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Home My WebLink AboutMiscellaneous - 7 LACONIA CIRCLE 4/30/2018 (2) 7 LACONIA CIRCLE 240/1068-0120-0000.0 .r i I North Andover Board of Assessors Public Access Page 1 of 1 Y } NORTH North Andover Board of Assessors •� t� CHU t� —4property Record Card Click Seal To Retum Parcel ID:210/106.B-0120-0000.0 FY:2011 Community :North Andover SKETCH PHOTO Click on Sketch to Enlarge Click on Photo to Enlarge Search for Parcels Search for Sales SII t Summary Residence Detached Structure ' Condo 7 LACONIA CIRCLE 1 Commercial Location: 7 LACONIA CIRCLE Owner Name: RICHARDS,JAMES K RICHARDS,CONSTANZA Owner Address: 7 LACONIA CIRCLE City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 7-7 Land Area: 1.01 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 2588 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 524,700 544,200 Building Value: 299,000 318,500 Land Value: 225,700 225,700 Market Land Value: 225,700 Chapter Land Value: LATESTSALE Sale Price: 445,000 Sale Date: 03/31/2002 Arms Length Sale Code: Y-YES-VALID Grantor: ORLANDO,RICHARD Cert Doc: Book: 06752 Page: 0253 http://csc-ma.us/PROPAPP/display.do?linkld=1708053&town=NandoverPubAcc 5/19/2011 Residential Property Record Card PARCEL_ID:210/106.6-0120-0000.0 MAP:106.B BLOCK:0120 LOT:0000.0 PARCEL ADDRESS:7 LACONIA CIRCLE FY:2011 PARCEL INFORMATION Use-Code: 101 Sale Price: 445,000 Book: 06752 Road Type: T Inspect Date: 04/29/2008 Tax Class: T Sale Date: 03/31/02 Page: 0253 Rd Condition: P Meas Date: 04/29/2008 Owner: Tot Fin Area: 2588 Sale Type: P Cert/Doc: Traffic: M Entrance: C RICHARDS,JAMES K Tot Land Area: 1.01 Sale Valid: Y Water: Collect Id: RRC RICHARDS,CONSTANZA Grantor: ORLANDO, RICHARD Sewer: Inspect Reas: C Address: 7 LACONIA CIRCLE Exempt-B/L% / Resid-B/L% 100/100 Comm-B/LP/o Indust-B/L% / Open Sp-B/L% / NORTH ANDOVER MA 01845 RESIDENCE INFORMATION LAND INFORMATION Style: CL Tot Rooms: 7 Main Fn Area: 1450 Attic: NBHD CODE: 7 NBHD CLASS: 7 ZONE: R1 Story Height: 2.00 Bedrooms: 4 Up Fn Area: 1138 Bsmt Area: 1450 Seg Type Code Method Sq-Ft Acres Influ-YIN Value Class Roof: H Full Baths: 2 Add Fn Area: Fn Bsmt Area: 1200 1 P 101 S 43560 1.000 225,640 Ext Wall: FB Half Baths: 1 Unfin Area: Bsmt Grade: 2 R 101 A 0 0.010 76 Masonry Trim: Ext Bath Fix: 0 Tot Fin Area: 2588 VALUATION INFORMATION Foundation: CN Bath Qual: T RCNLD: 299023 Current Total: 524,700 Bldg: 299,000 Land: 225,700 MktLnd: 225,700 Kitch Qual: T Eff Yr Built: 1983 Mkt Adj: Prior Total: 544,200 Bldg: 318,500 Land: 225,700 MktLnd: 225,700 Heat Type: FA Ext Kitch: Year Built: 1979 Sound Value: Fuel Type: G Grade: G Cost Bldg: 299,000 Fireplace: 2 Bsmt Gar Cap: Condition: A Aft Str Val 1: Central AC: Y Bsmt Gar SF: Pct Complete: Aft Str Va12: Aft Gar SF: 600%Good P/F/E/R: /100/100/85 Porch Type Porch Area Porch Grade Factor P 116 W 246 SKETCH PHOTO 12 246 Sq. 3 59 40 6 600 Sq.R FM/B FU 24 1$ 1450 94M Sq.R 28 28 5 10 s 7 LACONIA CIRCLE ,�ID:210/106.13-0120-0000.0 as of 5/19/11 Page 1 of 1 North Andover Board of Assessors Public Access Page 1 of 1 NOR7q Northi Andover Board ofAssessors O bttbo'6 ANO Ot •'' MATCHING PARCELS S"CNub Click on a column title to sort data by that column Click Seal To Return 23 items found,displayingall items.1 Fiscal Year Parcel ID StNo. Street Owner Name 2011 210/106.B-0120-0000.0 7 LACONIA CIRCLE CHARDS,JAMES K,RICHARDS, CONSTANZA 2011 210/106.13-0114-0000.0 8 LACONIA CIRCLE KULIK°FREDERICK W,SHIRLEY M Search for Parcels 2011 210/106.B-0119-0000.0 9 LACONIA CIRCLE GOODWIN,RONALD,GOODWIN,LORI L Search for Sales PRENDERGAST,MICHAEL J,JOANNE E 2011 210/106.13-0118-0000.0 13 LACONIA CIRCLE PRENDERGAST 2011 210/106.13-0115-0000.0 20 LACONIA CIRCLE RICH,GARY&HARROLD,ANNE, 2011 210/105.D-0153-0000.0 44 LACONIA CIRCLE OTTO,HAROLD S,ELIZABETH C OTTO 2011 210/105.D-0154-0000.0 52 LACONIA CIRCLE LETWIN REALTY TRUST,BRUCE W& MARY KING LETWIN,TRS 2011 210/105.D-0 155-0000.0 68 LACONIA CIRCLE KATHURIA,VIJAY&SANGEETA,C/O ROBERT J BROWN 2011 210/105.D-0150-0000.0 71 LACONIA CIRCLE HART TIMOTHY FRANCIS ROQUE, PATRICIA ANN HART 2011 210/105.D-0156-0000.0 80 LACONIA CIRCLE JENKINS,DALE,JENKINS,TIFFANY 2011 210/105.13-0151-0000.0 81 LACONIA CIRCLE KING,ROBERT G,CHRISTINE M KING 2011 210/105.D-0152-0000.0 85 LACONIA CIRCLE ENGSTROM,WILLIAM L,C/O PAULA J. KEATING 2011 210/105.D-0157-0000.0 100 LACONIA CIRCLE CONTI,JEFFREY,CONTI,LISA 2011 210/105.D-0158-0000.0 110 LACONIA CIRCLE MURPHY,CHRISTOPHER, 2011 210/105.D-0137-0000.0 115 LACONIA CIRCLE TOMASINO,ARTHUR,ROBIN TOMASINO 2011 210/105.D-0159-0000.0 120 LACONIA CIRCLE JAAC REALTY TRUST,KAREN A CRAWFORD,TR 2011 210/105.D-0160-0000.0 130 LACONIA CIRCLE LACONIA CIRCLE REALTY TRUST, SCHMIDT,GREGORY J.&DEBORAH L. 2011 210/105.D-0136-0000.0 135 LACONIA CIRCLE PAPASOULIOTIS,GEORGE, 2011 210/105.13-0161-0000.0 140 LACONIA CIRCLE DE PIETRO,ALFRED,ANNMARIE DE PIETRO 2011 210/105.D-0163-0000.0 150 LACONIA CIRCLE TIMPE,DAVID A,DARIA A TIMPE 2011 210/105.D-0133-0000.0 155 LACONIA CIRCLE GARG,JAGDISH,SUMAN GARG 2011 210/105.D-0132-0000.0 163 LACONIA CIRCLE DAVIS,ROBERT E,PAMELA J DAVIS 2011 210/105.D-0078-0000.0 171 LACONIA CIRCLE BHATNAGAR,HIMANSHU, 23 items found,displaying all items.1 http://csc-ma.us/PROPAPP/newSearch.do;jsessionid=Fl 3B91459E 105011 BD4745BE8B9... 5/19/2011 Joyeiem rumping Kocvra Form 4 DEP has provided this fort for use by local Boards of .tither fontsy be used, but the lntormaiton must be substantlauy the some at;that Pre gate. 8eforo;Wng this fomt,check with your local Board of Hearth to determine the form they use.The$ the 1=1 Board of HeaM or other approving au Pumping Record must be submitted to avcordanoe with 310 CMR 15 M. Y wpm!4� for the pumping date in A. Facility Information nuns out tonna I. System location: AIM key to move your Address cursor•do not /lea • � YI 6`//0 y e r use the MwM -- key. GbRown Zip Code vo 1 2. System Owner. Address(d dice W*0 WC&n) CRyRovm Stye Zip Code Telephone Number S. Pumping Record I. Date of Pumping i Ouan'2. Do My Pum : ped b d _ Geuons 3. Type of system: ❑ CesspoolM ep3Tan ❑ Tight Tank C) Grease Trap ❑ Other(describe): 4. Effluent tea Fater present? ❑ Yes No If yes,was it dearted? [] Yes ❑ No 5. Condition of System: c�SUO� 6. System Pumped By: Name � Vehicle t�oense Number c4fy e k SeQ+,c 7. Location where contents were disposed: LS �. Groff sgneture of muter Data $40tun of R*Wft Faa'tity t ►5toMI4.doa 03106 System Pumping ROOM\Page 1 of 1 NORTH 7015 1 I15 o w Town of North Andover ��'• HEALTH DEPARTMENT ,SSMC MUStt CHECK#: 40 DAT : T��) LOCATION: ff 11 4 H/O NAME: tw CONTRACTOR NAM 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 $1 Title 5 Report $ .� ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer .1 E %ORTN.. 7 0 '1 'l F?f.r .,• LS . Town of North Andover o� '•I,;,, :: , ' HEALTH DEPARTMENT ,Ss�CMUst� CHECK#: 410 DAT , LOCATION: VU I - J4 H/O NAME: CONTRACTOR NAME: W_f ) ) I 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 5Inspector $ QV Title 5 Report $ ❑ Other:(Indicate) $ Health Agent Initials' White-Applicant Yellow-Health Pink-Treasurer Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form .lot for Voluntary Assessments 7 Laconia Circle Property Address Derrick Kittler Owner Owner's Name information is required for every North Andover Ma. 01845 9-23-2014 page. City/Town 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. RECEIVED Important:When A. General Information filling out forms O A on the computer, SEp r� G 4 use only the tab 1. Inspector: key to move your TOWN OF NORTH ANDOVER cursor-do not F. Paul Cardone HEALTH DEPARTMENT use the return Name of Inspector key. Septic Compliance, Inc. "ray Company Name 447 Boston Street Company Address Topsfield _ Ma. 01983 City/Town State Zip Code 978-815-3115 978-681-0726 3294 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 Further ation by t ocal Approving Authority I or's ignature Date The system inspector shall submit a copy c' I nis 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 7 Laconia Circle Property Address Derrick Kittler Owner Owner's Name information is required for every North Andover Ma. 01845 9-23-2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/-11ways complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 3.10 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The house has a garbage disposal, we recommend removal of the disposal. It could have a negative impact on the septic system in the future. 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 deterrrl,,.ed" (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 f Title 5 Official Inspe(;tion Form Subsurface Sewage Disposal System Form -14ot for Voluntary Assessments 7 Laconia Circle Property Address Derrick Kittler Owner Owner's Name information is required for every North Andover Ma. 01845 9-23-2014 page. City/Town 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 re;)iaced ❑ 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 th-r .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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Laconia Circle Property Address Derrick Kittler Owner Owner's Name information is required for every North Andover Ma. 01845 9-23-2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ® ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® 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 cec:rpool ❑ ® Liquid depth in cessp gal is less than 6" below invert or available volume is less than 'h day flow t5ins•3/13 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 c,M 7 Laconia Circle Property Address Derrick Kittler Owner Owner's Name information is required for every North Andover Ma. 01845 9-23-2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. An portion of cesspool or privy is within 100 feet of a surface water supply o Y P P P Y pP Y r ❑ ® tributary to a surface water supply. ❑ ® Any portion of a cessp.�ol or privy is within a Zone 1 of a public well. 4 ❑ ® Any portion of a cess,,,00l or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If 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-3113 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 7 Laconia Circle Property Address Derrick Kittler Owner Owner's Name information is required for every North Andover Ma. 01845 9-23-2014 page. City/Town �3tate Zip Code Date of Inspection . 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? s ® ❑ Were the septic tank waiiholes 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 4 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Summary Record Card generated on 9/23/2014 3:39:17 PM by Karen Hanlon Page 1 Town of North Andover Tax Map # 210-106.B-0120-0000.0 Parcel Id 17524 7 LACONIA CIRCLE BRITTNY KITTLER 7 LACONIA CIRCLE NORTH ANDOVER, MA 01F-t-7 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.01 Acres FY 2015 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until BRITTNY KITTLER Owner 7 LACONIA CIRCLE NORTH ANDOVER,MA 01845 RICHARDS,JAMES&CONSTANCA Previous Customer Inactive 3/31/2011 7 LACONIA CIRCLE NORTH ANDOVER,NIA 01845 FORECLOSURE MARIANNE JENKINS Previous Customer Inactive 10/1/2010 930 BROADWAY EVERETT,MA 02149 NEVER OWNED THIS. BOUGHTATAUCTION BUT NEVER FINALIZED. DEUTSCHE BANK NATIONAL TRUST C Previous Customer Inactive 7/31/2011 C/O LPS FIELD SERVICES INC. ATTN: BOBBI OLIVER 10385 WESTMOOR DRIVE,SUITE 100 WESTMINSTER,CO 80021 UB Account Majnt. Account No Cycle Occupant Name Active/Inactive Bidg Id. 17522.0-7 LACONIA CIRCLE Last Billing Date 7/8/2014 3170192 03 Cycle 03 Active UB Services Maint. Account No.3170192 Service Code Rate Charge Multiplier/Users MISCFEEADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 64.60 11 UB Meter Maintenance Account No.3170192 Serial No Status Location Brand Type Size YTD Cons 33563411 a Active ERT HH b Badger w Water 0.63 0.63 428 Date Reading Code Consumption Posted Date Variance 9/12/2014 797 a Actual 18 4% 6/11/2014 779 a Actual 17 7/16/2014 43% 3112/2014 762 aActual 12 4/11/2014 -10% 12/10/2013 750 aActual 13 1/17/2014 33% 9/11/2013 737 a Actual 10 10/1512013 -35% 6/11/2013 727 a Actual 15 7/24/2013 39% 3/13/2013 712 aActual 11 412212013 6% 12111/2012 701 a Actual 10 1/9/2013 -4% 9/13/2012 691 a Actual 11 10/15/2012 -37% 6/11/2012 680 aActual 17 7/16/2012 40% 3/12/2012 663 a Actual 12 4/14/2012 -13% 12/13/2011 651 aActual 14 1/17/2012 182% 9113/2011 637 a Actual 3 10/13/2011 -24% 7/20/2011 • 634 f Final Bill 3 7/20/2011 -100% • Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 7 Laconia Circle Property Address Derrick Kittler Owner Owner's Name information is required for every North Andover Ma. 01845 9-23-2014 page. City/Town State Zip Code Date of Inspection D. System Information Description: ` Number of current residents: 5-2 adults 3 children 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 d Enclosed 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: CurrentlyOccupie d • 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 & DRAIN BORACZEKSERVICE ® THE PROFESSIONAL EXPERTS IN THE SEPTIC & DRAIN INDUSTRY • - PLEASE PAY FROM THIS BILL- Customer Name: ` 7 CHISHOLM ROAD Service Location: KINGSTON,NH 03848 �r r1�i z (603)329-6005•(978)374-8803 Phone: (978)921-5353•(978)465-2121 •(603)772-2759 Contact: www.boraczekseptic.com Billing Address: • RESIDENTIAL / COMMERCIAL • SERVICING THE ENTIRE NORTH SHORE �/ • CERTIFIED TITLE V INSPECTORS City. Alci . llri r,/oV Ct'' Zlp. • SAME DAY EMERGENCY SERVICE [Date of Service: Nature of Service Special Instructions ❑Completed '7- ,21) - /I/ ,Reg.Maint. ❑Incomplete/Reason: -i A ., A- 0 Reg. ❑Emergency Per: 0 Schedule: 4- 0 N/C .111-Day ❑Night /PM Services Rendered Vacuum Pumping 0 Car Wash w J d 13S ❑Dump Charges eptic Tank Observations Drain Cleaning minimum 5 tons of sand ❑Drywall RGood Condition ❑Main Line $ lton+9%fuel 0 Leach Pit/Overflow surcharge.Any amount over ❑Leach field Runback ❑Toilet Bowl 0 D-Box 5 tons will be billed. 0 Riding High ❑Kitchen Sink ❑Pump Chamber (liquid level) ❑Bathtub/Shower ❑Grease Trap 0 Yearly Profile Fee$ 0 Full to Cover ❑Vanity 0 Catch Basin 0 Excessive Solids 0 Floor Drain ❑Portable Toilet ❑Boraczek Charges Top 1 Bottom 0 Yard Drain 0 Other 0 Use No Powdered Soap ❑Vent Qty. $ 4 hour minimum 0 Heavy Grease 0 Water Jetting Size: $ 1 hour travel ❑Roots ❑Other �, ❑Suggest Electric Rootering ❑Footage: 0 ' Under 1000 gallons V'1000 gallons 71500 gallons 0 Van Called 0 2000 gallons 0 3600_gallons 0_4000 gallons ❑Other 0 5000 gallons 0 6000 gallons 0 other Miscellaneous 0 Digging Charge ❑Backhoe 0 Inspection ❑Location n.r in. ❑Kubota hrs. 0 Title V Inspection ❑Service Call 0 Consultation Reason: 0 Labor ❑Estimate ❑Pump Repair ❑Waiting Time 0 System Installation 0 Repair ❑Portable Toilet Rental ❑System Treatment -Digging Charge Is Per Driver's Discretion 0 Baffle ❑Rejuvenation Description of Work 2 t 11//1yef Gua �� : < !�,• Ir Recommendations ..Terms-of- Payment: C.O.D. PARTS Vacuum Pumping Drain Cleaning r Payment Req iced Upon S-a Trice ❑Cash r^ � TAX Yr. Month Yr. Month tI'theck ❑Credit Ll!:n Terms & Conditions oiscouNr 1.Not responsible for damage beyond the curb line. 3. 1.5%per month will be charged to accounts past due. 2.All complaints shall be reported within 48 hours. 4.The purchaser agrees to pay all cost of collection. TOTAL I the undersigned agree to all term and conditions. Customer Signature Servicemanr Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 7 Laconia Circle Property Address Derrick Kittler Owner Owner's Name information is required for every North Andover Ma. 01845 9-23-2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): 4 General Information Pumping Records: Source of information: Pump slip on file Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Pump truck tube Reason for pumping: Due for routine pump and to properly inspect interior or tank during inspection. 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): t5ins•3/13 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 7 Laconia Circle Property Address Derrick Kittler Owner Owner's Name information is required for every North Andover Ma. 01845 9-23-2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date irio<,alled (if known) and source of information: Approx 30 tears of age Plan on file Frank C Gelinas Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 14"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.): ( 1 9 9 ) Good None Septic Tank (locate on site plan): Depth below grade: 15"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: 1000 gallons 8'x6'x5' Sludge depth: 4" t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts N w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 7 Laconia Circle Property Address Derrick Kittler Owner . Owner's Name information is required for every North Andover Ma. 01845 9-23-2014 page. City/Town 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 Scum thickness 2" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Dip-Stick and tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): We recommend tank be pumped on a yearly basis,baffles were on,structural integrity appeared to be good, liquid level was good, no evidence of leakage. 4 Grease Trap (locate on site plan): Depth below grade: N/A 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 r Alet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Laconia Circle Property Address s Derrick Kittler Owner Owner's Name information is required for every North Andover Ma. 01845 9-23-2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal [j 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•3/13 Title 5 Official Inspection Form: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 7 Laconia Circle Property Address Qerrick Kittler Owner Owner's Name information is North Andover Ma. 01845 9-23-2014 required for 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 Good and even, Box was replaced August 2010 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.): Box was level, ran small amout of water through box to check distribution it was good, no evidence of solids carryover,no cracks of leals box is in like new condition all 4 lines had levelers . 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.): N/A * 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•3/13 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 7 Laconia Circle Property Address Derrick Kittler Owner Owner's Name information is North Andover Ma. 01845 9-23-2014 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: ® leaching fields number, dimensions: 1 Field 24'x 45' ❑ 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.): Gravelly None None No Grassy back yard area. 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 Form -Not for Voluntary Assessments 7 Laconia Circle Property Address Derrick Kittler Owner Owner's Name information is required for every North Andover Ma. 01845 9-23-2014 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.): N/A 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 -_F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Laconia Circle Property Address Derrick Kittler Owner Owner's Name information is North AndoverMa. 01845 9-23-2014 required for every --- — page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately I V Y `3 .T i" t5ins•3113 me 5 cxel�s1 1-111-1——__,. ... o sw a90 owPoxU�r tcrP Page l�Oi 1/ Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Laconia Circle Property Address Derrick Kittler Owner Owner's Name information is required for every North Andover Ma. 01845 9-23-2014 page. City/Town 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: 7' 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: 9-9-78 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: All liquid levels were good, No Sump Pump, Soil Logs on File, basement finished and dry. Before filing this Inspection Report, plea-is� see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 7 Laconia Circle Property Address Derrick Kittler Owner Owner's Name information is • required for every North Andover Ma. 01845 9-23-2014 page. City/Town 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 MC'RTN 1 ' 55 / v O 4e y0 Fl•:.r .. • P9 . Town of North Andover s,�'•>,;;;:: HEALTH DEPARTMENT VSs^cNustt CHECK#: ATE: D LOCATION: --� H/O NAME: CONTRACTOR NAME: 1Ype 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) $ ❑ �TitleInspector $ Title 5 Report $ ❑ Other. (Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer r Commdnwealth of Massachusetts . Title 5 official Inspection Form tiA��` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °wM 7 Laconia Circle Property Address One West Services L.L.C. Owner Owner's Name information is No. Andover Ma. 01845 8-2-2011 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. RECEIV ft- Important: A. General Information When filling out forms on the AUG — Z U 1 computer,use 1. Inspector: only the tab key to move your F. Paul Cardone TOWN OF NORTH ANDOVER cursor-do not Name of Inspector I 14FALTH DEPARTMENT -J! use the return key. Septic Compliance, Inc. Company Name r� 447 Boston Street Company Address Topsfield Ma. 01983 n City/Town State Zip Code 978-407-1808 978-681-0726 3294 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 Furthe aluation by the Local Approving Authority pector's Signatur 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. 7 Laconia Cir No Andover8-2-11Wells Fargo-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 .0_. i Commdnwealth of Massachusetts w Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M Syey'.p 7 Laconia Circle Property Address One West Services L.L.C. Owner Owner's Name information is required for No. Andover Ma. 01845 8-2-2011 every page. City/Town 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: This system was last inspection August 2010. The bank that now owns property wanted it re- inspected System has a garbage disposal, not designed for one,we recommend it be removed, ,could possibly have a negative effect on field in the future. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 7 Laconia Cir No Andover8-2-11 Wells Fargo-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 s Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c;M 7 Laconia Circle Property Address One West Services L.L.C. Owner Owner's Name information is required for No. Andover Ma. 01845 8-2-2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: 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. 7 Laconia Cir No Andover8-2-11Wells Fargo•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts NMMAW Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 7 Laconia Circle Property Address One West Services L.L.C. Owner Owner's Name information is required for No. Andover Ma. 01845 8-2-2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the 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. 7 Laconia Cir No Andover8-2-11Wells Fargo•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Laconia Circle GSM Property Address One West Services L.L.C. Owner Owner's Name information is required for No. Andover Ma. 01845 8-2-2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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- 1 0,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If 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. 7 Laconia Cir No Andover8-2-11Wells Fargo•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 7 Laconia Circle Property Address One West Services L.L.C. Owner Owner's Name information is required for No. Andover Ma. 01845 8-2-2011 every page. City/Town 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 S SAS on the site has rp System (SAS) 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)] 7 Laconia Cir No Andover8-2-11Wells Fargo•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 a ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Laconia Circle Property Address One West Services L.L.C. Owner Owner's Name information is required for No. Andover Ma. 01845 8-2-2011 every page. City/Town State Zip Code Date of Inspection 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 Number of current residents: 0 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 ears usage d 063462 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: Last inspected August 2010 Commercial/Industrial Flow Conditions: Type of Establishment: N/A 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: Last date of occupancy/use: Date Other(describe): 7 Laconia Cir No Andover8-2-11 Wells Fargo-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Laconia Circle Property Address One West Services L.L.C. Owner Owner's Name information is required for No. Andover Ma. 01845 8-2-2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Pump Slip Dated 8-9-2010 Title 5 Inspection 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 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: Approx. 30 years of age Plan on file. Frank C, Gelinas Were sewage odors detected when arriving at the site? ❑ Yes ® No 7 Laconia Cir No Andover8-2-11 Wells Fargo•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Laconia Circle Property Address One West Services L.L.C. Owner Owner's Name information is required for No. Andover Ma. 01845 8-2-2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 14"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.): Good None Septic Tank(locate on site plan): Depth below grade: 15"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: 1000 Gallons 8'x 6'x 5' Sludge depth: Approx. 2" Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle 0-1" Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Septic Dip-Stick 7 Laconia Cir No Andover8-2-11Wells Fargo-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Y 7 Laconia Circle Property Address One West Services L.L.C. Owner Owner's Name information is required for No. Andover Ma. 01845 8-2-2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): We recommend tank be pumped on a yearly basis,baffles were on and working,structural integrity appeared to be good,liquid levels were good,no appeared leakage. Grease Trap (locate on site plan): N/A Depth below grade: feet Materialf o 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 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: N/A Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 7 Laconia Cir No Andover8-2-11Wells Fargo-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Laconia Circle Property Address One West Services L.L.C. Owner Owner's Name information is required for No. Andover Ma. 01845 8-2-2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: N/A 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 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Good and even...Box was replaced August 2010 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.): Box was level...Ran water through box for 20 minutes distribution was equal....No solids carryover....New box, no leakage in or out. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 7 Laconia Cir No Andover8-2-11Wells Fargo•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Laconia Circle Property Address One West Services L.L.C. Owner Owner's Name information is required for No. Andover Ma. 01845 8-2-2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 Field 24'x45' ❑ 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.): Gravelly No None No Grassy back yard area. 7 Laconia Cir No Andover8-2-11Wells Fargo•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 7 Laconia Circle Property Address One West Services L.L.C. Owner Owner's Name information is required for No. Andover Ma. 01845 8-2-2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A Privy (locate on site plan): Materials of construction: N/A Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 7 Laconia Cir No Andover8-2-11Wells Fargo-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M v " 7 Laconia Circle Property Address One West Services L.L.C. Owner Owner's Name information is required for No.Andover Ma. 01845 8-2-2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. t t i • r D 7 Laconia Cir No Andover8-2-11 Wells Fargo•08/06 Title 5 Official Inspection Form:Subsurface Serge Mpaszi System•Page 14 of 15 e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Laconia Circle Property Address One West Services L.L.C. Owner Owner's Name information is required for No. Andover Ma. 01845 8-2-2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells 7' Estimated depth to ground water: 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: 9-9-78 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: All liquid levels were good,basement was dry, no sump,Dug around area during last inspection. 7 Laconia Cir No Andover8-2-11Wells Fargo-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 DelleChiaie, Pamela From: DelleChiaie, Pamela Sent: Thursday, May 19, 2011 12:21 PM To: 'Gary.Cobuzzi@realliving.com' Subject: I.R. -Septic-7 Laconia Circle- Health Dept. Scanned File Attachments: 20110519115446331 Importance: High Follow Up Flag: Follow up Flag Status: Flagged To: Gary Cobuzzi Reference: 978.685.5000 Dear Gary, Attached is the health department file regarding the septic system at 7 Laconia Circle. I understand that the property is currently in foreclosure. The property does have a current COC (Certificate of Compliance)from the Health Dept.from last year for updating the Distribution Box,so the property does not need another Title 5,as it is within the 2 year timeframe. Please call the office if you have any further questions. Have a great day!--O Veit,RegmA Pamela DelleChiaie Departmental Assistant I Community Development I Health Department Town of North Andover 1600 Osgood Street I Bldg 201 Suite 2-36 North Andover,MA o1845 2 Office-978-688-9540 Fax-978-688-8476 0 Email-ndellechiaie(@townofnorthandover.com J Website http://www.townofnorthandover.com/Pages/index "We can never see the path of our life if we are too busy focusing on the pebbles under our feet."--Anonymous If you are happy with the customer service you have received from town departments,please let us know...feel free to complete the general Comment Form (link below): http://www.townofnorthandover.com/Pages/NAndoverMA WebDocs/contact I ` OORT14 ro O`�t l[D 0 6 1 q�O O L O f COPY T COtw CMIw..A OX ��SSACHUs��y PUBLIC HEALTH DEPARTMENT (ommunity Development Division CER2I FIC.32'E Off' CO�VI�GA11-L E As of. August 3 0, 2010 ,This is to cert that the individuafsubsurface d4osaCsystem received a SM S FAC"IORT INS(PECY TOY of the: &p&cement of a Component: Distri6ution Box— 91-20 Tor an On Site Sewage V sposal System B . y ,day Currier At: T.Laconia Cirrfe Slap-106.B; Parcef— 0120 %orth.Andover, 90 01845 ,The Issuance of this certificate shaff not 6e construed as a guarantee that the system wiff funct' n satisfactortfy. i hefe E. Gran J (Puffic Ifeafth Inspector 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com NORTH ,�" Q��TLLC 16�-•O A f�E COPY TAO LOCH COIWKK y1 SSACHUS� PUBLIC HEALTH DEPARTMENT Community Development Division CERTI FICArAE 01F C09V1PLI. OXff 1--L As of: August 3 0, 2010 This is to cert that the indivicfuafsubsurface disposafsystem received a S,gVST,gCT0R2'1YYPECrH0Yqf the: ft&cement of a Component: Distri6ution Box— M-20 Eor an On Site Sewage D4=[System By. Jay Currier At: T.Laconia Circre Wap-106.B; Tarcef— 0120 J1 Forth Andover, WA 0184.5 The Issuance of this certificate shaft not 6e construed as a guarantee that the system wdl funct' n satisfactorily. IPAef�e Gran (Puffic Yfeafth Inspector 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8416 Web www.townofnorthandover.com J � TRANSMISSION VERIFICATION REPORT TIME 08130/2010 15:00 NAME HEALTH FAX 9786888476 TEL 9786888476 SER.# OOOB4J12O96O DATE DIME 08130 14:59 FAX NO./NAME 19787746685 DURATION 00:00:37 PAGE{S} 01 RESULT OK MODE STANDARD t%QRTF{ � R eeealCMR ky1' PUBLIC HEALTH DEPARTMENT Community Development Dlvi5iOn RTjw.LL. .JYaC SCJ Y C As of. Aumist 30 2010 q ais is to cenify that the individuafsu6Sv face duposarsystem received a SAT,rS(F,9.CT0RT.T,YSTEIOMof the: &placement of a Component. oistribution Bo — 20 q'or anon.-Site Sewage Dispasa[System By: gay cum t: T Laconia Circ& 9day..106. : Tarcef- 0120 I' 0 MTN ' Commonwealth of Massachusetts Map-Block-Lot 106.60120 ----------------------- Board of Health Permit No ; BHP-2010-0709_ _ ____ North Andover _____________ __ __ G • _ �+�'• P.I. FEE 7s3�CMu51t`� F.I. $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted James_Currier to(Repair-D-BOX)an Individual Sewage Disposal System. at No 7 LACONIA CIRCLE as shown on the application for Disposal Works Construction Permit No. BHP-2010-070 Dated Augu�6,2010 ------------ -Fit, CCS�---------------------- Issued On:Aug-26-2010 Board of Health f "0"Y" "1 Commonwealth of Massachusetts Map-Block-Lot Board of Health - --- ------- .j P f � � North Andover b'••�o CERTIFICATE OF COMPLIANCE �s3 tMUsti THIS IS TO CERTIFY,That the Individual Sewage Disposal System (Repair-D-BOX) by .James Curve -------- ------- --- ------------------------------ Installer at No 7 LACONIA CIRCLE has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. _BHP-2010-070 Dated August 26,2010----- --- ------ ---- --------- Printed On:Aug-26-2010 Board of Health `t J ORTM Town of North Andover `�'•;; o:: HEALTH DEPARTMENT ,SSACHUSE� CHECK#: -��/� DATE: ��J LOCATION: H/O NAME: CONTRACTOR NAME: . Type of Permit or Licene: (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 $ ❑ -Design Approval $ 7eptic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer a Application for Septic Disposal System ;Construction Permit - TOWN OF TODAY' DATE ORTH ANDOVER, MA 01845 $25 - air 125.00 -Comp onen SSCHUS� Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the �G computer,use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key to move your Repair or replace an existing system component—What? cursor-do not use the return key. A. Facility Information ff VQ Address or Lot# IL R City/Towri i 2.-*TYPE OF SEPTIC SYSTEM*: ❑ Pump ❑ Gravity(choose one) ***If pump system, attach copy of electrical permit to application*** ❑Conventional System(pipe and stone system) ❑ Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D-Box)(Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D-Box Present)S.A.S. 2. Owner Information 3 .. f Name e, Address(if different from above) City/Town State Zip Code Telephone Number 3. Installer Information NTufe3 tin/I!kr � 5 �cs_� � 'f Name Name of Company dd r City/Town State Zip Code Telephone umbe (Cell Phone#if possible please) 4. Designer Information Name Name of Company Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit-Page 1 of 2 V a A a Application for Septic Disposal System o=Construction Permit — TOWN OF TODAY'S DATE , MA 01845 $250.00—Full Repair ORTH ANDOVER •..°••°tom $125.00-Component SS�CHus PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: 0 0 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 " suedbY this Board of Health. me Date App. tion Approve y: (Board of Health Representative) Appe Date licati Disapproved for the following reasons: For Office Use Only: 1. Fee Attached. YesNo v 2. Project Manager Obligation Form Attached? Yes No 3. Pump System? If so,Attach cop-y ofElectrical PermitY No 4. Foundation As-Built?(new construction ronly): Yes No (Same scale as approved plan) 5. Floor Plans?(new construction only): Yes No Application for Disposal System Construction Permit•Page 2 of 2 i 'r , SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: (Address of septic system) For plans by (Engineer) Relative to the application of •.1 W�'►aS - 1,'�e/ (Installer's name) And dated (Original ate Dated / Says ate With revisions dated (Last revised date) I understand the following obligations for management of this project: 1. As the installer,I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the a1212roved plans and the permit on site when any work is being done. 2. As the installer,I must call for any and all inspections. If homeowner,contractor,project manager,or any other person not associated with my company schedules an inspection and the system is not ready,then item three shall be applicable. 3. As the installer,I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or m�:company. a. Bottom of Bed—Generally,this is the first (VS inspection unless there is a retaining wall,which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection—Engineer must first do their inspection for elevations,ties, etc. As-built of verbal OK(or e-mail to: healthdept@townofnorthandover.com) from the engineer must be submitted to the Board of Health,after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system,all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade—Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation)and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover,significant fines to all persons involved are also possible. 5. As the installer,I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board of Health staff or consultant. d. Installation of tank, D-Box, pipes, stone, vent,pump chamber, retaining wall and other components. 6. As the installer,I understand that I am solely responsible for the installation of the system as per the Qi2rr ved plans No instructions by the homeowner,general contractor or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: LIA �,/,� (Today's Date) Ll ame—Print) me— igne c TRANSMISSION VERIFICATION REPORT TIME 06/30/2010 15:00 NAME HEALTH FAX 9786888476 TEL 9786888476 SER.# 0OOW12096O DATE DIME 08/30 14.59 FAX N0./NAME 19787746685 PAGE(S) DURATION 008: 00:37 RESULT OK MODE STANDARD �pRT11 pFae 4 � R eecn5ilnw,en y1' PUBLIC HEALTH DEPARTMENT Community Development Division , `-�--' T[(F(CA 7—' o'.1.• CO LA./-L Y As of: August 30, 2010 This is to cell Mat tftte indtviduarsri6sttiface dtsposatVsteitt received'a SATIS egCToX(Y TjysTEGTIO,Vof the: ftfiwement ofd Component: Vstfi6ution9 JAI-20 !'or an -Site Sewage Tispasal System By: ,gay Cunier -A.t-. , 7 Laconia Circre av-106A Tarcef-- 0120 h tAORTli 0��1�ao t6,1 ? .. O T T / * C'0 [OCMIG�WKM y1 � I✓ 7 Ars o �'Ss CHUS�� PUBLIC HEALTH DEPARTMENT 7 (ommunity Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: ��1� MAP: LOT: INSTALLER. &I&A DESIGNER: PLAN DATE: C y BOH APPROVAL DATE ON PLAN: / r INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ gallon tank has been installed loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Inspection Form lune 2008 • pORTH O�'1.c0-0 16gti0 O to O COCMIC MIWKM 1 ,! V 7,9 A044TEo SSAC HUSH PUBLIC HEALTH DEPARTMENT Community Development Division testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of final grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ gallon Pump Chamber installed ❑ loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Watertightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 918.688.9540 Fox 918.688.8416 Web www.townofnorthandover.conn Inspection Form June 2008 p►ORTF� O�At1.E� / �•. bw � � ey � O C0C"1CM2WKM 1 A04ATEO /.PP'y�5 �SSAC HUS '( PUBLIC HEALTH DEPARTMENT Community Development Division DISTRIBUTION-BOX / Installed on stable stone base [v� H-20 D-Box ❑, Inlet tee (if pumped or >0.08'/foot) �f Hydraulic cement around inlet & outlets [/ Observed even distribution []� Speed levelers provided (not required) Comments: SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel-less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com Inspection Form June 2008 tt NORTi4 /6 6 OL O to O ccc"1cM WKK y^ �SSACHLI PUBLIC HEALTH DEPARTMENT fommunity Development Division BM = HR = HI = SYSTEM ELEVATIONS ROD ELEVATION AS-BLT INVERT ELEV DESIGN INVERT ELEV Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 TOP Lateral 1 INVERT Lateral 2 TOP Lateral 2 INVERT . Lateral 3 TOP Lateral 3 INVERT Lateral 4 TOP Lateral 4 INVERT Lateral 5 TOP Lateral 5 INVERT Lateral 6 TOP Lateral 6 INVERT Top of Chamber Bottom of Bed/Chamber 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Inspection Form lune 2008 NORTIy O��i► IL ID j6'�ti0 0 * � A A-O 7.e gDRc0c.c1TED S$ACHUS� PUBLIC HEALTH DEPARTMENT Community Development Division SKETCH PLAN 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofoorthandover.com Inspection Form June 2008 i pORTH Q�,, %.&D 16,6 OL O to L �Co[MIC IWKM �f,9 A°R�rEo �Pa1,�'�5 SSAC HUSH PUBLIC HEALTH DEPARTMENT (ommunity Development Division CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- ® Waterline 10 10 101 ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh,Inland/Coastal Banka 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib.to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot.Area ® Reservoirs 400 400 ® Drains(wat. supply/trib.) 50 100 ® Drains(intercept g.w.) 25 50 ® Drains(Other)Foundation 10(5) 20(10) ® Drywells 20 25 I Suction line 222(2) 2100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54,and 10.30,respectively,pursuant to 15.211(3),also by NA wetland bylaws 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Inspection Form June 2008 • Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments o�^M 7 Laconia Circle Property Address Marianne Jenkins Owner Owner's Name information is required for every No. Andover Ma. 01845 8-9-2010 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When A. General Information filling out formskPICOVED on the computer, use only the tab 1. Inspector: key to move your AUG 17 2010 cursor-do not F. Paul Cardone kee the return Name of Inspector TOWN OF NORTH MDOVER Y Septic Compliance, Inc. LO&MTHDEPARTMENT r� Company Name 447 Boston Street Company Address Topsfield Ma. 01983 City/Town State Zip Code 978-407-1808 978-681-0726 3294 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 Further Eval by the Local.Approving Authority —>Irp-02fror's 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. Marianne Jenkins 7 Laconia Cir No Andover8-92010.08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 �! Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Laconia Circle Property Address Marianne Jenkins Owner Owner's Name information is required for every No. Andover Ma. 01845 8-9-2010 page. Citylrown 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. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: D-Box in need of replacement ❑ 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 Marianne Jenkins 7 Laconia Cir No Andover8-92010.08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts v Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Laconia Circle Property Address Marianne Jenkins Owner Owner's Name information is required for every No. Andover Ma. 01845 8-9-2010 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B System Conditionally Passes (cont.): 1 Y Y ( ) ® 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: 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. Marianne Jenkins 7 Laconia Cir No Andover8-92010.08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 � Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 7 Laconia Circle Property Address Marianne Jenkins Owner Owner's Name information is required for every No. Andover Ma. 01845 8-9-2010 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the 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. Marianne Jenkins 7 Laconia Cir No Andover8-92010•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 7 Laconia Circle Property Address Marianne Jenkins Owner Owner's Name information is required for every No. Andover Ma. 01845 8-9-2010 page. Cit /Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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 flow of 10 000 d to 15 000 d. design9P � 9p For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the Y 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. Marianne Jenkins 7 Laconia Cir No Andover8-92010.08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Laconia Circle Property Address Marianne Jenkins Owner Owner's Name information is required for every No. Andover Ma. 01845 8-9-2010 page. City/Town 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)] Marianne Jenkins 7 Laconia Cir No Andover8-92010.08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments cwM 7 Laconia Circle Property Address Marianne Jenkins Owner Owner's Name information is required for every No. Andover Ma. 01845 8-9-2010 page. City/Town State Zip Code Date of Inspection 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 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): enclosed Sump pump? ❑ Yes ® No Last date of occupancy: 2 years prior to inspection 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: Last date of occupancy/use: Date Other(describe): Marianne Jenkins 7 Laconia Cir No Andover8-92010•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Laconia Circle Property Address Marianne Jenkins Owner Owner's Name information is required for every No. Andover Ma. 01845 8-9-2010 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: last time on file 12-11-2000 Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? pump truck tube Reason for pumping: Routine pum ....and to properly inspectect structural integrity of the tank Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Approx. 30 years of age Plan on file. Frank C. Gelinas Assoc. Were sewage odors detected when arriving at the site? ❑ Yes ® No Marianne Jenkins 7 Laconia Cir No Andover8-92010•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Laconia Circle Property Address Marianne Jenkins Owner Owner's Name information is required for every No. Andover Ma. 01845 8-9-2010 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 14" 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.): Good None Septic Tank(locate on site plan): Depth below grade: 15"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 -------------------------------------------------------------------------------------------------------------------------- f Dimensions: 1000gallons8'xf'x5' ''` Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 1" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Septic-Dipstick&Tape Marianne Jenkins 7 Laconia Cir No Andover8-92010.08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Laconia Circle Property Address Marianne Jenkins Owner Owner's Name information is required for every No. Andover Ma. 01845 8-9-2010 page. CitylTown 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.): We recommend pumping on a yearly basis,baffles are on,structural integrity appeared to be good, liquid level was good, no apparent leaks. Grease Trap (locate on site plan): Depth below grade: N/A 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 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: N/A Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Marianne Jenkins 7 Laconia Cir No Andover8-92010.08/06 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts u u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Laconia Circle Property Address Marianne Jenkins Owner Owner's Name information is required for every No. Andover Ma. 01845 8-9-2010 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: N/A 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 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Below pipe 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.): Box was level ran water through box for over 30 minutes no solids carryover box has several cracks due to age, needs replacement and one pipe needs to be straightened. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Marianne Jenkins 7 Laconia Cir No Andover8-92010.08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM e''r 7 Laconia Circle Property Address Marianne Jenkins Owner Owner's Name information is required for every No. Andover Ma. 01845 8-9-2010 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pets number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 Bed 24'x45' ❑ 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.): Gravelly No None No Grassy back yard area Marianne Jenkins 7 Laconia Cir No Andover8-92010.08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Laconia Circle Property Address Marianne Jenkins Owner Owner's Name information is required for every No. Andover Ma. 01845 8-9-2010 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: N/A Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Marianne Jenkins 7 Laconia Cir No Andover8-92010.08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Laconia Circle Property Address Marianne Jenkins Owner Owner's Name information is required for every No. Andover Ma. 01845 8-9-2010 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. t l Marianne Jenkins 7 Laconia Cir No Andover8-92010.08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Laconia Circle Property Address Marianne Jenkins Owner Owner's Name information is required for every No. Andover Ma. 01845 8-9-2010 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells 7' Estimated depth to ground water: 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: 9-9-78 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: All liquid levels were good,basement dry,No sump pump,dug around in bed area very dry. Marianne Jenkins 7 Laconia Cir No Andover8-92010.08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Commonwealth of Massachuetts City/Town of I System Pumping Record SEP 2 5 2006 Form 4 �.y TOWN OF NCRTH ANDOVER DEP has provided this form for use by local Boards of Health.. The Systei��a�ping•`Recofd m st be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. SySt m LOC forms computer, r,,use use only the tab key Address to move your cursor-do not !t Cit own r use the�return y Stat Zip Code .key. System Owner: Name Address(if different from location) City/rown Sta ( � Zig,�de`-J�� Telephone Number B. Pumping Record 1. Date.of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank- ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ ,wts If yes, was it cleaned? ❑ Yes ❑ No 5. Conditio f Sys m: 6. Syste Pape " Name Vehicle License Number Company 7. Locati here content ere6 sed: - � Signa) re Ha ler Date hftp://www.mass.gov/dep/watertapprovalt/t5forms.htrn#inspect t5form4.doc•06103 System Pumping Record•Page 1 of 1 North Andover Board of Health Andover Septic 120 Main St. 47 Railroad St. North Andover Ma.01845 Bradford Ma. 01835 Haul Lic. #151-OOH December 2000 Install Lic. # 128-0 Date Name &Address Gallons Comments 12/1/2000 Murphy - 16 Crossbow Lane 1500 12/2/2000 Manzi -72 Foster St 1000 - 12/4/2000 Grifin - 240 Candlestick Rd 1500 12/5/2000 Mcilvien - 57 So .Cross Rd 1500 Flooded 12/6/2000 Small - 440 Fosrer St 1000 12/6/2000 Orlando - 274 Foster St 1000 12/7/2000 Weger- 29 Barco lane 1000 12/8/2000 Walton - 161 Bridges Lane 1500 12/11/2000 Coflan - 73 Christian Way 1500 12/12/2000 Orlando - 7 Laconia Cir 1000 12/12/2000 Fitzgerald - Sharpner Pond Rd 1500 12/18/2000 Mangano - 324 Bradford St 1500 12/19/2000 Galea -= 1589 Salem St 1000 12/19/2000 Johnson - 91 Boston St 1000 12/22/2000 Senton - 1620 Turnpike St 1250 Flooded NEW ENGLAND ENGINEERING SERVICES INC January 26, 2000 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT: 7 Laconia Circle,North Andover, MA Dear Sirs: Enclosed is a copy of the Title V report for the above referenced property. The systemap sses our inspection. If there are any questions please call me at my office, 686-1768. Sincerely Benjarrfm C. Osgood r E.I.T. President 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 • i.i i i ' •^r 00 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS '} DEPARTMENT OF ENVIRONMENTAL PROTECTION Y ONE WINTER STREET,BOSTON MA 02108 (617)2924500 , TRUDY CORE $ecratA?Y, t ARGEO PAUL CELLUCCI DAVID JI.STRUHS Governor Cotnmiuontr• r, SUBSURFACE SEWAGE DISPOSAL$YSTEM•INSPECTION FORM PART A CERTIFICATION Property Address. I—li C O U 1 0 G 1 1261-E Name of Owrw D104, 7 U(ZL_A N v 0 AN n 0Q1:R /M0) Address of Owner: —7 I—A c.o N i i<} C L t2 C#r Data of Inspectkm: I`o t of Name of Inspector:(Please Print)Benjamin C. Osgood, Jr. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.0001 Company Name: New England Engineering SPrvirns, Inc. Mang Address: 60 Beec r, MA 01845 Telephone Number 686-1768 CERTIFICATION STATEMENT 1 certify that 1 have personally inspected the sewage disposal system at this address end that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience In the proper function and maintenance of on-site sewage disposal systems. The system: V Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)-days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department aKrivironmeraM Protection. The original should•be sent to'ttm system owner and copies sent to the buyer,if applicable• and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page I of II rmled on Recycled Paper U IRCI14ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ! , CERTIFICATION(continued) Property Address:7 Laconia Cir.,North Andover Owner:Dick Orlando Date of Inspection:1/19/00 a INSPECTION SUMMARY: Check A, -B, C, or A ZI PASSES :e not found any information which indicates that any of the failure conditions described in 310 CMR 1.5.303 exist. Any failure- criteria ailure criteria not evaluated are indicated below. COMMENTS: 8. 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 o1 the.replacement or repair,as approved by the Board of Health, will pass. Indicate yes,no,or not determined(Y.N,or ND). Describe basis of determination in all instances. If"not determined",explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection:or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank_ is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumpirtg-Tnore than fouriimes a yeardue to broken or obvructed pipe(s). The system WillV'aas-� inspection if(with approval of the Board of Health): -- broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 1ofIt Yr+, —""ZSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOAM. PART A property Address:7 Laconia Cir.,North Andover CERTIFICATION(continued) Owner:Dick Orlando Date of Inspection:1/19/00 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: i 3 Conditions exist which require further evatuation by the Board of Health in order to determine if the system Is fairing td protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM. IS NOT FUNCTIONING IN A MANNER WHICH.3MLLPRQTECT THE PUBLIC NEALTHAND SAFETY.AND THE ENVISONMEHT: _ Cesspool or privy is within 50 Leet of 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 SYSTEMA IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: - The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well.unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER .. revised 9/2/98 Page3of11 tUSSURFACE SEWAGE DISPOSAL SYSTEM INSPECT16N FORM PART A , CERTIFICATION(continued) Property Address:7 Laconia Cir.,North Andover Owner:Dick Orlando Date of Inspection: 1/19/00 . D. SYSTEM FAILS: t You must indicate either "Yes"or'No" to each of the following: 1 have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into{ecility-or-srtemcomponent-dueto an overloaded oreloggedSAS 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. I Liquid depth in cesspool is less than 6"below invert or available volume is less than 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is-within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for -coliform bacteria,volatile organic-compounds,ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No" to each of the following. The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system•ie-within 200 feet ot-0-t«butory-teasurtao*-dAnking•watar-supply •• -- -- - the system is located In a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(21. Please consult the local regional office of the Department for further information. revised 9/2/98 rw4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F-dRM PART B CHECKLIST Property Address:7 Laconia Cir.,North Andover Owner:Dick Orlando Date of Inspection:1/19/00 ( _ Check if the following have been done:You must indicate either "Yes'or"No' as to each of the following: i Yep No J _ Pumping information was provided by the owner,occupant,or Board of Health. None of the system:eompoaonu.l.aua boon puaV*datoratJeast iwo wo&kc and-rhs'aystam hasb000aacamniag wosmw Bow . rates during that period. large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with NIA. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components,excluding,the Soil Absorption System,have been located on the site. The septic tank manholes were uncovered,opened,and the interior of the septic tank was.inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. sor tion System orrthe site has been determined based on: location of the Soil Ab y The size and P Existing information.For example,Plan at B.O.H. _ J Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) / 115.302(3)(b)) The facility owner(and.occupanu.if different from.owner).ware.prauided.with rnformatioann r�� ;^•.maintanaoca�t SubSurface Disposal Systems. revised 9/2/98 Page 5of11 . rx5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ! PART C SYSTEM INFORMATION Property Address:7 Laconia Cir.,North Andover t .;. Owner:Dick Orlando u Date of Inspection:1/19/00 I FLOW CONDITIONS "<'¢ RESIDENTIAL: Design flow: 1,6V g.p.d./bedroom. Number of bedrooms(designl:_Y- Number of bedrooms(actual): Total DESIGN flow&V D Number of current residents:Z Garbage grinder(yes or no).- Laundry(separate system) (yes or no):.LVC: If yes, sepaweinspection-required Laundry system inspected (yes or no) Seasonal use(yes or no):_ Water meter readings,if available(last two year's usage(gpd): Sump Pump(yes or no)-_6'O Last date of occupancy: a�,-rrZ COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: cpd ( Based on 15.203) Basis of design flow Grease trap present:(yes or no)_ Industrial Waste Holding Tank present:(yes or no)_ Non-sanitary waste discharged to the Title 5 system:(yes or no)_ Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information:, &J21DOT I to i l L y t;R25 PE2 OWN e a System pumped as part of inspection:(yes or no) .NO If yes,volume pumped: gallons Reason for pumping: - TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) I/A Technology etc.Attach copy of up.to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date installed4if known)-end source ofwrformation: Pe Sewage odors detected when-arriving at the site:(yes or no)A/9 revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPE&noN FORM PART C ..: .SYSTEM INFORMATION(continued) Property Address:7 Laconia Cir.,North Andover Owner:Dick Orlando Date of Inspection: 1/19/00 al t �a BUILDING SEWER: (Locate on site plan); Depth below grade: Material of construction:,cast iron 40 fVC_other(explain) Distance from private water supply well or suction line At& Diameter " Comments:!condition of joints,venting,evidence of(sakage,-etc.) '�� PC � L.00 f1,5 (Soo p t v (�ASE•�tEN'+ SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction: concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is Inetal,list age_ Js.age.confirmed by Certificate of Compliance_(Yes/No) Dimensions: r000 65rA 001 Sludge depth:— Z' r� _ Distance from top of sludge to bottom of outlet tee orbaffte:Zo Scum thickness: Z% rt Distance from top of scum to top of outlet tee or baffle: & Distance from bottom of scum to bottom of outlet tee or baffle:Z3_ How dimensions were determined:n4'A50i2 G Silt K Comments: • (recommendation for pumping,condition of inlet and outlet tees or•baffles, depth of liquid level in relation to outlet invert,etructurelintegrity, evidence of leakage,etc.) 0 07 c an>c(2 t T�2 S t N UnvA L) 0 AA GREASE TRAP-_" (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) revised 9/2/98 Page 7ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORD • r PART C Y' SYSTEM INFORMATION(continued) Property Address:7 Laconia Cir.,North Andover Owner:Dick Orlando Date of Inspection: 1/19/00 l 1 TIGHT OR HOLDING TANK•; (Tank must be pumped prior to, or at time of.inspection) (locate on site plan) Depth below grade:_ C , Material of construction._concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX:_ (locate on site plan) K q Depth of liquid level above outlet invert: P Comments: (note if level and distribution is equal.evidence of solids carryover,evidence of leakage into or out of box, etc.) — - — 13Vx iN OA Cv�D �OA/ N,35oI19 fx of- / E►4�r}c-r o �Z sC, —.,• PUMP CHAMBER-.A& (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber.condition of pumps and appurtenances.etc.) revised 9/2/98 Page aofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C ; SYSTEM INFQRMATION(corrdnued) ! Property r Address:7 Laconia Cir. e North Andover Owner:Dick Orlando Date of Inspection: 1/19/00 ( ( SOIL ABSORPTION SYSTEM($AS) (locate on site plan..if possible:excavation not.required,location may be approximated by non-intrusive methods) If not located,explain: ` Type: leeching pits,number:_ leaching chambers,number:_ leeching galleries,number:_ ' leeching trenches,number,length: leeching fields,number,dimensions:) f=1 ELD ,2 overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure,level of ponding, damp soil,condition of vegetation, etc.) QEF} F 1=1r=1.Q LooKs OM+ IU O0 F f�c'Nr,l t7(r- _ QFFMI� SOiL y 2 J AJ s. ,4 L. V r rr L;_�Thi i>o A/ CESSPOOLS: ARF (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as pert of inspection) Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of.vegetation, etc.) PRIVY:ALff } (locate on site plan) Matery'els of construction: Dimensions: Depth of solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation;etc.) revised 9/2/98 Page 9of11 .. .•_til ' * TEM INSPECTION FORM • SUBSURFACE SEWAGE D POSAL SYS PART C T. .� SYSTEM INFORMATION(continued) Property Address:7 Laconia Cir.,North Andover Owner:Dick Orlando Date of Inspection:1/19/00 NRCS Report name 'Cl.l. Sv —S5 L X CoJ v AA iIHSS itJ o r2TZ�l; ti fhGT Soil Type_ C' A T Typical depth to groundwater' 7 'O USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope ' Surface water Check Cellar Shallow wells Estimated Depth to Groundwater "/ Feet Please indicate all the methods used to determine High Groundwater Elevation: _C_Obtained from Design Plans on record Observed.Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) & -I.-pi51 l^MDICAP . Iq %�!2 71D 7' 0l 2)• 0G5 D1��F>< WDrc /1TeS c• R7 2 ? C) 3) sus; --- L-T .N 'f 11A A MAs SEEN Fr LLIr f) t o Z �E�T, revised 9/2/98 Page 11 of 11 _s5 4!K, F r /V u _r n v r: li� L:. E C. .SETA CA;_C A_- aoKs _T )ON iES-T KO Tli T. To ELEVA```.!oN s 47 UQ,4-T ION - � t c `�IDIL PROFILE-DEEP --- f 'T ELEVA-T!ON :J 3S01L ' V'4ATEfC ELEVATION SUBSURFACE DISPOSAL SYSTEM CHECK LIST NORTH_ ANDOVER BOARD OF HEALTH ROVIDED DISAPPROVED DATE TIME REASON SPP ,OVER DATE _P __ title 5 Reg. 2. 5 Fail OK The submitted plan must show as a minumum: the lot to be served (area,dimensions ,2ot #,abutters) (Planning Board files) location and log of deep observation holes-distance to. ties location and results of percolation tests-distance to ties design calculations & calculations showing required leaching area ocation and dimensions of system (including reserve area) existing and proposed contours location of any wet areas within 100' of the sewage disposal system o1- disclaimer (check wetlands mapping) surface and subsurface drains within 100' of sewage disposal system or disclaimer ocati.on of any drainage easements within 100' of sewage disposal system or disclaimer (planning board files) known sources of water supply within 200' of sewage disposal system or disclaimer location of any proposed well to serve the lot (100' from leaching facility) location of water lines on property (10' from leaching facilities) location of benchmark driveways o garbage disposers p no PVC is to be used in construction ' ( a profile of the system (elevations of basement , plumb( pipe septic tank, distribution box inlets and outlets, distribution field piping and any other elevations) tion in area of sewage dispo. maximum ground water eleva . system lan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Septic Tanks deg, 6 (a) Capacities - 150% of flow, water table , tees, depth C tees , access, pumping, Cleanout C) 10' from cellar wall or inground swimming pool (d) 25 ' from subsurface drains Torth 'Andover Subsurface disposal system check list - Page 2 Fail OK Distribution Boxes Zeg.10.2 )(b lope greater than 9.08 Zeg.10.4 Sump Leaching Pits Leaching pits are preferred where the installation is possible Zeg.11 .2 (a) Calculations of leaching area (minimum 500 S.F.) Zeg.11 .4 (b) Spacing Zeg.11 .1 C (c) Surface drainage 2% ieg Cover Smaterial .1 (, �) A-/ t Leaching Fields (�) Zeg.15.1 X(a) oGreater than 20 minutes/inch Zeg-15.1 ea (minimum 900 S.F.) Zeg.15.4 nstruction of field Zeg.15,8rface drainage 2% Zeg. 3.7 (e) 20' from• cellar wall or inground swimming pool Leaching Trenches Zeg.14.1 (a) Calculations of leaching area (min. 500 S.F.) Zeg.14.3 (b Spacing (4 ft. min. 6 ft. with reserve between) Zeg.14.4 (c� Dimensions 14.5 Zeg.14.6 (d) Construction Zeg.14.7 (e) Stone Zeg.14.1 (f) Surface drainage 2% Downhill Slope (a) Slope y/x = (to be shown) (b) y/x X 150 = (to be shown) Pum-p 'Leg, 9.1 (a) Approval 'Leg, 9.6 (b) Stand-by power ward of Health . SEPTIC SYSTEM forth Andover.,Mass. INSTALLATICK CHECK LIST LOT /� ��/ �PPROVED D DISAPPRO ED RCAVATICH OK FAIL r easonst LT-1 %n OS 1. Distance To: i j l a. Wetlands b. Drains c. Well 2. Water Line Location 3. No PVC Pipe 4. Septic Tank a. Tess - Length do To Clean Out Covers b. Cement Pipe to Tank - On Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Equal Amounts c. No Back Flog b. Leach Field or Trench a. Dimensions 1-�' �C �17 % b. Stone Depth c. Capped Ends d. Clean Double Washed Stone 7. Leach Pits a. Dimensions b. Stone Depth c. Splash Pads d. Tees e.Xemient Pipe to Pit - Both Sides ;,./' Clean Double Washed Stone No Garbage Disposal 9. Dual Grading Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System e. Location with Regard-to Pere Test d. Elevations e.. Water Table SOIL PROFILE & PERCOLATION TEST DATA Town/City O N Q• No•&Street LAC.0 Lot No. [ !5 Loc./Subdiv.. I G A L)(;�P1an Owner Inv estigator-ZT R.4 tR-GL6 Observer3s CL/E 6 N AS a SOIL PROFILES-DATE 1. 2. Elev. — Elev. 0 5 �t ' ? o ( g7S 0 0 Wilk lop 2 L 2 SiiS 2 2 3 3 3 3 v;o\ O 4 4 4 4 -Q-to v \� � j 5 5 �TtLL 5 S J d � in 6 6 6 G o �YF-cP�� A.NE 7 7 7 8 8 8 8 9 9 9 9 0 10 10 10 Benchmark Location Elevation Datum ( jj Percolation Tests-Date { E � Pit Number 1 2 3 4 5 Start Saturation Soak-Mins. IS Start Test-Time Drop of 3"-Time Drop of 6"-Time Mins. lst 3"Dro 2► Mins. 2nd. 3"Dro 30 Notes & Sketches on Back Frank C. Gelinas & Associates, North And. 17f00007:lfJ PAGE 01!01 Summary Record Card gen9ralod an 81812010 3:%16:58 PM by Kann Hanlon Page 1 • Town of North Andover Tax Map # 210-106.B-0120-00000 Parcel Id 17624 7 LACONIA CIRCLE MARIANNE JENKINS 930 BROADWAY _ EVEREYT, MA 02149 Class 101 Slagle Family Property type 1 Residential size Total 1.01 Acres FY 2011 UB Mailing Index Nama/Address Type Loan Number Activellnact. From Until MARIANNE JENKINS Owner 930 BROADWAY EVERETT,MA 02149 RICHARDS,JAMES&CONSTANCA Previous Customer lnaetive 8/412010 7 LACONIA CIRCLE NORTH ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name ActiveNnactive Bldg Id.17522,0-7 LACONIA CIRCLE Last Billing Date 7/7/2010 3170192 03 Cycle 03 Active UB Services Maint. Account No,3170192 Service Code Rate Charge Multiplier/Usem MISCFEE ADMIN FEE 0.635/8 7.82 t/ WTR WATER 01 ALL METER SIZE li UB Meter Maintenance Account No,3170192 Serial No Status Location Brand Type Size YTD Cons 33563411 a Active ERT HH b Badger w Water 0.63 0.63 279 Data Reading Code Consumption Posted Date variance 6!712010 630 a Actual 0 7/1612010 -100% 3/1012010 530 a Actual 0 4114/2010 -100% 12110/2009 630 a Actual 0 1/12/2010 -100% 9/10/2009 630 a Actual 0 10/1512009 -100% 618/2009 630 a Actual 0 7/20/2009 -100% 3/12/2009 630 a Actual 9 4129/2009 -71% 12/9126D8 621 a Actual 30 1/2012009 -74% 91912008 591 a Actual 123 10/10/2008 -6% 6/5/2008 468 a Actual 117 711612008 221% 311112008 S51 a Actual 32 41111200$ -70% 12110/2007 319 a Actual 111 1122/2008 -55% 9/412007 208 a Actual 208 10/12/2007 0% 6114/2007 0 n New Meter 0 7/20/2007 0% 6114/2007 6475 r Replacement -11 7/20/2007 -128% 311512007 6485 m Manuel estimate 40 4/1612007 -35% 12112/2006 6446 m Manual estimate 60 111912007 -45010 MSG 9112/2006 6386 a Actual 109 10/20/2006 98% Trouble Code;03 6/13/2006 6277 a Actual 60 7/1 M006 6% Trouble Code:03 3/6/2006 6217 a Actual 43 4117/2006 58% Trouble CodvOS North Andover Board of Health Andover Septic 120 Main St. 47 Railroad St. North Andover Ma.01845 Bradford Ma. 01835 Haul Lic. #151-OOH December 2000 Install Llc. # 128-0 Date Name &Address Gallons Comments 12/1/2000 Murphy- 16 Crossbow Lane 1500 12/2/2000 Manzi -72 Foster St 1000 - 12/4/2000 Grifin - 240 Candlestick Rd 1500 12/5/2000 Mcilvien - 57 So .Cross Rd 1500 Flooded 12/6/2000 Small - 440 Fosrer St 1000 12/6/2000 Orlando - 274 Foster St 1000 12/7/2000 Weger- 29 Barco lane 1000 12/8/2000 Walton - 161 Bridges Lane 1500 12/11/2000 Coflan - 73 Christian Way 1500 12/12/2000 Orlando - 7 Laconia Cir 1000 12/12/2000 Fitzgerald - Sharpner Pond Rd 1500 12/18/2000 Mangano - 324 Bradford St 1500 12/19/2000 Galea -= 1589 Salem St 1000 12/19/2000 Johnson - 91 Boston St 1000 12/22/2000 Senton - 1620 Turnpike St 1250 Flooded L1r`° Board of Health North AndoversNaas: SEPTIC SZSTIM lAeelllA 'INSTALLATION CHECK LIST LOT �� APPROVED DA E � DII SUFR(,M � AVATI ' OK L Rearonst i►AIL OK 1. Distance To: a. Wetlands b. Drains c. Well 2. Water Line Location 3• No PVC Pipe 4. Septic Tank a. Tess - Length & To Clean Oat Covers b. Cement Pipe to Tank- On Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Equal Amounts c. No Back Flow 6. Leach Field or Trench a. Dimensions y�jC b. Stone Depth c. Cabled Eads d. Clean Double Washed Stone 7. Leach Pits a. Dimensions" b. Stone th c. Spl Pads d. T s meat Pipe to Pit - Both Sides Clete Double Washed Stone /18. No Garbage Disposal 9. Final Grading Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System c. Location with Regard_to Pere Test d. Elevations e: Water Table SUBSURFACE DISPOSAL SYSTEM CHECK LIST NORTH ANDOVER BOARD OF HEALTH APPROVED DATE PROVIDED DISAPPROVED DATE TIME REASON Title 5 Reg. 2.5 Fail OK The submitted plan must show as a minumum: he lot to be served (area,dimensions ,lot //,abutters) (Planning Board files) location and log of deep observation holes-distance to ties location and results of percolation tests-distance to ties design calculations & calculations showing required leaching area ocation and dimensions of system (including reserve , I ' area) existing and proposed contours location of any wet areas within 100' of the sewage disposal system ot- disclaimer (check wetlands mapping) surface and subsurface drains within 100' of sewage disposal system or, disclaimer ocation of any drainage easements within 100' of sewage disposal system or disclaimer (planning board ! files) known sources of water supply within 200' of sewage disposal system or disclaimer location of any proposed well to serve the lot (100' from leaching facility) location of water lines on property (10' from leaching l facilities) location of benchmark driveways o garbage disposers p no PVC is to be used in construction ( a profile of the system (elevations of basement, plumbers pipe septic tank, distribution box inlets and outlets, distribution field piping and any other elevations) maximum ground water elevation in area of sewage disposal system an must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Septic Tanks Reg. 6 (a) C pacities - 150% of flow, water table, tees, depth of tees , access, pumping, Cleanout c) 10' from cellar wall or inground swimming pool (d) 25' from subsurface drains North Andover Subsurface disposal system check list - Page 2 Fail OK Distrib tion Boxes Reg.10.2 (a lope greater than 0.08 Reg.10.4 (b Sump Leaching Pits Leaching pits are preferred where the installation is possible Reg.11 .2 (a Calculations of leaching area (minimum 500 S.F. ) Reg.11 .4 (b Spacing Reg.11 .1 (c Surface drainage 2% Reg.11 .11 d) Cover material e 2 -a W, plash o-4 . �/ S P g� re e of e.l bo�a �rw �{{,V rte, i Leaching Fields Reg.15.1 (a) oGreater than 20 minutes/inch Reg.15.1 ( Area (minimum 900 S.F. ) Reg.15.4 c) Construction of field Reg.15.8 (d) Surface drainage 2% Reg. 3.7 (e) 20' from cellar wall or inground swimming pool Leaching Trenches Reg.14.1 (a) Calculations of leaching area (min. 500 S.F.) Reg.14.3 (b) Spacing (4 ft. min. 6 ft. with reserve between) Reg.14.4 (c Dimensions 14.5 Reg.14.6 (d) Construction Reg.14.7 (e Stone Reg.14.1 (f) Surface drainage 2% Downhill Slope (a) Slope y/x = (to be shown) (b y/x X 150 = (to be shown) Pum-pp- Reg. umppReg. 9.1 (a) Approval Reg. 9.6 (b) Stand-by power 1 SOIL PROFILE & PERCOLATION TEST DATA Town/City_ (!p ;A N Q, No.&Street_ LAC.0 N f Lot No.�� Loc./Subdiv..J�3G A f-d.-SI Plan Owner Investigator--YJ".P:,A rZ(3 aCq.L.L6 Observe rua Cuf S�4;; INA S SOIL PROFILES-DATE S IS c3 1' 1ev. 2' Elev. 3. Elev. 4'Elev. 0 S Ig 0 $h 8 0 0 2 -7 6 L E 2 SUS 2 2 3 3 3 3 0K 4 4 4 4 1 J `a / 5 5 -Ti LL S 5 0 � it dJ 6 6 6 6 ° oLYMP�c. i...ANE 7 7 8 8 8 8 T'E s'r 9 9 9 9 10 10 10 10 Benchmark Location Elevation Datum Percolation Tests-Date Pit Number 1 2 3 4 S Start Saturation Soak-Mins. Start Test-Time Drop of 3"-Time Drop of 6"-Time Mins.lst 3"Dro 2(.. Mins.2nd 3"Dro 30 Notes & Sketches on Back Frank C. Gelinas & Associates, North And. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i . PART G SYSTEM INFORMATION(continued) Property Address:7 Laconia Cir.,North Andover Owner:Dick Orlando Date of Inspection: 1/19/00 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks ` locate all wells within 100'(Locate where public water supply comes into house) 2� Hs X0.5 h y revised 9/2/98 Page ioorii !1. 1 i C � X � i � y I NV- PIPE OUT OF NSE. t_ C_j Q$ E5ulLT IAIV_ PIPE INTO-M)4tL S►.\l PIPEOt.]TDF T-AM L 1. V�- U �� D I ��►�. INV PIPE I N►TO D.BOX i L, I - SY'ST EM I MV, pt PF- OLJT D=Foix ,NV E-MD OF P1 PE F o t2 F24.KV- GGFes-,N�sS } A8gOG1�.TES . ... `� �431 LS.►.1 L"�T/�.i2 �T t�o.AN UO�IE-2 . z f �I 1 : ` r r r { �,. vr AE E l..EN/AT I ONe. LNlVPIPE OUT OF N5E _ r ACJ buiL "T I KI V_ DIKE I NTO-rA mIL I -� l kA\/ R PE OUTOF TNI IL I N V_ Pt PE I NTO D. 1 NV.Dt PE OUT D-e2aX ll4V. END OF PI PE �. • � F2s�.ntK GGt��N�sS � Assaclo.-r�'S • � ENG�tN'E�tZS� AI2C.HtT'EGT� ...-.. �f3t A►..I�ECZ3T f�a.ANrx��lEtZ..