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Home My WebLink AboutMiscellaneous - 72 WINDSOR LANE 4/30/2018 (2)North Andover Board of Assessors Public Access Page 1 of 1 µORTy P, -A Return to the Home page click on logo New Search Sales Summary Residence Detached Structure Condo Commercial Comparable Sales • S. • 1 a a • • • _ li4 A82 KA==l - - It Parcel ID: 210/106.D-0070-0000.0 SKETCH Click on Sketch to Enlarge 14 Property Record Card Community: North Andover PHOTO Click on Photo to Enlarge 72 WINDSOR LANE Location: 72 WINDSOR LANE Owner Name: POLIZZOTTI, LOUIS L SUSAN POLIZZOTTI Owner Address: 72 WINDSOR LANE City: NORTH ANDOVER State: MA ZIP: 01845 Neighborhood: 6 - 6 Land Area: 1.01 acres Use Code: 101 - SNGL-FAM-RES Total Finished Area: 2464 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 509,400 543,300 Building Value: 300,700 312,400 Land Value: 208,700 230,900 Market Land Value: 208,700 Chapter Land Value: LATEST SALE Sale Price: 266,000 Sale Date: 09/24/.1991 Arms Length Sale Code: Y -YES -VALID Grantor: STONE, PETER & JENNI Cert Doc: Book: 03321 Page: 0158 h� p://csc-ma.us/NandoverPubAcc/jsp/Home.jsp?Page=3&Linkld=1181691 1/22/2008 I A - FA E R G L,I- '7- D L/N� : �� isc� • 8s - D / //: �Ia' __,1.S v p �-/3• / SEP �/ C ¢/.} N/� . . ' P C:,,eCixon Professional Stormwater 00 Management System and Septic System Inspectors OFFICIAL TITLE V INSPECTION REPORT for the property located at 72 WINDSOR LANE NORTH ANDOVER, MASSACHUSETTS Prepared for: Matthew Carpenter 72 Windsor Lane North Andover, MA 01845 Prepared by: Scott P. Cameron, P.E. Mass Certified Title V System Inspector # 12345 Cameron Site Inspection, Inc. P.O. Box 262 Middleton, MA 01949 P: (781) 520-9496 MARCH 18, 2014 CSI Job No.2014-001 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. t� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Windsor Lane Property Address Matthew Carpent Owner's Name North Andover Cityfrown MA 01845 March 17, 2014 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. A. General Information Inspector: Scott P. Cameron, PE Name of Inspector Cameron Site Inspection, Inc Company Name PO Box 262 Company Address Middleton City/town (781)520-9496 Telephone Number B. Certification MA State S112345 License Number 01949 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 ❑ NeedArther Evalua# on by the Local Approving Authority -3 lip 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 R Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,b 72 Windsor Lane Property Address Matthew Carpenter Owner Owner's Name information is required for every North Andover MA 01845 March 17 2014 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: . ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System in good functioning condition, current owner has regularly maintained. New Distribution Box. System Conditionally Passes: e or more system components as described in the "Conditional Pass" section need to be repFaw,d or repaired. The system, upon completion of the replacement or repair, as approved by the Boa f Health, will pass. Check the box for ", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please ex n. The septic tank is metal and o 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltrXQn or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replace ith a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is strually sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 year Id is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 3113 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 72 Windsor Lane Property Address Matthew Carpenter Owner Owner's Name information is required for every North Andover MA 01845 March 17, 2014 page. City/Town State Zip Code Date of Inspection B.. Certification (cont.) Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if \Sumtem ps/alarms are repaired. B) Conditionally Passes (cont.): ❑ ObsenXtion of sewage backup or break out or high static water level in the distribution box due to brokeNr obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspe ion if (with approval of Board of Health): ❑ replaced broken\box ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruved ❑ Y ❑ N ❑ ND (Explain below): ❑ distribueveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 tim system will pass inspection if (with approval of ❑ broken pipe(s) are replaced ❑ obstruction is removed a year due to broken or obstructed pipe(s). The Krd of Health): ❑ N ❑ ND (Explain below): ❑ Y N�] 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 ord 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 31 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect pu is 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Commonwealth of Massachusetts .1190001 Title 5 Official Inspection Form lo Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 72 Windsor Lane Property Address Matthew Carpenter Owner Owner's Name information is required for every North Andover MA 01845 March 17, 2014 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, sWety and environment: ❑ Th system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet surface water supply or tributary to a surface water supply. ❑ The syst has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic to and SAS and the SAS is less than 100 feet but 50 feet or more from a private water sup well**. Method used to determine distan ** This system passes if the well water analysis, erformed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence< ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure cri is are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts 1 11 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Windsor Lane Property Address Matthew Carpenter Owner Owners Name information is North Andover MA 01845 March 17 2014 required for every , page. City(rown 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. Ie Systems: To be considered a large system the system must serve a facility with a an flow of 10,000 gpd to 15,000 gpd. For large sys you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section Yes No ❑ ❑ the system is within feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive a (Interim Wellhead Protection Area — IW or a mapped Zone II of a public wa upply well If you have answered "yes" to any question in Section E the system is considere i nificant threat, or answered "yes" in Section D above the large system has failed. The owner or opera any large system considered a significant threat under Section E or failed under Section D shall upgra system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Windsor Lane Property Address Matthew Carpenter Owner Owner's Name information is required for every North Andover MA 01845 March 17, 2014 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 t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Windsor Lane Property Address Matthew Carpenter Owner Owner's Name information is required for every North Andover MA 01845 March 17, 2014 page_ Cityrrown State Zip Code Date of Inspection D. System Information Description: Grease trap present? Industrial waste holding tank present? ❑ Yes ❑ No ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ No Water meter readings, if available: t5ins • 3/13 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection Yes ® No information in this report.) Laundry system inspected? �� Yes ❑ No �5 Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 49 GPD Detail: Based on actual water readings 2/3/14 to 5/2/12 Sump pump? ❑ Yes ❑ No Last date of occupancy: Date merciaUlndustrial Flow Conditions: Type of Establish Design flow (based on 310 CM 03): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc. . Grease trap present? Industrial waste holding tank present? ❑ Yes ❑ No ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ No Water meter readings, if available: t5ins • 3/13 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 72 Windsor Lane Property Address Matthew Carpenter Owner Owner's Name information is required for every North Andover MA 01845 page. City/town State Zip Code 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 March 17, 2014 Date of Inspection Board of Health - Last Pump 11/6/12 - 1,500 Gal not pumped gallons not pumped not pumped ❑ 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): t51ns • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Windsor Lane Property Address Matthew Carpenter Owner Owner's Name information is required for every North Andover MA 01845 March 17 2014 page. City/rown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 28 y/o - 8/2/86 Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: ® cast iron ® 40 PVC ❑ other (explain): Distance from rivate water su I well or suction line ❑ Yes ® No 18" feet cast iron in dwellino. PVC at tank +30' to Water Service F pp y feet Comments (on condition of joints, venting, evidence of leakage, etc.): Sewer in good condition, no evidence of cracks, leaks within the dwelling. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal An feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: not metal years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ® No Dimensions: 10'-6" x 5'-2" x 5'-0" Sludge depth: t5ins • 3/13 <6,. 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 D. System Information (cont.) Septic Tank (cont.) RA 01845 Zip Code Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle 15" <1" 6" Distance from bottom of scum to bottom of outlet tee or baffle 20" March 17, 2014 Date of Inspection How were dimensions determined? slude judge, ruler and measuring stick 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 in good condition, baffle secure and typical for a 28 y/o tank, inlet secure. (locate on site plan): Depth below Material of construction: ❑ concrete El metal ❑fiberglass 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: t5ins • 3113 feet ❑ polyethylene ❑ other (explain): Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17 72 Windsor Lane Property Address Matthew Carpenter Owner Owner's Name information is required for every North Andover page. Cityrrown D. System Information (cont.) Septic Tank (cont.) RA 01845 Zip Code Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle 15" <1" 6" Distance from bottom of scum to bottom of outlet tee or baffle 20" March 17, 2014 Date of Inspection How were dimensions determined? slude judge, ruler and measuring stick 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 in good condition, baffle secure and typical for a 28 y/o tank, inlet secure. (locate on site plan): Depth below Material of construction: ❑ concrete El metal ❑fiberglass 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: t5ins • 3113 feet ❑ polyethylene ❑ other (explain): 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 72 Windsor Lane MA 01845 March 17, 2014 State Zip Code Date of Inspection D. System Information (cont.) CoTments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liqui evels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (t k must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Property Address Capacity: Matthew Carpe Owner Owner's Name information is required for every North Andover page. City/Town MA 01845 March 17, 2014 State Zip Code Date of Inspection D. System Information (cont.) CoTments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liqui evels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (t k 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: Xglons Design Flow: Alarm present: ❑ Yes Alarm level: Alarm in Date of last pumping: Date Comments (condition of alarm and float switches, etc.): day ,,,❑No order: ❑ Yes ❑ No * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 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 72 Windsor Lane Property Address Matthew Carpenter Owner's Name North Andover MA 01845 March 17, 2014 City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D -box replaced as part of inspection. Approximately 42" deep. Concrete risers added to within 6" of finished grade. Flow equalizers added. Plenty of slope on d -box outlets to field. Chamber (locate on site plan): Pumps in working Alarms in working order: Comments (note condition of pump chamber, ❑ Yes ❑ No* ❑ Yes ❑ No* of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass_ Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 3113 Title 5 Official Inspection 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 72 Windsor Lane Property Address Matthew Carpenter Owner Owner's Name information is required for every North Andover MA 01845 March 17, 2014 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 3 @ 53' 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.): Field located at top of small hill. No evidence of breakout or hydraulic failure on the ground surface (snow cover during inspection, no melted snow or irregularities observed). Excavated test hole at d - box. No standing/weeping water encountered at field. Trench dimensions obtained from system plan of record indicate at least 4' wide x 30" deep trenches. Soil is moderately well drained, 20 minute per inch rate according to design plan of record. (cesspool must be pumped as part of inspection) (locate on site plan): Number and Depth — top of liquid to inlet Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No l5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y� 72 Windsor Lane Property Address Matthew Carpenter owner Owner's Name information is required for every North Andover MA 01845 March 17, 2014 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) (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 failur level of ponding, condition of vegetation, etc.): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Windsor Lane Property Address Matthew Carpenter Owner Owner's Name information is required for every North Andover MA 01845 March 17, 2014 page. 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 C TAMC tN 4.1.6` -- Ib.b' TANr, otrt- D- 430 K 60 .S � 4q .�.' •- a-6oX o '15AIA ou t o TMMC t N C r #?2 �, r 3� r w � r q r r \A1i'.LJ'D5z>V, L -ANE NAT- To SCALE t5ins - 3/13 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 72 Windsor Lane Property Address Matthew Carpe Owner's Name North Andover CitylTown D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: nnn n1 RAR OLOLU uN %,vuc At least 6' feet March 17, 2014 Date of Inspection Please indicate all methods used to determine the high ground water elevation: /1 a ❑0 Obtained from system design plans on record If checked, date of design plan reviewed 5/14/86 Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Observed leaching field at top of small hill. Nearest estimated groundwater observation in detention pond in rear of parcel, at least 10' below bottom of system. Also checked system design plan which indicates a seasonal groundwater elevation of 140.00. System As -Built (8/2/86) assuming 30" of stone per design plan, bottom of lowest trench elevation 146.00. Also excavated near d -box. No water observed. No evidence of water in basement, it was observed to be dry and homeowner reports no history of water. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 72 Windsor Lane Property Address Matthew Carpenter Owner Owner's Name information is required for every North Andover MA 01845 March 17, 2014 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 `SSP txon E 14 C� �Man IPand Septic S Water Usage Calculation Address: 72 Windsor Lane North Andover, MA 01845 Proj. No.: 2014-001 Date: March 18, 2014 Meter Days Between Average Date Reading Readings Usage per Day (GPD) 2/3/2014 648 94 51.6 11/1/2013 632 87 54.3 8/6/2013 611 97 47.1 5/1/2013 591 86 51.4 2/4/2013 572 97 44.1 10/30/2012 549 90 45.6 8/1/2012 528 91 43.4 5/2/2012 501 Average 49.0 Summary Record Card generated on 2/14/2014 8:54:20 AM by Karen Hanlon Town of North Andover Tax Map # 210-106.D-0070-0000.0 Parcel Id 17827 72 WINDSOR LANE MATTHEW & MONICA CARPENTER 72 WINDSOR LANE NORTH ANDOVER, MA 01845 Page 1 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.01 Acres FY 2014 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until MATTHEW & MONICA CARPENTER Owner 72 WINDSOR LANE NORTH ANDOVER, MA 01845 POLIZZOTTI, LOUIS Previous Customer Inactive 2/15/2008 72 WINDSOR LANE N. ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant.Name Active/Inactive Bldg Id. 13417.0 - 72 WINDSOR LANE Last Billing Date 12/16/2013 2100062 02 Cycle 02 Active UB Services Maint. Account No. 2100062 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0,635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 81.55 /1 UB Meter Maintenance Account No. 2100062 Serial No Status Location Brand Type Size YTD Cons 32707583 a Active ERT HH b Badger w Water 0.63 0.63 508 Date Reading Code Consumption Posted Date Variance 2/3/2014 648 a Actual 16 -29% 11/1/2013 632 a Actual 21 12/20/2013 17% 8/6/2013 611 a Actual 20 9/18/2013 -7% 5/1/2013 591 a Actual 19 6/18/2013 -7% 2/4/2013 572 a Actual 23 3/13/2013 2% 10/30/2012 549 a Actual 21 12/13/2012 -21% 8/1/2012 528 a Actual 27 9/26/2012 -10% 5/2/2012 501 a Actual 30 6/20/2012 12% 2/1/2012 471 a Actual 27 3/14/2012 9% 11/1/2011 444 a Actual 24 12/15/2011 4% 8/4/2011 420 a Actual 24 9/14/2011 0% 5/3/2011 396 a Actual 22 6/13/2011 48% 2/7/2011 374 a Actual 17 3/15/2011 -19% 11/2/2010 357 a Actual 20 12/13/2010 -31% 8/2/2010 337 a Actual 28 9/13/2010 16% 5/5/2010 309 a Actual 25 6/9/2010 8% 2/2/2010 284 a Actual 23 3/11/2010 -27% 11/3/2009 261 aActual 31 12/11/2009 69% 8/6/2009 230 aActual 20 9/11/2009 -21% 5/1/2009 210 a Actual 23 6/16/2009 6% 2/2/2009 187 a Actual 22 3/16/2009 26% 11/5/2008 165 a Actual 18 12/10/2008 -18% 8/5/2008 147 a Actual 23 9/12/2008 -21% 5/1/2008 124 a Actual 23 6/18/2008 282% 2/15/2008 101 f Final Bill 8 2/15/2008 -36% 11/6/2007 93 aActual 12 1/15/2008 -41% RECEIVED IVED L\- Commonwealth of Massachusetts CityfTown of N2V 046 2012 System Pumping Record NORTH ANDOV Rw,,0,,RTHMWVIM Form 4 HEALTH DEPARTMENT DEP has provided this form fqr 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 Heafth or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. A. Facility Information 1. System Location: I'll -) - , OC /<A I 'I Address City[Town 2. System Owner: Name State Zip Code Address (if different frost location) Cityfrown State Zip Code ` Telephone Number — B. Bumping Record 1. Date of Pumping- 2. Quantity Pumped: Date Daltons / 3. Type of system: CessPool(s) *6pbc.Tank [Q Tight Tanis rl Grease Trap Other (describe), 4. Effluent Tee Fifter present? des Ej No iff yes, was itcleaned?' es D No 5. Condition of System: 6. System Pumped By: Name , Vettrcte t tcense tlllrFtl�er company 7. Location where contents were disposed:. Sig Haul e Da.te Si lure of Receiving s^ac4i�Y _ Date: t5foeml.doc-03106 System Purnpir ;Record Page t of t COMMONWEALTH OF MASSACHUSETTS MASS.DEP It APPRQVED TITLE 5 SYSTEM INSPECTORc Scoff Cameron 14IQmberl Lane Middleton, MA 01949 S1345 413012014 PURSUANT THE GENERAL LAWS N n At 577 Main Street Hudson MA 01749 800-499-1682 FEB 2 5 2008 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT WIND RIVER ENVIRONMENTAL TITLE V OFFICIAL INSPECTION PROPERTY ADDRESS: 72 Windsor Lane, North Andover PROPERTY OWNER'S NAME: Louis & Susan Poliaotti PROPERTY OWNERS ADDRESS: 72 Windsor Lane DATE OF INSPECTION: January 31, 2008 NAME OF INSPECTOR: Greg Fuller Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form w,y Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6115/2000. Inspection forms may not be altered in any way. A. Certification Important: When filling out 1. Property Information: forms on the computer, use 72 Windsor Lane only the tab key Property Address to move your Louis & Susan Polizzotti cursor - do not use the return Owner's Name key. 72 Windsor Lane Owner's Address North Andover City/Town Date of Inspection: 2. Inspector: Grea Fuller Name of Inspector Wind River Environmental Company Name 163 Western Ave Company Address Gloucester City/Town 978-282-7315 Telephone Number MA State 1/29/08 Date MA State 01845 Zip Code 01931 Zip Code 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails E]Aflends Furth�rEvaly�jajqn by the Local Approving Authority In p or' ature 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. 1.29.08_72WindsorLane_NorthAndover.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 1 of 16 t t Commonwealth of Massachusetts Title 5 Official Inspection Fora Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 72 Windsor Lane Property Address _North Andover MA 01845_ City/Town State Zip Code Louis & Susan Polizzotti 1/29/08 Owner's Name Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If "not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: 1.29.08_72WindsorLane_NorthAndover.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 72 Windsor Lane Property Address North Andover MA 01845 City/Town State Zip Code Louis & Susan Polizzotti 1/29/08 Owner's Name Date of Inspection 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 ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 1.29.08_72WindsorLane_NorthAndover.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts Title 5 Official Inspecti®n Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 4,M A. Certification (cont.) 72 Windsor Lane Property Address North Andover MA 01845 City/Town State Zip Code Louis _& Susan Polizzotti 1/29/08 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (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 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: 1.29.08_72WindsorLane_NorthAndover.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form _X Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 72 Windsor Lane Property Address North Andover MA 01845 Cityrrown State ZipCode Louis & Susan Polizzotti _ 1/29/08 _ Owner s Name Date of Inspection D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections:. Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® 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 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.] 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. 1.29.08_72WindsorLane_NorthAndover.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System < Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form a Not for Voluntary Assessments Subsurface Sewage Disposal System Form wM A. Certification (cont.) 72 Windsor Lane Property Address North Andover MA _01845 City/Town State Zip Code Louis & Susan Polizzotti 1/29/08 Owners Name Date of Inspection 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. 1.29.08 72WindsorLane NorthAndover.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form a Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M B. Checklist 72 Windsor Lane Property Address North Andover _ MA _ 01845 _ Cityrrown State Zip Code Louis & Susan Polizzotti 1/29/08 Owner's Name Date of Inspection 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(3)(b)) 1.29.08_72WindsorLane_NorthAndover.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection For Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information Yes 72 Windsor Lane No Property Address Yes North Andover MA 01845 Cityrrown st-ate Zip Code Louis & Susan Polizzotti 1/29/08 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Last date of occupancy/use: Other (describe): 1.29.08 72WindsorLane NorthAndover.doc • 11/2004 A A!1 1) ❑ Yes ® No ❑ Yes ® No ® Yes ❑ No ❑ Yes ® No see attached ❑ Yes ® No current Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M C. System Information (cont.) 72 Windsor Lane Property Address — -- North Andover _ MA_ 01845 City/Town State Zip Code __ Louis & Susan Polizzotti 1/29/08 Owner's Name Date of Inspection Pumping Records: Source of information: General Information owner Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: 1500 gallons truck/ measured ® Yes ❑ No to check the tank's structural integrity ® 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: 8/2/86 Were sewage odors detected when arriving at the site? ❑ Yes ® No 1.29.08_72WindsorLane_NorthAndover.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form a Not for Voluntary Assessments ^� Subsurface Sewage Disposal System Form C. System Information (cont.) 72 Windsor Lane Property Address North Andover MA 01845 City/Town State Zip Code Louis & Susan Polizzotti 1/29/08 _ Owner's Name Date of Inspection Building Sewer (locate on site plan): Depth below grade: 6"feet Material of construction: ® cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good clean joints. Good venting. No evidence of leakage Septic Tank (locate on site plan): Depth below grade: 1 6 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ❑ No certificate) Dimensions: 10'6" x 5'8" x 5'8" Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle 12 Scum thickness 3" 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 20 How were dimensions determined? Sludge judge, Rod, Ruler 1.29.08_72WindsorLane_NorthAndover.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 72 Windsor Lane Property Address North Andover MA 01845 Cityrrown State Zip Code Louis & Susan Polizzotti _ _ 1/29/0_8 _ Owner's Name Date of Inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Service annually. Inlet and outlet baffles in good condition. Liquid level at 0 to outlet invert. No evidence of leakage. Tank is structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑. polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 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): 1.29.08_72WindsorLane_NorthAndover.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 72 Windsor Lane Property Address North Andover MA 01845 City/Town State Zip Code Louis & Susan Polizzotti 1/29/08 Owner's Name Date of Inspection Tight or Holding Tank (cont.) Dimensions: Capacity: Design Flow: Alarm present: Alarm level: Date of last pumping: gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date Comments (condition of alarm and float switches, etc.): Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D -Box is level and distribution is equal. No evidence of leakage. Minimal solid carryover. Pump Chamber (locate on site plan): Pumps in working order: Alarms in working order: ❑ Yes ❑ No ❑ Yes ❑ No 1.29.08_72WindsorLane_NorthAndover.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspecti®n Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 72 Windsor Lane Property Address North Andover MA 01845 City/Town State Zip Code Louis & Susan Polizzotti 1/29/08 Owner's Name Date of Inspection 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: Type: ❑ leaching pits ❑ leaching chambers ❑ leaching galleries ❑ leaching trenches ® leaching fields ❑ overflow cesspool ❑ innovative/alternative system Type/name of technology: number: number: number: number, length: number, dimensions: number: 1 @ 20'x25' Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil is clean and dry. No signs of hydraulic failure. Normal vegetation. 1.29.08_72WindsorLane_NorthAndover.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form a Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 72 Windsor Lane Property Address North Andover MA 01845 City/Town State Zip Code Louis & Susan Polizzotti 1/29/08 _ Owner's Name Date of Inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): 1.29.08_72WindsorLane_NorthAndover.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspecti®n Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 72 Windsor Lane Property Address ----- North Andover MA 01845 _ City/Town State Zip Code Louis _& Susan Polizzotti 1/29/08 Owner's Name Date of Inspection 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. Atop=21' EtoA=61' BtoD=27' CtoD=35' 1.29.08_72WindsorLane_NorthAndover.doc • 11/2004 EtoB=EE' EtoC=69' C=9'9" bg A&B=2'bg Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 15 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments w Subsurface Sewage Disposal System Form C. System Information (cont.) 72 Windsor Lane Property Address North Andover _ MA 0184_5 City/Town State Zip Code Louis & Susan Polizzotti 1/29/08 Owner's Name Date of Inspection Site Exam: Slope yes Surface water no Check cellar yes Shallow wells no Estimated depth to ground water: 41+ 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: 8/2/86 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: maps You must describe how you established the high ground water elevation: Listed on plans as 51" to 54". Checked abutting properties and accessed us s website maps of area. 1.29.08_72WindsorLane_NorthAndover.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 16 of 16 MAKE PAYMENTS TO %0 Billing NDRTy 12/14/2005 •": '�."°D� TOWN OF NORTH ANDOVER Information ° 120 MAIN STREET (978)688-9550 Reading Information ' NORTH ANDOVER MA 01845 �S��CH115 S�9 978-688-9550 (978)688-9570 OFFICE HOURS Mon to Fri. 8:30am to 4:30pm RETAIN THIS PORTION FOR YOUR RECORDS MOVING? PLEASE CALL 978-688-9570 IXi POLIZZOTTI, LOUIS 72 WINDSOR LANE N. ANDOVER, MA 01845 ;Prevtnz.ous urrent Consumption Nb of z Reading X Reading Days 4, y WATER USAGE K IO`O! 11/3/05 '_388 2397 9 Actual 85 MESSAGE w ON OR BEFORE 01/13/06 ,► $38.33 ACCOUNT:NO ,,, , N BILI ING DATE 2100062-416704929 12/14/2005 -� SER�IC,I✓ DAT'ES,.� ,;AUE DATE: 9/1/2005 - 11/30/2005 01/13/06 1 72 WINDSOR LANE I Payments Through 12/14/2005 Adjustments / Late Charges Interest as of: 1/13/2006 Balance Forward WATER ADMIN FEE E Sub -Total Total (75.62) rani int 30.51 7.82 38.33 PAYMENTS SHOULD BE MADE: TOWN HALL C 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX C P.O. BOX 184, MEDFORD, MA 02155 Water rate: First 20 units@ $3.39 Over 20 units $5.30 Sewer rate: First 20 units @ $3.81 Over 20 units a $5.49 Bypass Meter Water rate: all units (a), $5.30 YMENTS TO RETAIN THIS PORTION FOR YOUR RECORDS MOVING? PLEASE CALL 978-688-9570 IN ADVANCE POLIZZOTTI, LOUIS 72 WINDSOR LANE N. ANDOVER, MA 01845 w UTIQ ON OR BEFORE 04/12/06 , $55.28 ' ACOUNTnN OfB%ILT TNG DATE , Billing 3/13/2006 TOWN OF NORTH ANDOVER Information (978)688-9550 120 MAIN STREET Reading Information TR BA, "ION ` HTS' RiOD � a fi,AMOUNT�; NORTH ANDOVER MA 01845 Payments Through 03/13/2006 (38.33) ;gv 978-688-9550 (978)688-9570 tt OFFICE HOURS Mon to Fri. 8:30am to 4:30pm RETAIN THIS PORTION FOR YOUR RECORDS MOVING? PLEASE CALL 978-688-9570 IN ADVANCE POLIZZOTTI, LOUIS 72 WINDSOR LANE N. ANDOVER, MA 01845 w UTIQ ON OR BEFORE 04/12/06 , $55.28 ' ACOUNTnN OfB%ILT TNG DATE , 2100062-416704929 3/13/2006 gn€ cs", "A ` a`SERICE"DA`rES k 12/1/2005 - 2/28/2006 04/12/06 r 72 WINDSOR LANE TR BA, "ION ` HTS' RiOD � a fi,AMOUNT�; Previous Balance 3 33 Payments Through 03/13/2006 (38.33) Adjustments / Late Charges - Interest as of: 4/12/2006 - Balance Forward - feV10U5 SR if CIf ✓yam rr v.'r a;: r Ear _ ?2?:.rax 1frent }3mal)Pt3l�rc zX. z ii ..,:.. 7Sa.4rP%I.;l ��. P...:.� � , , � nrtsx.. �,�� MAKE PAYMENTS TO B1LIJING DATE 2100062-416704929 6/20/2006 o TOWN OF NORTH ANDOVER x 120 MAIN STREET ' NORTH ANDOVER MA 01845 �S3AGWi1+ 978-688-9550 Billing Information (978)688-9550 Reading Information (978)688-9570 OFFICE HOURS Mon to Fri. 8:30am to 4:30pm RETAIN THIS PORTION FOR YOUR RECORDS MOVING? PLEASE CALL 978-688-9570 IN ADVANCE POLIZZOTTI, LOUIS 72 WINDSOR LANEl N. ANDOVER, MA 01845 Previous. Current Consumption Nb of. Reading rZeading ,; Daysd .WATER USAGE 2/8106 5/25/06 8 22 14 Actual 106 MESSAGE w ON OR BEFORE 07/2/06 t $55.28 AGCOUNTNO ,, ; B1LIJING DATE 2100062-416704929 6/20/2006 ,xSEitVICE,DATES,, ; Y .:'� ,.. DUE DA`I'S 3/1/2006 - 5/31/2006 07/20/06 72 WINDSOR LANE =TRANSACTIONzTi,ff ?ERIOD AIvIbUNT Previous Balance 55.28 Payments Through 06/20/2006 (55.28) Adjustments / Late Charges Interest as of: 7/20/2006 - Balance Forward - Current Bill DetailUsage%iJmt � Amount WATER 14 47.46 ADMIN FEE 7.82 Sub -Total 55.28 Total � PAYMENTS SHOULD BE MADE: TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @ P.O. BOX 184, MEDFORD, MA 02155 Water rate: First 20 units @ $3.39 Over 20 units @ $5.30 Sewer rate: First 20 units @ $3.81 Over 20 units @ $5.49 Bypass Meter Water rate: all units (a) $5.30 - -A IIT T TT11-11 --0 T/lTl TirlT1 111-11 T A Ill. /1-'l.1T Cl MAKE P&YMENTS TO Billing 10 1 "°F"+ Information • "'� M'! � TOWN OF NORTH ANDOVER ; •'� (978)688-9550 o 120 MAIN STREET APO0 a "' NORTH ANDOVER MA 01845 Reading Infor patio\ ' + (978)688.9570 f # 978-688-9550 / �s�^twus�tt� OFFICEhIO S 1 Moq/to F i. 8:30arti to :30pm RETAIN THIS PORTION FOR YOUR RECORDS 1 MOVING? PLEASE CALL 978-688-9570 IN ADVANCX 1 POLIZZOTTI, LOUIS 72 WINDSOR LANE / N. ANDOVER, MA 01845 41 ON OR BEFORE 10/13/06 00.S42.25 ACCOUNTI�O BIIt G:DATE - 2100062-416704929 9/13/2006 w== SERVICE`DATES ..:' DU".E.DATB' 6/1/2006 - 8/31/2006 10/13/06 '1 72 WINDSOR LANE I Payments Through 09/13/2006 Adjustments / Late Charges Interest as of: 10/13/2006 Balance Forward 1Previous r A urent� Consumption " N� of Currentfl3tll r °S r.x`°�TM'..' L f� TX�*.,Z-wY�J" r ,�.Readmg+�e ... 1,,mn Reading a ter, . r,�'- rx - 3 -.;,.e ��ays s:,s 1",. >.s^�7� ,xary 7`'��.=' '�.,�a.."�"ta,w.ew N,�q.,.;;- WATER USAGE WATER 5. '5'.."6 8/21/06 ADMIN FEE 33 11 Actual 88 MESSAGE 11 Sub -Total Total (55.28) Amount. 34.43 7.82 42.25 PAYMENTS SHOULD BE MADE: TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @ P.O. BOX 184, MEDFORD, MA 02155 Water rate: First 20 units @ $3.13 Over 20 units @ $4.84 Sewer rate: First 20 units a $3.45 Over 20 units @ $4.96 Bypass Meter Water rate: all units @ $4.84 dAAKE P54YMENTS TO Billing 41 ,,aar„ '•' Information oTOWN OF NORTH ANDOVER (978)688-9550 120 MAIN STREET NORTH ANDOVER MA 01845 Reading Information Water rate: (978)688-9570 978-688-9550 Over 20 units C $4.84 OFFICE HOURS First Mon to Fri. Over 20 units 8:30am to 4-36in Bypass Meter Water RETAIN THIS PORTION FOR YOUR RECORDS l MOVING? PLEASE CALL 978-688-9570 IN ADVAN E��j I I POLIZZOTTI, LOUIS { (� 72 WINDSOR LANE N. ANDOVER, MA 01845 w ON OR BEFORE 01/22/07 , $36.10 ACCOUNTNO, BII LING DATE 2100062-416704929 12/22/2006 r SERV:I.CE-DATES , DUE'DATE 9/l/2006- 11/30/2006 01/22/07 SERVICE ADDRESS 72 WINDSOR LANE TRANSACTION THIS P;ERIOD.:`. AMOUNT Payments Through 12/22/2006 Adjustments / Late Charges Interest as of: 1/22/2007 Balance Forward Previous urrenL �onsum tion �Nbof ; 5 aF s `vr - txn ,.._" P r 9 ;� �:f Current 811141 ,IteadingReadmg WATER USAGE WATER 9:2117i(, I li2io6 ADMIN FEE 3: 42 9 Actual 73 MESSAGE z (42.25) Sub -Total 35.99 Total PAYMENTS SHOULD BE MADE: TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX a P.O. BOX 184, MEDFORD, MA 02155 Water rate: First 20 units @ $3.13 Over 20 units C $4.84 Sewer rate: First 20 units @ $3.45 Over 20 units @ $4.96 Bypass Meter Water rate: all units 0 $4.84 M MAKE PAYMENTS TO Billing oORT,4 Information TOWN OF NORTH ANDOVER (978)688-9550 120 MAIN STREET y NORTH ANDOVER MA 0184 Reading Information 978-688-9550 (978)688-9570 �sA;4;;sEsOFFICE HOURS �/� ��d 7 Mon to Fri. r 8:30am to 4:30pm X/3 RETAIN THIS PORTION FOR YOUR RECORDS MOVING? PLEASE CALL 978-688-9570 IN ADVANCE POLIZZOTTI, LOUIS 72 WINDSOR LANE N. ANDOVER, MA 01845 PreviousCurren t Consumption. Reading Reading Days WATER USAGE llt2ru6 2/21/07 42 53 11 Actual 111 MESSAGE ON OR BEFORE 04/23/07 , $42.25 :?> SERVICE DAZES r` DUE DATE 12/1/2006 - 2/28/2007 04/23/07 1 72 WINDSOR LANE Payments Through 03/23/2007 (36.10) Adjustments / Late Charges - Interest as of: 4/23/2007 - Balance Forward - PAYMENTS SHOULD BE BILLING DA TE 2100062-416704929 3/23/2007 :?> SERVICE DAZES r` DUE DATE 12/1/2006 - 2/28/2007 04/23/07 1 72 WINDSOR LANE Payments Through 03/23/2007 (36.10) Adjustments / Late Charges - Interest as of: 4/23/2007 - Balance Forward - PAYMENTS SHOULD BE MADE: TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @ P.O. BOX 184, MEDFORD, MA 02155 Water rate: First 20 units @ $3.13 Over 20 units @ $4.84 Sewer rate: First 20 units @ $3.45 Over 20 units @ $4.96 Bypass Meter Water rate: all units @ $4.84 NO R T/I O O ,0 A ��SSA H Us��,�5 PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF. COMPLIANCE As of 3/17/14 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Repair of D -Box By: Robert Amor At: 72 Windsor Lane Map 106D Lot 0070 North Andover, MA 01845 of this cgtif cate shill not be construed as a guarantee that the system will function satisfactorily. Michele Grant" `J Public Health Agent 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES 110101-AT[ehlI►`IM6 : ►77��I_ri OYL ADDRESS: 72 Windsor Lane INSTALLER: Robert Amor DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS MAP: 106D LOT: 0070 TANK INSPECTION: 3/17/14 (D -Box) DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: , SITE CONDITIONS Comments: SEPTIC TANK ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROLPANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION -BOX Installed on stable stone base �- H-20 D -Box Inlet tee (if pumped or >0.08'/foot) El Hydraulic cement around inlet & outlets 0� Observed even distribution Speed levelers provided (not required) Comments: > Commonwealth of Massachusetts Map -Block -Lot 106.D0070 BOARD OF HEALTH - - -----Permit No ------------ • North Andover BHP -2014-0453 x--------------- -- FEE $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Robert -T. -Amor to (Repair) an Individual Sewage Disposal System. at No -72--WI-NDS-OR-LANE-15-- -J��------_____ as shown on the application for Disposal Works Construction Permit No. BHP i2014.045N Dated March 17, 2014 ---------------------- ----------------------------- ' -------- --- ----------------- Issued On: Mar -17-2014 BOARD OF HEALTH ---------------------------------------------------------------------------------- ,aRt„ Application for Septic Disposal System Of i,.ao .a �4• 3� •`�°'- � TODAY'S DATE AConstruction Permit — TOWN OF ORTH ANDOVER, MA 01845 $ 25Q-00 — Full Repair C. Esq 125.00 CHus Component SA Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer, use f epair or replace an existing on-site sewage disposal syste * only the tab key to move your epair or replace an existing system component — What? cursor - do notuse the return A. FaInformation key. a— Addreis`oko't # ruf no- nnmu I� City own 2.- *TYPE OF SEPTIC SYSTEM*: ❑ Pump ravity (choose one) ***If pLAO system, attach copy of electrical permit to application*** Conventional System (pipe and stone system) ' (_J Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D -Box Present) S.A.S. el e;inK _10 Address (if different from above) City/Town 3. State Telephone Number Zip Code 4. Designer Information Name Address City/Town Telephone Number (Cell Phone # if possible please) Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 °pry Application for Septic Di-�I)Q sposal System • `Construction Permit —TOWN OF TODAY'S ATE $ 250.00 - Full Repair ORTH ANDOVER, MA 01845 $125.00 - Component ]_fir]=+4[el W A. Facility Information continued.... 5. Type of Building..,�Residential Dwelling or ❑Commercial B. Agreement (( )� The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. 114 Name Date Applicat'in A roved By: (Board of Health Representative) I� r' 4 I Name;' Date A/lication Di pproved for the following reasons: For Office Use Only: 1. Fee Attached.? Yep/ No 2. Project Manager Obligation Form Attached? Yes No 3. Pump Svstem? If so, Attach copv ofElectrical Permit No 4. Foundation As -Built? (new construction ronly): Yes o (Same scale as approved plan) 5. Floor Plans? (new construction only): Yes No Application for Disposal System Construction Permit • Page 2 of 2 TOWN OF NORTH ANDOVER Building Department 1600 Osgood Street Building 2- Suite 2-36 Building Dept North Andover MA 01845 Tel: (978) 688-9545 Fax (978) 688-9542 COMPLAINT FOR INVESTIGATION DATE: ✓a/yfl��-ora ,; j TEL #: %%S'Ad1f NAME OF COMPLAINTANT: ADDRESS,-: , �Q Gv.1*dSo/L COMPLAINT TYPE: Electrical: Plumbing: Gas: uilding: Property Owner: 1�71Wt 6'q y'Wie"e_ Address: I Other: &; �a RO ck.r A1,4 6/ o ✓U- 44'M X '00 L 0 u/�i e�/ aLow �;�•� s r/oHJ Y4"1;110 5 /77441�e2 cJ> 7% o/ D&Ge_ Signed: Complaint Form - Revised 6.2007 t w t.- C '! Yi. Y LelL,�S+ v�:%`7y{y y C.q •yyP.R y ' ° K •. - i . t is y .E'.:+: t ` ` Y • .. ° i '' * "�1+M1 1-.:.. "y , ,! , �iL.ys� - _`r`.: 2e. ... •:1 � �i ;;� _ i`T , r �}r'i t �Y i is i rv1°"' °ry �,6" y`t •:i z• 2F,Yr ,r .,�./g ,� - ". 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