HomeMy WebLinkAboutMiscellaneous - 721 MIDDLETON STREET 4/30/2018 (2)® MAPFRE The Commerce Insurance Company1m
Citation Insurance Company1m
Commerce"
Gore Road, Webster, Massachusetts 01570
INSURANCE" 508.949.15001 www.commerceinsurance.com
April 08, 2015
BUILDING COMMISSIONER or Board of Health or
INSPECTOR OF BUILDINGS Board of Selectmen
TOWN/CITY HALL Town/City Hall
NORTH ANDOVER MA 01845
RE: Our Insured: DOMINIC DISARIO / DEBRA KILEY
Property Address: DOMINIC DISARIO, 721 MIDDLETON RD
Policyk BDGZJT
Date of Loss: 02/27/2015
File#: JYWY27-HRMXA4
Claim has been made involving loss, damage, or destruction of the above captioned
property which may exceed $1,000, or cause Massachusetts General Laws, Chapter 143,
Section 6 to be applicable.
If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate,
please direct it to my attention. Please reference the above captioned insured, location,
policy number, date of loss, and file number on any correspondence.
JEFFREY ILVONEN Telephone: (508)949-1500 Ext: 11483
CLAIM SPECIALIST, CASUALTY Toll Free: 1-800-221-1605, Ext: 11483
On this date, I cause copies of this notice to be sent to the persons indicated above, at the
address above, by first class mail.
April 08, 2015
CIC 254 (Rev. 4/95) MAIL I21
Adh
C3c
CLAIMS DEPT.
May 07, 2012
Ccmmerce Insurance m
The Commerce Insurance CcmpanysM
Citation Insurance CcmpanysM
Members of The Commerce Group, Inc.s"
11 Gore Road, Webster, Massachusetts 01570 (508) 949-1500
www.Commerceinsurance.com
BUILDING COMMISSIONER or
INSPECTOR OF BUILDINGS
TOWN/CITY HALL
NORTH ANDOVER MA 01845
Board of Health or
Board of Selectmen
Town/City Hall
RE: Our Insured: DOMINIC DISARIO / DEBRA KILEY
Property Address: 721 MIDDLETON RD
Policy#: BDGZ7T
Date of Loss: 10/29/2011
Filek YVR165-WRKN24
Claim has been made involving loss, damage, or destruction of the above captioned
property which may exceed $1,000, or cause Massachusetts General Laws, Chapter 143,
Section 6 to be applicable.
If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate,
please direct it to my attention. Please reference the above captioned insured, location,
policy number, date of loss, and file number on any correspondence.
DIANE LECLAIR Telephone: (508)949-1500 Ext: 15004
CLAIM REP SR, PROPERTY Toll Free: 1-800-221-1605, Ext: 15004
On this date, I cause copies of this notice to be sent to the persons indicated above, at the
address above, by first class mail.
May 07, 2012
TREES FELL ON FENCE.
Ct)mmCrc Companies .... COME GROW WITH us
CIC 254 (Rev. 4/95) MAIL C78
RECEIVED
Commonwealth of Massachusetts `' 011
W City/Town of No. Andover JU 6
a System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
4:1
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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
1. System Location: 07 --) i L -A I r-0 It:> kc(
-
Address '
No.Andover Ma
City/Town State
2. System Owner:
Name
Address (if different from location)
City/Town
State
Telephone Number
B. Pumping Record �01 �j I
1. Date of Pumping Date 2. Quantity Pumped:
3. Type of system:
❑ Other (describe)
❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped
U i K -In& C�
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
01845
Zip Code
Zip Code
Gallons
❑ Grease Trap
If yes, was it cleaned? ❑ Yes ❑ No
Vehicle License Number
RA- ^A A1/
Signature
t5form4.doc• 03/06
System Pumping Record • Page 1 of 1
DelleChiaie, Pamela
From: Domenic DiSario [ddisario@solutionsunplugged.com]
Sent: Tuesday, April 12, 20119:50 AM
To: DelleChiaie, Pamela
Subject: RE: I.R. - Septic - 721 Middleton Street
Thanks You very much Pamela.
I really appreciate it.
Have a great day,
Dom
Domenic DiSario
Business Solutions Unplugged
617-532-0634 x 201
ddisario ci.solutionsunplugged.com
www.solutionsunplugged.com
hA. Please consider the environment before printing this e-mail
From: DelleChiaie, Pamela[mailto:pdellechC&townofnorthandover.com1
Sent: Tuesday, April 12, 20119:30 AM
To: 'ddisario@yahoo.com'
Subject: I.R. - Septic - 721 Middleton Street
Reference: 617.548.0915 - Dom
Hello Dom,
Here is a scanned copy of your file for 721 Middleton Street, North Andover. Please call the office if you have
any further questions.
c
Pamela DelleChiaie
Departmental Assistant I Community Development I Health Department
Town of North Andover
1600 Osgood Street I Bldg 20 ( Suite 2-36
North Andover, MA o1845
12 Office - 978-688-9540
Fax - 978-688-8476
Email - pdellechiaie(@townofnorthandover.com
'25 Website http://www.townofnorthandover.com/Pages/index
"We can never see the path of our life if we are too busy focusing on the pebbles under our feet. "--Anonymous
Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more
information please refer to: http://www.sec.state.ma.us/pre/preidx.htm.
Please consider the environment before printing this email.
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Tel: (978) 475-4786
Fax: (978) 475-5451
BATESON ENTERPRISES, INC.
Excavating -Water& Sewer Lines -Septic Systems & Pumping Service
111 Argilla Road Andover, Mass. 01810
Title 5 Inspection Report
Property Address: 721 Middleton Street, North Andover
Owner: Turner
Date of Inspection: 6/1/2007
My report contained herein does not constitute a guarantee of future usage and the functionality of the existing
septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further
operation of your current septic system.
Bateson Enterprises, Inc.
COMMONWEALTH OF MASSACHUSETTS0
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS /
DEPARTMENT OF ENVIRONMENTAL PROTECTION (X6_4',
v
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A u
CERTIFICATION
Property Address: 721 Middleton Street
_ North Andover
Owner's Name: Stephen Turner _
Owner's Address: 721 Middleton Street _
_ North Andover, MA 01845_
Date of Inspection; 6/1/2007_
Name of Inspector: Neil J. BaBateson_
Company Name: Bateson Enterprises Inc
Mailing Address: _111 Argilla Road
_Andover, MA 01810
Telephone Number: _(978) 4754786
RECEIVED
JUN 12 2007
TOWN OF NORTH ANDOVEt2
HEALTH DEPARTMENT
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fail
Inspector's Signature:/),fDate: 6/1/2007
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or
DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments:
****This report only describes conditions at the time of Inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the some or different
conditions of use.
Page 2 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 721 Middleton Street
—North Andover
Owner:_ Turner
Date of Inspection: 6/1/2007 _
Inspection Summary: Check A,B,C,D or E /ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which
indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure
criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described
in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement
or repair, as approved by the Board of Health, will pass. 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
"filtration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying
septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup
or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken,
settled or uneven distribution box. System will pass inspection if (with approval of Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more
than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the
Board of Health):
broken pipe(s) are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 721 Middleton Street
_North Andover
Owner: Ins_Turner _
Date of pection: 6/1/2007 _
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the
system is not functioning in a manner which will protect public health, safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the
system b functioning in a manner that protects the public health, safety and environment:
_ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
— The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Page 4 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 721 Middleton Street
_ North Andover
Owner: Turner
Date of &spectloa: 6/1/2007
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following for all inspections:
No Backup of sewage into facility or system component due to overloaded orclogged SAS or cesspool
No Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
No Liquid depth in cesspool is less than 6" below invert or available volume is V2 day flow.
No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
No Any portion of the SAS, cesspool or privy is below high ground water elevation.
No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
No Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ No Any portion of a cesspool or privy is within 50 feet of a private water supply well.
No Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
• performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
Indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No) The system faN! . I have determined that one or more of the above failure criteria exist as described
in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to
determine what will be necessary to correct the failure
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes" or `ho" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
— _ the system is within 400 feet of a surface drinking water supply
_ _ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped
Zone H of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: _721 Middleton Street
_ North Andover _
Owner: _Turner
Date of Inspection: _611/2007
Chock if the following have been done. You must indicate "yes" or `5 W' as to each of the following:
Yes No
Yes Pumping information was provided by the owner, occupant, or Board of Health
No_ Were any of the system components pumped out in the previous two weeks ?
Yes — Has the system received normal flows in the previous two week period?
No Have large volumes of water been introduced to the system recently or as part of this inspection?
Yes Were as built plans of the system obtained and examined?
Yes Was the facility or dwelling inspected for signs of sewage back up ?
Yes _ Was the site inspected for signs of break out ?
Yes Were all system components, excluding the SAS, located on site ?
Yes Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the
condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of
scum ?
Yes _ Was the facility owner (and occupants if different from owner) provided with information on the
proper maintenance of subsurface sewage disposal systems ?
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Yes No
Yes Existing information.
_Yes _ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable) [3 10 CMR 15.302(3)(b)j
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 721 Middleton Street-
-
North Andover_
Owner: _Turner
Date of inspection: 6/1/2007
FLOW CONDITIONS
RESIDENTIAL.
Number of bedrooms (design): _4 Number of bedrooms (actual); 4
MR
DESIGN flow based on 310 C 15.203 _600
Number of current residents: _2
Does residence have a garbage grinder (yes or no): No
Is laundry on a separate sewage system (yes or no): No _
Laundry system inspected (yes or no):
Seasonal use: (yes or no): _No
Water meter reading: _On well water
Sump pump (yes or no): Yes_
Last date of occupancy: _ Current _
COM MRCIALIINDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR 15.203): ____gpd
Basis of design flow (seats/persons/sq%etc.): _
Grease trap present (yes or no):
Industrial waste holding tank present (yes or no):
Non -sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: Pumped 2006, owner _
Was system pumped as part of the inspection (yes or no): No
If yes, volume pumped: ,gallons -- How was quantity pumped determined?
Reason for pumping: _
TYPE OF SYSTEM
X Septic tank, distribution box, soil absorption system
Single cesspool Overflow cesspool
_ Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
�.Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be
obtained from system owner)
Tight tank _ Attach a copy of the DEP approval
Other (describe):
Approximate age of all components, date installed (if known) and source of information _1987 house built, owner
Were sewage odors detected when arriving at the site (yes or no): No
Page 7 of 11
OFFICIAL INSPECTION FORM -- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _721 Middleton Street
_ North Andover _
Owner: _Turner_
Date of Inspection: _6/1/2007
BUILDING SEWER _ X _ (locate on site plan)
Depth below grade: 36"
Materials of construction: _ cast iron _X_ 40 PVC other
DIstance from private water supply well or suction line:
Comments (on condition of joints, venting, evidence of leakage, etc) _ 4" cast iron thru wall, 3" PVC in house,
no leaks visible.
SEPTIC TANK: X
Depth below grade: 2' _
Material of construction: X concrete metal fiberglass _polyethylene
_otha(explain)
If tank is metal list age: _„_ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of
certificate)
Dimensions: 10'x 5' x 4'
Sludge depth: 5"_
Distance from top of sludge to bottom of outlet tee or baffle: 22" _
Scum thickness: _411
_
Distance from top of scum to top of outlet tee or baffle:"
_8
Distance from bottom of scum to bottom of outlet tee or baffle: 17" _
How were dimensions determined: _Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc _ Pumped septic tank Inlet tee ok. Outlet tee ok. Depth of
liquid at outlet invert. No evidence of septic tank leaking. Inlet & outlet covers has riser exposed._
GREASE TRAP: (locate on site plan)
Depth below grade: ____,
Material of construction: _concrete metal fiberglass ,__polyethylene other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 721 Middleton Street-
- North Andover_
Owner: Turner_
Date of Yaspection: YU2097
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass _polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: _ gallons/day
Alarm present (yes or no):
Alarm level: Alarm in working order (yes or no):
Date of last pumping.
Comments (condition of alarm and float switches, etc.):
DISTRIBUTIONBOX X ( locate on site plan }
Depth below grade _18"_
Depth of liquid level above outlet invert: _0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.) D -Box level & distribution equal. No evidence of carryover. No evidence of
leakage._
PUMP CHAMBER: X (locate on site plan)
Pump in working order (yes or no): Yes
Alarm in working order (yes or no): Yes_
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Has riser cover to
grade. Pump was replaced two years ago. Pump ok. Alarm ok, has both visual & audible alarm. _
Page 9 of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _721 Middleton Street_
_ North Andover_
Owner: _Turner_
Date of Inspection: 6/U2007
SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan, excavation not required)
If SAS not located explain why:
Type
leaching pits, number: _
leaching chambers, number:
leaching galleries, number:
X leaching trench, number, length: 3 trenches 40' long_
leaching field, number, dimensions: _
overflow cesspool, number:
itmovativelalternative system Typelname of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.) _Soil ok. Vegetation ok. No sign of ponding to surface. _
CESSPOOLS:
Number and configuration:
Depth — top of liquid to inlet invert:
Depth of sludge layer:
Depth of scum layer:
Dimensions of cesspool: _
Materials of construction:
Indication of groundwater inflow (yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Page 10 of 11
OFFICIAL INSPECTION FORM -- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: _721 Middleton Street _
—North Andover
Owner: _Turner _
Date of Inspection: 6/1/2007
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
D -
Bog
Septic Tank P
ump1 2 ank 3
Deck
B A
House
To Well
Driveway
Ato1=14'4"
Ato2=1419f1
Ato3=16'9"
A to D -Box = 421411
B to 1= 501311
Bto2=58'10"
Bto3=631
B to D -Bog = 641411
Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 721 Middleton Street _
_ North Andover
Owner: iTurner_
Date of nspection: _6/1/2007 _
SITE EXAM
Slope _ No _
Surface water No _
Check cellar —Dry _
Shallow wells _ No _
Estimated depth to ground water 4' _
Please indicate (check) all methods used to determine the high ground water elevation:
X Obtained from system design plans on record - If checked, date of design plan reviewed: _9/21/1985
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health. -explain:
Checked with local excavators, installers- (attach documentation)
Accessed USGS database -explain: _
You must describe how you established the high ground water elevation: As per design plan, no water 41below
trenches—
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Commonwealth..of Massachusetts
City/Town of i
System Pumping Record EE. C -I E
Form 4
JUN 1 1 2007
DEP has provided this form for use by local Boards -of Health.. T e System Putppi rd must
be submitted to the local Board of 'Health or other approving aut ,� OF NO - H Ar�;�t ��
ACi11U PART p ENT
X Facility Information
Important:
When filling out 1. Syste Location:
comps the '? / v '-��
compute
r, use
only the tab key Address
to move your
cursor - do not
use ftretum Cityfrown
State
.key. Zip Code
2. System Owner.
Agdress of d(fferent from location) —
CityfTown
State
Zip Code'
c 1j"
'telephone Ntpniber `
.B. P =pirjg .Record
.1. ' . Date. of Pumping Date 2. Quantify f )umped: -
- Gallops
I Type of system: ❑ Cesspool(s) Cr Septic Tank- ❑ Tight Tank
❑ Other (describe):
4.' Effluent Tee Filter present? ❑ Yes [}
5. " Condition of System:
if yes, was it cleaned? ❑ Yes' ❑ No
6. SysCe Pu ped B
LNam Vehicle givens@ Number
Company ' ..
7. i;ocatioti re contents re osed:
:_�41
Si�naT r of aut r tate
lftp://www.mass:govtdep/waterlapprovals/t5forms.htm#inspect
00=4.doc• 06/03
Sysfein'purrppIng Record • Page t 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.
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSACHUSETTS
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
9. System Location: ,
02 f� �e)C
Address
_ x1d
City/Town
State Zip Code
2. System Owner: ,
Address (if different from location)
City/Town
B. Pumping
I. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
�� 2Q��
711z�
4�A/—
elep�hone Number
K
Cesspool(s)
4. Effluent Tee Filter present? ❑ Yes QLo
6. Condition of System
6. System Pumped By:
rvame
"-�g &
?G
Company -AA 1 „%f..'
— 2. Quantity Pumped: 1 5,0 -
Gallons
�eptic Tank ❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
/ Vehicle License Number
,.&- — , - .
7. Ln where ntents were dISDosed:
~�� C
Signature of Hau
http://www.mass.gov/dep/Water/approvals/tSforms.htm#inspect
t5form4.doc• 06/03
�/j
System Pumping Record • Page 1 of 1
DATF: Q. 7
TOWN OF NORIIX ANDOVER
SYSTEM PIJMPING RECORD
S
SYS`! RM OWNER & ADF7RI;SS
ZDV, Xj?4-
7 �-AiAl/ek
&A
i t'f tr;j�ti)gqS � '
DAT}, OF PUMPING!
_ _._ QUAN I'ITY FUMPEU
CESSPOOL NO,,, y 7s
SEPTIC TANK NO-_ YF?S
NATUItF? Ur� Sp
ItVICI?: ROUTINLP�_ L'%ItC3ENCY
OBSERVATIONS;
(]()OD CONDITIONw±FULL TO CQVI?It
Fll>•~AVY (iR.Et#SI:? t3AI'I?F,F3S IN LACE---__ _
ROOTS �-- LP,ACHFIF?LDRUNDACK �_—
cxc,F„SSIV!?SOl.,II)S ._ _ _ FLOODED _...__..._.._.
SOLID CARRYOVER OT"FUM PXPLAIN
5YS'I'IiM PUMPBD BY
COMMENTS:
C4N'!'EN'1'3 'I'RA%ISI7EIttt1?U
• `�•3YN OF NORTH' •., 0 THANDOVER..
S' STVM P.UfqpIjlC PXCU411(6R
• • f.;
� l 57E,5M U1� HeR & A00ftESS ,, SYSTEM LOCATION
(example: -lefl (roof of bousr
1��7le.IgJ4
,41
•rr.••♦w�.r�•wwu
DATE OF PUMPtNC: QUAKTITY PUMPEDCA LLO:N,
C'Iiy�13UUL: Y89SEPTIC TANK: NO YES
XATVRi,0F $ERYICSs ROUTINE C�M>t;RGENCY
oliseRYATIONSs,
• GOOD COMylTIOX �FULL TO COYI~it
fil;AVY CREASE BAFFLESs IN t'LACI:
ROOTS LEACH FIRLD AUNBACK,
EXCESSIV9 $CLIDS FLOODETY
301,108 CARRYOYSR �. iPRHXR (EXPLAJN)
iYS ITIM PUMPC� av: vle
('04010TS:
�. 'le ` ...
c U�'!•isN'I'S' TRANb'FORR80 TO;
DATE:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
791
DATE OF PUMPING: 6 L QUANTITY PUMPED �GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
X—
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EX , CESSIVE, SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY: S'
COMMENTS:_'__FWadPry
-
56;
CONTENTS TRANSFERRED TO:
M).
APR 4 2001
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS
SYSTEM LOCATION
(example: left front of house)
ae-
DATE OF PUMPING: Llazcs)
QUANTITY PUMPED DOD GALLONS
CESSPOOL: NO �ES SEPTIC TANK: NO YES.
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO:
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
DRINKING WATER LABORATORY
-- CERTIFIED —
36 Pelham Rd.
Salem, NH 03079
Laboratory Number: 529
Submitted By: 4 Star Const Co.
26Th 5Th Ave
Haverhill; Mass
Sample Source:
Quick Results, Sample Pick -Up
(603) 898-2504
(603) 898-6526
Sample Date:
Oct 3--37
Lot A -A Milford Road -North Andover
Analysis: According to Standard Methods of dater & Wastewater
Analysis, 1 fh Ed. Standard Your results
Total Coliform 0 per loo mg/l
o per 100 ml
Comment:
Chlorides ............ 2�0 .mgA ............. 30
PH .............. 6.,5 ,to 8.5 ....... 7.0
..... . ...
Hardness .. • . , , , , , . 75 to 150, ma/1 87
Manganese ............5 m.... . ......... ...0.009
Sodium ........... 20, t9.250. m9/1......... 111.1
0.3 mg /1 0.02
Iron .......................... .............
N itrate . .... 10 mq/1 ............. 1.1
Nitrite ................. 10 ,w& .. ,11
Arsenic ................05. mg/l ............ 0.0
This sample meets EPA recommended limits
_?z
AllafY St
mgi L
mg/L
rng/L
mg/L
mg/L
mg/L
mg/L
P.P.B.
Septic Compliance, Inc.
.affilliate of Thomas E. Neve Assoc., Inc.
April. 29, 1997
North Andover Board of Health
146 Main Street
North Andover, MA 01845
Attn: Sandra Starr
Re: Sanitary Disposal System Inspection
721 Middleton Road - Dr. Howard Zolot
Dear Ms. Starr:
In accordance with the Commonwealth of Massachusetts, Department of Environmental
Protection, State Environmental Code (Title V), 310 CMR 15.301, paragraph 7, please find
attached a "Subsurface Sewage Disposal System Inspection Form" for your records.
If you have any questions regarding -this report or any of its contents, please do not hesitate to
contact this office. We thank you, in advance, for your continued cooperation in these matters.
Very truly yours,
I aul %,aLUV11U
Certified Septic Inspector
Attachment
N.Andletsam
• SYSTEM INSPECTORS •
• SOIL EVALUATORS • •. ENVIRONMENTAL ENGINEERS -
447 Old Boston Rd., US Route 1, Topsreld, MA 01983
Tel (508) 887-8586 Fax (508) 887-3480
Property Address:
Septic Compliance, Inc.
affilliate of Thomas E. Neve Assoc., Inc.
SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
721 Middleton Road, No. Andover, Ma. 01945 Address of Owner:
(if different)
Date of Inspection: April 24, 1997
Name of -Inspector: Paul Cardone
Company Name, Septic Compliance, Inc.
Address and - 447 Old Boston Road, Topsfield, MA 01983
Telephone Number: (508) 887-8586
Certification Siatement
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 sewage disposal systems. The system:
XX Passes
Conditionally Passes
Needs furtEvaluation By the Local Approving Authority
Inspector's Signature: � ��_� 1/ il Date: April 24, 1997
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 to the appropriate regional office 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.
• SYSTEM INSPECTORS • • SOIL EVALUATORS • • ENVIRONMENTAL ENGINEERS -
447 Old Boston Rd., US Route 1, Topsfield, MA 01983
Tel (508) 887-8586 Fax (508) 887-3480
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 721 Middleton Road, No. Andover, Ma. 01845
Owner: Dr, Howard Zolot
Date of Inspection: April 24, 1997
INSPECTION SUMMARY:
Check A, B, C, or D:
A) SYSTEM PASSES:
XX I have not found any information which indicates that the system violates any of the failure criteria as defined in 310
CMR 15,303. Any failure criteria not evaluated are indicated below.
0) SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or
repair, passes inspection.
Indicate yes, no, or not determined (Y,N, or ND). Describe basis of determination in all instances. if "not determined", explain why.
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or
tank failure is imminent, The system will pass inspection if the existing septic tank is replaced with a
conforming septic tank as approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to
broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system
will pass inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
The system required pumping more than four 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
2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART A
CERTIFICATION (continued)
Property Address: 721 Middleton Rd., No. Andover, Ma. 01845
Owner: Dr. Howard Zolot
Date of Inspection: April 24, 1997
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 the public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS THE BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT.
Cesspool or privy is within 50 feet of a surface water.
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF
APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS
THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT.
The system has a septic tank and soil absorption system and is within 100 feet to a surface
supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public water
supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water
supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or
more from a private water supply well, unless a well water analysis for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 721 Middleton Rd., No. Andover, Ma. 01845
Owner: Dr. Howard Zotot
Date of Inspection: April 24, 1997
D) SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR
15.303. The basis for this determination is identified below. The Board of Health should be contact 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 water due to an overloaded or
clogged SAS or cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s)
Number of Times Pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater
elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 721 Middleton Rd., No. Andover, Ma. 01845
Owner: Dr. Howard Zolot
Date of Inspection: April 24, 1997
D) SYSTEM FAILS (continued)
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. 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 design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exists:
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),
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 5.00 and 6.00. Please consult the local regional office of the Department for further
information. -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 721 Middleton Rd. , No. Andover, Ma.41845
Owner: Dr. Howard Zolot
Date of Inspection: April 24, 1997
Check If the following have been done:
Y Pumping information was requested of the owner, occupant, and Board of Health.
Y None of the system components have been pumped for at least two weeks and the system has been receiving
normal flow rates during that period. Large volumes of water have not been introduced into the system
recently or as part of this inspection.
Y Asbuilt plans have been obtained and examined. Note if they are not available with N/A.
Y The facility or dwelling was inspected for signs of sewage back-up.
Y The system does not receive non -sanitary or industrial waste flow.
Y The site was inspected for signs of breakout.
Y All system components, excluding the Soil Absorption System, have been located on the site.
Y The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for
condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of
SCUM.
Y The size and location of the Soil Absorption System on the site has been determined based on existing
information or approximated by non -intrusive methods.
Y The facility owner land occupants (if different from owner) were provided with information on the proper
maintenance of Subsurface Disposal System.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 721 Middleton Rd,, No. Andover, Ma. 01845
Owner: Dr. Howard Zoiot
Date of Inspection: April 24, 1997
FLOW CONDITIONS
Design flow: 600 gallons
Number of bedrooms: 4
Number of current residents: 4
Garbage grinder (yes or no): no
Laundry connected to system (yes or no): yes
Seasonal use (yes or no): no
Water meter readings, if available:
Last date of occupancy: occupied
Type of establishment:
Design flow:
Grease trap present (yes or no):
Industrial Waste Holding Tank present (yes or no):
Non -sanitary waste discharged to the Title V
system (yes or no).
Water meter readings, if available:
Last date of occupancy:
OTHER (Describe):
Last date of occupancy:
7
gallons/day
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 721 Middleton Rd., No. Andover,Ma. 01845
Owner: Dr. Howard Zoiot
Date of Inspection: April 24,1997
GENERAL INFORMATION
PUMPING RECORDS and source of information:
owner said he has it pumped every three years
System pumped as part of inspection (yes or no): yes
If yes, volume pumped: 1,500 gallons
Reason for pumping: To check baffles, to check for leaks, to check structural integrity of the tank.
TYPE OF SYSTEM
X Septic tank/distribution bax/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or not) (If yes, attach previous inspection records, if any]
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information:
7 years old 9-21-85 B. 0. H. office
Sewage odors detected when arriving at the site (yes or no): no
SEPTIC TANK: yes
(locate on site plan)
Depth below grade: 4' riser to grade
Material of construction: X concrete metal FRP
8
Other (explain)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 721 Middleton Rd., No. Andover, Ma. 01845
Owner: Dr. Howard ZoIot
Date of Inspection: April 24, 1997
Dimensions: 10'6" x 6' 4"x 5'4Y
Sludge Depth: 6"
Distance from top of sludge to bottom of outlet tee or baffle: V7
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 4"
Distance from bottom of scum to bottom of outlet tee or baffle: 1' 8"
Comments:
(recommendations 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.)
I would recommend that a tank with a riser so high it should be pumped every year, and also the risers should be at least T 6" around
for upkeep purposes, baffles in tact and working, no signs of leaks, tank fairly new structural integrity good.
GREASE TRAP: none
(locate on site plan)
Depth below grade:
Material of construction: Concrete Metal FRP
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:
9
Other (Explain)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 721 Middleton Road, No. Andover, Ma. 01845
Owner: Dr. Howard Zolot
Date of Inspection: April 24, 1997
Comments: _
(Recommendations 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.)
TIGHT OR HOLDING TANK: none
(locate on site plan)
Depth below grade:
Material of construction: Concrete Metal FRP
Dimensions:
Capacity:
Design flow:
Alarm level:
gallons
gallons/day
Comments:
(Condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: yes
(locate on site plan)
10
Other (explain):
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 721 Middleton Rd., No. Andover, Ma. 01845
Owner: Dr. Howard Zolot
Date of inspection: April 24, 1997
Depth of liquid Ievel above outlet invert: Even
Comments:
(Note if level and distribution is equal evidence of solids carryover, evidence of leakage into or out of box, etc.)
equal no evidence of carryover no leaks in or out of box
PUMP CHAMBER: yes
(Locate on site plan)
Pumps in working order (yes or no): yes
Comments:
(Note condition of pump chamber, condition of pumps and appurtenances, etc.)
In very good condition, pumps in good condition,checked wires and switch all looked good.
SOIL ABSORPTION SYSTEM (SAS): yes
(Locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods)
If not determined to be present, explain:
11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 721 Middleton Rd., No. Andover, Ma. 01845
Owner: Dr. Howard Zolot
Date of Inspection: April 24, 1997
Type:
Leaching pits, number:
Leaching chambers, number:
Leaching galleries, number:
Leaching trenches, number, length:
Leaching fields, number, dimensions:
Overflow cesspool, number:
3 trenches approx. 40'
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
normal none none grassy area
CESSPOOLS: none
(Locate on site plan)
Number and configuration:
Depth -top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
Inflow (cesspool must be pumped as part of inspection):
12
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 721 Middleton Rd. , No.Andover, Ma. 41845
Owner: Dr. Howard Zolot
Date of Inspection; April 24, 1997
Comments (Note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY: none
(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.):
13
SKETCH OF SEWAGE DISPOSAL SYSTEM
Include ties to at least two permanent references, landmarks or benchmarks.
_______•Locate all wells within 100'.
AS
• p.1�11o�d�E�e�
0
-2
N
3.
DEPTH TO GROODWAUR
Depth to groundwater: 8' no water feet
Method of determination or approximation: Deep hole test perfdrmed by kaminskl and Assoc., 200 Sutton Street No. Andover.
14
_ r
K o
J/ 3. o
44
• 4
•
. /
DEPTH TO GROODWAUR
Depth to groundwater: 8' no water feet
Method of determination or approximation: Deep hole test perfdrmed by kaminskl and Assoc., 200 Sutton Street No. Andover.
14
Name of Inspector
Company.
Address
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Paul Cardone
Septic Compliance, Inc.
447 Boston Road, Topsfield, MA 01983 (508) 887-8586
I certify that i have personally inspected the sewage disposal system at this address and that the information
reported is true, accurate and complete as of the time of inspection. The inspection was performed and any
recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in
the proper function and maintenance of on-site sewage disposal systems.
Check one;
I have not found any information which indicates that the system fails to adequately protect public health or
the environment as defined in 310 CMR 15.303. Any failure criteria not evaluated are as stated in the
XX FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and the environment as defined in 310 CMR
15.303. The basis for this determination is provided in the FAILURE CRITERIA section of this form.
Inspector's Signature:
Date:
Copies to:
Buyer (if applicable) Approving authority:
April 24, 1997
Board of Health
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SOD., PROFILE ))Iejv-s
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OFFICES OF. ,d�'� Town of
APPEABUILDING
�� ,: NORTH][ ANDOVER
BUILU[NG � s,�'t�
CONSERVATION �'01"'� DIVISION OF
HEALTH
PLANNING PLANNING & COMMUNITY DEVELOPMENT
KAREN H.P. NELSON, DIRECTOR
Conservation Commision
120 Ma1n Street
North Andover.
Massachusetts O 1845
(617) 685.4775
August 20, 1987
re: Lot AA Middleton Road
A revised plan by Richard Kaminski dated October
17, 1985, was approved for this lot on October 18, 1985.
Sincerely,
Michael Graf
mg:ml
BOARD OF HEALTH
No.Andover, Mass.
APPROVED
Providdds
t r'
.i.
Title 'V
-Reg..2.5
Reg 6
Reg 10.2
Reg 10.1
DATE lV � l tb '65
WV«tc)A
Mau
DISAPPROVED DATE I t�
Reasonst
7-7
The submitted plan must show as.a minimums
a) the lot to be eerved•-area dimensions lot ##abutters
b location and log deep observation Meeidistance to ties
c location and results percolation tests -distance to ties
d design calculations & calculations showing required leaching areal:
e location and dimensions of system -including reserve area
f8 existing and proposed contours
g) location any vet areas Atbin 1001 of sewage disposal
disclaimer -check wetlands mapping
h) surface and subsurface drains within 1001 of sewage disposal
system or disclaimer '..
i) location any drainage easements Within 3.001 of sewage disposal
system or disclaimer -Planning Hoard files
J) known sources of water supply within 2001 of sewage disposal
system or disclaimer
k) location of any proposed well to serve lot -1001 from leaching faci]
1) location of water lines on property -101 Brom leaching facility
M) location of benchmark
�nj driveways
o garbage disposals
;p no PVC to be used in construction
,q) profile of system-elevatione of basement, plumb, pipes septic .tank,
distribution box inlets and outlets, distribution field piping ;and
otter elevations ' =>
'r) maximum ground water elevation in area sewage disposal system .
s) plan must be prepared bij a Professional Engineer or other. :k
professional authorized by lax to prepare such plans 3a;
$ tic Tanks
a) eapac es- 5DA of flow) (rater table$ teess, depth of tees#
accesss pumping
b) cleanout
c 101 from cellar wall or inground swimming pool
d) 251 from subsurface drains
e
Distribution Boxes
pegreater Ua 0.08
b) ,s►imP
00
d
ORDER OF CONDITIONS
Page 3
LOT AA-MIDDLETON STREET DEQE #242--425
12. The work shall conform to the following plans and additional
Conditions:
Notice of Intent received Aug. 3, 1987 and dated
July 27, 1987 - six (6) pages, for Four Star
Construction, 26 Fifth Avenue, Haverhill, MA by
JJB Associates Inc., 145 Marston Street, Lawrence, MA
Plan entitled "Proposed Site Plan located in North
Andover, MA prepared for Four Star Construction by
JJB Associates, Inc., Scale 1"-30' Dated July 3, 1987.
13. The following wetland resource areas are affected by the proposed
work: bank, land under water, land subject to flooding (isolated
and/or bordering), and bordering vegetated wetland. These resource
areas are significant to the interests of the Act and Town Bylaw
as noted above. These resource areas are also significant to the
wildlife and recreation interests of the Bylaw. The applicant has
not attempted to overcome the significance of these resource areas
to the identified interests.
14. The NACC agrees with the applicant's delineation of the wetland
resource areas at the site.
15. In advance of any work on this project the applicant.shalll notify
the NACC, and at the request of the NACC, shall arrange an on-site
conference among the NACC, the contractor, and the applicant to
ensure that all of the Conditions of this Order are understood.
This Order also shall be made a part of the contractor's written
contract.
16. The applicant, or its successors, shall notify the NACC in writing
of the identity of the on-site construction supervisor hired to
coordinate construction during the work on the site and to ensure
compliance with this Order.
17. Commencing with the issuance of this Order, and continuing through
the existence of same, the applicant shall submit to'the NACC a
written progress report every three months detailing what work has
been done in or near resource areas, and what work is anticipated
to be done over the next period.
18. Prior to any activity on the site, a filter fabric fence or a double
row of staked hay bales shall be placed between all construction
areas and wetland areas per Soil Conservation Service or D.E.Q.E.
standards. This barrier shall be inspected and approved by the NACC
prior to start of construction. This row of hay bales or filter
fabric shall remain intact until all disturbed areas have been
mulched, seeded, and stabilized to prevent erosion.
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BATESON ENTERPRISES, INC.
Excavating -Water& Sewer Lines -Septic Systems & Pumping Service
111 Argilla Road Andover, Mass. 01810
Title 5 Inspection Report
Property Address: 721 Middleton Street, North Andover
Owner: Turner
Date of Inspection: 6/1/2007
Tel: (978) 475-4786
Fax: (978) 475-5451
My report contained herein does not constitute a guarantee of future usage and the functionality of the existing
septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further
operation of your current septic system.
Neil J. Bat son
Bateson Enterprises, Inc.
s
BATESON ENTERPRISES, INC.
Excavating -Water& Sewer Lines -Septic Systems & Pumping Service
111 Argilla Road Andover, Mass. 01810
Title 5 Inspection Report
Property Address: 721 Middleton Street, North Andover
Owner: Turner
Date of Inspection: 6/1/2007
Tel: (978) 475-4786
Fax: (978) 475-5451
My report contained herein does not constitute a guarantee of future usage and the functionality of the existing
septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further
operation of your current septic system.
Neil J. Bat son
Bateson Enterprises, Inc.
COMMONWEALTH OF MASSACHUSETTS "�
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS /
DEPARTMENT OF ENVIRONMENTAL PROTECTIONd
v�
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: _721 Middleton Street-
- North Andover_
Owner's Name: _Stephen Turner _
Owner's Address: _721 Middleton Street _
_ North Andover, MA 01845_
Date of Inspection: _6/1/2007_
Name of Inspector: Neil J Bateson_
Company Name: Bateson Enterprises Inc._
Mailing Address: _111 Argilla Road_
_Andover, MA 01810
Telephone Number: _( 978 ) 475-4786_
RECEIVE)
JUN 12 2007
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fail
c
Inspector's Signature: d Date: _6/1/2007_
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or
DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments:
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Page 2 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: _721 Middleton Street-
-
North Andover—
Owner: _ Turner
Date of Inspection: _6/1/2007 _
Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which
indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure
criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described
in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement
or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for
the following statements. If "not determined" please explain.
The septic tank is metal and over 20
years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or
exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying
septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain
Observation of sewage backup
or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken,
settled or uneven distribution box. System will pass inspection if (with approval of Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more
than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the
Board of Health):
broken pipe(s) are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: _721 Middleton Street-
-
North Andover_
Owner: _Turner _
Date of Inspection: 6/1/2007 _
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the
system is not functioning in a manner which will protect public health, safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the
system is functioning in a manner that protects the public health, safety and environment:
_ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance _
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: _721 Middleton Street-
-
North Andover—
Owner: _Turner_
Date of Inspection: 6/l/2007 _
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or `no" to each of the following for all inspections:
_ _No Backup of sewage into facility or system component due to overloaded or domed SAS or cesspool
_No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
NoLiquid depth in cesspool is less than 6" below invert or available volume is'/2 day flow.
_No__ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
No Any portion of the SAS, cesspool or privy is below high ground water elevation.
_No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_No_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
_No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described
in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to
determine what will be necessary to correct the failure
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
10d-
You must indicate either `yes" or `no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
_ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped
Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: _721 Middleton Street_
_ North Andover _
Owner: _Turner_
Date of Inspection: _6/1/2007
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
Yes _ Pumping information was provided by the owner, occupant, or Board of Health
No_ Were any of the system components pumped out in the previous two weeks ?
Yes — Has the system received normal flows in the previous two week period ?
No Have large volumes of water been introduced to the system recently or as part of this inspection ?
Yes ` Were as built plans of the system obtained and examined?
Yes — Was the facility or dwelling inspected for signs of sewage back up ?
Yes _ Was the site inspected for signs of break out ?
Yes _ Were all system components, excluding the SAS, located on site ?
_Yes_ _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the
condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of
scum ?
_Yes_ _ Was the facility owner (and occupants if different from owner) provided with information on the
proper maintenance of subsurface sewage disposal systems ?
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Yes No
_Yes_ — Existing information.
_Yes_ _ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable) [3 10 CMR 15.302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: _721 Middleton Street-
-
North Andover–
Owner: _Turner_
Date of Inspection: 6/1/2007
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): _R4_ Number of bedrooms (actual): _4_
DESIGN flow based on 310 CM15.203 _600
Number of current residents: _2
Does residence have a garbage grinder (yes or no): _No_
Is laundry on a separate sewage system (yes or no): No _
Laundry system inspected (yes or no): _
Seasonal use: (yes or no): _No
Water meter reading: _On well water_
Sump pump (yes or no): Yes_
Last date of occupancy: _ Current _
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR 15.203): ,gpd
Basis of design flow (seats/persons/sgft,etc.): —
Grease trap present (yes or no): _
Industrial waste holding tank present (yes or no):
Non -sanitary waste discharged to the Title 5 system (yes or no): —
Water meter readings, if available: —
Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: _Pumped 2006, owner _
Was system pumped as part of the inspection (yes or no): _No_
If yes, volume pumped: _ gallons -- How was quantity pumped determined? —
Reason for pumping:
TYPE OF SYSTEM
X_ Septic tank, distribution box, soil absorption system
_ Single cesspool _ Overflow cesspool
_ Privy
_ Shared system (yes or no) (if yes, attach previous inspection records, if any)
_ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be
obtained from system owner)
Tight tank _ Attach a copy of the DEP approval
Other (describe):
Approximate age of all components, date installed (if known) and source of information _1987 house built, owner
Were sewage odors detected when arriving at the site (yes or no): _No
Page 7 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _721 Middleton Street
_ North Andover _
Owner: _Turner_
Date of Inspection: _6/1/2007
BUILDING SEWER _ X _ (locate on site plan)
Depth below grade: _36"
Materials of construction: _ cast iron _X 40 PVC other
Distance from private water supply well or suction line:
Comments (on condition of joints, venting, evidence of leakage, etc.) _ 4" cast iron thru wall, 3" PVC in house,
no leaks visible.
SEPTIC TANK: X
Depth below grade: _2' _
Material of construction: X concrete — metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: , Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of
certificate)
Dimensions: _101z 5' x 4'
Sludge depth: 5"_
Distance from top of sludge to bottom of outlet tee or baffle: 22" _
Scum thickness: _4"
Distance from top of scum to top of outlet tee or baffle: -
8" -Distance from bottom of scum to bottom of outlet tee or baffle: _17" _
How were dimensions determined: _Tape Measure _
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc _ Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of
liquid at outlet invert. No evidence of septic tank leaking. Inlet & outlet covers has riser exposed._
GREASE TRAP: _(locate on site plan)
Depth below grade: _
Material of construction: _concrete _metal _fiberglass polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _721 Middleton Street-
-
North Andover—
Owner: _Turner_
Date of Inspection: _6/1/20(17
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present (yes or no):
Alarm level: Alarm in working order (yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
DISTRIBUTION BOX X ( locate on site plan )
Depth below grade _18"_
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 -Boz level & distribution equal. No evidence of carryover. No evidence of
leakage._
PUMP CHAMBER: X (locate on site plan)
Pump in working order (yes or no): Yes_
Alarm in working order (yes or no): Yes_
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): _Has riser cover to
grade. Pump was replaced two years ago. Pump ok. Alarm ok, has both visual & audible alarm. _
Page 9 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _721 Middleton Street _
_ North Andover—
Owner: _Turner_
Date of Inspection: _6/1/2007_
SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan, excavation not required)
If SAS not located explain why:
Type
— leaching pits, number: _
leaching chambers, number: —
leaching galleries, number:
_X leaching trench, number, length: _3 trenches 40' long_
leaching field, number, dimensions:
overflow cesspool, number:
innovative/alternative system Typetname of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):—Soil oL Vegetation ok. No sign of ponding to surface. _
CESSPOOLS:
Number and configuration:
Depth — top of liquid to inlet invert: —
Depth of sludge layer:
Depth of scum layer: _
Dimensions of cesspool:
Materials of construction: _
Indication of groundwater inflow (yes or no): —
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: _721 Middleton Street _
North Andover
—
Owner: _Turner _
Date of Inspection: _6/1/2007_
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmazks or
benchmarks_ Locate all wells within 100 feet. Locate where public water supply enters the building
=14'4"
=14'9"
=16'9"
-Boz = 424"
= 50'3"
= 58'10"
= 63'
-Boz = 64'4"
Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _721 Middleton Street_
—North Andover—
Owner: _Turner_
Date of Inspection: _6/1/2007 _
SITE EXAM
Slope _ No _
Surface water _ No _
Check cellar _ Dry _
Shallow wells _ No _
Estimated depth to ground water 4' _
Please indicate (check) all methods used to determine the high ground water elevation:
X Obtained from system design plans on record - If checked, date of design plan reviewed: _9/21/1985_
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain: _
Checked with local excavators, installers- (attach documentation)
Accessed USGS database -explain: _
You must describe how you established the high ground water elevation: _As per design plan, no water 4'below
trenches_
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Commonwealth.of Massachusetts
City/Town of I loll®
System Pumping Record RECEIVED
Form 4
JUN 1 1 2007
DEP has provided this form for use by local Boards of Health.. T e System Pum ,� �v P rd must
be submitted to the local Board of -Health or other approving aut 6OF
ACThI DEPARTMENT
A. Facility Information
Important:
Whenfilling out 1. Syste[n Location:
forms the ►1 %?' V Sy `CA
computer. use
only the tab key Address
to move your
cursor - do not
use the:return City/Town State Zip Code
key. 2. System Owner:
Name
Address (if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record f
1. Date of Pumping �✓1 �
p g Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank- ❑ Tight.Tank
❑ Other (describe)'
4. Effluent Tee Filter present? ❑ Yes 9 -No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:.
6. Syste Pu p..QB \ ��
Name Vehicleticense Number
Company -- .
7. Location re contentsre osed:
Sig.nat r of aul r Date
http://www.mass.gov/dep/water/approvals/t5forms. htm#inspect
t5form4.doc• 06/03 S tem Pum in Record •Pae 1 of 1
YS. _ .P g 9
Commonwealth of Massachusetts
IR
City/Town of NORTH ANDOVER, MASSACHUSETTS
° System Pumping Record
Form 4
GSM
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board. of Health or other approving authority.
A. Facility Information
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
�Q
ieMn
1. System Location:
O21
Address ,y /
City/Town
2. System Owner:
Name
Address (if different from location)
City/Town
B. Pumping
1. Date of Pumping
REC
3. Type of system: ❑
4
MAY 112006
U TH DEPARTMEN
Date
Cesspool(s)
State
Zip Code
State^��� �iJ
Telephone Number
2. Quantity Pumped: C\ Sero
Gallons
Veptic Tank ❑ Tight Tank
❑ Other (describe):
Effluent Tee Filter present? ❑ Yes o
5. Condition of System""
6. System Pumped By:
h
Name_
vG"O�/
Company
7. Location where ntents were disposed: 14
o?O (SY,
Signature of Hau4
http://www. mass.gov/dep/water/approvals/t5forms. htm#inspect
If yes, was it cleaned? ❑ Yes ❑ No
Vehicle License Number
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
DATE,�_.�/4;��- i?
a
M
OWNER & ADDRESS
SYSTEM LOCATION-------
amof eg�� -
DATE OF PlJMPIN-G5t/2,.,-
__QUANTITY P, WED
CESSPOOL NO X.YES,
SEPTIC TANK NO__
NATURE OF SF_RVjCp
R6UrNF
EMERGENCY-,
OBSERVATIONS.
GOOD CONDITIOI__X, FULL TO COVER
HEAVY GREASE BAFFLES IN LACE,
ROOTS
EXCESSIVE SOLI LEACHFIELD RUNBACK
DS- FLOODED
SOLID CARRYOVER- OTIWR EXPLAIN
SYSTEM PUMPED BY
COMMENTS-,
CONTENT'S TRANSFERRED TO
�'►N OF NORTH'ANDOVER
SYSTEM PIPING RECORD
1) A'r'F.:
l'STEM O WMFR & ADDRESS SYSTEM LOCATION -
e (example: left front of house) .
A,,aV1e1/D,7
/7Z�4Ji;
uA't'E OF PUMPIKC: f�Y-QUANTITY i'VMPCOJI`) CALLO.,
C;:aSI'UUL: YES SEPTIC TANK: NO YES
NATURE OF SERVICE; ROUTINE EMERGENCY
ulla(:RVAT1ONSs ,s. -
• GOOD CONylTIM FULL TO COYCit
HEAVY GREASE BAFFLES IN PLACL
ROOTS LEACHFIELD RIJIQACK.,
EXCESSIVE SOLIDS � FLOODED
SOLIDS CARRYOVER AN ER (EXPLAJN)
i 1'a'1 vim PUM PC- o
b BY: tjr! [!•'
c vvulvI I.NTS
UNTI-,NTS TRANSPERRED T0:
,4..1
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
0
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
ou
DATE OF PUMPING: 1 QUANTITY PUMPED Q---V60GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
I
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED _
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:IQG�r�
S
CONTENTS TRANSFERRED TO: IMUTM®iao
42 001
0 6/
APR
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: 3/43 D0?
SYSTEM OWNER & ADDRESS
ZC0� .
-)C Rta�dk �m &
SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: % QUANTITY PUMPED 008 GALLONS
CESSPOOL: NO /""YES SEPTIC TANK: NO
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO:
YES
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
'Y'FOUING"'S WATER ANALYSIS .
DRINKING WATER LABORATORY
— CERTIFIED — r
36 Pelham Rd.
Salem, NH 03079
Laboratory Number: 529
Submitted By: 4 Star Const Co.
26Th 5Th Ave
Haverhill, Puss
Sample Source:
Quick Results, Sample Pick -Up
(603) 898-2504
(603) 898-6526
Sample Date:
Oct 3-87
Lot A -A Milford Road -North Andover
Analysis: According to Standard Methods of Water & Wastewater
Analysis, 15Th Ed. Standard Your results
Comment:
Total Coliform
..... _ .. o per loo mg/1
per 100 ml
O
Chlorides ............25Q
.mg/l..............
30
mg/L
PH ...............
.•.5.to. 8.5 ...............
7.0
Hardness ..........
75 to 150 ma/1
87
mg/L
Manganese ...........0..
...... .............
0.009
mg/L
Sodium ...........
20. to 250. mg/1 ..........
11.1
mg/L
Iron ...................0;
3 ma/1............
0.02
mg/L
Nitrate ................ mg/l..............
1.1
mg/L
Nitrite ................1;0 .ma/1.............. •
11
nig/L
Arsenic ...............:05.
mg/.1
.
0.o
P.P.B.
This sample meets EPA recommended limits
r
Analyst
.I'
Septic Compliance, Inc
affilliate of Thomas E. Neve Assoc., Inc.
April 29, 1997
North Andover Board of Health
146 Main Street
North Andover, MA 01845
Attn: Sandra Starr
Re: Sanitary Disposal System Inspection
721 Middleton Road - Dr. Howard Zolot
Dear Ms. Starr:
..........w^.1.- r"i....i, a�
Y 2199,
T
In accordance with the Commonwealth of Massachusetts, Department of Environmental
Protection, State Environmental Code (Title V), 310 CMR 15.301, paragraph 7, please find
attached a "Subsurface Sewage Disposal System Inspection Form" for your records.
If you have any questions regarding this report or any of its contents, please do not hesitate to
contact this office. We thank you, in advance, for your continued cooperation in these matters.
Very truly yours,
L aui %.aiuviit.
Certified Septic Inspector
Attachment
N.Andlet.sam
• SYSTEM INSPECTORS • • SOIL EVALUATORS • • ENVIRONMENTAL ENGINEERS -
447 Old Boston Rd., US Route 1, Topsfield, MA 01983
Tel (508) 887-8586 Fax (508) 887-3480
Septic Compliance, Inc.
affilliate of Thomas E. Neve Assoc., Inc.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 721 Middleton Road, No. Andover, Ma. 01945 Address of Owner:
(if different)
Date of Inspection: April 24, 1997
Name of Inspector: Paul Cardone
Company Name, Septic Compliance, Inc.
Address and 447 Old Boston Road, Topsfield, MA 01983
Telephone Number: (508) 887-8586
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 inspection. The inspection was performed based on my training and experience in the proper
function and maintenance of on-site sewage disposal systems. The system:
Inspector's Signature:
XX Passes
Conditionally Passes
Needs f irtbq Evaluation By the Local Approving Authority
Date: April 24, 1997
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 to the appropriate regional office 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.
• SYSTEM INSPECTORS • • SOIL EVALUATORS • • ENVIRONMENTAL ENGINEERS -
447 Old Boston Rd., US Route 1, Topsfield, MA 01983
Tel (508) 887-8586 Fax (508) 887-3480
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 721 Middleton Road, No. Andover, Ma. 01845
Owner: Dr. Howard Zolot
Date of Inspection: April 24, 1997
INSPECTION SUMMARY:
Check A, B, C, or D:
A) SYSTEM PASSES:
XX I have not found any information which indicates that the system violates any of the failure criteria as defined in 310
CMR 15.303. 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
repair, passes inspection.
Indicate yes, no, or not determined (Y,N, or ND). Describe basis of determination in all instances. If "not determined", explain why .
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or
tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a
conforming septic tank as approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to
broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system
will pass inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
The system required pumping more than four 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
F)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 721 Middleton Rd., No. Andover, Ma. 01845
Owner: Dr. Howard Zolot
Date of Inspection: April 24, 1997
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 the public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS THE BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT.
Cesspool or privy is within 50 feet of a surface water.
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF
APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS
THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT.
The system has a septic tank and soil absorption system and is within 100 feet to a surface
supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public water
supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water
supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or
more from a private water supply well, unless a well water analysis for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 721 Middleton Rd., No. Andover, Ma. 01845
Owner: Dr. Howard Zotot
Date of Inspection: April 24, 1997
D) SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR
15.303. The basis for this determination is identified below. The Board of Health should be contact 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 water due to an overloaded or
clogged SAS or cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s)
Number of Times Pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater
elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 721 Middleton Rd., No. Andover, Ma. 01845
Owner: Dr. Howard Zolot
Date of Inspection: April 24, 1997
D) SYSTEM FAILS (continued)
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 acceptablewater 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 design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exists:
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).
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 5.00 and 6.00. Please consult the local regional office of the Department for further
information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 721 Middleton Rd., No. Andover, Ma.01845
Owner: Dr. Howard Zolot
Date of Inspection: April 24, 1997
Check if the following have been done:
Y Pumping information was requested of the owner, occupant, and Board of Health.
Y None of the system components have been pumped for at least two weeks and the system has been receiving
normal flow rates during that period. Large volumes of water have not been introduced into the system
recently or as part of this inspection.
Y Asbuilt plans have been obtained and examined. Note if they are not available with N/A.
Y The facility or dwelling was inspected for signs of sewage back-up.
Y The system does not receive non -sanitary or industrial waste flow.
Y The site was inspected for signs of breakout.
Y All system components, excluding the Soil Absorption System, have been located on the site.
Y The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for
condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of
SCUM.
Y The size and location of the Soil Absorption System on the site has been determined based on existing
information or approximated by non -intrusive methods.
Y The facility owner land occupants (if different from owner) were provided with information on the proper
maintenance of Subsurface Disposal System.
6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 721 Middleton Rd., No. Andover, Ma. 01845
Owner: Dr. Howard Zolot
Date of Inspection: April 24, 1997
FLOW CONDITIONS
RESIDENTIAL
Design flow: 600 gallons
Number of bedrooms: 4
Number of current residents: 4
Garbage grinder (yes or no): no
Laundry connected to system (yes or no): yes
Seasonal use (yes or no): no
Water meter readings, if available:
Last date of occupancy: occupied
Type of establishment:
Design flow:
Grease trap present (yes or no):
Industrial Waste Holding Tank present (yes or no):
Non -sanitary waste discharged to the Title V
system (yes or no).
Water meter readings, if available:
Last date of occupancy:
OTHER (Describe):
Last date of occupancy:
7
gallons/day
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 721 Middleton Rd., No. Andover,Ma. 01845
Owner: Dr. Howard Zolot
Date of Inspection: April 24, 1997
GENERAL INFORMATION
PUMPING RECORDS and source of information:
owner said he has it pumped every three years
System pumped as part of inspection (yes or no): yes
If yes, volume pumped: 1,500 gallons
Reason for pumping: To check baffles, to check for leaks, to check structural integrity of the tank.
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or not) [If yes, attach previous inspection records, if any]
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information:
7 years old 9-21-85 B. 0. H. office
Sewage odors detected when arriving at the site (yes or no): no
SEPTIC TANK: yes
(locate on site plan)
Depth below grade: 4' riser to grade
Material of construction: X concrete metal FRP
8
Other (explain)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 721 Middleton Rd., No. Andover, Ma. 01845
Owner: Dr. Howard Zolot
Date of Inspection: April 24, 1997
Dimensions: 10' 6" x 6' 4"x 5' 4"
Sludge Depth: 6"
Distance from top of sludge to bottom of outlet tee or baffle: 1'7"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 4"
Distance from bottom of scum to bottom of outlet tee or baffle: 1' 8"
Comments:
(recommendations 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.)
1 would recommend that a tank with a riser so high it should be pumped every year, and also the risers should be at least 2'6" around
for upkeep purposes, baffles in tact and working, no signs of leaks, tank fairly new structural integrity good.
GREASE TRAP: none
(locate on site plan)
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:
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 721 Middleton Road, No. Andover, Ma. 01845
Owner: Dr. Howard Zolot
Date of Inspection: April 24, 1997
Comments:
(Recommendations 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.)
TIGHT OR HOLDING TANK: none
(locate on site plan)
Depth below grade:
Material of construction: Concrete Metal FRP
Dimensions:
Capacity:
Design flow:
Alarm level:
gallons
gallons/day
Comments:
(Condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: ves
(Locate on site plan)
10
Other (explain):
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 721 Middleton Rd., No. Andover, Ma. 01845
Owner: Dr. Howard Zolot
Date of Inspection: April 24, 1997
Depth of liquid level above outlet invert: Even
Comments:
(Note if level and distribution is equal evidence of solids carryover, evidence of leakage into or out of box, etc.)
equal no evidence of carryover no leaks in or out of box
PUMP CHAMBER: yes
(Locate on site plan)
Pumps in working order (yes or no): yes
Comments:
(Note condition of pump chamber, condition of pumps and appurtenances, etc.)
In very good condition, pumps in good condition,checked wires and switch all looked good.
SOIL ABSORPTION SYSTEM (SAS): yes
(Locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods)
If not determined to be present, explain:
11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 721 Middleton Rd., No. Andover, Ma. 01845
Owner: Dr. Howard Zolot
Date of Inspection: April 24, 1997
Type:
Leaching pits, number:
Leaching chambers, number:
Leaching galleries, number:
Leaching trenches, number, length:
Leaching fields, number, dimensions:
Overflow cesspool, number:
3 trenches approx. 40'
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
normal none none grassy area
CESSPOOLS: none
(Locate on site plan)
Number and configuration:
Depth -top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
Inflow (cesspool must be pumped as part of inspection):
12
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 721 Middleton Rd. , No.Andover, Ma. 01845
Owner: Dr. Howard Zolot
Date of Inspection: April 24, 1997
Comments (Note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY: none
(Locate on site plan)
Materials of construction:
Depth of solids:
Dimensions:
Comments (Note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
13
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to at least two permanent references, landmarks or benchmarks.
__. Locate all wells within 100'.
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IS '9117 4::C CULT 'o J
DEPTH TO GROUNDWATER
Depth to groundwater: 8' no water feet
Method of determination or approximation: Deep hole test performed by Kaminski and Assoc., 200 Sutton Street No. Andover.
td
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector Paul Cardone
Company Septic Compliance, Inc.
Address 447 Boston Road, Topsfield, MA 01983 (508) 887-8586
Certification Statement
I certify that I have personally inspected the sewage disposal system at this address and that the information
reported is true, accurate and complete as of the time of inspection. The inspection was performed and any
recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in
the proper function and maintenance of on-site sewage disposal systems.
Check one:
I have not found any information which indicates that the system fails to adequately protect public health or
the environment as defined in 310 CMR 15.303. Any failure criteria not evaluated are as stated in the
XX FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and the environment as defined in 310 CMR
15.303. The basis for this determination is provided in the FAILURE CRITERIA section of this form.
Inspector's Signature:
Date: April 24, 1997 \
Copies to: Board of Health
Buyer (if applicable) Approving authority:
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SOIL PROFILE DATES
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54
OFFICES OF:
APPEALS
BUILDING
CONSERVATION
HEALTH
PLANNING
Of HORr,4 e
Town of -.
n
,» NORTH ANDOVER
@,OMU9e DIVISION OF
PLANNING & COMMUNITY DEVELOPMENT
KAREN H.P. NELSON, DIRECTOR
Conservation Commision
120 Main Street
North Andover,
Massachusetts 01845
(617) 685-4775
August 20, 1987
• re: Lot AA Middleton Road
A revised plan by Richard Kaminski dated October
17, 1985, was approved for this lot on October 18, 1985.
Sincerely,
Michael Graf
mg:ml
BOARD OF HEALTH
No.Andover, Mass.
APPROVED DATES
Provided:
Title V
-2.5
Reg 6
Reg 10.2
Reg 10.1
SIM .
f
• SUBSURFACE DISPOSAL DESIGN CHECK LIST
LOT #A,
DISAPPROM DATE__La_7 v5
Reasons=
5i -_v9
F PLM1,
The submitted plan must show as a minimum:
a) the lot to be served-area..dimensions lot #,jabatters
b location and log deep observation hoes -;.distance to ties
c location and results percolation tests -distance to ties
d design calculations & calculations showing required leaching area
e) location and dimensions of system -including reserve area
;f) existing and proposed contours
;g) location any wet areas within 100' of sewage disposal system,or
disclaimer -check wetlands mapping
;h) surface and subsurface drains within 100' of sewage disposal
system or disclaimer
;i) location any drainage easements within 100' of sewage disposal
system or disclaimer -Planning Board files
;j) known sources of water supply within 2001 of sewage disposal a .
system or disclaimer
;k) location of arc proposed well to serve lot -1001 from leaching facilit;
(1) location of nater lines on property -101 from leaching facility -
(m) location of benchmark
(n) driveways
(o garbage disposals
(p� no PVC to be used in construction
(q) profile of system -elevations of basement, plumb., pipe, septic tank
distribution box inlets and outleta, distribution field piping and
Other elevations
(r) maximum ground water elevation in area sewage disposal system
(s) plan mast be preparedby a Professional Engineer or other
professional, authorized by law to prepare such plans
Septic Tanks
(a) capacities -15o;6 of flow.. water table., tees.9 depth of tees,
access., pumping
(b) cleanout
(c) 101 from cellar wall or inground swimming pool
(d) 25+ from subsurface drains
Distribution Boxes
(a) slope grreator than 0.08
�b)rip
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Page 3
ORDER OF CONDITIONS LOT AA-MIDDLETON STREET DEQE #242-425
12. The work shall conform to the following plans and additional
Conditions:
Notice of Intent received Aug. 3, 1987 and dated
July 27, 1987 - six (6) pages, for Four Star
Construction, 26 Fifth Avenue, Haverhill, MA by
JJB Associates Inc., 145 Marston Street, Lawrence, MA
Plan entitled "Proposed Site Plan located in North
Andover, MA prepared for Four Star Construction by
JJB Associates, Inc., Scale 1"-30' Dated July 3, 1987.
13. The following wetland resource areas are affected by the proposed
work: bank, land under water, land subject to flooding (isolated
and/or bordering), and bordering vegetated wetland. These resource
areas are significant to the interests of the Act and Town Bylaw
as noted above. These resource areas are also significant to the
wildlife and recreation interests of the Bylaw. The applicant has
not attempted to overcome the significance of these resource areas
to the identified interests.
14. The NACC agrees with the applicant's delineation of the wetland
resource areas at the site.
15. In advance of any work on this project the applicant .shalll notify
the NACC, and at the request of the NACC, shall arrange an on-site
conference among the NACC, the contractor, and the applicant to
ensure that all of the Conditions of this Order are understood.
This Order also shall be made a part of the contractor's written
contract.
16. The applicant, or its successors, shall notify the NACC in writing
of the identity of the on-site construction supervisor hired to
coordinate construction during the work on the site and to ensure
compliance with this Order.
17. Commencing with the issuance of this Order, and continuing through
the existence of same, the applicant shall submit to the NACC a
written progress report every three months detailing what work has
been done in or near resource areas, and what work is anticipated
to be done over the next period.
18. Prior to any activity on the site, a filter fabric fence or a double
row of staked hay bales shall be placed between all construction
areas and wetland areas per Soil Conservation Service or D.E.Q.E.
standards. This barrier shall be inspected and approved by the NACC
prior to start of construction. This row of hay bales or filter
fabric shall remain intact until all disturbed areas have been
mulched, seeded, and stabilized to prevent erosion.
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• Town of North Andover
`�.'•�;.;, ::` ry` HEALTH DEPARTMENT
CHU
CHECK #: QV�.' DATE: / le"I
LOCATION:
H/O NAME:
CONTRACTOR NAME:
Type of Permit or License: (Check box)
❑ Animal $
❑ Body Art Establishment
$
❑ Body Art Practitioner
$
❑ Dumpster
$
❑ Food Service - Type:
$
❑ Funeral Directors
$
❑ Massage Establishment
$
❑ Massage Practice
$
❑ Offal (Septic) Hauler
$
❑ Recreational Camp
$
❑ Sun tanning
$
❑ Swimming Pool
$
❑ Tobacco
$
❑ Trash/Solid Waste Hauler
$
❑ Well Construction
$
SEPTIC Sustems:
❑ Septic - Soil Testing $
❑ Septic - Design Approval $
❑ Septic Disposal Works Construction (DWC) $
❑ Septic Disposal Works Installers (DWI) $
❑ T�itle•5Inspector $
9,00
, Title 5 Report $
❑ Other: (Indicate) $
2460
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer