The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 70 LOST POND LANE 4/30/2018 (2) 70 LOST POND LANE 210/104._g-0210 0000.0 - - -- --- I t Residential Property Record Card PARCEL ID:210/104.B-0210-0000.0 MAP:104.6 BLOCK:0210 LOT:0000.0 PARCEL ADDRESS:70L-2 LOST POND LANE PARCEL INFORMATION Use-Code: 101 Sale Price: 505,000 Book: 07082 Road Type: T Inspect Date: 05/14/2003 Owner: Tax Class: T Sale Date: 09/12/2002 Page: 0176 Rd Condition: P Meas Date: 05/14/2003 KNAPP, HEATHER G&ERIC E Tot Fin Area: 2128 Sale Type: P Cert/Doc: Traffic: M Entrance: X Address: Tot Land Area: 0.55 Sale Valid: Y Water: Collect Id: RRC 70 LOST POND LANE Grantor: KELSEY,WILLIAM Sewer: Inspect Reas: C NORTH ANDOVER MA 01845 Exempt-B/L% / Resid-B/L% 100/100 Comm-B/LOW Indust-B/L% 0/0 Open Sp-B/L% 0/0 RESIDENCE INFORMATION LAND INFORMATION Style: CL Tot Rooms: 8 Main Fn Area: 1064 Attic: NBHD CODE: 7 NBHD CLASS: 7 ZONE: R1 Story Height: 2 Bedrooms: 4 Up Fn Area: 1064 Bsmt Area: 1040 Seg Type Code Method Sq-Ft Acres Influ-Y/N Value Class Roof: G Full Baths:. 2 Add Fn Area: Fn Bsmt Area: 1 P 101 S 24045 0.55 183,069 Ext Wall: FB Half Baths: 1 I Unfin Area: Bsmt Grade: VALUATION INFORMATION Masonry Trim: Ext Bath Fix: Tot Fin Area: 2128 Current Total: 481,400 Bldg: 298,300 Land: 183,100 MktLnd: 183,100 Foundation: CN Bath Qual: T RCNLD: 271165 Prior Total: 460,500 Bldg: 286,200 Land: 174,300 MktLnd: 174,300 Kitch Qual: T Eff Yr Built: 1996 Mkt Adj: 1.1 Heat Type: HW Ext Kitch: Year Built: 1996 Sound Value: Fuel Type:. O Grade: GV Cost Bldg: 298,300 Fireplace: 1 Bsmt Gar Cap: Condition: V Att Str Val 1: Central AC: Bsmt Gar SF: 572 Pct Complete: Att Str Va12: Att Gar SF: %Good P/F/E/R: M98 Porch Tvue Porch Area Porch Grade Factor P 125 S 168 W 196 SKETCH PHOTO 14 12 W 196 Sq.R. 168 Sq.R. 14 14 14 2 , 572 Sq.111040/Sq.F1. 26 26 30 , 70 L-2 LOST POND LANE •�� ter• 5 125's A. 0 Parcel ID:210/104.6-0210-0000.0 as of 7/7/05 Page 1 of 1 North Andover Board of Assessors Public Access 0� Page 1 of 1 Parcel ID: 210/104.13-0210-0000.0 Community: North Andover SKETCH PHOTO Click on Sketch to Enlarge Click on Photo to Enlarge a. ,ilIIS I 70 L-2 LOST POND LANE LJ i i i Location: 70L-2 LOST POND LANE Owner Name: KNAPP, HEATHER G & ERIC E Owner Address: 70 LOST POND LANE City: NORTH ANDOVER State: MA ZIP: 01845 Neighborhood: 7 - 7 Land Area: 0.55 acres Use Code: 101 - SNGL-FAM-RES Total Finished Area: 2128 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 481,400 460,500 Building Value: 298,300 286,200 Land Value: 183,100 174,300 Market Land Value: 183,100 Chapter Land Value: LATESTSALE Sale Price: 505,000 Sale Date: 09/12/2002 Arms Length Sale Code: Y-YES-VALID Grantor: KELSEY,WILLIAM Cert Doc: Book: 07082 Page: 0176 http://csc-ma.us/NandoverPubAcc/jsp/Home jsp?Page=3&Linkld=466751 7/7/2005 • , d ! .r .;sC.%.c.. a "`_-+ny{,„+k '^j• v�.,u: +✓y?�;, . �'r� i, 4~! ! 'r.� 5 N 1 ►��' � aM1 M1 .{. 1t yJ N t 3kgiyrpl,�. ''S _ � _ '1 �.: �, �R i L i y� •'.l. '� .• .. �M1,��k�.t 7Cv'7•y�♦�.§�i:� .j''i.?t. .,. - - •• +., f'! + 9 d.'r!i.>:�x� �•� M�+7,k�I r r�i�� 1 .yA rnF/-�.l•.. -,.. �.. MAP wi ' LOT # f. PARCEL # STREET_� �`: _ • CON=. APP. HAS PLAN REVIEW FEE .BEEN NO PLAN APPROVAL: DATE DESIGNER: // 1�C� PLAN DATE. - CONDITIONS WATER SUPPLY: TOWN WELL WELL RE T DRILLER WELL TESTS: CHEMICAL DALE APPROVED '"BACTERIA I DA I E (IPPRUVEU BACTERIA II DAZE APPFtUVEll COMMENTS: FORM U APPROVAL: APPROVAL TO ISSUE- YES U DATE ISSUED A0 /4-15- BY CONDITIONS: FINAL APPROVAL: . ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NU SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NU ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: BY: i •, � �E��G�SYS_•C��L�.NSSfl�L.HZ.I4N �y:Xr \ �'i. •,. • \ L: •Y': •,J : +...'I•�u�,.I T.� f A �. 1 � 1 �.; .rte . THE INSTALLER LICENSED? r `+ ,t YES NO ` TYPE' OF' CONSTRUCTION: t EW REPAI R -:':NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YES NO CONDITIONS OF:.APPROVAL YES NO f (FROM FORM U) .,. -'..ISSUANCEOF DWC PERMIT YES NO DWC ;PERMIT N0. � INSTALLER:� iy �p BEGIN, INSPECTION DE5 NO .:_ EXCAVATION •INSPECTION: NEEDED: PASSED h BY CONSTRUCTION INSPECTION: NEEDED: . 7777 .1 _ 1 AS BUILT PLAN SATISFACTORY: : Y( ESQ) _APPROVAL TO BACKFILL: DATE: BY ,FINAL . GRADING APPROVAL: DATE BY DATE: FINAL CONSTRUCTION APPROVAL: I Commonwealth of Massachusetts RECEIVED _ City/Town of System Pumping Record AUG Form 4 SOWN OF NORTH AN DEP has provided this forrri for use-,by local Boards of Health. Other fo HEALTH DEPA TI iEN information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/Right front of house, Left Aii ht rear of hous Left/right side of house, Left/ Right side of building, Left/Right front of building, Left Ig rear of building, Under deck Address �70 City/Town State Zip Code 2. System Owner. Name ' PqC Address(if different from location) Cityrrown State � Co f� A^ Telephone Number � r i B. Pumping Record r7 Com► 1. Date of Pumping Date 2. Qu�antity Pumped: Gallons —? 3. Type of system: ❑ Cesspool(s) 0 ept� is T �ank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No; 5. Conditio o Systeme " ` V1111 6. System Pumped By.- Nell. y:Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: G S. Lowell Waste Water Sig Haul Date t5fomi4.doc-06/03 System Pumping Record•Page 1 of 1 - r . Commonwealth of Massachusetts RECEIVE Title 5 official Inspection Form NOV oo� Subsurface Sewage Disposal System Form-Not for Voluntary Assessme t 9 p Y g TOWN OF NORTH ANDOVER HEALTH DEPARTMENT NT PO Xf 70 Lost Pond Ln Property Address L Z Bartlett Owner Owner's Name information is required for every North Andover MA 01845 11/6/2012 — 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. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Chad Jablonski_ use the return Name of Inspector key. CJ Jablonski Septic Inspection& Repair r� Company Name 237 Merrimac St. ;�, Company Address r f ' Newburyport MA 01950 _ City/Town State Zip Code 978-360-9358 4574 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 Evaluation by the Local Approving Authority 1-7 Ins)aWdrs Signa r Date The system ' spector shall submit a copy of this inspection report to the Approving Authority (Board of Health r DEP)within 30 days of completing this inspection. If the system is a shared system or has a d I-n flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report t e 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. 15ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 o'17 Commonwealth of Massachusetts Title 5 official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments «M= 70 Lost Pond Ln Property Address Bartlett Owner Owner's Name information is required for every North Andover MA 01845 11/6/2012 page. Cityrrown State Zip Code Date of Inspection B..Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SAS and all components in good working order. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 70 Lost Pond Ln Property Address Bartlett _ Owner Owner's Name information is North Andover MA 01845 11/6/2012 required for every -- page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): v Y N ND (Explain below): obstruction is removed ❑ ❑ ❑ ) ❑ ( p ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y [ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1.. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts L Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - 70 Lost Pond Ln _ Property Address Bartlett Owner Owner's Name information is North Andover MA 01845 11/6/2012 required for every - page. CitYRo` n state Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•11110 Title 5 Official Inspection Foran:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 4 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Lost Pond Ln Property Address Bartlett Owner Owner's Name information is North Andover MA 01845 11/6/2012 required for every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 m, g 9 eq pp 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 falls. 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 11 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. i5ins•11/10Title 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 70 Lost Pond Ln Property Address Bartlett Owner Owner's Name information is North Andover MA 01845 11/6/2012 required for every page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) (� ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? ❑ Were all system components, excluding the SAS, located on site? * ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 440 E 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts fig Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 70 Lost Pond Ln Property Address Bartlett Owner Owner's Name information is North Andover MA 01845 11/6/2012 required for every - page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? Z Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd))� Attached Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Occupied _ Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: - 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 70 Lost Pond Ln Mt Property Address Bartlett Owner Owner's Name information is North Andover MA 01845 11/6/2012 required for every page. City[Town State Zip Code Date of Inspection D. System Information (cant.) Last date of occupancy/use: Date Other(describe below): I General Information Pumping Records: Source of information: Pumped 7/24/2012- N. Andover BoH Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: na gallons How was quantity pumped determined? na _ Reason for pumping: na_ Type of System: 2 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w -„ 70 Lost Pond Ln Property Address Bartlett Owner Owner's Name information is North Andover MA 01845 11/6/2012 required for every — page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: As-built plan dated 11/16/1995 Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below rade: Under footing De p g feet Material of construction: ❑ cast iron [Z 40 PVC ❑ other(explain): - - Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Waterti ht at foundation Septic Tank(locate on site plan): Depth below grade: feel a Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: na -- _ years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10.5 x 5.5 x 5.5 1" Sludge depth: - --- -- t5ins•11/10 Title 5 Official Inspection Form:Subsurface sewage Disposal System•Page 9 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 70 Lost Pond Ln Property Address Bartlett Owner Owner's Name information is North Andover MA 01845 11/6/2012 required for every p 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 33" — Scum thickness minimal Distance from top of scum to top of outlet tee or baffle 5" — Distance from bottom of scum to bottom of outlet tee or baffle 14" — How were dimensions determined? measuring.�ape___ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is structurally sound, inlet and outlet tee in good working condition. Crease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: -- Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 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 70 Lost Pond Ln Property Address Bartlett Owner Owner's Name information is North Andover MA 01845 11/6/2012 required for every State Zip Code Date of Inspection page. CitylTown 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.): I Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: --- — — Capacity: gallons -- Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: - Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): " Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins 11!10 Title 5 Official Inspection Form:Subsurface Sewage Ois oral System Page 11 of 17 Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 70 Lost Pond Ln Property Address Bartlett _ Owner Owner's Name information is North Andover MA 01845 11/6/2012 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 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is level and distributing equally. Box was replaced 7/12/2005 Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 70 Lost Pond Ln _ Property Address Bartlett Owner Owner's Name information is MA 01845 11/6/2012 required for every North Andover 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: 2-74' _ leaching fields number, dimensions: overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No sign of hydraulic failure or ponding 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts • i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments IIS ..''t 70 Lost Pond Ln Property Address Bartlett Owner Owner's Name information is required for every North Andover MA 01845 11/6/2012 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.): I 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•11110 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments rt 70 Lost Pond Ln Property Address Bartlett — - — Owner Owner's Name information is North Andover MA 01845 11/6/2012 required for every y page. Cit frown 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 L c2 5 J �0 i l O v t3- G 33: 51 l Q - � 2 16 -Page 15 of 17 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 70 Lost Pond Ln Property Address Bartlett — Owner Owner's Name information is North Andover MA 01845 11/6/2012 required for every Y page. Cit /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 L 7D iia. �a S 1 fS ,h — � rjl. tl I3 - � 2'�j• � � t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 70 Lost Pond Ln Property Address Bartlett Owner Owner's Name information is North Andover MA 01845 11/6/2012 required for every 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: 4' below trenches 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: Plan approved 10/10/1995 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 USES database - explain: You must describe how you established the high ground water elevation: Soils test performed 9/15/1995 Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins-11/10 Tnle 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 70 Lost Pond Ln Property Address Bartlett Owner Owner's Name information is North Andover _ MA 01845 11/6/2012 required for every State Zip Code Date of Inspection page. Citylrown E. Report Completeness Checklist • Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 17 of 17 Summary Record Card generated on 11/6/2012 2:14:07 PM by Maureen McAuley Page 1 Town of North Andover Tax Map # 210-1043-0210-0000.0 Parcel Id 16533 70 LOST POND LANE MICHAEL & CATHERINE BARTLETT 70 LOST POND LANE NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential ZZoning3 1 Residential oning2 1 Residential Size Total 0.55 Acres FY 2013 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until MICHAEL&CATHERINE BARTLETT Owner 70 LOST POND LANE NORTH ANDOVER,MA 01845 KNAPP,ERIC&HEATHER Previous Customer Inactive 9/8/2005 70 LOST POND LANE NORTH ANDOVER,MA 01845 UB Account Maint. Active/Inactive Account No Cycle Occupant Name Bldg Id. 17993.0-70 LOST POND LANE Last Billing Date 10/2/2012 3180022 03 Cycle 03 Active UB Services Maint. Account No.3180022 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 180.68 /1 UB Meter Maintenance Account No.3180022YTD Cons Serial No Status Location Brand Type Size 13242256 a Active 00 METE METE w Water 0.63 0.63 519 Date Reading Code Consumption Posted Date Variance 39 10/15/ 9/19/2012 1013 a Actual 6/18/2012 974 a Actual 17 7/16/2001212 45% 122% 12 4/14/2012 -47% 3/20/2012 957 a Actual 23 1/17/20 12/19/2011 945 a Actual 0% 9/16/2011 922 a Actual 52 10/13/20011 1 1990% 17 7/20/2011 70% 6/13/2011 870 a Actual 10 4/13/2011 -44% 3/15/2011 853 a Actual 72% 12/15/2010 843 a Actual 18 1/12/2011 67 10/15/ 9/16/2010 825 a Actual 6/14/2010 758 a Actual 21 7/15/2001010 199% 32% 18 1/122/2010 3/18/2010 737 a Actual 13 4/1 12/14/2009 724 a Actual /2010 23�o 9/ 16/2009 706 a Actual 41 10/15/2009 6/10/2009 665 a Actual 29 7/20/2009 -44% 3 /17/2009 636 a Actual 15 4/29/2009 -46% 12/15/2008 621 a Actual 26 1/20/2009 52 10/10/2008 -5% 9/16/2008 595 a Actual 49 7/16/2008 277% 6/10/2008 543 a Actual -52% 3/14/2008 494 a Actual 13 4/11/2008 41% 12/17/2007 481 a Actual 29 1/22/2008 9/14/2007 452 a Actual 45 10/12/2007 17% 6/20/2007 407 a Actual 43 7/20/2007 162% 3/16/2007 364 a Actual 16 4/16/2007 13 1/19/2007 -62% 12/13/2006 348 a Actual 37 10/20/2006 97% 9/19/2006 335 a Actual 6/20/2006 298 a Actual 19 7/10/2006 370°° 3/20/2006 279 a Actual 10 4/17/2006 Commonwealth of MassachusettsFHEALTH DED City/Town of 5 2013 System Pumping Record Y p TH A(V®OVER Form 4 PARTh9ih? DEP has provided this form for use,by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/Right front of house, Left ht rear of ho , Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address lJ� CitylTown State Zip Code 2. System Owner: J+v� Name Address(if different from location) Cityfrown star-, Zip de Telephone Number B. Pumping Record 1. Date of Pumping Date 2• Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank Other(describe): 4. Effluent Tee Filter present? ❑ Yes 3 No If yes, was it cleaned? Yes El No S. Conditior ystem: a � 6. System Pumped By: j Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: /GLI-S-W Lowell Waste Water Signite Haule Date t5form4.doc•06103 System Pumping Record•Page 1 of 1 f Town of North Andover, Mass chusetts Form No,z BOARD OF HEALTH � w P DESIGN APPROVAL FOR Ss,C"°SE` SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant- — Test No. Site Location Reference Plans and Specs. leryh ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. CHA1RM`A4Q','B0AR0 OF HEALTH DL d� Fee Site System Permit No. COMMONWEALTH OF MASSACHUSETTS Z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ~ d DEPARTMENT OF ENVIRONMENTAL PROTECTION r� See TITLE 5 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 70 Lost Pond Lane_ North Andover_ Owner's Name:_Eric Knapp_ Owner's Address: 70 Lost Pond Lane_ North Andover,MA 01845_ Date of Inspection 7/12/2005_ Name of Inspector: Todd J.Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address:_111 Argilla Road_ _Andover,Ma.01810_ Telephone Number:_(978)4754786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: I X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: - Date: _7/12/2005_ The system inspector shalt/submit a cop, this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments:After permit from B.O.H.,install new d-bog,inspection from B.O.H.,septic system now passes Title 5 Inspection. ****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. .P COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS o DEPARTMENT OF ENVIRONMENTAL PROTECTION A W M WY �v �� SYoy TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_70 host Pond Road_ North Andover— Owner's Owner's Name•_Eric Knapp_ Owner's Address:. 70 Lost Pond Road_ North Andover,MA 01845_ JUL _ 5j 2005 Date of Inspection 6/29/2005_ Name of Inspector: Neil J.Bateson_ TOWN HEALTH DEPARTM TER Company Name: Bateson Enterprises Inc._ Mailing Address:_111 Argilla Road_ _Andover,Ma.01810_ Telephone Number:_(978)475-4786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes _X Conditionally Passes Navds Fwther Evaluation by the Local Approving Authority ai -�A &47� Inspector's Signature: Date: _6/29/2005_ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments: ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 70 Lost Pond Road- - Andover_ Owner: Knapp_ Date of Inspection: 6/29/2005_ 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: X 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.D-Boz needs replaced. N 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: N Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: N The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of l l OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 70 Lost Pond Road_ _North Andover— Owner: Knapp_ Date of Inspection:_6/29/2005_ C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and g P P the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other:_ Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_70 Lost Pond Road_ _North Andover Owner: Knapp Date of Inspection:_6/29/2005_ D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: _ No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool No Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool No_ Liquid depth in cesspool is less than 6"below invert or available volume is'/2 day flow. No Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped No_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _ _No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia i nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] _No_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 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. ii � r Page 5 of 11 � OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 70 Lost Pond Road_ _North Andover_ Owner: Knapp_ Date of Inspection: 6/29/2005_ Check if the following have been done You must indicate"yes"or"no"as to each of the following: Yes No _Yes_ Pumping information was provided by the owner,occupant,or Board of Health No Were any of the system components pumped out in the previous two weeks? _Yes_ _ Has the system received normal flows in the previous two week period? No Have large volumes of water been introduced to the system recently or as part of this inspection? Yes Were as built plans of the system obtained and examined? Yes Was the facility or dwelling inspected for signs of sewage back up? Yes Was the site inspected for signs of break out? _yes_ — Were all system components,excluding the SAS,located on site? _YQ3_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? yes _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _Yes _ Existing information. _yes_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 70 Lost Pond Road_ _North Andover Owner: Knapp_ Date of Inspection:_6/29/2005_ EWER X locate on site plan) BUILDING S P ) Depth below grade:_41 _ Materials of construction: _cast iron _X 40 PVC other Distance from private water supply well or suction line: , Comments(on condition of joints,venting,evidence of leakage,etc.) 4"PVC thru wall to septic tank,3"PVC in house,no leaks visible_ SEPTIC TANKS:_X_ Depth below grade: 3'_ Material of construction: X concrete—metal_fiberglass_polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) i Dimensions: 10'x 5' x 4' Sludge depth 3"_ Distance from top of sludge to bottom of outlet tee or baffle: 25"_ Scum thickness:_3"_ Distance from top of scum to top of outlet tee or baffle: 8"_ Distance from bottom of scum to bottom of outlet tee or baffle:_19"_ How were dimensions determined:_Tape measure_ Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.)_Pumped septic tank.Inlet tee ok.Outlet tee oL Depth of liquid at outlet invert.No evidence of leakage._ GREASE TRAP: (locate on site plan) Depth below grade:_ Mt —a Material of construction: concrete metal fiberglass_polyethylene ._other _ (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 70 Lost Pond Road_ _North Andover_ Owner: Knapp Date of Inspection:_6/29/2005 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: _X leaching trenches,number,length:_2 trenches 74'long_ leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.):_Soil ok.Vegetation ok.No sign of ponding to surface. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert:_ Depth of sludge layer:_ Depth of scum layer:_ Dimensions of cesspool: Materials of construction: . Indication of groundwater inflow(yes or no):_ Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):_ PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): i Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property a Address: 70 Lost Pond Road P _ _ _North Andover — Owner: Knapp_ Date of Inspection:_6/29/2005_ 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. Driveway later Meter House A Porch Deck TTI A to Tank=4513" A to D-Boz=57' B to Tank=3315" B to D-Boz=29'7" SeptiTank i D-Boz I Page 11 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 70 Lost Pond Road— _North Andover— Owner: Knapp_ Date of Inspection: 6/29/2005 SITE EXAM Slope Surface water Check cellar Shallow wells j Estimated depth to ground water _4'_ Please indicate(check)all methods used to determine the high ground water elevation: X Obtained from system design plans on record-If checked,date of design plan reviewed:_9/5/1995_ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain:_ Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: As per design plan_ Summary Record Card generated on 7/5/2005 9:42:47 AM by Elaine Barclay Page 1 Town of North Andover Tax Map # 210-104.B-0210-0000.0 70 LOST POND LANE KNAPP, ERIC & HEATHER 70 LOST POND LANE NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 0.55 Acres FY 2005 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until KNAPP, ERIC& HEATHER Payor 70 LOST POND LANE NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 2958.0-70 LOST POND LN Last Billing Date 4/6/2005 3180022 03 Cycle 03 Active UB Services Maint. Service Code Rate Charge Multiplier/Users MISCFEE•ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 50.40 /1 UB Meter Maintenance Serial No Status Location Brand Type Size YTD Cons 13242256 a Active ERT HH METE METE w Water 0.63 0.63 0 Date Reading Code Consumption Posted Date Variance 6/14/2005 174 a Actual 21 38% 3/23/2005 153 a Actual 18 4/5/2005 -42% 12/15/2004 135 a Actual 28 1/14/2005 -51% 9/17/2004 107 a Actual 61 10/8/2004 24% 6/14/2004 46 a Actual 27 7/30/2004 233% 4/23/2004 19 a Actual 19 5/17/2004 0% 12/23/2003 0 n New Meter 0 12/23/2003 0% . %S ACCOUNT HISTORY 3180022-KNAPP, ERIC &HEATHER METER 41: 3IA022 ------------------- BK:70 LOST POND LN # CYCLE SERVICE PRIOR CURRENT USE WATER SEWER FEES TOTAL 12000-13 10/01/1999 558 670 112 305.76 0.00 0.00 305.76 22000-23 01/24/2000 670 733 63 171.99 0.00 0.00 171.99 32000-33 03/31/2000 733 759 26 70.98 0.00 0.00 70.98 42000-43 06/22/2000 759 801 42 114.66 0.00 0.00 114.66 52001-13 09/26/2000 801 851 50 136.50 0.00 11.00 147.50 62001-23 12/12/2000 851 885 34 92.82 0.00 11.00 103.82 72001-33 04/02/2001 885 930 45 122.85 0.00 11.00 133.85 82001-43 06/19%2001 930 970 40 109.20 0.00 11.00 120.20 92002-13 09/0 /2001 970 1032 62 200.18 0.00 5.55 205.73 10 2002-23 03/01/2&02 1120 1120 0 0.00 0.00 0.00 0.00 112002-33 04/ld/�,' 02 1120 1127 7 17.29 0.00 5.55 22.84 122002-43 06/17/28,02 1127 1150 23 60.17 0.00 5.55 65.72 13 2002-35F 02/26/2002 1032 1120 88 271.12 0.00 35.00 306.12 14 2003-13 09/17/2002 1171 1171 0 0.00 0.00 5.97 5.97 15 2003-23 12/16/2002 1171 1187 16 38.08 0.00 5.97 44.05 162003-33 03/17/2003 1187 1203 16, 38.08 0.00 5.97 44.05 172003-43 06/12/2003 1203 1222 19 45.22 0.00 5.97 51.19 18 2003-11F 09/11/2002 1150 1171 21 51.40 0.00 35.00 86.40 REVIEW CHOICE # or<ENTER>MORE HISTORY: I I Tel. (978) 475-4786 Fax: (978) 475-5451 a I BATESON ENTERPRISES, INC. Excavating-Water.& Sewer Lines-Septic Systems&Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report i Property Address: 70 Lost Pond Road, North Andover Owner: Knapp Date of Inspection: 6/29/2005 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. QBat Bateson Enterprises, Inc. I i i Commonwealth of Massachusetts City/Town of RECEIVED System Pumping Record Form 4 APR 2 2008 DEP has provided this form for use by local Boards of Health. the information must be substantially the same as that provided he or in, eck with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: `� m ✓ �, l Q When filling out 1. System Location, forms on the computer,use only the tab key Address to move your 0 cursor-do not Gky/rown State Zip Code use the return key. 2. System Owner: Name Address(if different from location) City/Town State(� � Zi�� 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 El ryo If yes,was it cleaned? ❑ Yes ❑ No 5. Condition ofSyystem: C\� `�-� V\,- 6. System PX7 By- Name Name 'k�ehicle License Number w Company 7. Locatioyaere contents a disp Signatur of au Date t5form4.doc^06/03 System Pumping Record^Page 1 of 1 HORT1� Town of North Andover � of",�•° ,•,� Office of the Health Department Community Development and Services Division . : 400 OSGOOD STREET `�, • �'' North Andover,Massachusetts 01845CH��s•" �e� S�cHus Susan Y. Sawyer, RENS/RS 978.688.9540-Phone Public Health Director 978.688.8476-Fax C2qWq7ICA�IE OAF CO�I�I�GIA�1�CE As of: ,duly 12, 2005 This is to cert that the individual subsurface diisposal system Constructed(-- or repaired- 1�-(B0.� Only — (-A �y Todd Bateson At 70 .cost Pond Lane North Andover, W,4 01845 Yfas been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Yfealth regulations. ,lie Issuance of this certificate shall not 6e construed as a guarantee that the system will function satisfactorily.. Susan T Sawyer, RvfSM Tu6fic ifealth Director 130ARI)OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Q• �J TOWN OF NORTH ANDOVER MORTM Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 400 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845 �'SS�C t� Susan Y. Sawyer,REHS/RS 978.688.9540—Phone / Public Health Director 978.688.9542—FAX D SEPTIC SYSTEM CONSTRUCTION NOTES ADDRESS: MAP:_ LOT: INSTALLER: DESIGNER: PLAN DATE: BOH APPROVAL DATE bK PLAN: /V/,4 DATE OF BED BOTTOM INSPECTION: f DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SELECT SYSTEM TYPE GRAVITY DISTRIBUTION PRESSURE DISTRIBUTION PRESSURE DOSING HOLDING TANK ADVANCED TREATMENT OTHER COMPONENT SUMMARY FROM PLAN GALLON TANK = LOADING OF SEPTIC TANK = GALLON PUMP CHAMBER = LOADING OF PUMP CHAMBER = TYPE OF SAS = DIMENSIONS AND DETAILS OF SAS: SITE CONDITIONS ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: Page 1 of 4 Q 0 O N OF NORTH ANDOVER NORTH Office of COMMUNITY DEVELOPMENT AND SERVICES a �t`• ' `�� HEALTH DEPARTMENT 400 OSGOOD STREET "'► r+" NORTH ANDOVER, MASSACHUSETTS 01845 �''s"„CM„se�� Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.9542—FAX SEPTIC TANK ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ gallon tank has been installed (H-10 or H-20) (monolithic or 2 piece) ❑ Water tightness of tank has been achieved (Visual or Vacuum Test or Water held for 24hrs) ❑ Inlet tee installed, under access port ❑ Outlet tee (gas baffle or effluent filter) installed, under access port ❑ inch cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ gallon Pump Chamber installed (H-10 or H-20) (monolithic or 2 piece) ❑ Inlet tee installed, under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off float working ❑ Drain hole in pressure line ❑ inch cover to within 6" of final grade installed over one access port ❑ Water tightness of tank has been achieved Visual or Vacuum Test or Water held for 24 hrs ❑ Hydraulic cement around inlet & outlet Comments: Page 2 of 4 0 TOWN OF NORTH ANDOVER OE NORTH Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT ►O- -' 9 400 OSGOOD STREET = NORTH ANDOVER MASSACHUSETTS 01845 4'ss"nO'�e' ACHUS Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.9542—FAX D-BOX ❑ Installed on stable stone base ❑ Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets Observed even distribution Speed levelers provided (not required) Comments: SOIL ABSORPTION SYSTEM ❑ Bottom of SAS excavated down to soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 3/4-1 Y2" double washed stone installed ❑ 1/8-1/2" (peastone) double washed stone installed ❑ laterals installed and ends connected to header (and vented if impervious material above) ❑ Orifices @ 5 & 7 o'clock positions ❑ Gravelless disposal systems: type, number and location as per plan ❑ Elevations of laterals installed as on approved plan ❑ 40 Mil HDPE barrier installed ❑ Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: PRESSURE DISTRIBUTION ❑ inch manifold ❑ laterals installed with end sweeps size: material: ❑ Squirt test ft in height ❑ Equal distribution to all laterals ❑ orifice size inch as per plan Comments: Page 3 of 4 y 0 0 >: TOWN OF NORTH ANDOVER of NORTI Office of COMMUNITY DEVELOPMENT AND SERVICES a •`t ` �O� F w A HEALTH DEPARTMENT Fx 400 OSGOOD STREET ► NORTH ANDOVER, MASSACHUSETTS 01845 �'ss;CHU t� Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.9542—FAX CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: ❑ Rated for exterior if placed outside Comments: SYSTEM ELEVATIONS Benchmark: Rod at Benchmark: Height of Instrument: INVERT ON DESIGN PLAN ELEV TOP OF PIPE INVERT ELEVATION Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN D-Box OUT Manifold Lateral 1 HIGH Lateral 1 LOW Lateral 2 HIGH Lateral 2 LOW Lateral 3 HIGH Lateral 3 LOW Lateral 4 HIGH Lateral 4 LOW Lateral 5 HIGH Lateral 5 LOW Page 4 of 4 � Commonwealth of Massachusetts Map-Block-Lot Permit No ----------------------- to(Rep LY)an Individual Sewage Disposal System. as shown on the application for Disposal Works Construction Permit No. BHP-2005-020 Dated July 07,2005 ! Disposal Works Construction Permit � � � Issued On:Jul--07-2005 .^~........~~~~.,..^.....~.,^,..~......,.,.~~~~..........~~..~..........~~~~.~........,~~.,~.~........,~~~~^........~~~~.~.....~..~~~~~ � Commonwealth of Massachusetts � ----------------------- Board of HealthNorth Andover � Certificate of C impliance THIS IS TO CERTIFY,T at t e !--idual'Sewage Disposal System (Repair-D-BOX ONLY) TH' IS To ERTIF 'That the Installer j j has been i led in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the ap 1* 1 n for Disposal Works Construction Permit No. BHP-2005-020 Dated July_07,2005........ ---------------------------------------------------------------- � Town of, North Andover Health Department Date: /xi", Location: �- (Indicate Address,if Residential,or Name of Business) Check#• 1/ Type of Permit or License:(Circle) ➢ Animal $ ➢ Dumpster $ ➢ Food Service-Type: $ ➢ Funeral Directors $ ➢ Massage Establishment $ ➢ Massage Practice $ ➢ Offal(Septic)Hauler $ ➢ Recreational Camp $ ➢ SEPTIC PERMITS: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ v . OyS tic Disposal Works Construction(DWC)$ ❑ Septic Disposal Works Installers(DWI) $ ➢ Sun tanning $ ➢ Swimming Pool $ ➢ Tobacco $ ➢ TrashlSolid Waste Hauler $ ➢ Well Construction $ 4 ➢ OTHER:(Indicate) Health Agent Initials 891 Y White-Applicant Yellow-Health Pink-Treasurer r ,., TOWN OF NORTH ANDOVER MCRTM 'w Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 400 OSGOOD STREET ',►*� ,,,,,�„ e NORTH ANDOVER, MASSACHUSETTS 01845 414 Sq ,µ,b 978.688.9540—Phone Susan V.Sawyer, REHS/RS 978.688.9542—FAX Public Health Director healthdepi@townofnorthandover.com-e-mail www.townofnorthandover.com-website APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: "7— 0 LOCATION• 7d �ds `►� LICENSED INSTALLER NAME: 1<9 7Le_5,',t1' - PLEASE PRINT SIGNATURE: TELEPHONE# 4 CHECK ONE: FULL SYSTEM REPAIR: ($250) -- �dlC 7 OMPONENT REPAIR(indicate what parts): $125 ( ) O * NEW CONSTRUCTION: * If NEW CONSTRUCTION, please attach the Foundation As-Built Pian. $250.00 or$125 Fee Attached? Yes No Project Manager Obligation From Attached? Yes No T Foundation As-Built? Yes No Floor Plans? Yes No Date: Approval of Health Agent .S a� INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the � relative to the application property of 27o dated___" —for plans by and dated with revisions dated I understand the following obligations for management of this project: I. As the installer 1 am obligated to obtain all permits and Board of Health approved plans prior to performing any work on site. I must have the approved 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 manger,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 necgssary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Tile 5 and the Board of Health Regulations may result in a-$50.00 fine being levied against my company. a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As-built or s for verbalOK non tiTom engineer must be submitted to Board of me. Installer must be present for this inspection. Health, after pwhich system fall eleler ctrical inspection work must be ready and able to cause pump to work and alarm to function. C) Final Grade—Installer must request inspection when all grading is complete. Does not have to be on site. 4. As the installer I understand that only I.may perform the work(other than simple excavation) required to complete the installation of the system identified in the attached application for in installation, I further understand that work by others uTtlicensed to install orprevocationeptic s or North Andover can constitute reasons for denial of the system, and/ 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. b. As the installer I understand that I am solely responsible for thinstallation of the system as any other per the approved plans. No instructions b the homeowner, general persons shall absolve ve me of this obligation. Undersigne iiceennsed Septic Installer Date: isposal Works Construction Permit# _.. _ a s. _ •w.x ;'�,�'% � .rte .,+. - p F. Town of North Andover, Massachusetts Form No. 3 40RTN BOARD OF HEALTH 1- 9 DISPOSAL WORKS CONSTRUCTION PERMIT ,,TSACMUS�t Applicants NAME ADDREM TELEPHONE Site Location Permission is hereby granted to Construct or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN,BOARD OF HEALTH Fee D.W.C. No. _t i .p �:r x gas e o , Town of North Andover, Massachusetts Form No.3 t kO TN 1 BOARD OF HEALTH 3 C 19 0 9 DISPOSAL WORKS CONSTRUCTION PERMIT SS�ICMUs�t Applicant auy_� 0S-a i QfA - NAME ADDRE_% TELEPHONE Site Location Permission is hereby granted to Construct X�) or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN,BOARD OF HEALTH 5'D Fee D.W.C. No. i Plan o f L an d ©ova/ a 5 � �gOARD�F VA ��jN North Ando ver, Mass. 311995 f.� e OGS Showing 0 "As—Built " Foundation Location o Acol, ``� - - -Lot 2 — Lost Pond Lane ° Prepared For Flin tlock Inc. �! r L Scale: 1" = 40' Date: October 2.3, 1995 lb � 24,045 S.F. Upland = 24,045 S.F. g, Zoning District.' R-- 1 Residence 1 i (Planned Residential Development) o 0.50 Acres ' Top Of Foundation Note: 'p� � Elevation = 141.86' �� ,� Property line data token from o Definitive 5t Subdivision plan by Neve Assoc.,Inc.,dated 0 fid' 7�D� Qj Sept.23, 1994,revised to Feb. 1 1995 O� In my opinion, this foundation is not in c �d ' �� Flood Hazard Zone as shown on the U.S.D.H.U.D.e Flood Hazard Boundary Maps. ' 99.61 a► Community Panel No.250098 0007 C � 1 , Hereby Certify That The Foundation On This 'Cob— i O e Property /s Located As Shown On Plans And Complies With Zoning Requirements Of The Town Of North Andover,Mass. Qt 0f Thomas E., Neve Associates, 'Inc. v 447 Old Boston Road — U.S. Route 1 Engineers — Surveyors — Land Use Plcnners ; Topsfield, Massachusetts 01983. (837-8586) , Professional. L veyor Plan o f L on d ok a�oFa /n 5 , e �o a��h North Ando ver, Mass. e Sho wing � �0 "As—Built " Foundation Location i Lot - Lost Pond Lane X199 Prepared For Flim tlock Inc. �f Scale: 1" = 40' Date: October 23, 1995 `6 ` 24,045 S.F. 0) a Upland = 24,045 S.F. �g Zoning District.' R— 1 Residence 1 0.50 Acres (Planned Residential Development) o h, _ `l �5 No te: Top Of Foundation�� /.\�� Property line data token from a Definitive Elevation — 141.86 5x, �e f Subdivision plan by Neve Assoc.,Inc.,dated T ej Sep t.23, 1994,re vised to Feb. 1 1,995 ��_ 6 V � In my opinion, this foundation is not in a yZ Flood Hazard Zone as shown on the U.S.D.H.U.D. N \ -i J �0 �\6 Flood Hazard Boundary Maps. 99.61' L O� a. Community Panel No.250098 0007 C 4_N'9t, o i O l Hereby Certify That The Foundation On This 00— i '�[ Property /s Located As Shown On Plans And Complies With Zoning Requirements Of The Town Of North Andover,Mass. IF QC � G Thomas E. Neve Associates; Inc. v 447 Old Boston Road — U.S. Route 1 Engineers — Surveyors — Land Use Plonners Topsfield, Massachusetts 01983 (887-8586) Professional LWor 0 FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: F NT'a J( C Phone 4 � S LOCATION: Assessor's Man Number /0q 8 Parcel Subdivision C o5 f 6ND Lots) Street L o ST St. Number O Use Only************************ RECOMMENDA O S /OF TO AGENTS: Date Ammroved Conservation Administrator n Date Rejected Comments Fks W 15 co�7 , Q e l �re_= Date Approved Town Planner Date Rejected Comments Date Approved Food Inspect--o�r--Health Date Rejected ,�A - Date Approved /,> Septic Inspector-Health Date Rejected Comments Public Works - sewer/water connections - driveway permit ( L4_) Fire partment : � 6wG.�GCi-� /0,741`_q_A ca 0 ~71 eceived by Bitildi.n Inspec or Date i �-$"�t,44 ORTH Andover Towno 6 NO. ©� o dower, Mass. G��_ �3 19q COCHICMEWICK - ' ' ,44 C DRATED BOARD OF HEALTH PERMIT TFood/Kitchen Septic System � THIS CERTIFIES THAT. r BUILDING INSPECTOR l-�� - - oundation p 123 a� has permission to erect ... �C... buildings on .10..... - ........�.�.. � ,............. z� 1TI -44r I c to be occupied as at�.. ...4�1�? .. . #........... .....�z.. �... � �,...... j imneyC7 — provided that the person accepting this permit shall in every respect co orm to the terms of the application on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Final Buildings in the Town of North Andover. PERMIT FOR FOUNDATION ONLY PL B G NSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. REGULATED BY PARA. 114.8-S. B.C. u PERMIT EXPIRES IN 6 MON ��FEE PAID t� - toy f r S� o ELEC CSP C UNLESS CONSil TTS ou << �N�S IN �I O PERMIT FOR FRAMUBUILDING � BUILDING ECTOR DATE: L?IZ+�v I. pAID. 1 Final Uccupa`anncy Ver nit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough /+- Final (� No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Ins - ' $urner - Y PLANNING FINAL CONSERVAT FINAL Street No. Smoke Det. , � s __..- _-_CC\A/CD /IAIATCD CIAIAI hDl\/CIA/A\/ CAI D\/ DCDAAIT I i ~a 0 PLAN REVIEW CHECKLIST ADDRESS �p,> a OJT ��3rVd ENGINEER A/CVG GENERAL 3 COPIES 1� STAMP LOCUS �� NORTH ARROW SCALE C�-- CONTOURS 4-,— PROFILE �� SECTION �� BENCHMARK �� SOIL & PERCS ELEVATIONS WETS. DISCLAIMER WELLS & WETS �-- WATERSHED? DRIVEWAY � (Elev) WATER LINE L"." FDN DRAIN I SCH40 °1/ TESTS CURRENT?_ SOIL EVAL j; �j� 'LJ,e,50 SEPTIC TANK / MIN 1500G . 17V v IN ERT DROP GARB. GRINDER(+200a EDF) 25 ' TO CELLAR V MANHOLE 1/ ELEV GW # COMPS. D-BOX SIZE # LINES � FIRST 21 LEVEL STATEMENT I INLET 133, /a - OUTLET (2 11 OR . 17 FT) TEE REQ 'D? LEACHING MIN 660 GPD? ,�/ RESERVE AREA 1-"" 4 ' FROM PRIMARY? t/ 2% SLOPE 100 ' TO WETLANDS X1100 ' TO WELLS `� 4 ' TO S .H. GW (5 ' >2M/IN) 35 ' TO FND & INTRCPTR DRAINS 325 ' TO SURFACE H2O SUPP 4 ' PERM. SOIL BELOW FACILITY t/ MIN 12" COVER �FILL? (25 ' if above natural elev; 101if below) BREAKOUT MET? TRENCHES tt t MIN 660 d SLOPE min . 005 or 6 100 qp � ( / ) SIDEWALL DIST. 3X EFF. W OR D (MIN 6 ' ) " RESERVE BETWEEN TRENCHES? L---' �� IN FILL? MUST BE 10 ' MIN. e, � 4" PEA STONE? VX VENT? (>3 ' COVER; LINES >50 ' ) BOT + SIDE X LDNG Ate(/ = TOT 410 eo'd (L x W x #) (DxLx2x#) (G/ft2) Z Z/- 7a Copyright 0 1995 by S.L. Swrr 0 0 NORTH ANDOVER BOARD OF HEALTH DESIGN REVIEW REPORT FEE: PERMIT # DATE RECEIVED SEPT APPLICANTMAP PARCEL ADDRESS LOT ## ENG. /NEVE A550C STREET ADDRESS PLAN DATE I/Z0�9,S� REV. DATE CONDITIONSOFAPPROVAL APPROVED DISAPPROVED REASONS FOR DISAPPROVAL: A /CVtCb z- ��Gti �,e�� ss T�,9•v ate-' ro <�/v.� 3 koT eA91'C7 /5 �GEv. Off= G'CJ /A/ /�- /T5 1991- -#LIV. 6,e)gllv ? Q I7�5i6.0 �fJ�E 0 o Town of North Andover E 40RTM .4 OFFICE OF 3? ,�' ''e 0 COMMUNITY DEVELOPMENT AND SERVICES A • 09q ° i 146 Main Street KENNETH R.MAHONY North Andover, Massachusetts 01845 9SSACHUs�t Director (508) 688-9533 September 15, 1995 Thomas Neve Neve Associates 447 Boston Road Topsfield, MA 01983 Re: Lot #2 Lost Pond Road Dear Tom: This is to inform you that the proposed plans for the site referenced above have been disapproved for the following reasons: 1) Insufficient testing in disposal area, at least 2 additional observation holes required and at least one perc (depending upon soil log. ) 2) If 1978 code is being used, then everything must comply with that code; same for 1995 code. So, there is insufficient fill area - need 25 feet or variance from North Andover Board of Health and Department of Environmental Protection for retaining wall or insufficient leach area. 3) Foundation drain missing. 4) Leach area only 20 feet from foundation. If you have any questions, please do not hesitate to call the Board of Health Office at the number below. Sincerely, Sandra Starr, R.S. Health Administrator SS/cjp BOARD OF APPEALS 688-9541 BUILDING 688-9345 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Julie Parrino D.Robert Nicetta Michael Howard Sandra Starr Kathleen Bradley Colwell O e. 4 DATE Sheet of 4 t, BOARD OF xEALTH TOWN OF NORTH ANDOVER (� SUBSURFACE DISPOSAL DESIGN REVIEW FEE 7 �0 PERMIT # DATE RECEIVED 9 APPLICANT 1V DP-,5-7 D ASSESSOR'S MAP ADDRESS PARCEL # LOT # oZ, e� STREET .�D5T �Ta�(J b •� /,� ENGINEER ADDRESS PLAN DATE REVISION DATE CONDITIONS OF APPROVAL: APPROVED DISAPPROVED k /1U 6 514 /5 L C 5U� TT/ P f � /4T a , �L !`I78� �//VG v Cp, Ti�E•V CUE/�YTi`fiiiJG M057- Co1VpZ—y /99� COI��• D� Ti'/��'E 15 /BU 5U/=�"�e/��v7" T�L.G •��.9 - /V EE,D o'��` 'G�2 Vl��/Aivc� d /e /A-J-5 /GriF-tiT 1 I O PLAN REVIEW CHECKLIST ADDRESS 205-7- /'/VA ENGINEER GENERAL ,, / 3 COPIESy STAMP LOCUS &-' NORTH ARROW SCALE CONTOURSy PROFILE L--' SECTION L, BENCHMARK C---' SOIL & Gw 0 PERCS A- ELEVATIONS WETS. DISCLAIMER WELLS & WETS WATERSHED? Ajo DRIVEWAY 4-- ("Elev) WATER LINE (/ FDN DRAIN SCH40 L-----TESTS CURRENT? �� SOIL EVAL U,e66 /5, 57 9 '2 SEPTIC TANK MIN 1500G L/ . 17 INVERT DROP GARB. GRINDER(+200% EDF) 25 ' TO CELLAR MANHOLE ELEV GW # COMPS. D-BOX SIZE # LINES a4c-- FIRST 2 ' LEVEL STATEMENT INLET OUTLET_/ (2 11 OR . 17 FT) TEE REQ'D? °6 LEACHING / MIN 660 GPD?� RESERVE AREAy 4 ' FROM PRIMARY? -&--- 2% SLOPE 100 ' TO WETLANDS L,-' 100 ' TO WELLSL--' 4 ' TO S.H.GW (5 '>2M/IN)J�- 35 ' TO FND & INTRCPTR DRAINS >�' 325 ' TO SURFACE H2O SUPP --- 41 4 ' PERM. SOIL BELOW FACILITY , MIN 12" COVER L-� FILL? (25 ' if above natural elev; 101if below) BREAKOUT MET? TRENCHES MIN 660 gpd- SLOPE (min . 005 or 611/1001 ) 1-' SIDEWALL DIST. 3X EFF. W OR D (MIN 6RESERVE BETWEEN TRENCHES? SIN FILL? MUST BE 10 ' " ?� 1 MIN. 4 PEA STONE. VENT. L� (>3 COVER; LINES >50 ) i BOT .444- + SIDE ,?f6 X LDNG r to = TO (L x W x #) (DxLx2x#) (G/ft2) Copyright© 1995 by S.L.Starr I Art`, Y s •� �� tt" i t d�..a j wi r ros r� ',�,crt't�1 r i t 3. ��,. -t v 1 ',� XZ 1t , h yy��i �3Lf rVIt _ { — 7N V — I — I ! TZ ' v ID I � �l J ' qj -r. I i z� 01 . _ a as f s _ s ,.q�- - { S'fr.�.t N,c}�'Et'{b�f�'f �% .p, g� r .0; � � ja`a �°sC'r n � g:c�i�va � ��ldj c,'` S� �*•f��f r r 77 ../ t .r r'�. i�i r°i t.r 7' f jt,q f�ls•.ft2�,7 �(!k t`� @Fi^^t� i.? i f .k 1 { l ,t ly+ }rt•-lt r � '•t 1 - r 1 t t' t �1 ..{ Q MCI Iy:r' i , I 1 C' _L - -- - - -- -- - - - f/i i-bd0 / v� Ells ------ Y 7 tk�r• Y A 1 _ s'• „nP r. 4+ Y, y Y s 5� t t_rv'+ -. '+-'�T 1`''�s + �f*�� ,.'i + i 4 1~�N h �4}:h3y�?� 1�91'Z .,.F.I.z°+1.'�f• 4�+3��'"� �. 6 riF3'Iy'^t1�:..- f r ss...�:.i�.:ai�2'aa. �'.l.f _ _ :}:... a• -.. ��M r vi 3 - � ■ _� ..yam 4- y� 7 f� L T � 7F d 77 } x" vF 3 '• r V Y ' � E w�'. a s. O`MORT:,y 6298 Town of North Andover .. ,' HEALTH DEPARTMENT ,SS,\CHUStt . CHECK#: Q DATE: LOCATION: D H/O NAME: a v CONTRACTOR NAME L 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 $ Title 5 Report $ f �� ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer Commonwealth of Massachusetts - fj- EI`E City/Town of System Pumping Record L .i t'u Z Form 4 19 To N 1`40r T1_1 N�UVF-R HEALTH DEPARMTMENT DEP has provided this form for use by local Boards of Health. Other forms may a use use], the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/Right front of house, Left/ trear of hous , Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address VP6�,� Lv,, Ah City/Town C State V� Zip Code i2. System Owner. Name Address(if different from location) City/rown Stat Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2• Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes a No If yes,was it cleaned? ❑ Yes ❑ No 5. Conditio of System: LQIU-0—k '� V% 6. System Pumped By: Neil Bateson F5821 Name .Vehicle License Number Bateson Enterprises Inc Company 7. Lo ere contents were disposed: G.L S. Lowell Waste Water tt 11 1� Sign a Haule Date t5fonn4.doc•06/03 System Pumping Record•Page 1 of 1 RECEIVED TOWN OF OCT 1 9 2004 SYSTEM PUMP NG RECORD TOWN OF NORTH ANDOVER HEALTH DEPARTMENT /D DATE: 0 SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example:left front of house) a/ DATE OF PUMPING. _ ( QUANTITY PUMPED : / GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE J EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste 0 COMMONWEALTH OF MASSACHUSETTS A EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL, ., , T .f T I Ka .= i BOARD OF HEALTH 5" JAN 3 1 2002 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 70 Lost Pond Road_ _North Andover_ Owner's Name:_Tom Murphy_ _ Owner's Address:_70 Lost Pond Road_ O OF NORTH ANDOv _North Andover,Ma.01845_ ° BOARD OF HEALTH Date of Inspection:_1/28/2002_ Name of Inspector:_Neil J.Bateson FOB _ { 202 Company Name: Bateson Enterprises Inc._ Mailing Address:_111 Argilla Road_ _Andover,Ma.01810_ --- _ Telephone Number: (978)475-4786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes X Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fail ' �� Inspector s Signature: Date: _1/28/2002_ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments:Needs inlet tee in septic tank. ****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. _ I I oPage 2 f O 0 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 70 Lost Pond Road_ _North Andover— Owner: Murphy Date of Inspection:_1/28/2002_ 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 31.0 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: _X_ 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. Needs inlet tee in septic tank. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. _No_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: _No_ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: _No_ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 0 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_70 Lost Pond Road_ _North Andover— Owner: Murphy Date of Inspection:_1/28/2002_ 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 waters 1 or tributary to a surface water supply. uPP Y �'Y The system has a septic tank and SAS and the SAS is within a Zone l of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution.from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: i I L 0 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 70 Lost Pond Road_ North Andover Owner: Murphy — Date of Inspection:_1/28/2002_ D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool —No— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool No_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _No_ Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow _ NoRequired pumping more than 4 times in.the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ _No_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well.with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] No�(Yes/No)The system fails.I.have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either`yes"or`no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Atea—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. Page 5 of 11 0 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:_70 Lost Pond Road_ _North Andover— Owner: Murphy Date of Inspection: 1/28/2002_ Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Yes _ Pumping information was provided by the owner,occupant,or Board of Health No Were any of the system components pumped out in the previous two weeks? Yes _ Has the system received normal flows in the previous two week period? No Have large volumes of water been introduced to the system recently or as part of this inspection? _Yes _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) Yes_ _ Was the facility or dwelling inspected for signs of sewage back up? Yes _ Was the site inspected for signs of break out? Yes_ _ Were all system components,excluding the SAS,located on site? _Yes_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _Yes_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Yes _ Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] Page 6 of 11 C 0 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 70 Lost Pond Road_ _North Andover_ Owner: Murphy Date of Inspection:_1/28/2002_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_4_ Number of bedrooms(actual):_4` DESIGN flow based on 310 CMR.15.203(for example: 110 gpd x#of bedrooms):_440 Number of current residents:_4 Does residence have a garbage grinder(yes or no):_No Is Laundry on a separate sewage system(yes or no):_No_ [if yes separate inspection required] Laundry system inspected(yes or no):_ Seasonal use:(yes or no):_No_ Water meter readings:_Nov.99 to Nov 01=41,200 Ft3 z 7.5=309,000 GalsJ 730 days=423 Gals./Day_ Sump pump(yes or no),_No_ Last date of occupancy:_Current COMMERCIAL/INDUSTRUL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial.waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter.readings,.if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:_Pumped Sept.01,owner_ Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallon --How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information:_7 years old. 11/16/1995 As built plan. Were sewage odors detected when arriving at the site(yes or no):_No C 0 Page 7ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 70 Lost Pond Road_ _North Andover — Owner: Murphy Date of Inspection:_1/28/2002 BUILDING SEWER(locate on site plan)X Depth below grade: 4' Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.):_4"PVC out thru wall to septic tank.3" PVC in house.No leaks. SEPTIC TANK:_X_locate on site plan) Depth below grade:_3'_ Material of construction:—X—concrete_metal fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 10'x 5'x 4' Sludge depth1" Distance from top of sludge to bottom of outlet tee or baffle: 26" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle:—8"— Distance "Distance from bottom of scum to bottom of outlet tee or baffle:_19" How were dimensions determined: Subtract scum&sludge depth to tee length._ Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.):_No inlet tee.Outlet tee ok.Depth of liquid at outlet invert. No evidence of leakage._ GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_concrete metal fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from.top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid.levels as related to outlet invert,evidence of leakage,etc.): i Page 8 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_70 Lost Pond Road _North Andover- Owner: Murphy Date of Inspection:_1/28/2002_ TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) i Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_0_ Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.):_D-box level&distribution equal.No evidence of leakage.Evidence of carryover,pumped d-box to clean._ PUMP CHAMBER: (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.): I o Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_70 Lost Pond Road_ _North Andover— Owner: Murphy Date of Inspection:_1/2812002_ SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS.not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: _X_leaching trenches,number,length: 2 trenches 74'long_ leaching fields,number,dimensions: overflow cesspool,number: innovative/alterative system. Type/name of.technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Soil ok.Vegetation ok.No sign of ponding to surface.— CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet.invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 11 of 11 C o SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_70 Lost Pond Road_ _North.Andover — Owner: Murphy. Date of Inspection:_1/28/2002_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 4 feet Please indicate(check)all methods used to determine the high ground water elevation: _X_Obtained from system design plans on.record-If checked,date of design plan reviewed:_9/5/1995_ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with,local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: As per design plan_ i Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating-Water.& Sewer Lines-Septic Systems&Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 70 Lost Pond Road, North Andover Owner: Murphy Date of Inspection: 1/28/2002 I My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. ea/o nn Bateson Enterprises, Inc. i I i TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: "4 SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example: left front of house) IcIP10 L614 P6vj l i. DATE OF PUMPING: --I I `O ( QUANTITY PUMPED 1< GALLONS CESSPOOL: NO / YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY j OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFWLD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: A17'-,56C ` COMMENTS: CONTENTS TRANSFERRED TO: a 0 ('ommonweal tIt of Massachusetts "�massacliuseus System Pumping Record System Owner System Location VA Date of Pumping: Quantity Pumped: g Cesspool: No-N' Yes U Septic 'Tank: No Yes + System Pumped by: getre000 5ii&nh1ided License# Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: TG',/VN OF NORTH ANDOVER/ QOARD�I)OF H ALTfi "-4 3 ►�'�3 i