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Miscellaneous - 68 LACONIA CIRCLE 4/30/2018 (2)
68 LACONIA CIRCLE - 210/105_D-0155-0000.0 I A 1 6L 03/1412012 Commonwealth of Massachusetts Form 4--System Pumping Record" Massachusetts System Pumping Record RECEIVED 'A' System Owner System Location Brown Robert Priaary Homy TO'NN OF NORTH ANDOVER F,r:ALTH DEPARTMENT 69 Laconia Circlz 69 Laconia Circle ;,orth :kndover, !Qk, 01845 I,orth Andover, VSA, 01945 (617)--233-5341 x (617)-233-5341 x Brown Type: Emergenc Routine Cesspool: No v Yes Septic Tank: No = YesQ Date of Pumping: /"y 9 /y Quantity Pumped: l3Zif- Gallons System Pumped By: Wind River Environmental,LLC Permit#: Contents Transferred to: Contents Disposed at: Date: Pumper Signature: Condition of System/Other Comments U `� 7 VIU Noted on remled paver Dep Approved Form-12/07/95 V Commonwealth of Massachusetts F rm 4 �i W ecor r Massachusetts System Pumping Record uv` I Q 2013 C lxzz.T ff',MBF L System Owner System Location Bror:.n Robort Primary Horse +53 LAconia. Circle 68 Laconia Circle Ixorth Andover, MA, 01.845 ,;orth Andover, HA, 01845 (617)-'?33--5341 r, (61.7)-233-5341 x ro^-m Type: Emergency Routine Cesspool: No Yes Septic Tank: No Yes Date of Pumping: Quantity Pumped: /s�� Gallons System Pumped By: Wind River Environmental,LLC Permit#: Contents Transferred to: Contents Disposed at: Date: Pumper Signature: ori �Condition of System/Other Comments North Andover, MA- I � l ® Printed on recycled paper Dep Approved Form-12/07/95 � Commonwealth of Massachusetts EMEMCity/Town of 19 System Purrrping Record NORTH ANDOVER Form 4 be used.but the DER has provided this form for use by local Boards oo Health. here,ten forr using this form,check with your information must be supstantially the somard must 99 local Board of Health to determine the form they use.within 14 days fromhe System in he Pumping datbe inubmttte g Reco the local Board of Hean or other approving r+tY apoordant:e witYl 310 CMR 15.351. A. Facility information AP '� [Ut2 lmp°rta°L When 1. System Location, TOWN OF NORTH ANDOVER filUog oui , i{faALTH Q,EPARTMEI�IT - 4 __...._•.. •• forms on U1B [.,�f •- -� .-.--�—��. colter,use —.�.�..,.— - coni - _.....�._ . .—^ Wy Me M MY Address /f to move your — late [.tea cursor-do not City(rown use the return key. 2. System Owner: -.�kab .-. ,..1.3. Name _ _ .._�., _..r._. — ,. .._�..- ... .. ---•• ... ...__..,__.,. .,___. w. Address(if different from location) 1pp _ ZfGoft tyrrawn Telephone Number B. Pumping Record 1. Date of Pumping 0 to '. Quantity Ptar,�ped Irons Cess o! s Imopeptic Tank ❑ Tight Tank © Grease Trap 3. Type of system: Q PQ � � " ❑ other(describe): 4. Effluent Tee Filter present? ] Yes ❑ 1Vo If yes, was it cleaned? ❑ Yes Q No 5. Condition of System: 6. System Pumped By' Vehirie License Number Name p�� Company t . 7. Location whete contents were disposed: • . gK3 wure of Ftauiex S"lure of Re calving FaGIlity ._ , ._...•.,. ------..._ - Qete System pumping Record•Page t of 1 15famo.dm-030 ■ o Fire&Water—Cleanup&Restoration'"" SERVPRO of Billerica/Tewksbury 978-663-9833 SERVPRO of Lawrence 978-688-2242 SERVPRO of Lowell 978-454-7577 SERVPRO of Salem/Plaistow 603.893.9700 SERVPRO of The Anclovers 978-475-1199 Toll Free 800-535-6322 jo v 3976 pORT/ Of 4o �yo OL FO 9 Town of North Andover HEALTH DEPARTMENT ,SSACHUSE� CHECK#: DATE: LOCATION: el,9 H/O NAME: CONTRACTOR N IE Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 I %ector $ the 5 R $ ❑ -Other. (Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer 9 '% u . O 9 Town of North Andover s.,,,o t HEALTH DEPARTMENT S4C MUS CHECK#.: J DATE: LOCATION: fir- 0' Z/I \ 1 H/O NAME: CONTRACTOR N E: �AA Type of Permit or License:(Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ [,I.,,.-Vtl 5Report $ �' ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer Commonwealth ofMassachusetts V RECE1 ED ion Title 5 Official Inspect o FormSEP 2 8 2009 Subsurface Sewage Disposal System Form-Not for Voluntary Assessm ants OF NORTH ANDO yt 68 Laconia Circle TOW HEALTH DEPARTMENTER Property Address Vijay Kathuria Owner Owner's Name information is North Andover MA 01845 9/11/2009 required for State Zi Code Date of Inspection every page. City/Town P P Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Neil J. Bateson cursor-do not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover Ma 01810 City/Town State Zip Code 978-475-4786 SI15 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Nee F her Evaluation by the Local Approving Authority 9/11/2009 Inspe ors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Officialp Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 68 Laconia Circle Property Address Vijay Kathuria Owner Owner's Name information is required for North Andover MA 01845 9/11/2009 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old'or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 68 Laconia Circle Property Address Vijay Kathuria Owner Owner's Name information is North Andover MA 01845 9/11/2009 required for every page. 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 ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Forth: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 M 68 Laconia Circle Property Address Vijay Kathuria Owner Owner's Name information is required for North Andover MA 01845 9/11/2009 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins.09/08 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 68 Laconia Circle Property Address Vijay Kathuria Owner Owner's Name information is required for North Andover MA 01845 9/11/2009 every page. CitylTown 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" u or non 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•09/08 Title 5 Official Inspection Forth: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 M 68 Laconia Circle Property Address Vijay Kathuria Owner Owner's Name information is required for North Andover MA 01845 9/11/2009 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 600 t5ins•09/08 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 Form-Not for Voluntary Assessments M 68 Laconia Circle Property Address Vijay Kathuria Owner Owners Name information is required for North Andover MA 01845 9/11/2009 every page. CitylTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Yes Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 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 68 Laconia Circle Property Address Vijay Kathuria Owner Owner's Name information is required for North Andover MA 01845 9/11/2009 every page. Cityfrown 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 two years ago, owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Measured 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 I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): l5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Laconia Circle Property Address Vijay Kathuria Owner owner's Name information is required for North Andover MA 01845 9/11/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 20 Years old, 8/10/1989 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4"Cast iron thru wall to tank. 3" PVC in house, no leaks visible Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x 5'x4' Sludge depth: 2 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Laconia Circle Property Address Vijay Kathuria Owner owner's Name information is required for North Andover MA 01845 9/11/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness 2 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 19" 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. Inket 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts 7 r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 68 Laconia Circle Property Address Vijay Kathuria Owner Owner's Name information is required for North Andover MA 01845 9/11/2009 every page. Cityffown 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 resent: Yes No P ❑ ❑ 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 68 Laconia Circle Property Address Vijay Kathuria Owner Owner's Name information is required for North Andover MA 01845 9/11/2009 every page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box level &distribution equal. No evidence of leakage. No evidence of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 68 Laconia Circle Property Address Vijay Kathuria Owner Owner's Name information is North Andover MA 01845 9/11/2009 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 3 trenches 45'long ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok.Vegetation ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Laconia Circle Property Address Vijay Kathuria Owner Owner's Name information is required for North Andover MA 01845 9/11/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts WMTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Laconia Circle Property Address Vijay Kathuria - Owner Owner's Name information is North Andover MA 01845 9/11/2009 required for State Zip Code Date of Inspection every page. CityrFown 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 kto Cocom e- wc�k.ev- t` ((oCt � �( ® d_a14iL4 it 3o-lc 3L t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts T Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Laconia Circle Property Address Vijay Kathuria Owner Owner's Name information is required for North Andover MA 01845 9/11/2009 every page. 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. 7/16/1985 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: As per design plan test pit data no water 4'below trenches Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Laconia Circle Property Address Vijay Kathuria Owner Owner's Name information is required for North Andover MA 01845 9/11/2009 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts City/Town of a System Pumping Record M Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used b information must be substantially the same as that provided here. Bere Record re using this form local Board of Health to determine the form they use. The System Pumpin but the the local Board of Health or other approving authority. check with your d must be submitted to A. Facility Information �. System Location: Left side of house, Right side of house, ,ft front of��Right front Left rear of house, Right rear of house. - 9 of house, Address City/i own 0 U State Zip Code � 2. System Owner: Name �v + 1 ^t Address(if different from location) CitylTown 686 r, Zip Code Telephone Number B. Pumping Record I. Date of Pumping Of Date 2. Quantity Pumped: 3. Type of system: canons ❑ Cesspool(s) ❑ tic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: C-- h9x 6. System Pumped By: Neil Bateson Name Bateson Enter rises Inc Vehicle License Number F5821 Company 7' L°cati contents were disposed: Xnu *' 5 Lowell Waste Water r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Summary Record Card generated on 9/14/2009 2:24:13 PM by Karen Hanlon Page 1 Town of North Andover Tax Map # 210-105.D-0155-0000.0 Parcel Id 17116 68 LACONIA CIRCLE VIJAY KATHURIA 68 LACONIA CIRCLE NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 1.29 Acres FY 2010 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until VIJAY KATHURIA Owner 68 LACONIA CIRCLE NORTH ANDOVER,MA 01845 LESCARBEAU,JOHN Previous Customer Inactive 6/24/2004 68 LACONIA CIRCLE N.ANDOVER,MA 01845 UB Account Maint, Account No Cycle Occupant Name Active/Inactive Bldg Id. 17556.0-68 LACONIA CIRCLE Last Billing Date 7/8/2009 3170226 03 Cycle 03 Active UB Services Maint. Account No.3170226 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 112.44 /1 UB Meter Maintenance Account No.3170226 Serial No Status Location Brand Type Size YTD Cons 0032506430 a Active R ENC L METE METE w Water 0.63 0.63 208 Date Reading Code Consumption Posted Date Variance 6/9/2009 3743 a Actual 29 7/20/2009 55% 3/13/2009 3714 a Actual 20 4/29/2009 -23% 12/9/2008 3694 a Actual 25 1/20/2009 -69% 9/9/2008 3669 a Actual 84 10/10/2008 51% 6/5/2008 3585 m Manual estimate 50 7/16/2008 123% MSG 3/11/2008 3535 a Actual 24 4/11/2008 -50% 12/10/2007 3511 a Actual 50 1/22/2008 -58% 9/5/2007 3461 a Actual 97 10/12/2007 138% 6/18/2007 3364 a Actual 49 7/20/2007 140% 3/15/2007 3315 m Manual estimate 20 4/16/2007 -25% 12/12/2006 3295 a Actual 26 1/19/2007 -71% Trouble Code:03 9/12/2006 3269 a Actual 90 10/20/2006 51% Trouble Code:03 6/13/2006 3179 a Actual 65 7/10/2006 159% Trouble Code:03 3/6/2006 3114 a Actual 19 4/17/2006 -43% Trouble Code:03 12/21/2005 3095 a Actual 41 1/17/2006 -67%Trouble Code:03 9/20/2005 3054 a Actual 135 10/14/2005 304% Trouble Code:03 6/13/2005 2919 a Actual 28 7/15/2005 45% Summary Record Card generated on 9/14/2009 2:24:13 PM by Karen Hanlon Page 2 Town of North Andover Tax Map # 210-105.D-0155-0000.0 Parcel Id 17116 68 LACONIA CIRCLE VIJAY KATHURIA 68 LACONIA CIRCLE NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 1.29 Acres FY 2010 3/22/2005 2891 a Actual 23 4/5/2005 -65% 12/13/2004 2868 a Actual 58 1/14/2005 -30% Trouble Code:03 9/16/2004 2810 a Actual 79 10/8/2004 10% Trouble Code:03 6/24/2004 2731 f Final Bill 60 6/25/2004 145% 4/15/2004 2671 a Actual 42 5/17/2004 0% Trouble Code:03 Plan 0 f f cn d In North Andover , MA showing Proposed lmprovement5 For Lot 2 - A Laconia Circle Prepared For John Ali5ol? Lescorbeou & Scale:1' =40' Date: MarchZ3, /9 9 4 y, 6, /99f osed Back No/l 'r-s CTHOMAS WEVE P.E. & R.L.S. AI Property Line Data & Site Improvements Taken From A Plon By Thomas E. Neve Associates, Inc. Titled.- 5qque s t rias '5s rC.1 t&5 L o coma Circ% - Lor 2-A S can it ary Disposct/ System Dated ,1uy 16, 1986 Building Location Taken From A Plan By Thomas E. Neve Associates, Inc. Titled- F/an of L and in Nort h Ando vcr, M^ ghowin�c "A5- C3uilt " p w&_ n Lacat ion Lot - -A L oconlo Cir-cle o2.ed M!Y2/1 1993 Septic System Location Taken From A Plan By Thomas E. Neve Associates, Inc. Titled.' Plo n of L on d in Nor t h /}r)do Ye r, M A 5howin9 "A!S- Built " S4nitory U/sPosa/ 5.yst eT?? Dated Auj.io,198 9 Thomas E. Neve Associates, Inc. Engineers — Surveyors — Land Use Planners 447 Old Boston Road — U.S. Route 1 Lot 1- C L of 2-A e�t 56,2 6 2 SF t yem 1 2 9 /+c. d P°Ole' 0 n o � d t Cl E oy Lo .0o r vUv� ^ � Ol ( ' V ;ro �ro� o sel gig ,�9 s �e Clk Z('VV X /Z'0 e1� P\ V it f H ' � r I A I EX/'stif Septic Systen ■ - 139. g� , Ci Si t e Plan COMMONWEALTH OF MASSACHUSETTS MID EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION !4 .i SV TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 68 Laconia Circle_ _North Andover_ `�� Owner's Name: John Lescarbeau_ PS'��11'► Owner's Address: 68 Laconia Circle_ �0��►� _North Andover,MA 01845_ Date of Inspection:3/16/2004_ Name of Inspector: Neil J.Bateson_ Company Name: Bateson Enterprises Inc._ r Mailing Address:_111 Argilla Road_ _Andover,Ma.01810_ Telephone Number:_(978)475-4786_ Y L- CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ils Inspector's Signature: Date: 3/16/2004— The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments: ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Address: 68 Laconia Circle Property Add _ Circle— North Andover_ Owner: Lescarbeaa Date of Inspection:_3/16/2004_ Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: 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. n or not determined N ND in the for the following statements.If"not determined"please Answer es o (Y, ) Y explain. _The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 68 Laconia Circle_ —North Andover_ Owner:_Lescarbeau_ Date of Inspection: 3/16/2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance__ "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 ` OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 68 Laconia Circle_ _ North Andover— Owner:_Lescarbeau_ Date of Inspection: 3/16/2004 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ _No_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _No_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool No Liquid depth in cesspool is less than 6"below invert or available volume is'/z day flow. No Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ _No_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _ _No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ _No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone I1 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 68 Laconia Circle_ _North Andover— Owner:_Lescarbeau Date of Inspection: 3/16/2004_ Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Yes _ Pumping information was provided by the owner,occupant,or Board of Health No Were any of the system components pumped out in the previous two weeks? Yes_ _ Has the system received normal flows in the previous two week period? No_ Have large volumes of water been introduced to the system recently or as part of this inspection? Yes_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) Yes — Was the facility or dwelling inspected for signs of sewage back up? Yes_ Was the site inspected for signs of break out? _Yes _ Were all system components,excluding the SAS,located on site? _Yes_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _Yes_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _Yes_ _ Existing information. _No_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_68 Laconia Circle_ _North Andover— Owner:_Lescarbeau_ Date of Inspection: 3/16/2004_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_4_ Number of bedrooms(actual):_4_ DESIGN flow based on 310 CMR 15.203 for example: 110 d x#of bedrooms : 600 Number of current residents:_4 Does residence have a garbage grinder(yes or no): Yes_ Is laundry on a separate sewage system(yes or no):_No_ Laundry system inspected(yes or no):` Seasonal use:(yes or no):_No_ Water meter readings: Yes_ Sump pump(yes or no):_No Last date of occupancy:— Current-COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):, Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:_Pumped 2002,,owner_ Was system pumped as part of the inspection(yes or no): Yes_ If yes,volume pumped:_1500_gallons--How was quantity pumped determined?_Measured tank Reason for pumping: _Inspect tank&tees_ TYPE OF SYSTEM _X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe):_ Approximate age of all components,date installed(if known)and source of information:_15years old,8/10/1989, As built plan_ Were sewage odors detected when arriving at the site(yes or no):_No Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_68 Laconia Circle_ —North Andover— Owner:_Lescarbeau_ Date of Inspection: 3/16/2004_ BUILDING SEWER(locate on site plan)X Depth below grade:_24"_ Materials of construction: _cast iron _X_40 PVC_other Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.):_4"Cast iron thru wall to septic tank. 3" PVC in house,no leaks visible_ SEPTIC TANK: X locate on site plan) Depth below grade:_12"_ Material of construction:—X—concrete_metal_fiberglass polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions:_10'x 5'x 4' Sludge depth:—4"— Distance from tp of sludge to bottom of outlet tee or baffle: 23"_ Scum thickness:_6"_ Distance from top of scum to top of outlet tee or baffle:_8" Distance from bottom of scum to bottom of outlet tee or baffle:_15"_ How were dimensions determined: _ 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.No evidence of septic tank leaking.Depth of liquid at outlet invert. _ GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 Laconia Circle- -North Andover- Owner:_Lescarbeau Date of Inspection: 3/16/2004 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: _0" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.):_D-box level& distribution equal.D-box cover broken,replaced cover.No um d-box to clean. Evidence of solid carryover, evidence of leakage out of d box. vi pumped _ PUMP CHAMBER:_(locate on site plan) Pump in working order(yes or no):— Alarm in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):_ • Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 Laconia Circle_ —North Andover— Owner:_Lescarbeau Date of Inspection: 3/16/2004_ SOIL ABSORPTION SYSTEM(SAS):—X (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: X_ leaching trenches,number,length:_3 trenches 45'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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of I 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 Laconia Circle_ —North Andover_ Owner:_Lescarbeau_ Date of Inspection: 3/16/2004 SKETCH OF SEWAGE DISPOSAL SYSTEM least Provide a sketch of the sewage disposal system including ties to at two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. A to Tank=16'9" A to D-Box=3418" B to Tank=37' B to D-Box=557" House A B Water Meter Garage Septic Tank D-Box 45' I Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 Laconia Circle —North Andover — Owner:_Lescarbeau_ Date of Inspection: 3/16/2004_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water _41 _ Please indicate(check)all methods used to determine the high ground water elevation: X Obtained from system design plans on record-If checked,date of design plan reviewed:_7/16/1985_ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain:_ Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: __ You must describe how you established the high ground water elevation: Design plan_ �+ p - r7 tnLnriC�NLfStONd'®C♦M®NO.iAC%Cr : o wNNmcvl9o.�'�eNLn�» I �,-inN0 jl H Lo d•rl viLn ri ti L!:ei df ri rL tr r W ®t90®0nt90LnIVI0uS9CtiC�LtiC�h1 '��,,:• N W 0(961C90[9®01.AUSNI.A@CrC'.O+�C• �; --Y ±�. 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MIMS MAO'Yt10L :I3 3St1N3II4 #I3Pti3S I3ZtS - ----------------- 13 8It�00H'I 89-HS 9ZZOLT£ :T# U313W WHOP 'f U38Hd0S3`I-9ZZOLT£ AU013IH 1NAODOU 3/11 wmor3rt4� _,,A3�1PdI2id rr... _,. 0'y HV K r Ienuew 5al►W 1NIOd NhA01 SAS ' O's SMOPUI ==3AII=== IA .104 SA view-3 - Z6e4pPdn ' Tel: (978) 475-4786 Fax: (978) 475-5451 Y BATESON ENTERPRISES, INC. Excavating-Water.& Sewer Lines-Septic Systems&Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 68 Laconia Circle, North Andover Owner: Lescarbeau Date of Inspection: 3/16/2004 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Neil J. Bateson Bateson Enterprises, Inc. TOWN OF SYSTEM PUMPING,RE-CORD-'--- DATE: '3 4,6-0V SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example:left front of house) V DATE OF PUMPING: QUANTITY PUMPED : �`s GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES M 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 �LowellWaste FORM U - IAT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. 77*************Applicant fills out this section***************** APPLICANT: John & Alison Lescarbeau Phone (508)681-9335 LOCATION: p Number Par Assessor' s Ma 105D Cei 155 Subdivision Equestrian Estates Lot(s) Street Laconia Circle St. Number 68 ************************Official Use Only************************ RECOMMEME=,N,DATIONS OF TOWN AGENTS: Date Approved 1 Conservation Administrator Date Rejected Comments Date Approved Town Planner Date Rejected Comments Date Approved ood Inspect/or-health Date Rejected Date Approved Septic Inspector-Health Date Rejected Comments Public Werks - sewer/water connections _ - driveway permit Fire Demart—meat Received by Building Inspector Date &X13D ofHS T i-� �r 2-4 CACGu I� c� Nal�Tri' /�ti POVEI'�I MA, r �QPu CAN1 I D'�T'r S S 2,2, WTI G Sy S Appl�ovev /Pr�ovlN6 Co�Vf�IT�o�vs= D1�Q PPKU V�p R�ASoNS D� L� stp�(� SYSTEM i.��siA�T►��.� C-YG4U/JT(O1J J��C f?EG►�D�V U/JrC C1 04 E] F41L. �(NA<_ l VSP�cTfon� 4PPRdVE U/3 T6, ,��-z-�7 API'iznvlNG AUTHOR / r ADDITIDMAL, WSt bz: loN5 SIF=-hjy) l o6&q Gpprak?j 7reW1-5 Ccvid �n�CdA�c,�l fiO be—.P ��r D(SAPt'��v�l� D T-e- of (f) D,�-'4 k-(2--116 111-1-3 _ 1-3 8 ) )�'j�wGcj v,6-t Tv ove!' SL15T, -Vo- F( camsvr:)T Y to �l-Zo sem, 1� dS- 5���be G-�- /q— BOARD OF HEALTH No.Aiidover, Mass . • � , �, . SUBSURFACE DISPOSAL DESIGN CHECK .SST 2 LOQ' APPROM DAT'S DISAPPROPED DATE Provided: C Reasons: Title V FAIL CK Reg 2.5 The submitted plan must show as a minimums , a) the lot to be served-area,dimensions lot # abutters b location and log deep observation hoies-distance to ties c location and results percolation tests-distance to ties d design calculations & calculations showing required leaching area (e) location and dimene ons of system-including reserve area f) existing and proposed contours (g) location any vet areas within 1001 of sewage disposal system or disclaimer-check wetlands mapping J(h) surface and subsurface drains within ))0 t of sewage disposal system or disclaimer -- -- (i) location any drainage easements vithin 1001 of sewage disposal system or disclaimer-Planning Board VLes (0) known sources of water supply within 2 b1 of sewage disposal o system or disclaimer (k) location of my proposed yell to serve lot-1001 from leaching facility (1) location of water lines on propert 10 ' from leaching facility (m) location of benchmark (n) driveways (o) garbage disposals (p no PVC to be used in construction (q) profile of system-elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and Other elevations (r) maximum ground water elevation in area sewage disposal system s) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Reg 6 Septic Tanks (a) capac t es- 50,% of flow, water table, tees, depth of tees, access, pumping (b) cleanout (c) 101 from cellar wall or inground swiam*ng pool (d) 251 from subsurface drains Reg 10.2 7 Distribution Boxes (a) s pe greater 0.08 Reg l0.lt b) sump TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: ' SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example: left front of house) �-e S Cif ACOL V\, �rA 0 1 d �p � �.CCaUt t � l_ c�( • DATE OF PUMPING: QUANTITY PUMPED— GALLONS CESSPOOL: NO I 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 BY - COMMENTS:U B • _ COMMENTS: CONTENTS TRANSFERRED TO: �`� S I Coma mvea t l of Massachusetts 4A_&�assachusetts w stem Putnping Record System Owner System Location La coAcL � Date of Pumping: `� �� Quantity Pumped: /�5�gallolls Cesspool: No I Yes Septic Tank: No U Yes L-�- n System Pumped by: Fare-dea 6#al�ftid d License# Contents transferrred to : Greater Lawrence Sanitary District .Date: Inspector: k wPGF , a 14ikY 1 1 1999 Commonwealth of Massachusetts City/Town of I - System Pumping Record APR - VVj Form 4 9 2007. DEP has provided this form for use b local Boards:of Health. The S stem Tum og 1 R6coCRTH ANDOVERUit Y y `PumpiingiRecord�mii'st be submitted to the local Board of Health or other approving authority. . A. Facility Information Important: When filling out 1. System Location: t forms the e-'A ,1 computer.use �T only the tab key Address to move your C�p <F57 / cursor-do not ` use the return City/Town State Zip Code key. 2. System Owner: Name Address(if different from location City-frown Stat Zip Cbde' Telephone Number B. Pumping Record 1. Date.of Pumping pate 2• Quantity Pumped: Gallons 3. Type of system: Q Cesspool(s) e tic Tank Ti p El 'right Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes D No If yes, was it cleaned? El Yet`❑ No 5. Condition of System: 6. Syste Pu peck By Name Vehicle License Number Company .7. Location w re contents were disposed: Signatu o aul r Date hftp://www.mass.gov/dep/Water/approvals/t5forms.htm#inspect t5form4.doc•06103 System Pumping Record•Page.1 of 1