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HomeMy WebLinkAboutMiscellaneous - 73 CARLTON LANE 4/30/2018 (2)PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 8/9/16 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Repair of Outlet tee By: Todd Bateson At: 73 Carlton Lane Map 106.0 Lot 0020 North Andover, MA 01845 Th I uance of this certi c�te 11 not be construed as a guarantee that the system will function satisfactorily. ' I M c ele Grant Public Health Agent 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.lownofnorthandover.com North Andover Health Department Community and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 73 Carlton Lane INSTALLER: Todd Bateson DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: MAP: 106.0 LOT: 0020 INSPECTIONS Outlet tee INSPECTION: "1 DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: SEPTIC TANK ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Watertightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROLPANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION -BOX ❑ Installed on stable stone base ❑ H-20 D -Box ❑ Inlet tee (if pumped or >0.08'/foot) ❑ Hydraulic cement around inlet & outlets ❑ Observed even distribution ❑ Speed levelers provided (not required) ❑ Schedule 40 PVC Pipe Comments: Map -Block -Lot Commonwealth of Massachusetts 106-c0020 •tEDj --- ------------------ �- BOARD OF HEALTH Permit No BHP -2016-0250 North Andover ----------------------- FEE P.I. $175.00 ----------------------- F. 1. DISPOSAL WORKS CONSTRUCTION PERMIT Todd Bateson ------------------------------ Permission is hereby granted ______ __-- - --------------------------- - ------------------------- to (Repair) an Individual Sewage Disposal System. at No 73 CARLTON LANE - - ----- - } u ust 08 2016 as shown on the application for Disposal Works Construction Permit No. B_ - -__1.6-015_ �D,ated _-- g_____>-__-____-_-- ------------------------------------- ---------------------------- BOARD OF HEALTH Issued On: Aug -08-2016 -------- Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Application for Septic Disposal -System Construction Permit -TOWN OF NORTH ANDOVER, MA 01845 Construct a new on-site sewage disposal system' ff/ S"// L TODAY'S DATE — Full Repair � Component ❑ Repair or replace an existing. on-site sewage disposalsystem* [Kpair or replace an existing system component - What?e- A. Facility Information 73 Address or Lot # An City/Town AUG 0 6 2016 + 2: *TYPE OF SEPTIC SYSTEM*: 'TOWN OF NORTH ANDOVER ➢ ❑ Pump B15-rravity (choose one) HEALTH DEPARTMENT —if pump system, attach copy of electrical permit to application**' ➢ ❑ Conventional System (pipe and stone system) > ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your cerlificalion to install this type of system.) ➢ ❑ Pressure Distribution S.A.S. (No D -Box) ➢ ❑ Pressure Dosed (D -Box Present) S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES = (no further info. needed) NO = (installer must specify brand of filter before DWC issuance) What is the Make? What is the Moder- 2. Owner Information tName '% Address (if different from above) Cityrrown State Zip Code //,ry /d-3 3 Telephone Number Installer Information Name _ Name of ) ) /tgTl Address Cityrrown 4. Designer Information Name Address Citylfown EON ENTERPRISES, INC. 111 ARGILLA ROAD /n%fl- © / 8-1/ r� State Zip Code Telephone Number (Cell Phone # if possible please) Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 TODAY'S DA E $:250.00 T Full Repair $125.00 - Component PAGE 2OF2 A. Facility -Information continued.... S. Tvpe•of BuIldincesidentialDwelling or ❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system In accordance with the provisions of Title 5 of the . Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system th operation until a Certificate of Complla tce has been Issuedby this Board of Health. Application Disapproved. Date Date reasons: For Office Use Only: 1 Pee AttacbedP Yes NO 2.- ProjectAfariager Obligation Form Attached? Yes 1�/ Nq_ 3, ,61,F.1 Ifso) Attach QQ12V ofElectdcal Permit'. , No 4. FoundationAs Burl ? thew construction •ronly); Yes_ No (Same scale as apptored plan) A FloorPlans? (hew construction only). No .P .06attbn fior•pispobgi Oystetit:Oonstrudioo Permit'. Rana 2 of 9 N m i SEP'k`IC V,it 'l M•I�T 3'l '�RO, C1' i A ► r "VWGATIPM As dWNqAAadovar,Ucgwad ft Qa fo,C 4lbO W=tMift•ft.•th6a c faith ��? mp*opctty:� '7 Z,,. /.N .' {Adn an elup�C t�taa} -Ya PUN by zm:9fli2doAM dMad �• Diftl 1 --- '� wh ivd� I uadcrstoad tlu foDoovly bblipdofls fart gementofItia prrojcct: 1. As the 3asts I am.ebl�gatnd in abWa.ollpeaplis sad•Bostd of eakh approved pkmpft to faf= ing any: oa a etp— 3. 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Uadeeei d ceased S�pda.I� i'� / — Potwu lxl � `pRECEIVE® Commonwealth of Massachusetts Title 5 Official Inspection Form SEP 'za ooh Subsurface Sewage Disposal System Form - Not for Voluntary Assessmeet�s J OF NORTH pc)OVER I M °'t o 73 Carlton Lane HEALTH DEPART'�ENT Property Address Bruce Williams Owner Owner's Name information is required for North Andover MA 01845 8/9/2016 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your Neil J. Bateson cursor - do not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name VQ 111 Argilla Road Company Address Andover MA 0 awn City/Town State Zipp Code 978-475-4786 S115 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Ned urther Evaluation by the Local Approving Authority 8/9/2016 Ins dos fignatureV Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Carlton Lane Property Address Bruce Williams Owner's Name North Andover Cityrrown B. Certification (cont.) MA 01845 8/9/2016 State Zip Code Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: After permit from B.O.H., install new outlet tee with gas baffle, inspection from B.O.H., septic system now passes Title 5 Inspection. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins - 3113 Title 5 Official Inspection form: Subsurface Sewage Disposal System - Page 2 of 17 Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. VQ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Carlton Lane Property Address Bruce Williams Owners Name North Andover Cityfrown MA 01845 State Zip Code 8/4/2016 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. RECEIVED A. General Information 1. Inspector: Neil J. Bateson AUG 0 9 2016 TOWN OF NORTH ANDOVER Name of Inspector vqL r Bateson Enterprises Inc. Company Name 111 Arailla Road Company Address Andover MA 01810 Cityfrown State Zip Code 978-475-4786 S115 Telephone Number B. Certification License Number I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ NVsFer Evaluation by the Local Approving Authority 8/4/2016 Inspe Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Carlton Lane Property Address Bruce Williams Owners Name North Andover City/Town B. Certification (cont.) MA 01845 8/4/2016 State Zip Code Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ® N ❑ ND (Explain below): t5ins • 3113 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 2 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Carlton Lane Property Address Bruce Williams Owner Owner's Name information is required for North Andover MA 01845 8/4/2016 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins ° 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System ° Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Carlton Lane Property Address Bruce Williams Owner's Name North Andover MA 01845 8/4/2016 Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other. Outlet tee in septic tank needs to be replaced D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins • 3f13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Carlton Lane Property Address Bruce Williams Owner owner's Name information is required for North Andover every page. Cityfrown MA 01845 8/4/2016 State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone I I of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Carlton Lane Property Address Bruce Williams Owner Owner's Name information is required for North Andover MA 01845 8/4/2016 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 600 t5ins • 3r13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 X Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Carlton Lane Owner information is required for every page. Property Address Bruce Williams Owner's Name North Andover City/rown D. System Information Description: MA 01845 State Zip Code 8/4/2016 Date of Inspection Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Number of current residents: 2 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 9 ( Y 9 (gP ))- Yes Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Carlton Lane Property Address Bruce Williams Owner's Name North Andover Cityrrown D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: State Zip Code General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping.- Shared umping: Date 8/4/2016 Date of Inspection Pumped two years ago, owner 1500 gallons Measured tank Inspect tank & tees Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ® Yes ❑ No Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ine • 3/13 Title 5 official Inspection Foran; Subsurface Sewage Disposal System • Page 8 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Carlton Lane Property Address Bruce Williams Owner's Name North Andover Citylrown D. System Information (cont.) MA 01845 8/4/2016 State Zip Code Date of Inspection Approximate age of all components, date installed (if known) and source of information: 28 years old, 5/23/1988, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 3 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): — Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Partial finished cellar, unable to see piping leaving foundation, 3" PVC in house, no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 2 feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: -10'x 5'x 4' Sludge depth: 3" ❑ Yes ❑ No t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Carlton Lane Property Address Bruce Williams Owner Owner's Name information is required for North Andover MA 01845 8/4/2016 every page. City/town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle N/A 3" N/A = Outlet tee corroded off N/A 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.): Inlet tee ok. Outlet tee corroded off, needs to be replaced. Depth of liquid at outlet invert, no evidence of leakage. Inlet cover has riser 6" deep. Pumped septic tank. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: t5ins • 3/13 feet ❑ polyethylene ❑ other (explain): Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y Owner information is required for every page. 73 Carlton Lane Property Address Bruce Williams Owner's Name North Andover MA 01845 8/4/2016 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5in5 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Carlton Lane Property Address Bruce Williams Owner's Name North Andover citylrown D. System Information (cont.) nee A1QAr 8/4/2016 Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D -box level & distribution equal. Evidence of solid carryover, pumped d -box to clean. No evidence of leakage. D -box has riser 8" deep. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Carlton Lane Property Address Bruce Williams Owner's Name North Andover MA 01845 8/4/2016 Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 field 30'x 52' ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign ponding to surface. Tree & vegetation on top of field, should be removed. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Owner information is - required for every page. Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Carlton Lane Property Address Bruce Williams Owner's Name North Andover MA 01845 8/4/2016 Citylrown state Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 at 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Carlton Lane 8/4/2016 Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 1.00 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately b waw t��4-mac' b t5rns' 313 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 Property Address Bruce Williams Owner Owner's Name information is required for North Andover MA 01845 every page. Cityrrown State Zip Code 8/4/2016 Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 1.00 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately b waw t��4-mac' b t5rns' 313 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Carlton Lane ,p Property Address Bruce Williams Owner Owner's Name information is required for North Andover MA 01845 8/4/2016 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water. '4 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 5/23/1983 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Desian plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Test pit data on design plan shows water @ 7' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 73 Carlton Lane Property Address Bruce Williams Owner information is required for every page. Owner's Name North Andover City/Town MA 01845 8/4/2016 State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 15ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 Summary Record Card generated on 7126/20161:40:09 PM by Karen Hanlon Previous Customer Inactive 5/1/2014 Page 1 Brand Town of North Andover YTD Cons RUTH & BARBARA WILLIAMS Previous Customer Inactive 5/22/2014 Tax Map # 210-106.C-0020-0000.0 METE METE NORTH ANDOVER MA 01845 775 Parcel Id 17654 Reading Account No Cycle Occupant Name Active/Inactive 73 CARLTON LANE Last Billing Date 6/14/2016 2100144 02 Cycle 02 Active BARBARA & BRUCE WILLIAMS 10 Account No. 2100144 1% 73 CARLTON LANE Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ NORTH ANDOVER MA 01845 01 ALL METER SIZE 38.00 /1 11/2/2015 Class 101 Single Family aActual Property Type 1 Residential Zoning2 1 Residential 8/4/2015 Zoning3 1 Residential Size Total 1.27 Acres 9/14/2015 203% 5/4/2015 FY 2017 a Actual 10 6/22/2015 -7% 2/3/2015 1280 aActual UB Mailing Index 3/20/2015 -41% 11/3/2014 Name/Address Type Loan Number Active/lnact. From Until BARBARA& BRUCE WILLIAMS Owner 1250 aActual 73 CARLTON LANE 9/11/2014 22% 5/21/2014 NORTH ANDOVER MA 01845 f Final Bill 3 5/21/2014 THAMES, PATRICIA Previous Customer Inactive 6/27/2008 f Final Bill 73 CARLTON LN N. ANDOVER, MA 01845 JIM & EMILY KIME Previous Customer Inactive 5/1/2014 73 CARLTON LANE Brand NORTH ANDOVER, MA 01845 YTD Cons RUTH & BARBARA WILLIAMS Previous Customer Inactive 5/22/2014 73 CARLTON LANE k METE METE NORTH ANDOVER MA 01845 775 UB Account Maint. Reading Account No Cycle Occupant Name Active/Inactive Bldg Id. 14160.0 - 73 CARLTON LANE Last Billing Date 6/14/2016 2100144 02 Cycle 02 Active UB Services Maint. 10 Account No. 2100144 1% Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 38.00 /1 UB Meter Maintenance Account No. 2100144 Serial No Status Location Brand Type Size YTD Cons 13242563 a Active ERT HH METE METE w Water 0.63 0.63 775 Date Reading Code Consumption Posted Date Variance 5/3/2016 1369 aActual 10 6/21/2016 1% 2/2/2016 1359 a Actual 10 3/28/2016 -65% 11/2/2015 1349 aActual 28 12/30/2015 -8% 8/4/2015 1321 a Actual 31 9/14/2015 203% 5/4/2015 1290 a Actual 10 6/22/2015 -7% 2/3/2015 1280 aActual 11 3/20/2015 -41% 11/3/2014 1269 a Actual 19 12/15/2014 21% 8/1/2014 1250 aActual 12 9/11/2014 22% 5/21/2014 1238 f Final Bill 3 5/21/2014 4% 4/29/2014 1235 f Final Bill 11 4/29/2014 -3% 214/2014 1224 a Actual 13 3/17/2014 -44% 10/31/2013 1211 aActual 22 12/20/2013 -52% 8/1/2013 1189 aActual 46 9/18/2013 277% 5/1/2013 1143 aActual 11 6/18/2013 -5% 2/7/2013 1132 a Actual 14 3/13/2013 -68% 10/30/2012 1118 aActual 39 12/13/2012 -27% 8/2/2012 1079 aActual 55 9/26/2012 156% 512/2012 1024 a Actual 21 6/20/2012 67% Commonwealth of Massachusetts City/Town of . System P•umpin§ Record form 4 DEP has,provided this form for use.by local Boards of Health. Other forms may be`used, but the information' must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility. Information 1. System Location: Left /Right front of house, Left / "tit rear of nous eft/ right side of house, Left/ a Right side of building, Left I Right front of building, Left / Right rear of building, Under deck city/rown state 2. System Owner. C- Name' W Address (if different from location) Citylrown .B. Pumping Recoi 1. Date of Pumping 3. Type -of system: ❑ ❑ Other (describe): J Zip Code State Co L © a` Telephone Number 2-- q -- (,& Date 2. Quantity Pumped Cesspool(s)eptic Tank Gallons ❑ Tight Tank ` 4. Effluent Tee Filter present? ❑ Yeas No if yes, was it cleaned? 13 Yes ❑ Na 5. Condition of.System: 6. System Pumped By: Nell. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents -were disposed: GL _ S: Lowell Waste Water Sign a haul Date 5f0rm4.do6• 08103 System Pumping Record • Page 1 of 1 Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Q Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Carlton Lane Property Address James and Emily Kime Owner's Name North Andover Cityfrown MA 01845 State Zip Code 3-14-14 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information Inspector: Benjamin C. Osgood, Jr. Name of Inspector N/A Company Name 24 Julie Ave Company Address Salem Citylrown 603-458-2883 Tetephone'NVm' b r-= - ' NH State 870 License Number 03079 Zip Code B C:ertiflcation _ I certify. that;i have -personally inspected ithe sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 3-17-14 Inspedo Signature Date The system inspector shall submit a copy of this inspection report to the Ap roving 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 ,sentto the buyer, if applicable, and the approving authority. ***"This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the"MMe or different conditions of use. - I.... �... ...._.....-. Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Carlton Lane Property Address James and Emily Kime Owner's Name North Andover MA 01845 3-14-114 Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. 0 Y ❑ N ❑ ND (Explain below): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Carlton Lane Property Address James and Emi Owner Owner's Name information is North Andover required for every page. City/Town Kime MA 01845 State Zip Code 3-14-114 Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Carlton Lane Property Address James and Emily Kime Owner's Name North Andover MA 01845 3-14-114 Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. .❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Carlton Lane Property Address James and Emily Kime Owner Owner's Name information is required for every North Andover MA 01845 3-14-114 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ® the system is within 400 feet of a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply ❑ ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Carlton Lane Property Address James and Emily Kime Owner Owner's Name information is required for every North Andover MA 01845 3-14-114 page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 Commonwealth of Massachusetts Title 5 Official Inspection Form lu Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Carlton Lane Property Address James and Emily Kime Owner Owner's Name information is required for every North Andover MA 01845 3-14-114 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 1500 gallon tank to 800 square foot leach field Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: ❑ Yes ® No current Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Carlton Lane D. System Information (cont.) MA 01845 3-14-114 State Zip Code Date of Inspection Last date of occupancy/use: Date Other (describe below): General Information Pumping Records: Source of information: Nov 22, 2013 per owner receipt Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): Property Address James and Emily Kime Owner Owner's Name information is required for every North Andover page. Cityrrown D. System Information (cont.) MA 01845 3-14-114 State Zip Code Date of Inspection Last date of occupancy/use: Date Other (describe below): General Information Pumping Records: Source of information: Nov 22, 2013 per owner receipt Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Carlton Lane Property Address James and Emily Kime Owner Owner's Name information is North Andover MA 01845 3-14-114 required for every page. Citylrown state Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Approximately 1981 per inspector knowledge of area Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 3 feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: n/a feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipe looks good in basement Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal ■MM- 0 2' with riser to 6" feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 1500 gallons Sludge depth: >2 ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 73 Carlton Lane Property Address James and Emily Kime Owner Owner's Name information is required for every North Andover MA 01845 3-14-114 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 3" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Measure stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank in good condition. Cross baffle intact. Concrete tee in good condition Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Carlton Lane Property Address James and Emily Kime Owner Owners Name information is required for every North Andover MA 01845 3-14-114 page. City/rown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Desi n rlow' g gallons per day Alarm present: [I Yes F] No Alarm level: Alarm in working order: Ll Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Carlton Lane D. System Information (cont.) MA 01845 State Zip Code 3-14-114 Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box in good condition. No evidence of leakage in or out no evidence of carryover. Distribution to 4 outlet pipes equal. Box has riser to within 12" of grade. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Property Address James and Emily Kime Owner Owner's Name information is required for every North Andover page. Citylrown D. System Information (cont.) MA 01845 State Zip Code 3-14-114 Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box in good condition. No evidence of leakage in or out no evidence of carryover. Distribution to 4 outlet pipes equal. Box has riser to within 12" of grade. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: '� Commonwealth of Massachusetts ro Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Carlton Lane Property Address James and Emily Kime Owner Owner's Name information is required for every North Andover MA 01845 3-14-114 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields 1- 800 S.F. number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Area of system snow covered. No evidence of ponding or unusual vegetation. Probing into stone reveals that stone is clean and dry to bottom. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Carlton Lane ,p Kime MA 01845 3-14-114 State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): Property Address James and Emil Owner Owner's Name information is required for every North Andover page. Citylrown Kime MA 01845 3-14-114 State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Carlton Lane Property Address - - — — James and Emily Kime Owner -- information is Owners Name required for every North Andover MA 01845 3-14-114 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately T(4 ti')4 I.$_ n i3D X 5("o t✓L'"ivi7 (rfFc-t,0 rJ TANK r D r� Cc Y, I v� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Carlton Lane Kime D. System Information (cont.) Site Exam: ® Property Address ® James and Emi Owner Owners Name information is required for every North Andover page. City/Town Kime D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells MA 01845 State Zip Code 3-14-114 Date of Inspection Estimated depth to high ground water: >6 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database - explain: USSCS Maos You must describe how you established the high ground water elevation: Bottom of leach field located 2.5 feet below grade. USSCS maps indicate water table is >6 feet below grade. Before filing this Inspection Report, please see Report Completeness Checklist on next page. r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Carlton Lane Property Address James and Emily Kime Owner Owners Name information is North Andover MA required for every page. City/Town State E. Report Completeness Checklist 01845 3-14-114 Zip Code Date of Inspection ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information — Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: -73 C #az-iD A/ Lei &01272Y ,A .,)ov L)F*-?- Owner's Name: CARL Owner's Address: c ji z t_V>A/ L nr n� cJEY�. Date of Inspection: Name of Inspector: (please print)���+ i A� �.v e �sGrpvo Jac Company Name: �j�w CNCZA�i7 E�U(ErRW(r Mailing Address: (moo 8 G,, e jY w0.L) 6--1 /y 2772 A.voy 0I7 A-1 R Telephone Number: y 7 —,/ZLQ 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 onsite sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000 The system: _asses. _ Conditionally Passes _ Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: The system inspector shall submit a copy of this inZ report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. f 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 TEv—V� OF NORTH AVQ61..' =:'/ ROA90 OF HEALTH II---- ___ - JUN 15 2001 ****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 PROPERTY ADDRESS: 73 Canton Lane, North Andover OWNER Karl Pessinis DATE OF INSPECTION: 6/9/01 PART A VVRTIFICATION (continued) Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: 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 watcr 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: A I Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) ROPERTY ADDRESS: 73 Carlton Lane. North Andover OWNER Karl Pessinis DATE OF INSPECTION: 6/9/01 C. Further Evaluation is Required by the Board of Health: tCondition�sexist which require further evaluation by the Board of Health /31MR re if the systemis faiprotpublic health, safety or the environment. 1. will pass unless Board of Health determines in accordance wi3(1)(b) that the em ' not functioning in a manner which will protect public healtnvironment: Cessp or privy is within 50 feet of a surface water Cesspool ivy is within 50 feet of a bordering vegetated wet d or a salt marsh 2. System will fail unless the B d of Health (and blic Water Supplier, if any) determines that the system is functioning in a manner t t protects th ublic health, safety and environment: _ The system has a septic tank and it orption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a water supply. The system has a septic tank _ The system has a septic nk The system has a private water supply )A SAS and SAS and the SAS is within a Zone 1 of a public water supply. tank and SAS and the SA; Method used to determine is within 50 feet of a private water supply well. k less than 100 feet but 50 feet or more from a "This system p�6es if the well water analysis, performed at a P certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is ee from pollution from that facility and the prese(n f ammonia nitrogen and nitrate nitrogen is equal to or than 5 ppm, provided that no other failure are triggered. A copy of the analysis must be attached to form. Other: Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) PROPERTY ADDRESS: 73 Carlton Lane. North Andover OWNER Karl Pessinis DATE OF INSPECTION: 6/9/01 D. System Failure Criteria applicable to all systems: You must indicate "yes" or `ho" to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool �1 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool v' Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool V^ 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 SAS, cesspool or privy is below high ground water elevation. f Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. 1� Any portion of a cesspool or privy is within 50 feet of a private water supply well. t� 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 v (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 cojindei�aw red a large system the system must serve a facility with a design flow o 10,000 gpd to 15,000 Z� You museither `yes" or `ho" to each of the following:( Me follg crit 'apply to large systems in addition to the criteria ve) yes no the system is within 40 of a surface dr' g water supply the system is within 200 feet of &kfttary to a surface drinking water supply _ the system is located ' nitrogen sensitive err terim Wellhead Protection Area — IWPA) or a mapped Zone II of a publ' ter supply well If you have ans "yes" to any question in Section E the system is"bonsidered a significant threat, or answered "yes" in Soctron D above the large system has failed. The owner or operat any large system considered a significant threat under Section E or failed under Section D shall upgrade the 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 ROPERTY ADDRESS: 73 Carlton Lane. North Andover OWNER Karl Pessinis DATE OF INSPECTION: 619/01 Check if the following have been done. You must indicate `yes" or "no" as to each of the following: Yes No ✓_ Pumping information was provided by the owner, occupant, or Board of Health _ Were any of the system components pumped out in the previous two weeks ? Has the system received normal flows in the previous two week period ? Have large volumes of water been introduced to the system recently or as part of this inspection ? ✓ _ Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up ? Was the site inspected for signs of break out ? _ Were all system components, excluding the SAS, located onsite ? Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of—the-baffles br tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? _,ZO'�- 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 Existing information. For example, a plan at the Board of Health. _ ✓Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [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 'ROPERTY ADDRESS: 73 Carlton LaneSYSTEM INFORMATION. North Andover OWNER Karl Pessinis DATE OF INSPECTION: 6/9/01 FLOW CONDPTIONS RESIDENTIAL Number of bedrooms (design): `/ Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: -5� Does residence have a garbage grinder (yes or no): d0 Is laundry on a separate sewage system (yes or no): 1W [if yes separate inspection required] Laundry system inspected (yes or no): Seasonal use: (yes or no):" Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or no): _&O Last date of occupancy: E t COMNMERCIA AMUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgfl 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 meta readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: Z ' fie A as De vq-- O %-j A) r IL Was system pumped as part of the inspection (yes or no):" If yes, volume pumped: _gallons - How was quantity pumped determined? Reason for pumping: - TYPE OF SYSTEM Septic tank, distribution box, soil absorption system ?_- Single cesspool Overflow cesspool — ivy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the cement 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: Were sewage odors detected when arriving at the site (yes or no): - Page 7 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ROPERTY ADDRESS: 73 Carlton Lane. North Andover OWNER Karl Pessinis DATE OF INSPECTION: 6/9/01 BUILDING SEWER (locate on site plan) Depth below grade: /0 Materials of construction: _cast iron x/40 PVC _other (explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): P/PF In C21J 9 a9 AAsC-'n/1 '� SEPTIC TANK: _ (locate on site plan) Depth below grade: Material of construction: Zconcrete _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: l.5 oo 6-*i-(,oAj Sludge depth: y" Distance from top of sludge to bottom of outlet tee or baffle: go" 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: How were dimensions determined: inCA S o 2 C .5 -TM X Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK i .v o/4 cv,v a, _ CaAic re.T� i PPs r N Te9 tT i� c� i i w s,c iy q0 Svc; GREASE TRAP:01(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 I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) PROPERTY ADDRESS: 73 Carlton Lane. North Andover — OWNER Karl Pessinis — DATE OF INSPECTION: 6/9/01 — TIGHT or HOLDING TANK: Alk (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.): DISTRIBMON BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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, etcj: 1 n /'I /Gi�J/t ��i� F S1 (.1 G21, : NS 9t r Fi^✓ s to PUMP CHAMBER:/ (locate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 'ROPERTY ADDRESS: 73 Carlton Lane. North Andover OWNER Karl Pessinis DATE OF INSPECTION: 6/9/01 PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why. Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: leaching trenches, number, length: leaching fields, number, dimensions: / rCLn 1*'p1c0,y 3L x�o' overflow cesspool, number: _ innovativelaltcmative system Typetname of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): lug* of Ny /ZMAL. SnnE Ite,ig yid✓ /S e-LCA�LJ CESSPOOLS: a (cesspool must be pumped as part of inspectionxlocate on site plan) Number and configuration: Depth — top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: j H (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) PROPERTY ADDRESS: 73 Carlton Lane. North Andover OWNER Karl Pessinis DATE OF INSPECTION: 6/9/01 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. ,SLC, (' / Aila-p 9Cl_D Tospt(ro )0 t-.oc 4 7-10 N Page 11 of 11 Y OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C PROPERTY ADDRESS: 73 Carlton lane. SYSTEM INFORMATION (continued) North Andover OWNER Karl Pessinis DATE OF INSPECTION: 6/9/01 SITE EXAM Slope / % Surface water .v o a► t Check cellar .vu :5'/ . Shallow wells rvo ^ c Estimated depth to ground water Ip feet r� Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: 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: 1)05, -�- C,,i1r MAPS i",7fcIii1 ,.,AxC2 5[-, Gtnlo.— /ten,. i., t TVL k` N N( P>etoI,- Jnp,n(). FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *'"APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT AX-fx e C. A �- f A Ofr-,' �/'� ? s J��� LOCATION: Assessor's Map Number w UN LleArA SUBDIVISION STREET C Arti t fo,✓ [ /I ,✓f 11 C COMMENT OF PHONE PARCEL,/o,', r �' LOT (S) ST. NUMBER 7 r OFFICIAL USE N ADMINISTRATOR DATE APPROVED 10 -a • D! - DATE REJECTED TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD IN>S�EC�OR-HEALTH DATE APPROVED l/ f/ DATE REJECTED DATE APPROVED DATE REJECTED COMMENTS �y i o, e r C,..�_ s C�- i wi --*-- Z>� /- Z>g", PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT Noi RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm SP SOIL PROFILE & PERCOLATION TEST DATA North A71�� ,•_'_ Un RC+-rcc4 e11eL�TO.t-1 G� T,nt Nn. Loc./Subdiv._ Plan —Owner 41�zw Investigator� servers,`r'� s SOIL FROFILES-DATE 1. Elev. 2' Elev. 3. — 4'Elev. Elev. p s �2�,3 p �lz� S3 0 0 TSS Ties to Test Pits 2 2 2 2 3 3 3 3 4 0 4 40 _ 4 4 ---- 5 ei 5 5 5 6 - 6 3 6 6 P&Jz 7 V 7 7 7 — ��s 8 8 8 8 9 9 9 9 _0 10 10 10 Benchmark Location Elevation Datum Percolation Tests -Date ait Number Lativ----- 1 2 3 4 S Start Saturation Z �( Soak -Mins. �5 Start Test -Time DLop of 3" -Time- 3 oil� Drop of 6" -Time V 154 Mins. lst.3"Dro 30 Mins.2nd 3"Drop A`1 PernolAtion Rate Notes & Sketches on Back 4 NORrh OFFICES OF:fir' °m Town of 120 N1�Iin Street APPEALS NORTH ANDOVER North Andover, BUILDING �9'^e^.;.b%"",t9� MassEtchusetcS () I H4 CONSERVATION ss�c"uses DIVISION 01= (61 7) 685-4775 HE -TH PLANNING PLANNING & COMMUNITY DEVELOPMENT Mary Magliato 73 Carlton Lane North Andover, Mass. KAREN H.P. NELSON, DIRECTOR May 17 1988 re= 73 Carlton Lane Lot 28A This office has no record of complaints about the Septic System at this house. Sincerely l � ------------ Sanitarian Bo d of Health SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 J 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this a>Edavit will result in the denial of the issuance of the building it. Signed affidavit Attached Yes .......0 No ....... 0 SECTION 5 'Description otProposed Work(check ae a tale New Construction ❑ Existing Building ❑ 1 Repair(s) 0 Alteratiom is i ❑ Addition Accessory Bldg. ❑ Demolition 0 Other ❑ Specify Brief Description of Proposed Work: O9T rie.i 14rr, I SECTION 6 - RSTIMATM r0NCTR11Tf T1r rneme Item Estimated Cost (Dollar) to be OFFICIAL, USE ONLY Completed b permit applicant 1. Building (a) Building Permit Fee S o � Q� Multi tier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing 0 Building Permit fee (a) x (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number Q11?rTT"%T 7o nWAMD Alr7r= ni'/♦ lA m TT 11L1\ OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, fiT 21 Ct——���� as Chvner/Authorized Agent of subject property %EA horizto act on jn all matters relative to work authorized by this build ng permit application. SN Si rature of Owner Date SEgUON 7b OWNER/AUTHORIZED AGENT DECLARATION as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my and belief 12,xc P n Sr attire of Owner/Agent Date NO. OF STORIES SIZE 5' ' X 4 BASEMENT OR SLAB SIZE OF FLOOR TIMBE S 15 2 3 SPAN DMNSIONS OF SILLS DIMENSIONS OF POSTS DIIbIENSIONS OF GIRDERS HEIGHT OF FOUNDATION _ THICKNESS SIZE OF FOOTING k X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NA fU12AL GAS LINE q e 5 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/IEEeEtor of Buildings Date QWVTTnN t- CiTBiNMRMATTON 1.1 Property Address: 73 5..�� �Tsaai �--RN 1.2 Assessors Map and Parcel 6X k_W,\Rn4 Map Number Number. ff ric /q (5 arcel Number morl 7 (Print) 1.3 Zoning Information: Zoning District PTOD6SCMISC 11 1.4 Property Dimensions: t OLD $r -o' Lot Area /S_0 Fronts $ 1.6 BUILDING SETBACKS ft zj Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 3.1 Licensed Construction Supervisor: Not Applicable ❑ 1.7 Water Supply M G.L C.40. S4) 0 1�.5. �F�l�ood� Information: 1.8 Zone Outside Flood Zona 0 Municipal Sewerage Disposal System: 0 On Site Disposal Sysprivate SECTION 2 -PROPERTY OWNERSIMPIAUTMONly, ll Ac EN 1 1.1 Jul. i G,, lel o It 2.1 Owner of Record (Print) Address for Service ignature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ f;!?:t � e'f ) %a L 7 Licensed Construction Supervisor: License Number 4 �A(A�� s r :,vd • �o�tJc.� Address 3/a---Za� Expiration Date tgnature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number �%MI6e�° tet! �.Z ExpirationDateDate[Address Sii nature Telephone WSJ M X z 0 v rn 0 Z M 0 v r r aaa>. z a yard of Healt-h Orth kidpmerxyaaa. BRMC ST.STEK IBSTA=TICCl CHICK LIST LOT � 2 l� • L oT IOTz8A 13' L9T 27 w,pv ib -To \ Hoa F(vr7lNG y r 5 [ rte srr( LSD AUzoDy DuG Vi? 4F Tf-lt5 51C& awxi�QfVpT(oNs_ I sr Drvx 7S -- 5f 1>157' Say, c:'; irr �v ?No p73,- ;3�),r Iilcr - 14,4 c z"D D1sr j3vx%uLfiifr - 94 3S CAI D o F ,3 ED 1,Y YrRT r 94 o -C t� / i THC,"AAS \ ,\ c ; i .n • ,G ^ i�v• !JJ i j 5-Q, 0 / C A RLToN LA � - 9s3' Sc n I_ r- r /' -��� Board of Health North :.ndover,Mass SUBSURFACE DISPOSAL DESICN CHECK LIST APPROM DATE, Provided! DISAPPRUM DATE Reasons i LOT f iso Title V FAIL CE Reg 2.5 .The submitted plan must show as a minim=: a) the lot to be served -area, dimensions lot #,abutters b location and log deep observation holes -distance to ties a location and results percolation tests -distance to ties d design calculations & calculations shelving rewired leaching area location and dimensions of system -including reserve area f) existing and proposed contours g) location any vet areas Athin 100' of sewage disposal system or disclaimer -check Wetlands mapping surface and subsurface drains vithin 100' of sewage disposal system or disclaimer i} location any drainage easements -$thin 100' of serge disposal system or disclairyr-Planning Board fides J) knoun sources of -�.ater simply -within 2001 of sewage disposal,sya stem or disclaimer location of any proposed well to serve lot -1001 from leaching facility location of water lines on property -lot from leaching facility ro /location of benchmark driveways ' garbage disposals 10 no PVC to be used in construction q) profile of system -elevations of basement, plumb, pipe, septic tank., P distribution box inlets and outlets, distribution field piping and ®cher elevations r.) maximum ground aster elevation in area se -1, -age disposal system (s) plan must be prepared by a Professional Engineer or other professional authorized by lax to prepare such plans Reg. 6 S_etic�Tanks (a) capacities -150% of flow, nater table, tees, depth of tees, access, pumping cleanout P. 101 from cellar -w-all or inground sig pool 251 from subsurface drains Reg 10.2 Distribution Foxes (a) slope g: eater than 0.08 Reg 10.4L::b)I i ,..c t. ��V S Qti i'JE A.0 S Board of Health North Andover,Mass SUBSURFACE DISPOSAL DESIGN CHBCK LIST �e LOT # _2i fz�' APPR UDATE-s_,�c-z___ — Provided 1' .�n4A.44 DISAPPROVED DATE Reasons: Title V Reg 2.5 'kW Reg 6 Reg 10.2 Reg 10.4 — o'K ✓ ae The submitted plan must show as a minimums a) the lot to be served-area,dimensions lot #,abutters b location and log deep observation hoes -distance to ties location and results percolation tests -distance to ties design calculations & calculations shoeing required leaching area e) location and dimensions of system -including reserve area f) existing and proposed contours g) location any Met areas within 1001 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 sevage disposal system or disclaimer -Planning Board files 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 facility (1) location of water lines on property -101 from leaching facility (m) location of benchmark (n) driveways (o) garbage disposals no PVC to be used in construction (q) profile of system -elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and Other elevations (r) maximum ground water elevation in area sewage disposal system (s) plan mast be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Septi Tanks (a) capacities -15056 of flow, Mater fiable, tees, depth of tees, access, pumping 1(b) cleanout (c) 101 from cellar gall or inground swimmdng pool - (d) 25+ from subsurface drains Distribution Boxes (a) slope greater than 0.08 b) sursp v: i/ ✓ ✓ ✓ ✓ /I