � o 0 N C U Y O G O .S ,p � O O ❑ O H cn ztich 0 CY N 'OD N' N' N O 00 .G w N m O iC E cC G U V] 'o A rn c �. C� oo.A�3o:a. G V O� � O � O o E ea C o L O 9 w A L C4 M a U bD 7 c "= ' c a U ,y Q ti 23 T` U o ami y ti is O U p CID 0 A C 2 O W'O a O. p a C N <�°„ p 8 0 = v 'ca m c w 0 C O U ca . _ °>' G y ti U> C% U U `O U G N t U R L 3 a 3 a .UG O C C U Y O G O .S ,p CY N 'OD N' N' N O 00 .G t H as.+ N m O iC E cC G U V] 9 f W A -t P I" 3 0 05•=0 os ^o s ie c 3 e co v s 3 7 N o a fd ti .b U O 3y•�=a ,r cC a_ ti ti 0 J � C T > o° LI 3 s a° to 10 r- 12 Y O bq cC c`a U O s Y ^ O71O 2.0 3 a• V d0.. •N ,b E .o = c Q E;? °� awe �sF a0i o0 0 T ow a .� a3 ,o 3 o a itS O cO N b C T M U m o0 s oLl3 cj .�° °' o ro v 8 ro c? N u Q w ° oho oho ¢ O N `1 O ❑ V] V U >, T y C po cO O cC U n fit'' D\ `O m E O C❑❑ E & Y_ 'O N .�_ T E 3 E U vlFUvz �ti �:. cca g n.FUNZ 6� V r F l IAJ ,� AS -BUILT CHECKLIST 10 I OF 30 l�C�� 'MAY 2 9 2003 LOT NUMBER, STREET NAME Y ASSESSORS MAP & PARCEL NUMBER LOT LINES & LOCATION OF DWELLINGS LOCATIONS & DIMENSIONS OF SYSTEM, IKIM fVA, TIES TO LOT LINES & DWELLING, WELLS a. FROM SEPTIC TANK b. FROM LEACH AREA LOCATIONS OF DEEP HOLES & PERC TESTS ELEVATIONS OF DISPOSAL SYSTEM TOP OF FDN ELEVATION LOCATIONS OF WELLS, DRAINS, WATERCOURSES WITHIN I50' OF SYSTEM LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK & D -BOX -- ORIGINAL STAMP & SIGNATURE IMPERVIOUS AREAS - DRIVEWAYS, ETC. NORTH ARROW LOCATION & ELEVATIONS OF BENCHMARK USED Town of North Andovert HORTN OFFICE OF 3� o"e °0 COMMUNITY ]DEVELOPMENT AND SERVICES p 27 Charles Street : �9 North Andover, Massachusetts 01845 4ySsgc,HuS���h WILLIAM J. SCOTT Director (978)688-9531 Fax(978)688-9542 October 20, 1999 Bill Dufresne Merrimack Engineering 66 Park Street Andover, MA 01810 Re: 67 Vest Way Dear Bill: This is to inform you that the proposed septic system plans for the site referenced above have been approved. However, please be aware that a note required on the deed stating that there can be no additional flow to the septic system, ie., no additional rooms, because of the depth to ground water variance.. If you have any questions, please do not hesitate to call the Board of Health Office at 978-688-9540. Sincerely, Sandra Starr, R.S. Health Administrator SS/smc cc: John Pallone File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 F TO: Brian LaGrasse North Andover Board of Hea 27 �Tg'rles Street North Andover, MA _01845 FROM: SHAHEEN, PALLONE & ASSOC., P.C. CERTIFIED PUBLIC ACCOUNTANTS 861 TURNPIKE STREET NORTH ANDOVER, MA 01845 PHONE: (978) 686-7200 FAX: (978) 686-4314 -SUBJECT Sediment AnalysesDATE August 21, 2003 FOLD As we discussed on the phone, enclosed is the information I received from Greater Lawrence Sanitary District regarding the samples taken from my house. Please call me if you have any questions. {AUG 2b M03 H H SIGNED John M. Pallone 104951 (CLICK HERE AND TYPE RETURN ADDRESS) 508 685 7790 P.Odlwd 8/18/03 1 Analysis of material from F.P. Reilly sample dated 8/15/03 The material in question came from the distribution outlet of a failed septic system. The material was dilutcd with lab pure water and examined with a microscope set at 400x ' phase contrast. The sample contained silica particles (sand), sludge particles, a few pieces of cellulose (plant cells), a few microscopic worms and a large population of bacteria. There is no indication that this material is out of the scope of "normal' septic tank contents. 0 TOTAL P.02 ti W. T I 1 . N 0 m A on � o0 b ° Wo 'g y 0 00 o xis •d U i �� m � '� p d N pp C 6.0 N N w xc .4 ° m a 'fib o C 0>1 U A T.9 o S y 9j4; g .r.d ° o v $ 0 n c$ M x a d.. ^o d $ b �o Er Zvi a u m � 42 >, g g w-24 m pp „ A � � m � r,�. a�O3i � •C ❑ c rn v S N m oar .5 O O O M .Ni O O 0 0 z•ti w oxo Q w 0 a •U 7 �d CD y N V1 C wl o 0 o 00 h N O O O N 14 z 0 O N d 0 a 0 w T 0 .d o waN 4 d � vo 0 o13 � gDD�^� rnFU�i TjU' U A � d 'a v 00 x�5 0�•.7° � A� oC2, ADZ., 00o�o 5' °��rr aE°UNz�Fw i a Mill River & Susan meet with Homeowner -John Pallone-Site Review Page 1 of 2 DelleChiaie, Pamela From: Sawyer, Susan Sent: Wednesday, June 15, 2005 11:52 AM To: DelleChiaie, Pamela Subject: FW: Mill River & Susan meet with Homeowner -John Pallone-Site Review Importance: High So Lisa was thinking about this also. It sounds like Dan might be available so can you check with Mr. Pallone. Note that I have a tight schedule since Michele is out so 2-3 is about it for me. Thanks -----Original Message ----- From: DelleChiaie, Pamela Sent: Wednesday, June 15, 2005 10:29 AM To: Sawyer, Susan Subject: FW: Mill River & Susan meet with Homeowner -John Pallone-Site Review Importance: High Please advise. Thanks. -----Original Message ----- From: Lisa LeVasseur [mailto:lisal@millriverconsulting.com] Sent: Wednesday, June 15, 2005 10:01 AM To: DelleChiaie, Pamela Subject: FW: Mill River & Susan meet with Homeowner -John Pallone-Site Review Importance: High HI Pam, I need to confirm -are we still set for Friday? Thanks, Lisa Lisa LeVasseur Mill River Consulting Your Complete Source for Onsite Wastewater Management 2 Blackburn Center Gloucester, MA 01930-2259 978-282-0014 or 1-800-377-3044 fax: 978-282-0012 www. millriverconsultin.corn -----Original Message ----- From: DelleChiaie, Pamela [mailto:pdellechiaie@townofnorthandover.com] Sent: Wednesday, June 08, 2005 4:02 PM To: Sawyer, Susan; jmp@sp-cpa.com Cc: Daniel Ottenheimer (E-mail); Lisa LeVasseur (E-mail); McBrearty Andrew (E-mail) Subject: Mill River & Susan meet with Homeowner -John Pallone-Site Review Importance: High When: Friday, June 17, 2005 2:30 PM -3:00 PM (GMT -05:00) Eastern Time (US & Canada). Where: 67 Vest Way 6/15/2005 Mill River & Susan meet with Homeowner-John Pallone-Site Review Page 2 of 2 6/8/05 - This is scheduled as a tentative meeting. Mr. Pallone will be away Thursday & Friday, and requested the end of next week for the visit. Please -- everyone confirm with me, and we can firm up a date and time. Thanks. Pamela 6/15/2005 Town of North Andover, Massachusetts Form No. 2 t M0RY1V BOARD OF HEALTH O 3: - p 19 � DESIGN APPROVAL FOR ,ssACHU SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant Test No. 7A 101b Site Location11019 Reference Plans and Specs. h 9 11ENG NEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. Fee / "�A •' = CHAFRMAN, BOARD OF HEALTH Site System Permit No. 109P NORTH ANDOVER, MASS. 01845 APPLICATION FOR SOIL TESTS 50 a3 srn. i sij DATE: LOCATION OF SOIL TESTS: Assessor's map & parcel number: 1 vq B / GZ OWNER: J014tj Paj tt7 . TEL. NO.: ADDRESS: ENGINEER: TEL. NO.:.ZS�-3 CERTIFIED SOIL EVALUATOR: 120, Intend se o nd: residential subdivision, single family home, commercial Rep it sting Undeveloped lot testing N. Con ation Commission Approval: rtd. "Nc THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) 2. Plot plan 3. Fee of $275.00 per -lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of $75.00 per lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than 1 "-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. T p ' / PAC -EL (3 kn gRCEL A `�y � a rn �h 0 -4 0 L � oo7,3 8) 11 V /----S 7- W� �, s c A L.=. ; 1-= y o F -r. CAMERON BISHOP DIGINCERING CORP. 125 MAIN ST, STONEHAM CdA 02180 (617) 279-0733 /0 �% rdo. Da :e Q—ZS-BS_ _ _.-.-- --- FORM 11 - SOIL EVALUATOR FORhi Page 1 Date.....'Z Commonwealth of Massachusetts k'ouP Aik� , Massachusetts Performed By:..._. .t.__..........................................................u,61V'z-_..� ..._......._._. ................... ._. witnessed By:........_..... M ...... Leads A"VU r La t New Construction ❑ Repair O. -t Nie. —10AA) Tem /I Cdr ✓�S� Published Soil Survey Available: No ❑ Yes .Year Published ..l &- Publication Scale--Z.-!l5No Soil Map Unit ....... � . C .... .......................................................................�.._..._._.....:. /f .. .._.. Drainage Class Soil LimitationsiR/ Surficial Geologic Report Available: No Yes Year Published ...- .............. Publication Scale .................. Geologic Material (Map Unitl_........................._.......................................... Lendform................................................................................................_............................. Flood Insurance Rate Map: Above 600 year flood boundary Within 600 year flood boundary Within 100 year flood boundary No❑, / Yes No Yes 10 No 9/" Yes ❑ Wetland Area: National Wetland Inventory Map (map unit) ...... _... ............................. _..._............._.___.._..._................................_ Wetlands Conservancy Program Map (map unitl............................_............_........_..............._..._._._ .._......_.. Current Water Resource Conditions (USGS): Range : Above Normal ❑ Other References Reviewed: Month ...`'� Normal ❑ Below t TOWN OF NOR] H ANDUVttl/ SOAR AF ;rEAJH Normal SEP 2 41999 Fool 11 - SOIL EVALUAMR MRM Page 2 On- eWow • Deep Hole Number .1::L- Data:_��� Tlme:_.,�1 �o'' Weather Location (Identify on site plenl_..� Land Use ---41 -------- Slope (!61 JZ Surface f3tonea -..-- ...... vegetation Lwwform position on landscape (sketch an the backl.-- Distanoa$ from: Open Wata Body `feet Drelnege way....�M r feet, possible Wot Areas feet Property line ,_ feet Drinking Water feet Other DEW OBSERVATION ROLE C -y -7 papth Irom Eutaw VM Wim boa Tess tiON GoWr Ila I Mhuft Itnaiwel mom IlAuwdtl IStn � QotAAira. PQM e� �i L- 1 rj Y1t,y�!c Z 9 �zq 50 /(gYpS/� Parent Material (peoloolcl -. -.. ---- -_ - -- -- --- - -- Depth to Bedrock: DARtkiaAl2vadwim Standing Water In the Hole:( Weeping from Pit Face: n Estimated Seasonal High Ground Water:......... `. FORM 11 - SOIL EVALUATOR FORM Page 3 P. 1=1 I I M. I TVM111'Ar?T&F711 01 ❑ Depth observed standing in observation hole .... w. inches ❑ Depth weeping from side of observation hole _ inches E- Depth to soil mottles —q-tw Inches ❑ Ground water adjustment feet Index Well Number ._.._...___... Reeding. Data Index well level _ . _... Adjustment factor Adjusted ground water level __...____ .._ . Does at least four feet of naturally occurring pervious material exist Kell areas observed throughout the area proposed for the soil absorption system? ( -,5T' If not, what is the depth of naturally occurring pervious material? I certify that on rlff& (date) 1 have passed the examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experienoe described in 310 CMR 16.017. Signature Date F ORhf 12 - PERCOLATION IST COMMONWEALTH OF MASSACHUSETTS Massachusetts Site Passed l/ Site Failed ❑ Performed By: J/1 , Witnessed By: JZ , /ZU rp& Comments:. ....................... .................................................... Percolation Test Date:����'� Tihne• Observation Hole # - Depth of Parc U Start Pre-soak End Pre-soak Time at 12" Time at 8"7-7 Time at 6" Time W-6"1 Rate Min./Inch Site Passed l/ Site Failed ❑ Performed By: J/1 , Witnessed By: JZ , /ZU rp& Comments:. ....................... .................................................... 1/ X70 DAIS:- LOCATION: 6 .1/'-,e A"4- W, ENIN E BOH `NiTNE cE,=OOi TION - _ EOT-i ONI DE-�--TI-I Or--P'-7:,zC TEECST� 45 TIME O < (A E THM E .^,T TI v i E S=.=T= '' _", as .t °N ' > :. 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