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Miscellaneous - 675 FOSTER STREET 4/30/2018
675 FOSTER STREET - 1 210/104.6-0054-0000.0 _II i Commonwealth of Massachusetts °tiLHEALTH LVED City/Town of 2014 System Pumping-Record h pNVER �0 Form 4 ARTMENT DEP hasprovided 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 hou a Righ ear ou Left/right side of house, Left/ Right side of building, Left/Right front of bul din , Left/Right rear of building, Under deck 9 9 9 g g, Address Cdy/Town State Zip Code 2. System Owner. to � Name Address(if different from location) City/Town State Zi Code Telephone Number _ r B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) DISeptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yep No If yes, was ft cleaned? ❑ Yes ❑ Na ' S. Condition offSystem, 6. System Pumped By. Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locati re contents were disposed: a .0 Lowell Waste Water 1Y Sig qtHau`e1Upat t5fbmAdoc-06/03 System Pumping Record•Page 1 of 1 • S�.sTti�n� PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 9/30/2014 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Repair of D-Box and Outlet Tee By: Todd Bateson At: 675 Foster Street Map 104.B Lot 0054 T th Andover, MA 01845 e ssuan e of this certi 1, ate s all not b construed as a guarantee that the system will function satisfactorily. Michele Grant Public Health Agen :� 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com ��v�.T� S�Cti � ' �2� ' � � 6U��� J V � X � 211 V �/ � �' ° ' � •- 4w;►XVI Commonwealth of Massachusetts Map-Block-Lot • 104.B0054 ----------------------- BOARD OF HEALTH Permit No North Andover BHP-2014-0799 P.I. FEE F.I. $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted ((_\_ �J - - -- --477��bix------------------------------------------------- 4- -.. to(Repair)an Individual Sewage Disposal System. at No 675 FOSTER STREET --------------- as shown on theapplication for Disposal Works Construction Permit No. BHP-2014-0 .ted `5-- tet�ber 25,2014 Issued On: Sep-25-2014 BOARD OF HEALTH .............. ........................... 675 FOSTER STREET Reference No: BHJ-2014-000068 ................................... Permit No: BHP-2014-0799 Department: ................................... North Andover BOARD OF HEALTH ......................................................................................... Account No: 1001001.1.5.0510.00 FeeType: .................................... DWC-Component Repair PERMIT Receipt No: REC-2015-000392 .................................... ......................................................................................... Paid By: Paid in Full On: Thu Sep 25,2014 .................................... DEDOGLOU, PAUL ALEXANDRA DEDOGL ......................................................................................... Check No: 8313 Received By: .................................... Lisa Blackburn ......................................................................................... DEPARTMENT'S COPY Amount: $125.00 ........................... L........................................................................................................................................................................... 1 r Application for Septic.Disposal System 9'"d s' /L� TODAY'S DATE Construction Permit - TOWN OF NORTH ANDOVER, MA 01845 $2°oo-ComRepair Important: Application is hereby made for a permit to: When filling out ❑Construct a new on-site sewage disposal system* forms on the computer,use ❑Repair or replace an existing on-site sewage disposal'system* tory the tab keyRepair or replace an existing system component-What? �'-+��-� to move your cursor-do not use the return A. Facility Information _ key. 67 �� S Address or Lot# ab 2.-*TYPE OF SEPM SYSTEMA*: SEP `b ?014 ➢ ❑ Pump gKravity(choose one) TOWN OF NORTH ANDOVER 'If pump syst ach copy of electrical permit to application*** HEALTH DEPARTMENT ➢ E3,Conventional System(pipe and stone system) ➢ ❑Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system.) ➢ ❑Pressure Distribution S.A.S.(No D-Box) ➢ ❑Pressure Dosed(D-Box Present)S.A.S. ➢ ❑Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES=(no further info.needed) NO=(installer must specify brand of filter before DWC issuance) [khat is the Make? What is the ModldV 2. Owner Information Mame 11 Address(if different from above �-Liyr— CityrTown State Zip Code 21�'7 Telephone Number 3. Installer Information Name of Co PRISES,INC. Name 111 ARGILLA ROAD ANDOVER,MA 9151^ Address j City/Town State Zip Code ?7T R/s= a 7.� Telephone Number(Cell Phone#if possible please) 4. Designer Information Name Name of Company Address CityrTown State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 r°RTS A licati•on for Septic D' s os ISystem - • A Construction -Permit —' W1V.TOOF TODAY'S DATE «':` ORTH ANDOVER, MA 01845 C $.250.00-Full Repair ` — - $125-00.-Component s� �s PAGE 2 OF 2 A. Fadilltv.Information continued.... S. Type,of Building: esidential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system In accordance with the provisions of Title 5 of the Environmental Code,as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation until a Certificate of Compliance has been Issue0y this Board of Health. Name Date Application Approved By:jlard of Health Representative) Name Date Application Disapproed for 4th/efollowing reasons: For Office Use Only: 1 Fee A . ttacbed. yes • -- No 2.- ProjectMariager Obligation Form Attached. Yes Na_ 3.: Puma System? Ifso)Attach Cepv ofElectrical Permit` No 4. Foundation As-Built?(new construction-ronly). Yes_ (Same scale as approved plan) No A Flo orMans?(he.w construction only): yeS_ O Applict(on torpispp3al Systerii: onstrnctioo permft Page 2 of 2 SEM. C'S'YS'�' •FPT '9 ] f ESI'i4DB73nT • s d'13urthAadover cmsedthamlterf�srxite fva•:theaepc 7ti 4foi piau by Relatiiaa to du.epg8cadaa of 1®eato ices ) Abd doed Mth awed t revi ed date) I uadct od the foUawlag obligatiom fat mgnag=cltt of hb project: i. As the iosta&4 F Am Obligated to cbtaim IS p=tita and Board O' Mel h apgravad pias pft to fefforming any WO*on R aite. 2. .As fieia$t�1te�,I•*ust•.t#$far Wyaad ilia lom F£ham Qthtr peraaa oaf yrs ociated with my eaavae4 coatmctQ4,project msaagec,or any item dwvahalLh a pl cable. ° gc dines iaffipe oa sad the apateta is a©treacly,dlift j1Y °mSe.t9d•peof to the applicable=*ctsos�s ss dol aft ot th b4he Mud ah�u'Iid h' sC*iw*aha iliapec ft but dOeS-aot bane to b4 pusbti�, M bi3iit of i I Q Etta drrt tai p �{� etc, bi K of a and to: a ' be ttiLz;iitt ie.=cxrrd'afF•Yet , for eii 6—ect4.titan mlicr must be prestnt for tL inapecti* Vith at piu p �vgtlr mist be ratdp sad able to . :. •cause pw�p azi woarlc said e�ts�=to iia'c�azt... . • , . • - C. � tettessattet e : to t t saapexxtiost orb it dict 3s casztpltte: 1potailcr does tot have to bt+ �te.• ' 4. As-the , a lm-j ua'd ad tim oily IPAY t&mt ti tivc ac(taw ter�Win} I�;. ed is coMpiete thelaet qh*n of the aysterit ideatif d in#�.stt epi ippl ti for i:za taliadon.j qus na for deifial�f thts a�atern r filar` Lim • "z''�'�Y�P�.___•��7flia.Ltit 1rbQt218� MOA Andr, -Si 6xnt mea to +"� ` �YN6 flift .. lis the inatslltet;.t cWderataa�t tl sauat"be g nit t[tu mop ,of th fe►Rcswittg ccmri Com. .sus. ' • . 17ettsrn�o� ttbeFerelerntetauY af'the ccurr b beer r+cncledt h. Ipettiori aftbed'xadate�a he aged Q 'Fin:l.{aipeet�'oaf�pBoaut�€al.�STeffarcartulr�tt. d .1a�1�t11a�'at�ofmak,�-�$aa� pOv:store,vw4P=P choibber,&Wtivwwalfaadother . caarpczacae�r, � - $• Air a-bul l.&t the� t4t nn oft T h�- st•'�uu ii voe uie , NO insttLicii l bZ- kitai=ml�nf rsi.•w..s.� w Me of ++�ot:s�++,�s, � - +iFr.�soa3 eteAn-�bsai{ve Unders9aaiAcae:dSet�dc:ifletnftex Commonwealth of Massachusetts A Title 5 Official Inspection Form � o1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments L � LHEArLTH r JCL r r.r,...,; r-1 i, 675 Foster Street _ o=P�'�i:,; ,�r Property Address —J Paul Dedoglou Owner Owner's Name information is required for North Andover MA 01810 9/30/2014 every page. City/rown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Neil J. Bateson cursor-do not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name *a 111 Argilla Road Company Address Andover MA 01810 City/rown State Zip Code 978-475-4786 S115 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Need Further Evaluation by the Local Approving Authority 1 9/30/2014 In p ors Signature V Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DER The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 675 Foster Street Property Address Paul Dedoglou Owner Owners Name information is required for North Andover MA 01810 9/30/2014 every page. Cityrrown State Zip Code Date of Inspection B: Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: After permit from B.O.H., install new outlet tee with gas baffle in septic tank, new d-box&replace broken pipes, inspection from B.O.H. septic system now passes Title 5 Inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 NONT170 " " L • Town of North Andover HEALTH DEPARTMENT CHusts CHECK#: DATE: LOCATION: 1� Alpf �T H/O NAME: CONTRACTOR NAME: J* Type of Permit or License:(Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ TrashlSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ Title 5 Report $ �y ❑ Other. (Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer } 7012 HORTp , Of ,q4•� • Town of North Andover xti'•�,,,,,.:' HEALTH DEPARTMENT �SS�cNus�� CHECK#: 410DATE: ` LOCATION: P-�4pf H/O NAME: I" CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ 1 ❑ Body Art Establishment $ ❑ Body Art Practitioner $ J, ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ { ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: i ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ i Title 5 Report $ —'I yw ❑ Other:(Indicate) $ 1 Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer Commonwealth of Massachusetts Title 5 Official Inspection Form RECEIVED Subsurface,Sewage Disposal System Form-Not for Voluntary Assess ents 675 Foster Street Property AddressNURv Paul Dedo lou HEALTH DEPARTMENT Owner Owner's Name information is required for North Andover MA 01845 9/15/2014 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altIred in any g�A� way. Please see completeness checklist at the end of the form. f' Important: When filling out A., General Information forms on the computer,use 1. Inspector: only the tab key to move your Neil J. Bateson cursor-do not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name VQ 111 Argilla Road Company Address Andover MA 01810 "mD Cityrrown State Zip Code 978-475-4786 S115 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs urther Evaluation by the Local Approving Authority 9/15/2014 Ins ct es S nature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority_., ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 • Commonwealth of Massachusetts i jV, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 675 Foster Street Property Address Paul Dedoglou Owner Owners Name information is required for North Andover MA 01845 9/15/2014 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ® N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 675 Foster Street Property Address Paul Dedoglou Owner Owner's Name information is required for North Andover MA 01845 9/15/2014 every page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due 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 ❑ 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 privy ElCesspool or p vy i s within 50 feet of a borderingvegetated wetland or a 9 salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 675 Foster Street Property Address Paul Dedoglou Owner Owner's Name information is required for North Andover MA 01845 9/15/2014 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for 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: Outlet tee in septic tank, Outlet pipe into d-box, d-box, &collapsed pipes needs to be replaced. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins-3113 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 675 Foster Street Property Address Paul Dedoglou Owner Owner's Name information is required for North Andover MA 01845 9/15/2014 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. 1 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 you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 675 Foster Street Property Address Paul Dedoglou Owner Owner's Name information is required for North Andover MA 01845 9/15/2014 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the followinghave been done. You must indicate es"or no as to each of the following: Y 9 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? ® El 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): 600 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Foam-Not for Voluntary Assessments 675 Foster Street Property Address Paul Dedoglou Owner Owners Name information is required for North Andover MA 01845 9/15/2014 every page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage Yes 9 ( Y 9 (gPd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitarywaste discharged ed to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 675 Foster Street Property Address Paul Dedoglou Owner Owner's Name information is required for North Andover MA 01845 9/15/2014 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped 2010, owner Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a co of the cur gy copy rent operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 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 675 Foster Street Property Address Paul Dedoglou Owner Owner's Name information is North Andover MA 01845 9/15/2014 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 26 years old, 10-20-1988, as built plan. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.2 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 through wall, 3" PVC in house, No leaks visible Septic Tank(locate on site plan): Depth below grade. .2feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x 5'x 4' Sludge depth: 6" t5ins-3113 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 675 Foster Street Property Address Paul Dedoglou Owner Owner's Name information is required for North Andover MA 01845 9/15/2014 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle N/A Scum thickness 6.. Distance from top of scum to top of outlet tee or baffle N/A= Outlet tee corroded off Distance from bottom of scum to bottom of outlet tee or baffle N/A Howweredimensions determined? Tape Measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet tee ok. Inlet tee clogged, clean same. Flow back to normal.gg a Outlet tee corroded off, needs to be replaced. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑1 other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts RUVTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 675 Foster Street Property Address Paul Dedoglou Owner Owner's Name information is required for North Andover MA 01845 9/15/2014 every page. Cityrrown 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: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 675 Foster Street Property Address Paul Dedoglou Owner Owner's Name information is required for North Andover MA 01845 9/15/2014 every page. City/town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box cover broken &fill with sand. Shovel out d-box& replace cover. D-box corroded bad, needs to be replaced Evidence of leakage. Evidence of carryover. Pipe into d-box collapsed. Pipe out of d-box collapsed. Collapsed pipes need to be replaced. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts I uV,2 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 675 Foster Street Property Address Paul Dedoglou Owner Owner's Name information is required for North Andover MA 01845 9/15/2014 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 3 trenches 51' long ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 675 Foster Street Property Address Paul Dedoglou Owner Owner's Name information is required for North Andover MA 01845 9/15/2014 every page. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 675 Foster Street ,p Property Address Paul Dedoglou Owner Owner's Name information is required for North Andover MA 01845 9/15/2014 every page. CityrFown 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 a�3at6 t� we C) ± � IL 11 k ; 65a p PS S t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 III Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 675 Foster Street Property Address Paul Dedoglou Owner Owner's Name information is required for North Andover MA 01845 9/15/2014 every page. Cityfrown 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 ofd sign plan reviewed: 4/1/1985 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Design plan Checked with local excavators, - ❑ t s, Installers (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: As per design plan test pit data Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Forth: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 . ' 675 Foster Street Property Address Paul Dedoglou Owner Owner's Name information is required for North Andover MA 01845 9/15/2014 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed .® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17 Summary Record Card generated on 9/10/2014 2:45:58 PM by Karen Hanlon Page 1 Town of North Andover Tax Map # 210-1043-0054-0000.0 Parcel Id 16377 675 FOSTER STREET DEDOGLOU, PAUL 675 FOSTER STREET N. ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1:02 Acres FY 2015 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until DEDOGLOU, PAUL Payor 675 FOSTER STREET N.ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 18080.0-675 FOSTER STREET Last Billing Date 7/8/2014 3180108 03 Cycle 03 Active UB Services-Maint. Account No.3180108 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 81.55 /1 UB Meter Maintenance Account No.3180108 Serial No Status Location Brand Type Size YTD Cons 41832433 a Active 00 ERT HH b Badger w Water 0.63 0.63 138 Date Reading Code Consumption Posted Date Variance 6/12/2014 138 a Actual 21 7/16/2014 413% 3/14/2014 117 aActual 4 4/11/2014 7% 12/16/2013 113 aActual 4 1/17/2014 -3% 9/13/2013 109 a Actual 4 10/15/2013 -5% 6/14/2013 105 a Actual 4 7/24/2013 -76% 3/20/2013 101 a Actual 19 4/22/2013 -17% 12/13/2012 82 a Actual 20 1/9/2013 15% 9/19/2012 62 a Actual 19 10/15/2012 8% 6/18/2012 43 a Actual 17 7/16/2012 74% 3/20/2012 26 a Actual 10 4/14/2012 155% 12/19/2011 16 a Actual 4 1/17/2012 -55% 9/16/2011 12 a Actual 9 10/13/2011 143% 6/13/2011 3 aActual 3 7/20/2011 -100% 3/28/2011 0 n New Meter 0 4/13/2011 -100% 3/28/2011 1581 r Replacement 3 4/13/2011 -74% 12/15/2010 1578 m Manual estimate 10 1/12/2011 4% MSG 9/16/2010 1568 m Manual estimate 10 10/15/2010 17% MSG 6/14/2010 1558 a Actual 8 7/15/2010 -43% 3/18/2010 1550 a Actual 15 4/14/2010 137% 12/14/2009 1535 aActua1 6 1/12/2010 -34% 9/16/2009 1529 a Actual 10 10/15/2009 8% 6/10/2009 1519 a Actual 8 7/20/2009 -13% 3/17/2009 1511 a Actual 10 4/29/2009 -30% 12/15/2008 1501 aActual 14 1/20/2009 39% 9/16/2008 1487 a Actual 11 10/10/2008 1% 6/10/2008 1476 a Actual 10 7/16/2008 37% 3/12/2008 1466 aActual 7 4/11/2008 -14% N TR E E. . 5 Q � (O �5 I h� 00 GRADING ` EASEMENT EXISTING p HOUSE --� 0 O LOT 3 �,�SEPrICTANK N AREA A 44,33Z 5FFs�9�, 1 N Lor 5 ►O t 0 � ' � 1 � J LOT Zq t k. �SLOP�' lefQU//PE"ENT IS (-150) X = /50 S O c� DES/ON EL EV47-10N 47 .. ...... .(TOP OF 570Nf) 16V A� EXIST/NCS ELEI27-1ON .4T.. ... .. . . 2EQU/teED F/LL = DES/�!N 45 301L7- INV 3U/LTINV P/PE DUT OF 1100 E /36,47 135,5¢INV P/PE INTO T4NK 13G.17 13 5.3Z INV. PIPE OUT OF TANK 135,9Z ),35, 14- INV 35, 1¢INV PIPE /NTO D. BOX 13¢,92 ►34, 15 INV P/PE OUT' OF D. BOX 134.75 133,98 //V INV END OF PIPE 1 134.5-0 l3 .Gz. nORTf-/ ANDOVER , /MASS, 2 134,Sb /33.59 134.SO 13 3.4Z FOR GV,JTEie ELEk4T/ON 12-9.0 -OHN CAGNINA ,4VERWOE STONE 5C.4LE: 1 '1= 40 D4rE.• OCT zap H88 �EPT,S/ ,47 P,eOBE NOTE. 7-1115 PL,4N /5 NOT ,4 W441ff4NTY C�IRI STIQNSEN SERGI, INC. OF TWE SYSTEM BUT ,4 11E2/F/C,47-ION l&O SUMMER STREET -• HAVERH/LL,MASS. Of Tf/E LOC,QT/ON OF TWE Ea'/ST//VC ST�UCTU2ES. L,ANTOR CwAEEn l ( 4R� op HEO-i-H nor �I %dsT RsT �srarEs A?PL� 4jv- w,,j ❑ WELL_ A��ouCD jY1T'C �_ 5EPri c Sys ,—E," vii c- RgsoNs = C-XAV4TtoIJ lti�Pt�-6 roti V/JrG ��-�k - /JSS 4►� ~ FINAL I tiSP&--rlo0 -g?' APFROOIA)6 AjrHOj?t / X06 i DiSk �ov�V1, N / i �Iti6 FVAL APPROVAL (p- TH (5 C7� �IO THE VICTOR COMPANY,INC. REALTORS° 200 Pleoso�nr Sneer,Methuen,MA 01844 . 'N�MAu��� Ya5ewOff.(508)6862201 REALTOR® Res:(508)689-0180 Homes FOR LivinG© TOWN OF SYSTEM PUMPING RECO RI RECEIVED DATE: NOV 1'8 2005 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example:left front of house) )Dv,Az- ko� Aj DATE OF PUMPING: "�t v�QUANTITY PUMPED : ` c GALLONS CESSPOOL: NOy YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D� Lowell Waste Address . I os � Title of File Page of Date File 00en: Date file closed: Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes action Document/ document/ Num. Action _Department Board of Appeals - Board of Health - Planning Board - Conservation Commission - Buil-ding Department Conmtotmeallh of Massechusetls -�s'Iylassachusells system Pumpin Record System OwnerSystem Location V Dale of t umping: 9— Lo �' uattitY Ilnped: galltiii� Cesspool: No �.`�" Yes Seplic Tank: No Yes System Pumped by: 5dredort 5-Y&TOma License Contents transferrred to : Greater i,6 inci 80"Hary District llate: ittspector: TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: -�q`acF-8UANTITY PUMPED 1 C52-� GALLONS CESSPOOL: NO � YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: COMMENTS: rt CONTENTS TRANSFERRED TO: . 1 4 2001 a Commonwealth of Massachusetts City/Town of w RECEIVE ao System Pumping Record Form 4 1Q \!f r.'DEP has provided this form for use by local Boards of Heae=usedbut the information must be substantially the same as that provideMofm, 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 L in : Left side of house, Right side of house, Left front of house, Right front of house, L ar of hous , ' ht rear of house. Left rear of building. Right rear of building. Address 6. 17 _s— City/Town State Zip Code 2. System Owner. l Name Address(if different from location) City/Town State / Zip Code Telephone Number B. Pumping Record C 1. Date of Pumping � � I � p g Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes EJ-1q-6-- If yes, was it cleaned? ❑ Yes ❑ No 5. Coni ition pf Syst m: 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. eLocalionncontents were disposed: Lowell Waste Water g toe of Haul r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1