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Miscellaneous - 719 JOHNSON STREET 4/30/2018 (2)
Ij/u, -171Y/I t/©(fl NortK Andover Board of Assessors Public Access f NORTI{ p 4t��o s• �O OL a 1 SAC14US� Click Sea] To Return Search for Parcels Search for Sales Summary Residence Detached Structure Condo Commercial Page 1 of 1 North Andover Board of Assessors roperty Record Card http://csc-ma.us/PROPAPP/display.do?linkId=1513187&town=NandoverPubAcc 6/14/2010 Location: 719 JOHNSON STREET Owner Name: BURKE, THOMAS D FAITH A BURKE Owner Address: 719 JOHNSON STREET City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 7 - 7 Land Area: 1.02 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 1365 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 374,500 347,300 Building Value: 148,700 122,400 Land Value: 225,800 224,900 Market Land Value: 225,800 Chanter Land Value: http://csc-ma.us/PROPAPP/display.do?linkId=1513187&town=NandoverPubAcc 6/14/2010 i Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key v l� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 719 Johnson Street Property Address Faith Burke Owner's Name North Andover City/Town MA 01845 State Zip Code 6/12/2010 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Neil J. Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover Cityfrown 978-475-4786 Telephone Number B. Certification Ma State SI15 License Number 01810 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspector'signature 6/12/2010 Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins - 09/08 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 1 of 17 `qtr R Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 719 Johnson Street Property Address Faith Burke Owner's Name North Andover MA 01845 6/12/2010 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: After permit from B.O.H., install new outlet tee with gas baffle, inspection from B.O.H., septic system now passes Title 5 Inspection. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins - 09/08 Title 5 Official Inspection Fonn: Subsurface Sewage Disposal System - Page 2 of 17 Commonwealth of Massachusetts tipCity/Town of RECEIVED System Pumping Record Form 4 mlN 16 2014 MAN OF NORTH ANDOVFA DEP has provided this form for use -by local Boards of Health. Other fomes "a' a s;�b e information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/ Right front of house, Left/ Right near of house, Left / ght side of hous Left/ Right side of building, Left / Right front of building, Left / Right rear of building, Under ec c Address 17 19 "3 D City/Town Staten V 2. System Owner. Name Address (If different from location) City/Town ' B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ 4. Trp Code Stat ��Code Telephone Number ' 2. Quantity Pum Date Gallons Cesspool(s)D—S'eptic Tank El Tight Tank ❑ Other (describe): Effluent Tee Filter present?❑Yes 9 o If yes, was it cleaned? ❑ Yes ❑ Na 5. Condition of Sys_ ter�� � Q � •� � � `���/V� `.. 6. System Pumped By. Neil Bateson Name Bateson Enterprises Inc - Company 7. Locati ere contents were disposed: GOO S. Lowell Waste Water F5821 Vehicle License Number Date t5fomu4.doc- 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusettsrib w City/Town of System Pumping Record JUN. Q 3'2013 Form 4 TOWN OF NORTH ANDOVER HEALTH D@RARTMENT DEP has provided this form for usel by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left / Right front of house, Left / Right rear of house, Left ht side of hous Left / Right side of building, Left / Right front of building, Left / Right rear of building, Un er Address '71/, City/Town 6 State 2. System Owner. Name Address (if different from location) Zip Code City/Town State de Telephone Number B. Pumping Record Date 2. Quantity Pumped Cesspool(s) Septic Tank 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 5. Conditio of system: 6. System Pumped By: Neil Bateson rA t5form4.doc• 06/03 Name Bateson Enterprises Inc Company are contents were disposed: Lowell Waste Water iule Ge-�' Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No F5821 Vehicle License Number Date System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts FRECEED City/Town of 2012 System Pumping RecordForm 4 ARTME T ANDOVER NORTH yY DEP has provided this formlor use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left / Right front of house, Left / Right rear of house, Le �ng;htsideof hous LeftRight side of building, Left / Right front of building, Left / Right rear of buildinder ec c Address City/Town Y Jo � State 2. System Owner. Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ Date Cesspool(s) Zip Code State _ � � �s�Code Telephone Number —;/2-. Qua ty Pumped Septic Tank l �� Gallons ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 2- No Ifes was it cleaned? Y E] Yes ❑ No 5. Conditio_ n of Sysrtem� 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Lo 'on re contents were disposed: rG.L S. Lowell Waste Water 0i t5form4.doc• 06/03 F5821 Vehicle License Number Date. System Pumping Recons • Page 1 of 1 NORTFr tfj-eo F6gN0 O �^ O'VQ_ CO[KICKIMKK K - PUBLIC HEALTH DEPARTMENT Community Development Division C'(FRTIFTCA�E Off' C09VL�1'LIATrCE As of: June 30, 2010 This is to cert that the individual subsurface disposa(system received a S,4TISTACTORT lYST EC` IOY of the: W?p&cement of a Component: Bafffe Tor an On Site Sewage oisposaCS,ystem 0y: ToddBateson t• 719 hnson Street Wap --038.0; Tarcef-0072 NortkAncfover, WA 01845 The Issuance of this certificate shaft not be construed as a guarantee that the system will function satisfactorily. Susan T Sawy6r, RE-- l Pu6fic Y[ealth lDirector 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 918.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com t%ORTM D� 4-t 10 16 N,, '16 O F. 70 LAKI * K SAC PUBLIC HEALTH DEPARTMENT Community Development Division CE1271FICA`I�E OAF CO���IANCYE As of: June 30, 2010 This is to cert that the individuaf subsurface disposafsystem received a S TjSTAC`I'0l22'INSTEC` T0X of the: ft&cement of a Component: �a Tor an On Site Sewage 1DisposaCSystem By. ToddBateson t• 719 hnson Street 9Kap-038.0; Tarcef-0072 NortFiAndaver, 90 01845 The Issuance of this certificate shaff not be construed as a guarantee that the system wiff function satisfactorily. Adan T Sawyr, E, Pu6fic Ifeafth Director 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com t� F TOWN OF NORTH ANDOVER f NORTH O 1teo 6'91r Office of COMMUNITY DEVELOPMENT AND SERVICES or HEALTH DEPARTMENT A 1600 OSGOOD STREET; Building 2-36 NORTH ANDOVER, MASSACHUSETTS 01845 '"Ssac►i�sFt`h Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX ONSITE WASTEWATER SYSTENr�) STRUCTI ON NOTES LOCATION INFORMATION ADDRESS: j9 �n�� MAP: LOT: INSTALLER: >7 ` DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: SEPTIC TANK ❑Existin se tic tank property aba ones ❑Internal plumbing all to one building sewer ❑Topography not appreciably altered ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading Monolithic construction ❑ Water tightness of tank has been achieved (Visual or Vacuum Test or Water held for 24hrs) ❑ Inlet tee installed, centered under access port ❑ Outlet tee (gas baffle or effluent filter) installed, centered under access port ❑ 24" 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 Wastewater System Documentation — Feb 2006 Page 1 of 6 ADVANCED TREATMENT TECHNOLOGY ❑ ' Type of treatment device: ❑ Installed per manufacturers requirements ❑ All components working in accordance with manufacturer's requirements Comments: Wastewater System Documentation — Feb 2006 Page 2 of 6 t ,i TOWN OF NORTH ANDOVER E NaRrk O tTao a'9'4 Office of COMMUNITY DEVELOPMENT AND SERVICES 3� b` ,. • `° °o� HEALTH DEPARTMENT10 to «_ 1600 OSGOOD STREET; Building 2-36 "� ^�, .K...::. NORTH ANDOVER, MASSACHUSETTS 01845 �'"SsacHusEt`h Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public -Health Director 978.688.8476 — FAX Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ Combo Tank installed. Size: ❑ 1000 gallon Pump Chamber installed H-10 loading Monolithic construction) ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ . 24" inch cover to within 6" of final grade installed over pump access port ❑ Water tightness of tank has been achieved Visual testing ❑ Hydraulic cement around inlet & outlet Comments: ADVANCED TREATMENT TECHNOLOGY ❑ ' Type of treatment device: ❑ Installed per manufacturers requirements ❑ All components working in accordance with manufacturer's requirements Comments: Wastewater System Documentation — Feb 2006 Page 2 of 6 r• TOWN OF NORTH ANDOVER f NORT{{ O Rt�ao i6 AN Office of COMMUNITY DEVELOPMENT AND SERVICES°O, HEALTH DEPARTMENT A 1600 OSGOOD STREET; Building 2-36 4, -"« NORTH ANDOVER, MASSACHUSETTS 01845CH sNCHUs Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 - FAX D -BOX Comments: SOIL ABSORPTION SYSTEM Comments: Installed on stable stone base Inlet tee (if pumped or >0.087foot) Hydraulic cement around inlet & outlets Observed even distribution Speed levelers provided (not required) 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 Laterals vented if impervious material above Orifices @ 5 & 7 o'clock positions Gravel -less 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 Wastewater System Documentation — Feb 2006 Page 3 of 6 t i TOWN OF NORTH ANDOVER °f NORTH q Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT o . p 1600 OSGOOD STREET; Building 2-36 NORTH ANDOVER, MASSACHUSETTS 01845 �qss acNuB� Susan Y. Sawver, REHS/RS 978.688.9540 —Phone Public Health Director 978.688.8476 — FAX 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: 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: Wastewater System Documentation — Feb 2006 Page 4 of 6 i TOWN OF NORTH ANDOVER Q NORTH Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT A 1600 OSGOOD STREET; Building 2-36 NORTH ANDOVER MASSACHUSETTS 01845 SNGHUSB Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Wastewater System Documentation — Feb 2006 . Page 5 of 6 Tank SAS Sewer ❑ Property line 10 10 -- ❑ Cellar wall 10 20 ❑ Inground pool 10 20 -- ❑ Slab foundation 10 10 -- ❑ Deck, on footings, etc 5 10 -- ❑ Waterline 10 10 101 ❑ Private drinking well 75 1002 50 ❑ Irrigation well 75 100 ❑ Surface Water 25 50 ❑ Bordering Vegetated Wetland , Salt Marsh, Inland / Coastal Bank' 75 100 ❑ Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ❑ Trib. to surface water supply 325 325 ❑ Public well 400 400 ❑ Interim Wellhead Prot. Area ❑ Reservoirs 400 400 ❑ Drains (wat. supply/trib.) 50 100 ❑ Drains (intercept g.w.) 25 50 ❑ Drains (Other) Foundation 10 (5) . 20 (10) ❑ Drywells 20 25 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Wastewater System Documentation — Feb 2006 . Page 5 of 6 TOWN OF NORTH ANDOVER °f joRTH q Office of COMMUNITY DEVELOPMENT AND SERVICES .HEALTH DEPARTMENT 0 014.A 1600 OSGOOD STREET; Building 2-36 NORTH ANDOVER MASSACHUSETTS 01845 cps "�"° � SNCHU$E Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 —FAX SYSTEM ELEVATIONS INVERT ON DESIGN PLAN FIELD INVERT ELEV. Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT 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 Wastewater System Documentation — Feb 2006 Page 6 of 6 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd -Bateson to (Repair -BAFFLE) an Individual Sewage Disposal System. at No 9 JOHNSON - 7_19 JOHN -SON. ------------------------------------------------------------------------------------------------------------------------------ as shown on the application for Disposal Works Construction Permit No. BHP -2010-060 Dated June 02, 2010 p ------LE-��-------------------- Issued On: Jun -02-2010 FIoard of Health wts�r� Map -Block -Lot Commonwealth of Massachusetts p- '� 1 Board of Health 038.00072 a ----------------------- 4 North Andover °�•=41®•�'`�` CERTIFICATE OF COMPLIANCE THIS IS TO CERTIFY,That the Individual Sewage Disposal System (Repair -BAFFLE) by Todd Bateson ---------------------------------- ------------------------------------------------ ---------------------------------------------------------------- Installer at No 719 JOHNSON STREET ----------------------------------------------------------------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. BHP -2010-060 Dated ___June 02,_2010 Printed On: Jun -14-2010 Board of Health of Massachusetts Map -Block -Lot QybtOoRriq �® Commonwealth 038.00072 q Board of Health ---------------------- Permit No - North Andover BHP -2010-0607 . + P.I. a96a+416 �aa'��, --- -------------- FEE '4cHu¢i F.I. $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd -Bateson to (Repair -BAFFLE) an Individual Sewage Disposal System. at No 9 JOHNSON - 7_19 JOHN -SON. ------------------------------------------------------------------------------------------------------------------------------ as shown on the application for Disposal Works Construction Permit No. BHP -2010-060 Dated June 02, 2010 p ------LE-��-------------------- Issued On: Jun -02-2010 FIoard of Health wts�r� Map -Block -Lot Commonwealth of Massachusetts p- '� 1 Board of Health 038.00072 a ----------------------- 4 North Andover °�•=41®•�'`�` CERTIFICATE OF COMPLIANCE THIS IS TO CERTIFY,That the Individual Sewage Disposal System (Repair -BAFFLE) by Todd Bateson ---------------------------------- ------------------------------------------------ ---------------------------------------------------------------- Installer at No 719 JOHNSON STREET ----------------------------------------------------------------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. BHP -2010-060 Dated ___June 02,_2010 Printed On: Jun -14-2010 Board of Health HORT4d •7 `+ r)}i 5 V 6 8 af,, �'e , NNS "•„/ O — 9 Town of North Andover HEALTH DEPARTMENT $AC NUSf CHECK #:�.J� DATE G 1.29 - LOCATION: ��% , it�l V1�`• H/O NAME: CONTRACTOR NAME: / d Type of Permit or License: (Check box) ❑ Animal $ i ❑ Body Art Establishment i $ ❑ Body Art Practitioner ❑ Dumpster ,r $ ❑ Food Service - Type: i $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobaccos 'r $ ❑ TrasWS'olid Waste Hauler $ ❑ W, Construction $ SEP 'it Systems: ❑ Septic -Soil Testing $ ❑ Septic -Design ApprovalG�/�� $ Ooo4eptic Disposal Works Construction (DWC) $ �� ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Application for Septic Disposal Svstem TODArS DATE AConstruction Permit -TOWN OF °°•', '�' ORTH .ANDOVER MA 01845 $ 250.00 — Full Repair �C $925.00 - Component Important: Application is hereby made for a permit to: When filling out forms on the — [] Construct a new on-site sewage disposal system* computer, use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key to move your epair or replace an existing system component — What? cursor - do not use the return key. A. Facility Information � , f �m�� � % �o �► n! Vii✓ 5 /- Address or Lot # Cityrrown -- 2.- *TYPE OF SEPTIC SYSTEM*: RCI ❑ Pump ❑ Gravity (choose one) If pump system, attach copy of electrical permit to application*** 'JUN�01� ❑ Conventional System (pipe and stone system) TOWN OF NORTH ANDOVER ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to in EA TWD U=NT ❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D -Box Present) S.A.S. 2. Owner Information f` �i F,4 v 1L -x �p' /Lo Name Address (d different from above) AS- Cityrrown State Zip Code Telephone Number 3. Installer Information Name Name of Com' any NC. ARGILLq ROAD Address —AD1810 [ Cdy/Town State Zip Code Telephone Number (Cell Phone # if possible please) Information 4. D7Address Name of Company State Zip CodFe— Te one Telephone Number (Best # to ftnh) Application for Disposal System Construction Permit - Page 1 of 2 SEPTIC SYSTEM. INSTAL ERPROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction' for the septic system if6r the property at: (Address of septic system) For plans by (Engineer) Relative to the.application of Ir0'TX--C fid(✓ (Installer's name) And dated ngina date). DatedZe o ay s dM)_ With revisions dated (Last revised date) I understand the following obligations for management of this project: 1. As the installer, I am .obligated to obtainall permits and Board of Health approved plans prior to performing any work on a 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 manager, or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall. be applicable. 3. As the. installer,: I am required to. have the necessary work completed prior to the .applicable inspections as indicated below I understand that requests ig n inst�ection without completion of the items in accordmo my eompan�. a Bottom of Bed_ Generally, this is the first (15) inspection unless. there is a retaining *a]l, which should be done;first. The installer must request the inspection but does not have to be present.; b: Final. Constructs ri Inspection -Engineer must first do thein inspection for elevations, ties, etc. As -built of verbal OK (or e-mail to: healtlideptownofnorthandover corn) from the engineer must be submitted to the Board of Health, after which installer .calls for an inspection time. Installer must be present for this_inspection,. With a pump system, all electrical work:.. st be ready and able to cause pump to work and alarm.to function. C ,Final Gtade - Installer must request inspection when'all grading is complete.. Installer does :not have to be on=site. 4. As the installer, I understand that only I may perform the work (other than simple excavation) and I am required to complete the installation of the system identified in the attached application for installation. ':I further :, understand: that work done by others ulilicensed to install �PnN. :;, M-1 A ; as c.V11J'L revocation or susuension -,P-- license to otierate in the Tow -- -- .---- ��..� ulvalvcu sins also OSSlble. 5.. As the.installer, I understand that I steps: .must be:on-site during the.performance of the following construction 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 ofHealth staffor consultant. d. Installation.oftank, D -Box, pipes, stone, vent, pump chamber, retaining waUand other components. 6. As the installer. I me of this obli tion. Undersigned Licensed Septic Installer: (Today's Date) lV -r r,yl • r : r°`rM Application.for Septic Disposal Svstem c •,t.. ,. +tio _ pC:onstruction -Permit " TOWN OF TODAY'S DATE * ��' ORTH ANDOVER, MA 01845 $ 250.00 - Full.Repair CNUS t� $125.00 - Component PAGE 2OF2 A. Facility -Information continued 5. Type of Building: 26sidenfial Dwelling or []Commercial B. Agreement /71 17 The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation until a Certificate of Compliance has bAissuthis Board of Health. Na Date Application proved By: �(fB�&d of Health Representative) Name -I c> Date Application Disapproved for the following reasons: For Office Use Only: I. 2. Fee Attached. Project Manager Obligation Form Attached. Yes f/ -- Yes v No No I Puma Svste ? Ifso; Attach cony ofElectrical Permit' Yes_ N ' 4. Foundation As -Built. (new construction ronly): (Same scale as approved plan) Yes No 5. Floor Plans? (new construction only). Yes_ No Application for Disposal System Construction Permit • Page 2 of 2 LOCATION: H/O NAME CONTRACT I 4802 Type of Permit or License: (Check box) t r t Ot MORTN 0 $ ❑ s Town of North Andover '�► �.+ a ' ,SSACNU`��t HEALTH DEPARTMENT CHECK #:,j ,,.�� DAVE: lo'll, LOCATION: H/O NAME CONTRACT I 4802 Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ' ❑ Body Art Practitioner $ ❑ Dunpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ 4,. ❑ Recreational Camp $ k is ❑ Sun tanning $ { ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ f SEPTIC Systems: y ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ k ❑ Septic Disposal Works Installers (DWI) $ ❑ Title,5Inspector $ 'Title Report $ �• ❑ Other: (Indicate) $ 4/Uv, Health Agent Initials White - Applicant Yellow -Health Pink - Treasurer Commonwealth of Massachusetts Title 5 Official Insp Subsurface Sewage Disposal System Form 719 Johnson Street 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 5/22/2010 Inspe4�s�,ture ✓ Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 ection Fo EIVE - Not for Voluntary Assessme is JUN -i p°filling Property Address W When filling out Thomas Burke forms on the Owner Owner's Name 1. Inspector: only the tab key information is required for North Andover MA 01845 5/22/2010 every page. City town State Zip Code Date of Inspection 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 5/22/2010 Inspe4�s�,ture ✓ Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 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. p°filling A. General Information W When filling out forms on the computer, use 1. Inspector: only the tab key to move your Neil J. Bateson cursor - do not use the return Name of Inspector key. Bateson Enterprises Inc. Company Name 111 AMilla Road Company Address Andover Ma 01810 /MMCitylrown State Zip Code 978-475-4786 SI15 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ®. Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5/22/2010 Inspe4�s�,ture ✓ Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 719 Johnson Street Property Address Thomas Burke Owner Owners Name information is required for North Andover MA 01845 every page. Cityrrown State Zip Code B. Certification (cont.) 5/22/2010 Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System, Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ® N ❑ ND (Explain below): t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Owner information is required for every page. t5ins • 09108 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 719 Johnson Street Property Address Thomas Burke Owner's Name North Andover MA 01845 5/22/2010 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ® Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): ❑ Y ® N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 719 Johnson Street Property Address Thomas Burke Owner's Name North Andover MA 01845 5/22/2010 City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Outlet tee corroded off in septic tank needs to be replaced. D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 719 Johnson Street Property Address Thomas Burke Owner Owner's Name nformation is required for North Andover MA 01845 5/22/2010 for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 i ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts _ Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 719 Johnson Street Property Address Thomas Burke Owner Owners Name information is required for North Andover MA 01845 5/22/2010 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): N/A Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): N/A t5ins • 09/08 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 6 of 17 Water meter readings, if available: t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 719 Johnson Street Property Address Thomas Burke Owner Owner's Name information is required for North Andover MA 01845 5/22/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 9 ( Y 9 (gPd))� Yes Detail: Sump pump? ® Yes ❑ No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts u . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments yr< 719 Johnson Street Property Address Thomas Burke Owner Owner's Name information is required for North Andover MA 01845 5/22/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: Date Pumped 2009, owner UII gallons Measured tank Inspect tank & tees ® Yes ❑ No ® 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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 719 Johnson Street Property Address Thomas Burke Owner information is required for every page. t5ins • 09108 Owner's Name North Andover MA 01845 5/22/2010 City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Tank original, d -box & SAS installed 6/30/1987, as built plan Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 2 feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" Cast iron thru wall, 4" Cast iron in house, no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 2 feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: Tx 4' Sludge depth: 5't ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 { Commonwealth of Massachusetts : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M y 719 Johnson Street Property Address Thomas Burke Owner Owner's Name information is required for North Andover MA 01845 5/22/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle N/A Outlet tee corroded off Scum thickness 5" Distance from top of scum to top of outlet tee or baffle 0 Distance from bottom of scum to bottom of outlet tee or baffle 0 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. Outlet tee corroded off. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): 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: t5ins • 09/08 Date 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 719 Johnson Street Property Address Thomas Burke Owner Owner's Name information is required for North Andover MA 01845 5/22/2010 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ' ❑ other (explain): Dimensions: Capacity: Design Flow: Alarm present: Alarm level: Date of last pumping: i gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins - osros Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 Owner information is required for every page. t5ins • 09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 719 Johnson Street Property Address Thomas Burke Owner's Name North Andover MA 01845 5/22/2010 Cityrrown 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 C 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 & distibution equal. Evidence of carryover. No evidence of leakage 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: Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 719 Johnson Street Property Address Thomas Burke Owner Owner's Name information is required for North Andover MA 01845 5/22/2010 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ 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. Camera inside of pits thru outlet in d -box , no liquid ti invert. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins - 09/08 Title 5 official Inspection form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 719 Johnson Street Property Address Thomas Burke Owner information is required for every page. t5ins • 09108 Owner's Name North Andover Citylrown MA 01845 State Zip Code 5/22/2010 Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 719 Johnson Street Property Address Thomas Burke Owner information is required for every page. t5ins • 09108 Owner's Name North Andover MA 01845 5/22/2010 Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately a Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 719 Johnson Street Property Address Thomas Burke Owner's Name North Andover MA 01845 5/22/2010 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >4 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database - explain: Essex County Soil Map, You must describe how you established the high ground water elevation: Essex County Soil Map, Sheet # 36, Windsor Soil Water > 6' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 09/08 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 719 Johnson Street Property Address Thomas Burke Owner Owner's Name information is required for North Andover MA 01845 5/22/2010 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 09108 ' Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 Commonwealth of Massachusetts Gity/Town of System Pumping rn.ping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be. substantially the same as that provided here. Before using this form, check with your local Board of Health tq determine the form they use. The System Pumping Record must be submitted to the local Board of Health or-ottxar approving authority. A. Facility Information 1. System Location: Left side of house �ea eft front of house, Right front of house, Left rear of house, Right rear of house. L. Right rear of building. Address r`] �^ q 1 City/Town 2. System Owner: m nc nuu,— vn unrerent from location) City%rown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ Other (describe) State State Telephone Number r Date 2. Quantity Pumped ❑ Cesspool(s)eptic Tank Zip Code Zip Code Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes j-40, If yes, was it cleaned? ❑ Yes ❑ No 5. Conditi n of System - d44 0C.) 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location ere contents were disposed: L.S.D Lowgll Waste Water Signature F5821 Vehicle License Number ._—<�--a —rc) Date C, t5form4.doc• 06103 System Pumping Record • Page 1 of 1 Summary Record,Card generated on 5/14/2010 3:02:35 PM by Karen Hanlon Town of North Andover Class 101 Single Family Size Total 1.02 Acres FY 2010 UB Mailing Index Name/Address BURKE, THOMAS 719 JOHNSON STREET N. ANDOVER, MA 01845 UB Account Maint Account No Cycle Bldg Id. 14359.0 - 719 JOHNSON STREET 2100364 02 Cycle 02 UB Services Maint. Account No. 2100364 Service Code MISCFEE ADMIN FEE WTR WATER UB Meter Maintenance Account No. 2100364 Tax Map # 210-038.0-0072-0000.0 Parcel Id 13154 719 JOHNSON STREET BURKE, THOMAS 719 JOHNSON STREET N. ANDOVER, MA 01845 Property Type Type Loan Number Active/Inact. From Payor Occupant Name Active/Inactive Last Billing Date 3/2/2010 Active Rate Charge Multiplier/Users 0.635/8 7.82 1/ 01 ALL METER SIZE 57.00 /1 Serial No 13242115 Status a Active Location ERT HH Brand Type Date Reading Code METE METE W Water 5/4/2010 514 a Actual Consumption Posted Date 2/2/2010 498 a Actual 16 11/2/2009 483 a Actual 15 3/11/2010 8/4/2009 469 a Actual 14 12/11/2009 5/5/2009 453 a Actual 16 9/11/2009 2/3/2009 438 a Actual 15 6/16/2009 11/4/2008 423 a Actual 15 3/16/2009 8/4/2008 409 a Actual 14 12/10/2008 5/2/2008 391 a Actual 18 9/12/2008 2/6/2008 378 a Actual 13 6/18/2008 11/2/2007 363 a Actual 15 3/14/2008 8/3/2007 345 a Actual 18 1/15/2008 5/4/2007 325 a Actual 20 9/14/2007 2/21/2007 313 a Actual 12 6/22/2007 11/1/2006 290 a Actual 23 3/23/2007 8/1/2006 263 a Actual 27 12/22/2006 5/3/2006 237 a Actual 26 9/13/2006 2/2/2006 212 a Actual 25 6/20/2006 11/2/2005 190 a Actual 22 3/13/2006 8/2/2005 5/5/2005 162 a Actual 28 12/14/2005 2/15/2005 124 a Actual 38 9/12/2005 11/1/2004 102 a Actual 22 6/8/2005 8/11/2004 74 a Actual 28 3/15/2005 5/17/2004 55 a Actual 19 12/17/2004 2/12/2004 33 a Actual 22 9/20/2004 8 c Correction 25 6/14/2004 27 4/16/2004 Size 0.63 0.63 Page 1 1 Residential Until YTD Cons 107 Variance 8% 5% -12% 7% 0% 8% -21% 27% -3% -21% -10% 32% -19% -30% 2% 4% 16% -21% -29% 53% 5% 14% -9% -3% -4% 0% TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: ✓� I_ vim' t YSTEM OWNER & ADDRESS 9 v( �-c-, r7c 9 (example: left front of house) �r S 1 ,-A-e k-ouae DATE OF PUMPING: Lr<-�(-UANTITY PUMPED C C.�-� GALLONS CESSPOOL: NO '----YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINEEMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) COMMENTS: . .s..,�-Tom.-,-..�x TOWN ©AR ®OF HEMI l r"89' 14 tUU1 CONTENTS TRANSFERRED TO: TOWN OF,,1,,.r�.r SYSTEM PUMPING RECORD DATE: - a7 CS SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) V- t� DATE OF PUMPING: lam n QUANTITY PUMPED: 6 06 G ONS CESSPOOL: NO YES -SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D\/_ Lowell Waste t'. a- - TOWN OF i_ zoos D _ SYSTEM PUMPING RECORDQT DATE:O� SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: <i a�a QUANTITY PUMPED: 1.00-0 GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE 2 EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: (-5---2-. L'U11ii�i-5101 LAULM!Lei.,Q.c.�lJ timmealth of NIassachuseltS , Massachusetts &stem EllllljHH9 t:eCUr 171 q �jc) Date of i'umpinp D' �- a Quantlt� Pumpeds t � C i Cesspool: '�o ,I' 1 es ❑ Rewir Tanl•' Kl- Yes So� - ' System Pumped by- --r 2License #: Contents iransferred lo::_____�_ Date Inspeclor GILBERT REA 44 Rea St. .740: ANDOVER, MA 01845 Phone 682.9864 JOB 1_9 Rid, SHEET NO. SHEET CALCULATED BY CHECKED BY DATE -7_ DATE SCALE `J 7 .. .._....,. .... . .',._. .. _.. ...... ...... ... ..... ....._..... _ .. . . ._......... :.. .. .. a I' _....._.. _ Y . ... :. _ .............. .. A_ ICSo 0 F Ucy wC(j3 h Sic I&� ....... .. . . . xis loci o . ......... .............. ........... ........ .... ....;. ..... . _. ........ Dc y c,)e I CCcvto7 '• ......... Y, I's ... _.. .. ;.. _ A s: .+_.O ........... ............... .... ... .. ... ... y-zz -�F7 719 4o6 h,-cc,�, lu� rr"e 6-rDe 2c, �cGrs old �Iou5e cv,r(am► � vngccvto►ed b w�S d jed azr) ► T- IeA�-S -2 7 <5 2 �_ S,re �/ pdwd U pre-wou5i Tk d y �, G'q'1'I�' HJT G i T"� S��Gi T 5v��c��d• We �(Drn• CJ.�� i Z�Goq� 1e P���d ovT V45 Y�Iv� Gc�� �� 1 h 7�e 3 � �� ,�� ( J o�►v� sevi � r - r ,�I� MUu$� ►• � � moi' l t .� `erg f t�� li TOWN OF NORTH ANDOVER;. MASSACHUSETTS OFFICE or CONSERVATION COMMISSION o ;{ NoRTN ti °,.'"• TELEPHONE 683-7105 . .. - �,SSACIIt15Et. PURSUANT TO THE AUTHORITY OF THE WETLANDS PROTECTION ACT, MASSACHUSETTS GENERAL LAWS CHAPTER 131, SECTION 40, AS AMENDED, AND THE TOWN OF NORTH ANDOVER'S WETLAND PROTECTION BYLAW, THE NORTH ANDOVER r CONSERVATION COMMISSION WILL HOLD A PUBLIC HEARING ON April ,1987 AT 8:00 P.M. AT THE TOWN BUILDING SELECTMEN'S MEETING ROOM, 120 MAIN STREET, NORTH ANDOVER, MA ON THE NOTICE OF INTENT OF CRESTWOOD REALTY TRUST T0_ALTER LAND AT Lot's '6 & 7 COTUIT.STREET FOR PURPOSES OF Construrting twn diiplexeg including int -grading and installation of water. sewor, 'end electrical services. r PLANS ARE AVAILABLE AT THE CONSERVATION COMMISSION OFFICE, TOWN BUILDING, 120 MAIN STREET, NORTH ANDOVER, MA ON WEEKDAYS, FROM 8:30 to 4:3.0 P.M. AND BY APPOINTMENT. BY: •GUILLERMO J. VICENS •CHAIRMAN, NACC RUN ONCE IN THE North Andover CitizenON cc: PLANNING BOARD BOARD OF HEALTH PUBLIC WORKS HIGHWAY DEPT. APPLICANT ENGINEER DEQE FIRE CHIEF Bldg., Insp} April 16, 1987 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec. 36 To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectmen Aj addresses Re: Insured: Property address: Policy No. o 9") Loss of Q — / 19 File or Claim No. 6AJ '/ Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass Gen. Laws, Ch. 139 Sec. 3B is appropriate please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Title: On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. Signature and date CLAIN889RVIC9 O/ Miw� .IMC. MASSACHUSETTS CONNECTICUT NEW HAMPSHIRE VERMONT MAINE Boston Lawrence Bridgeport Claremont Brattleboro Augusta Barnstable Pittsfield New London Gorham Burlington Lewiston Brockton - Salem No. Haven Laconia Montpelier Skowhegan Fall River Springfield Stamford Manchester White River Jct. S. Portland Fitchburg Worcester Waterbury Portsmouth W. Hartford RHODE ISLAND Pawtucket NEW YORK Utica Nosrh Ati►�VEI�, MA, WAT SS L.or PP�� CAIv I , Sc�PPL7 QR5wjj ❑ UJEU- AP oyCD C 5 P-rlC ,Sy STS PES16,J i APR�OVPJ6 AuTljoi? ry , BPAJPlTiOAJ5- t i q:a l f ,.1 UISQPPR� vED • ; DgiE i it DLjr- 7R_ Sfp-r(6 SY STEM W STA U-ATl OAJ -' YFX4V4T(o1J ),AJSPEGTiOA J FINAL lV5pFGrlonj 4 PPROVEP ' &P(TIOMAL. 1,\)5Fbc (otic�o►-�y) DISAPP)�O\J;D Rj�pSp tvs RV4L APPIZVAL DArC prrt�' 2-r-?? Comm nwealth of Massachusetts ass achuse Us system Pumping Record System Owner . f� L) Date of Pumping: Cesspool: No f° -t'' Yes System Location 71q TofAIL4-� Quantity Pumped: I�� gallons Septic Tank: No 1.] Yes System !lumped by: Ferredole 5rr& pu ed License # Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: TOWl9 V" r"IRTt�d ANDOVER/ BOARD OP HEALTH FAPR2 6 1999 Sher--Tood Homes lot 51 Johnson St. APPLICATION FOR SEWAGE DISPOSAL I16MLIATION HEALTH DEPARTMENT - NORTH ANDOVER, MASS. I hereby make application for a permit for a sewage disposal installation at int K, .rnnnson St. . I will install this system in ac- cordance with all the laws of the Commonwealth of Massachusetts and regulations of the Board of Health of the Town of North Andover. Further, I will construct the house sewer of bell and spigot pipe, the minimum diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre- ceding the septic tank, where the grade shall not exceed 21o. I will install a con- crete septic tank of loon g@3. in size. A manhole (s) permitting easy cleaning will be provided with removable cover (s) of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with 4 inch perforated or open jointed pipe and laid in a series of trenches, the bottom of which will pro- vide a minimum of poo lineal QOM) feet of effective absorption area. The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling the trench, 2 inches of gravel or stone.l/g" to 1/4" (dia.) will be placed over the course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single tile line will exceed 100 feet in length and in any case, two lines of tile will be installed. A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No part of the installation will be less than 100 feet from -any private water supply, 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. I further agree not to cover any portion of this installation until approved by the inspection officer, as provided below, and to incorporate any additional requirements that may be attached to the permit. Plot Plans must be submitted with application. DATE 11 /27/bl ignature of Applicant I hereby issue the above permit for a Board o Health of the Town of North Andover, Massachusetts. DATE 11/27/61 -1Y ignature of Health Agent I have inspected the uncovered system indicated above and find everything done as described. DATE f b Z. - Signature of 1 peeting Officer Percolation Testtt� �_� . C,ai Garbage Grinder No November 18, 1961 Miss Mary Sheridan R. N. Health'Agent Board of Health North Andover, Mass. Dear Miss Sheridan: 6 An examination was made as requested in order to determine the suitability of the soil for the subsurface disposal of sewage on the proposed Johnson Street, Lot #5, building site of Sherwood Homes, Inc. The land in general is high. The subsoil in the area was of clay content and an 8 -minute percolation test was conducted. It is recommended that a 1,000 gallon concrete septic tank be installed together with 200 lineal feet of drain pipe. WJD : hd Very truly yours, i i *iNo TOWN OF SYSTEM DATE:_ _q SYSTEM OWNER & ADDRESS PIPING RECORD BOARD car- HEs ,,�j" SYSTEM LOCATION (example: left front of house) �4 -61 DATE OF PUMPING: QUANTITY PUMPED : 1000 GAL NS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson ]Enterprises, Inc. COMMENTS: coNTENTs TRANsFERRED To: G.L.S.D V Lowell Waste BOARD OF H=H Ta7N CU KWH ANDOVER9 L�M. + . + 00 00 0 6,4L.Ifo 06,5�fr- P'Tsc 10 V, o 10 HAM DM 6 o 2o ADDRMS or() "-7 15' o o LOP 110. --6 -:C-/ 91 1rlOocFEMROor3 -.300 *emu 7000 60 00 40 GARM0 GRIMM we e e 0 a .1700 A .0 0 .5o SHM DMNSIONS OF HOUSE 60 ORM DISTANCE 07 - HODSE TO AM PRWEJUT LJIM 7, SHOW DILMIONS OF LN 0, SHOT LOCAT ION AND SIZE Cg illC T1+* G MWFOOL . 90 rM3 I=& ION AD DlS= 07 C symn- 10, SHOT LOCATION G? BROOM S-IM239 DMIMD MCROPO L. Uo SHM DRANO 0 VMIC TM 02 GSSF00I FROM HOMO FW4-8 LOCAL RIMUIMOM SKDULD E3 FCM C&qMMM9 Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 s important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. 4A jean RECEIVED 71 AUG - 12007 TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. Othdr fAdh&Tk0VJk-0�-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 Address �� C q n A . � s'1 f /j. Citylrown CJ v V State 2. System Owner: Name Address (if different from City/Town B. Pumping Record 7 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Date k� Zip Code Stat S� ,ode Telephone Number -3�� 2. Quantity Pumped: �� Gallons Cesspool(s) eptic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of v\ oF � qj (,eve,p `^ 6. Systep P meed By: Sia.. Name Vehicle License Number Company 7. Location contents were osed: Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 �M DEP has provided this form for use by local Boards of information must be substantially the same as that pro, local Board of Health tQ determine the form they use.1 the local Board of Health orottxer approving authority. `` ECEIVED SEP 2 8 2009 Oth.erfarM e.ped, but the '� rm, check with your eC umping Record must be submitted to A. Facility Information 1. System Location: Left side of hou , Ri ht side of Left front of house, Right front of house, Left rear of house, Right rear of house. Left rear of building. Right rear of building. Address Cityrrown State 2. System Owner: Name Address (if different from location) Cityrrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): G-J'c �"2 0�-' C-4AJ\� Zip Code Sta Z' C e ,!5_q'� Telephone neoh Number q-1r� -(D� Date 2. Quantity Pumped Cesspool(s) eptic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: `(\.cCJ� 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed.- Lowell isposed: Lowell Waste Water Signature of Hauler Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. VQIkA 1�1 Commonwealth of Massachusetts C4/Town of RECEIVED System Pumping Record UG 6008 2 Form 4 A 2 DEP has provided this form for use by local Boards of Health. Other famis�rrtla Nbd-'U§-butithe information must be substantially the same as that provided here. Before using this#orm, 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 1. System �Location: A— e Address 1-7 t 9 J Citylrown 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): State 6C --:K- k-�� Zip Code Stat Sod Telephone Number Date 2. Quantity Pumped: Gallons Cesspools)eptic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition Af System: a 6. System Pu By: Name vehide License Number Company 7. Location t5form4.doc- 06/03 System Pumping Record o Page 1 of 1 William F. Weld Govemor Argeo Paul Celluccl L!. G"mor ,R/ i0 IPI OF R U` Fir Commonwealth of Massachusetts `bo, 'RD 0' Executive Office of Environmental Affairs Department• of rt Environmental '. Protecti n f` i fY Trudy Coxe i E Secretery r s David S. Struhs Comminkw4r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: S©V\ � �iQ�-,AAddress of Ownet: Date of Inspection: _ j — (If different) Name of Inspector. `PS(� Company Name, Address and Telep one Number. I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on' my training and experience in the proper function and maintenance of on-site sews pose] systems. The system: Passes r _ Conditionally Passes r �} _ Needs Further Evaluation By the Local Approving Authority r F Inspector's Signature: )bates The System Inspector shall submit a copy of this inspection report to the Approving Authority, within thirty (30) days of completing this ' inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report tc the appropriate iegional oilice of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority,. INSPECTION SUMMARY: Check A, B; C, or D: A)SYSTEM 77 PA07. I have not found any information which indicates that the system violates any of the failure criteria as derined in 310. CMR 16.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or re inspection. p pair, passes Indicate yes,. no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not) The septic tank is metal, cracked, structurally unbound, shows substantial infiltration or exmtration, .or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11/03/95) f One Winter Street a Boston, Massachusetts 02108 .4 ' FAX (617) 656-1049 i Primed on Recycled paper e Telephone (617) 292.5500 i SUBSURFACE SEWAGE [119POtiAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 2_ Property Addreer.. `9 Soy\ • P A�klldo�. , , i • , " r Owner. S^ Dale of Inspection: ^t, _ � "�\ , 91 SYS TEM CONDITIONALLY PASSES (continued) .: Sewage backup or breakout or high static loafer level observed in the distribution box i@ due to broken or obstructed pipe(s) or due to a broken, settled cr uneven distribution box. The system will pass inspection if (with approval of the Board of Healtb): =e, _ broken pipe(s) are replaced -- obstruction is removed distribution box is levelled or replaced . The arstetn required pumping more than four times a year due to broken or obstructed pipe(@). The system will pass' im ection if (with approvai of the Board of Health): "r broken pipe(s) are 'replaced.: obstruction is removed = . C1 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 the public health,' satfet.y and the environment. 1) SYSTEM WILL PAS9 UNLESS BOARD OF IEF.ALTH DETERMINES THAT THE SYSTEM 19 NOT FUNCTIONINO IN A MANNER WHICH WILL PROTECT !'HE POBLEC HEALTH AND SAFETY AND THE ENVIRONMENT: r Y t. i — Ce@npool or privy *Withln 60 fent of • sttrfeas wAter t Cesspool or pricy- i's,vithiu 60 feet of a bordering vegetated ivetland or a salt marsh. x) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) UETRPMINF�q_ THAT 'I'HE SYSTEM 19 FUNCTIONING IN,A MANNER.TRAT PROTECT THE PUBLIC HEALTH AND SAIrSTY AND THE ENVIRONMENT: _ The system has a c-epiic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The ryst.em hos a septic tank and soil absorption syc'em and is within a Zone I of a public water svpplyTwell. The system has a septic tank and soil absorption system and is within 60 feet of a private water supply well. The sSstem line a septic tank and soil absorption system and is less than 100 feet but 60 feet or more from a private water eurpiv well, rales a well water analysis for coliform bacteria and volatile organic compounds indicates that the well 14 free from )x)UWion from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 6 ppm. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ` C CERTIFICATI/O1N (continued) Property Address: Owner. Date of Inspection: Y'" \�D • �1 c342� �d W D) SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 16.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. — Backup of sewage into facility or system component due to an 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. r Static liquid level in the distribution bot above outlet invert due to an overloaded or clogged SAS or cesspool, Liquid depth in cesspool is tees than 6" below invert or available 'volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). ' Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. i Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface.water supply. _,. Any portion of a cesspool or privy is within a Zone I of a public well ; < Any portion of a cesspool or privy is within 60 feet of A private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 60 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well .water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design Clow of 10,000 gpd or greater (Large System) and the system is a Yigniticant threat to public health and safety and the environment because one or more of the following conditions exist: 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 H of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 6.00 and 6.00. Please consult the local regional office of the Department for further information. . (revised 11/03/95) 3 • r` SUBSURFACE SEWAQE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST It jf Property Address Owner. Date of Inspeotfon -Check it th=Pump have been done: _g information was requested of the owner, occupant, and Board of Health — None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates d hat period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ass haus been e>,tRtnsd and examined. Nos B they srs not available with »/A _ e fa ' ' y or dwelling was inspected for signs of sewage back-up. _Z s m does not receive non -sanitary or industrial waste flow �.�temeedmponbnti, site, inspected for signs of breakout: /Allexcludin the Soil Abso tion S stets have been loca on the site. !# Absorption System, ted _ e septic tank manholes were uncovered, opened, and the interior of the septic tank vias inspected for condition of baffles or tees, ma ' of construction, dimensions, depth of liquid, depth of sludge, depth of scum. _ L:.xi! and location of the Soil Absorption System on the site has been determined based on existing information or aPP Y non -intrusive methods: r' :a t a xf _ e facility owner (and occupants; if different from owner) were provided with lntormation on the proper maintenance of Sub - Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART C Q SYSTEM INFORMATION Property Address: 9 O lJvJ1 �GV\ V 1 ; ►`' : `�r PJ�� Date of Inspection: RESIDENTIAL: __ ( Design flow: 30_gallons l l p I QCbW: Number of bedrooms: Number of current residents: oZ Garbage grinder (yes or no): _ Laundry connected to system (yes or no): -& 5 Seasonal use (yes or no): N© Water meter readings, if available: Last date of occupancy: C off`_P t,-� COM M ERCIAL/INDUSTRIAL: Type of establishment: Design flow:_jallona/day Grease trap present: (yes or.no)_ ; Industrial Waste Holding Tank present: (yes or no) Non -sanitary waste diacharged to the Title 5 system: (yes or no) Water meter readings, if available:_ i Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION 3 PUMPING RECORDS and source of information: Gc- lq System pumped as part of inspection: (yes or no) Qg If yes, volume pum*,: kyr O r alio Reason for P Pin B - _ 'f JCZ� �cc ve..�. �Q� hf h TYPE OF VY Septic tank/distribution boz/eoU absorption Q system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) APPROXI?4A.XE AGE �of�all co mp ngnts, date ins t ed kno ) and source of information: Sewage odors detected when arriving at the site: (yea or no) �d (revised 11/03/95) ti SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ` SYSTEM INFORMATION (continued) Property Address: �� QS(D\A. (\S' civ\ �� • (�1 ,QVP�� Date of Inepeotlon: �S L ou,cse- GU W Q� SEPTIC TANW (locate on site plan) �_ 4� doh 4 Depth below de: t ,I l QUA, C ( � [i''� �{ �� Svve�s1y P far a r^ L.J. Material of construction: �ncrete _metal _FRP _other(explain) /I it CZ) . — � - Q. Dimensions 1'7 ' X t-/ ' 'l t' P' d 3 • y (3 • YJ - ( y Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 14 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle:— 17 Comments: (recommendation for a inlet and outlet tees or i w+ M lnm�s M, r , relation.to outlet Q�r•.��e GREASE TRAP. -AD v� f (locate on site plan) Oil Depth below grade: Material of construction: _concrete _metal _FRP —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: fi Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner. c Date of Inspection: u \ Se, s a- q(o4 TIGHT OR HOLDING TANK:V)OV\() (locate on elite plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: > ; Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) ! ' r DISTRIBUTION BOX: C/ .(locate on site plan) Depth of. liquid level above outlet invert: v PUMP CHAMBER:TQW—t Wj 5 (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 6,S,, IE4 Aj, "(I Owner. Date of Inspection. SOIL ABSORPTION SYSTEM (SAS): (li to bit *it* plan, if possible; excavation not required, but may be approximated by non•intrusivd methods) If not determined to be present, explain: leaching pits, number: o+ s ' ovkv— Ux_.,r leaching chambers, number:_ S `� 16 leaching galleries, number: leaching trenches, number,length: leaching Gelds, number, dimensions: overflow cesspool, number: CESSPOOLS: �We " (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: i inflow (oesepool must be pumped as part of inspection) r Comments: (note condition of @oil, signs of hydraulic failure, level of ponding,_ condition of vegetation, etc.) PRIVY: no h� (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.) (revised 11/03/95) g l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner. Date of Inspection: U SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 5-�►=(' U -i-- S-� 3 A- Ac) D -v -x -;v ` (01,31" Q� .sy = a3 ' k, sz a = D3 �40S,3 � B- ` /3 IQ / ay' DEPTH TO GROUNDWATER Depth to groundwater -Hfeet mithod of determination or annm:ir 0 )4G vis Q cn (revised 11/03/95) 9 Commonwealth of Massachusetts City/Town of MAY 2 a 2010 System Pumping Record [NEWA OOF NORTHANDOVER wM Form 4 LTH DEPARTMENT 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 side of house; Cightjdeof hous eft front of house, Right front of house, Left rear of house, Right rear of house. Left rear of building. Right rear of building. Address M i � ,- e — � d �G� 1 ,t „ City/Town 2. System Owner: Name Address (if different from location) Citylrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): R-1.) State Zip Code State Zip Code 55 � Telephone Number -la Date 2. Quantity Pumped' Cesspool(s) 2-- tic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes �b If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: —,,P. i j,j , Lowell Waste Water of F5821 Vehicle License Number � Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts MAY Z5 [011 4 City/Town of System Pumping Record TOWN OF NORTH ANDOVER Y p g HEALTH DEPARTMENT Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left front of house, right front of house, left side of house ri side of house, eft rear of house, right rear of house, left side of building, right rear of building, under deck. City/Town 2. System Owner: 1 ) V` Name Address (if different from location) City/Town A �- State Zip Code State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping �+ �� j' p g Date 2. Quantity Pumped: 3. Type of system: ❑ Cesspool(s) M /Septic Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes d No 5. Condition of System: 6. System Pumped By: Neil J. Bateson Name Bateson Enterprises Inc. Company contents were disposed: M4 ti�)(96 Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No F5821 Vehicle License Number t5form4.doc• 06/03 System Pumping Record a Page 1 of 1 Location No. Date /</ '/-f N°"TM TOWN OF NORTH ANDOVER Ottt�o �,ti0 p? •• 1 e OA „ Certificate of Occupancy $ 41 ' Building/Frame Permit Fee $ +O�+no �� 4y ,SSACMUSEt Foundation Permit Fee $ Other Permit Fee $ "Y Sewer onnection Fee $ awonnection Fee $ 0ID j TOTAL $ 00� 30 to CIOs Building Inspector �• �� Div. Public Works Location ?M i -o1%A)S ©AJ-' No. `l Date /6/3 0 . kORTPI TOWN OF NORTH ANDOVER o p Certificate of Occupancy $ Building/Frame Permit Fee $ JACH Foundation Permit Fee $ _ Jam, ( f Other Pmit Fee $ d �onnectlon Fee $ Water Connection Fee $ PID 0 TS L z ) $ zo . �-- �Y' Building<nspector Div. Public Works • PE&� �tIT,NO. APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 W� KVO. LOT NO. I 2 RECORD OF OWNERSHIP iDATE BOOK 'PAGE ZONE SUB DIV. LOT NO.I LOCATION O/ / S Q /v T o =A I D PURPOSE OF BUILDING /�/�'u/ I? a d- UE rte! FV OWNER' . " AME �g i d vi!F p NO. OF STORIES SIZE OWNW ADDRESS Gl D S 1 BASEMENT OR SLAB ARCHITECT'S NAME l SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME �o(� �-7. SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES — SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR F E E t--` I w (/ I.J L- 1 PERMIT GRANTED / 3 d 19 f- 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST EST. BLDG. COST PER SQ. FT. EST. BLDG. 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