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Miscellaneous - 73 RIVERVIEW STREET 4/30/2018 (4)
r T 4 � 0 Ir 1 PUBLIC HEALTH DEPARTMENT Town of North Andover Community -and Economic Development Division CERTIFICATE OF COMPLIANCE As of: 05N This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Repair of D -Box and risers By: John DiVincenzo At: 73 Riverview Street Map 072.0 Lot 0001 North Andover, MA 01845 of thi"e4ifcate skull not be construed as a guarantee that the system will function satisfactorily. Michele Grant Public Health Agent 110 Main St., North Andover, Massachusetts 01845 Phone 978.688.9540 fax 918.688.9542 Web www.northandoverma.gov North Andover Health Department Community and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 73 Riverview St. MAP: 072.0 LOT: 0001 INSTALLER: John DiVincenzo DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS D -box & risers: F BED BOTTOM IN PE TI N: 0 �� 4 lb DATE OS C O DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ 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 Comments: PUMP CHAMBER Comments: CONTROLPANEL Comments: DISTRIBUTION -BOX Comments: ❑ 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 ❑ 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 ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Installed on stable stone base H-20 D -Box ❑ Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets MObserved even distribution Speed levelers provided (not required) S hedule 40 PVC Pipe Commonwealth of Massachusetts Map -Block -Lot 072.00001 BOARD OF HEALTH Permit No North Andover - BHP -2016-0475 - --------------------- FEE $175.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted John L. D1Vincenz0 ------------------------------------------------------------------------------------- - -- -- - to (Repair) an Individual Sewage Disposal System. at No 73 RIVERVIEW STREET as shown on the application for Disposal Works Construction Permit No. BHP -2016-047 Da ed—,'7oilember 17, 2016 b �V ------------------------------------------- Issued On: Nov -17-2016 BOARD OF HEALTH ------------------ ----- – ��-�.��,•. Application for Septic Disposal System Construction Permit - TOWN OF NORTH ANDOVER, MA 01845 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. VQ Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system* A. HI I n 1 TODAY'S DATE - Full Repair Component ❑ Repair or replace an existing on-site sewage disposal system* /� < ®pair or replace an existing system component— What? A/5r Atx- k /2f aer5 11/® NOV 17 2016 City/Town 2.- *TYPE OF SEPTIC SYSTEM*: TOWN OF NORTH ANDOVER ➢ ❑ Pump Gravity (choose one) HEALTH DEPAR ENT -If pump stem, attach copy of electrical permit to application— ➢ MConventional System (pipe and stone system) I ➢ ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.) ➢ ❑ Pressure Distribution S.A.S. (No D -Box) ➢ ❑ 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) 2. What is the Make? What is the Model. Owner. Information 35 h nJ ! armne Name 71� l0Z l/eryi Address (if/`� different from above) City/Town State Zip Code Email address 3. Installer Information 6 its i ��N C��yts� Name} Telephone Number S�6 r! 'J Name of Company Address � � ✓ - a/ 1p City/Town State Zip Code Telephone Number (Cell Phone # if possible please) 4. Designer Information Name Name of Company Address City/Town State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 A0 Aa, � Application for Septic Disposal System Construction Permit - TOWN OF TODAY'S DATE NORTH ANDOVER MA 01845 $ -Full Repair $1775.5.00 00 -Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: esidential Dwelling or ❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage sposal s stem in accordance with the provisions of Title 5 of the Envi o e Co e, as ell as the Local Subsurface Disposal Regulations for the Town of No h nd r. I nd stand that until a final Certificate of Compliance has been issued by th' ar of he installed system is not approved. / % �� e Dat Approve y: ( hard of Health Representative) Date%�� Application Disapproved for the following reasons: For Office Use Only: J 1. Fee Attached? Yes No 2. Project Manager Ohligation Formched? Yes/ No 3. Pump S sy tem? Ifso, Attach co ofElectr' 1 Permit Yes No AppAcantreceived copy of "Electrical Inspection Notes for Septic System ' Yes No Handout? 4. Reviewed approval letter, all paperwork received? es Y No MisSing' 5. Foundation As -Built? (new construction only): Yes No (Same scale as approved plan) 6. Floor Plans? (new construction only): Yes No Application for Disposal System Construction Permit • Page 2 of 2 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: r� T_ (Address of septic system) For plans by Relative to the application of 1 p h d 2 � ► !/ Aou 6eA5Z 6 (Installer's name) Dated `� �� /b o ay s ate And dated With revisions dated I understand the following obligations for management of this project: (Engineer) (Original ate (Last revised date) 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner, contractor, project manager, or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that reauesting an inspection. without completion of the items in accordance with Title 5 and the Board of Health Regulations may result' a $50.00 fine being levied against me and/or 1123� compan�L. a. Bottom of Bed — Generally, this is the first (ls� inspection unless there is a retaining wall, which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection — Engineer must first do their inspection for elevations, ties, etc. As -built of verbal OK (or e-mail to: healthdept@northandoverma.gov) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system, all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade — Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation) and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board ofHealth staff or consultant. - d. Installation of tank, D -Box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer, I understand that I am solely responsible for the installation of the system as per the me of this obligation. 71161 Undersigned Licensed *Septic Installer: da 's Da ) �// (Name —Print) e —Signed) Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Asses: )?-7-r Avg Vt`ew ,S P Property Address Owner's Name City/Town State RECEIVED JUN 17 2009 vv i. ,,QRTH ANDC HEALTH DEpARTMEP rI � � la l� (0/o/09, �� Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information Inspector: .F"--1✓ %�519A, , cw Name of Inspector %fie �o�✓ =tie /y. Company Name /© F" / - Company Address City(rown State Zip Code 5-091- n).-- Z6 ? Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspector's Signature 6 //.?/C> P 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 sant to the buyer, if applicable, and the approving authority. 'This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments J -T - Property Address a/4t p-d't /* e1 _Owner -Owner's Name information is j - required for 1t'/t��� /9 /y (�� A44 01? lV -?/0 � every page.City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 11 . 1 0 /< �✓,e !f r`� f bl± l' Ax-. — II-,oL Ck.y tel' G — F 4.7 71-k a .f `%fit �2- 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/ng ther metal or not) is structurally unsound, exhibits substantial infiltration or exfiltrk failure is imminent. System will pass inspection if the existing tank is replaced with a coptic tank as approvedby the Board of Health. i * A metal septic tank will pass inspection if itis structur y sound, leaking and i a Cert icate of Compliance indicating th tank is less than 20 y rs old is a ilable. ❑ Y ❑ N ND (Explain bel ): t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is --required for /�%il�� �/VG:�v21 �1�< 1� 611 �lD% every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ fired pu ing mor han 4 times a ye due to broken or bstructed pi (s). The Th7bken syinspec ' n if (wit approval of the B and of Health): ❑ipe(s are rep ced Y ❑ N ❑ D ( ain belo❑on i rem ed ❑ Y ❑ N ND (Explain bel w): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the §pafd of Health in order to determine if the system is failing to protect public health, safety or a environme 1. System will pass unle Board of Health termines in cordance th 10 CMR 15.303(1)(b) that the to is not functi ing in a man which wil rote public health, safety and the env' onme ❑ Cess of or privy s within feet of a surfa water ❑ esspool or pri is hin 50 feet of a b rdering vegeta d wetland or salt marsh t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewag isposal System • Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection t5ins • 09/08 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 SA ' wit/50feea private water supply well. ❑ The system has a septic tank and SAS and the SAS i ess than 1feet or more from a private water supply well'. Method used to detemyge distance: ** This system p9dses if the ftil water anal ' , performed/ataEP certified labor ory, for c lifon bacteria indica s absent a the presence f ammonia nitnd nitrate nitro n is equa o or less than 5 p provided at no other f ' re criteria are td. A copy of th an m st be attached to is form. 3. 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 ❑ Zy"' Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ tom' Liquid depth .in cesspool is less than 6" below invert or available volume is less than Y day flow Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 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 Property Address ._Owner's Name �^ / City/Town 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. ❑ �31 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. ❑ K Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ An portion of Any p 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.] ❑ Eg/ The system is a cesspool serving a facility with a design flow of 2000gpd- / 10,000gpd. ❑ L�f_/ 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 syste i in 400 feet of a surface inking;ce ter ply '000 ❑ ❑ th ystem is w' in 200 feet of a t ' utary to a su drinking /dyes" the system is ocated in a nitr en sensitive a (Interim Wellhe d Prot ction Area — IWP or mappe one II of a pu is water supply we If ered "yes" to y question " Section E the stem is considered significa threat, ors" in Section above th arge system h failed. The owner or perator of ny large syed a signific t threa nder Section E failed under Section shall upgra a thesyance with 3 1C 15.304. The syst owner should con ct the appropr" toref the Departm t5ins • 09/08 Title 5 Oficial 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 ,M ?3 —?J- n(io.,-vi e w S i., Property Address C,^ A,^ II,Cc—s✓ f/0 PW l r Owner --Owner's Name information is required for _L�JUd T'Gr/�dylOP�/ 1/j/�i Q every page. City/Town 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? ❑ 0. Has the system received normal flows in the previous two week period? ❑ Re,", 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?. ex,❑ Was the site inspected for signs of break out? 2 ❑ 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: 0/ ❑ Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure 0/ ❑ 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): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): r �� t5ins - 09108 Me 5 Official inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name --information is --required for 0 t r W - ./'l��^ .�yr/�(/�./' every page. CIty[Town State Zip Code Date of Inspection D. System Information Description: 7 �'✓�- �/O(? � , Z �l%tc�. r`l Cj' � fi✓,.Glf l vZ,� Number of current residents: Does residence have a garbage grinder? ❑ Yes Pe"No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes f!;r No Laundry system inspected? P Yes ❑ No Seasonaluse? ❑ Yes No Water meter readings, if available (last 2 years usage (gpd)): Detail: %O l✓i✓ A,14- 7r 444,T y 14S-/'-Zk ct(bN Sump pump? ``❑ Yes No Last date of occupancy: Date '!!;�v Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gall s per'day (gp Basis of design flow (seats/person q.ft., tc.): Grease trap present? ❑ Ye ❑ No Industrial waste holdin ank present �f� ❑ No Non -sanitary wast discharged tot a Titl system? t/ ❑ Y s ❑ No Water meter r dings, if available: t5ins • 09/08 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 Property Address Ownel's Name OlUr 6 11.?/op City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occunnncv/usP- General Information Pumping Records: Source of information: G bra Was system pumped as part of the inspection? ❑ Yes ltd No &T 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 El Privy 7-reAc Hes ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 09/08 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form SubsurfaceSewageDisposal System Form - Not for Voluntary Assessments 2cfft/4-11i'A-art/ s , Property Address Owner Owner's Name ---information is �� required for div iv�r F, Co - every page. City/Town State Zip Code Date of Incnartinn u. system intormation (cont.) Approximate age of all components, date installed (if known) and source of information: IP y fQ,e AITACAa Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Mater' I of construction: cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: ❑ Yes No feet 10 f Fez, XW1a >,- feet Comments (on condition of joints, venting, evidence of leakage, etc.): 9e6�"�r �`.� ��� E✓v/k rhy Ce,� i�T .� i✓�'T �r ,rev ovrde'ice 0'4 4-Je0-14<ayd Septic Tank (locate on site plan): ` aC Depth below grade: Material of construction: feet f concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other (explain) 4eCT241 !P(Ie CZ04 PST ,S: ,OT(Z Tct✓t le.(- �^ c� ft -f- ry 14,E ®�� ,.� d Ie- If e If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes E3/No Dimensions: f0 � -1-;P" 4e(9 -4r SIP" Sludge depth: fir t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Glut ,t,� f `� �✓ �s^� <1 Owner Owner's Name information is required for T-14 ,f�/i/ Vic! ✓e.✓' � �t�� YI� 6 /!.?/ o q 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 u Scum thickness cr d Distance from top of scum to top of outlet tee or baffle e� Distance from bottom of scum to bottom of outlet tee or baffle l6 How were dimensions determined? f lUyg" `T` , Nl,��i fiyf�2t9 ��Llc Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): R OA Atilt ��+ � � � � � �( C� si'��vt ter: 1" �,e t %i 7-& C i f✓yo tt f�/tir�ts !ti t✓('741 Lr Q v 14 L,eye/ eL7- f r k%Q Zv�d..eAe-e- o .G `-ea./ca,-jPz tt-t i -o o e ovr- .temX -r lt-oot It , 1.607 -,rt l- it I r'— A-fJ d It Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness Distance fr top of scum to from bottom of of last pumping: feet ❑ fiberglass [Xolyethylene other ( of outleVee or baffle to bAom of outlet tee Date t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 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 Property Address Owners Name ,vdITti ,hili ,ves /!!IA 0/yjYr b112/ ©� City/Town 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 Dimensions: Capacity: Design Flow: Alarm presen Alarm le I. Date f last pu C ments (cq and float ❑ fiberglass ❑ polyethylene ❑ other (explain): gallons gallon per day Yes ❑ No Alarm in working or Date etc.): Yes I ❑ No " Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Pump Chamber (locate on site plan): Pumps in working order: Alarms in working order: ❑ Yes ❑ No ❑ Yes ❑ No Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I:e,i 6140-r t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form x Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner information is - —required for Owner's Name every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): It Depth of liquid level above outlet invert /`�"z 3 J N/ Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any (� ��d evidence of leakage into or out of box, etc.): ok /�•ewr^f L�ev�/ G�t'TG� f`f i �f�'J6il (o,v z Q(.'r4( ,12 vr.ear G e D �ro //,I Ca! fa ovz.- Pump Chamber (locate on site plan): Pumps in working order: Alarms in working order: ❑ Yes ❑ No ❑ Yes ❑ No Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I:e,i 6140-r t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' M Property Address Gc:6� �✓r`Cccti f-����1 Owner Owner's Name information is --required for ,�/f� every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): JrY Ike 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 cel ool Materials of t5ins • 09/08 groundwater inflow Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address - -Owner -Owners Name _ information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 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 Property Address Owner's Name 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: ❑ nd-sketch in the area below drawing attached separately t5ins - 09/08 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 Property Address 6e^ �"t' CCS. //v Ili e 1 Owner Owner's Name information is ,/ required for 6,0" TLl �/ls�d�2s' 44` � ('r r b //3/ o 9, every page. City/Town State . Zip Code Date of Inspection D. System Information (cont.) Site Exam: 19/check Slope` �e�� )—oo T- E✓ft Y Surface water %( heck cellar 7"C'-111 Shallow wells /"_A"1_e Estimated depth to high ground water: Y 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: Cama ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: -est/ � C�ff� r ��� d /lit! .r%� a? �� i�2 f �V �l. i �✓' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 GILIBERT REA 44 Rea St. NO. ANDOVER, MA 01845 Phone 682.9864 JOB---��e$'�..,.' rd SHEET NO,� CALCULATED BY CHECKED BY— SCALE OF g,ry DATE k F k DATE ..................... i........ ....i .............. ............ ;.............. ;........... ................... ..... ............................................... _......;..............._....:..............:........................ ..[......... . ..... ..... ...... ... 1 PRM MIwas Int, Omloq MM 01471. f r. Owner information is ---required for every page. t5ins • 09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address cvm 4". Owner's Name it/ti �r jr/cC e61A,- AIA c5 % T 1 C l! Y G City/Town State Zip CodeDate of Inspection E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked El"Inspection Summary D (System Failure Criteria Applicable to All Systems) completed Vsystem Information — Estimated depth to high groundwater ketch of Sewage Disposal System either drawn on page 15 or attached in separate file Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 `.i?"�"ii•;sirF`"y 5. .^ f•,'P y•�«it�`:'7�':,��::?'�.,; •.. Cot►on, ealth:of Massachusetts '`"C:ity Town of. NORTH ANDOVER MASS a, ACHUSETTS System Pumping Record RECEIVED 4:. Form 4 DEP has provided this form for use by local Boards of Health. rhe System Pumpingl6 Rec rd be submitted to the local Board of Nesith or other approving a mu: ' t �Yor- t,Ic�I�Tt� 1�njE:c;vEtzA. Facility Information EALTH DEPART.NAENT lrhPortant: When filling out 1. System Location: forms on the . computer, use only the tab key Address to move your cursor • do not CHyRawn use the return .- e ' State Zip Code key. 2. System Owner: r l Name �C:'C�► Address (I.f ddferent from iocatlo ..._ -- city/Town _ State 9Af-c;taZip Telephone Number -- �_�Cf ac rumpl`ng Record _• 1, Date of Pumping S�� • ioats -- 2. Quantity Pumped;---•�---__........ .... Gallons ' Type of system: ❑ Cesspool(s)Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No if yes, was it cleaned? ❑ Yes ❑ No r 5. Condition of System: lA Ve�hiciee license /. Location where contents were disposed: SI ature 0( Hatt Date http:/Iwww,mask'gov/dep/water/ provals/t5forms,htm#inspect a 15form4.doc• 06103 System Pumping Record • Page t of PEARSON C.B.D. " CERTIFIED TITLE V INSPECTION: TEL: 608/962-2687 !MOTE; THIS INSPECTION IS T❑ DETERMINE COMPLIANCE WITH TITLE V REGULATIONS ONLY. THIS IS NOT AN INSPECTION TO DETERMINE LONGEVITY OF THE SEPTIC SYSTEM. SEAN PEARSON COMMONWEALTH -OF MASSACHUSETTS EXECUTIVE 0 -. , • F Aimo r F'i,E, , NMENTAL AFFAIRS DEPARTN99t.'O'Py.Ei� itbNt;I� TA PitOTECTION Al T M TITLE 5 OFFICIAL INSPECTION FORM,in NOMFOR VOIr�JARY ASSESSMENTS ii4''.t.rw .. . • J L SUBSURFACE SE�WAGESPOSAL SYSTEM FORM PART A s CERTIFICATION . M1 10 `(f1H-;tst3l loldw tsOiiL•: ;'if+' 'rl' Property Address: �i "� icut ] SirkA Nov-, bisatiil :�xults)'�ntl .�ri� t t;:.. , Owner's Name: 10-,aN iSC13nr4w �,_,� Owner's Address: C :5o.m4. Date of Inspection: Name of Inspector: (please print) John J _ Sniicy CompanyNameSoucv's Sewer Serv�� yc. Mailing Address: 830 Liyi ngs" • St ree t�fr��`+i. Tewkshur.y. MA -X11 R'%r6,��,t�t's�"t�.�r�y �tii;r. ^:ltse,r,.•.:,� :t,�rt� . Telephone Number: (97R� R 51 _$$39 CERTIFICATION STATEMENT'-7,,�i; .1. sit- ._.:. eif; 0 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 ofthgnspectioal,The,inspection was performed based on my training and experience in the proper function and maultenancet%of on sitessewaga-disposal systems. I am a DEP approved system inspector pursuant to Section 15.*"0 '' itle 5 (310fi1 tii 15.000 ,The system: ps !�►{s3r iltit �U►:ux�in:�c ti .1•� Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails :� ' �3 .• .+ s ,�i1632 i(��� �o �rlrt�r'�/�-:'s'�'l+) �1:J`;;�;;1 �. Inspectors Signature: �.<. wr�;r �r,Date: , T�y� The system inspector shall sub a copy of inspecd •to thb Appr6* j Authority (Board of Health or DEP) within 30 days of compl g this inspection. If the iyhemis s sharedsynem or.has a design flow of 10,000 gpd or greater, the inspector and the system ow'neshaftftfloth1 reportioltheleopropriate 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 sub ytty a zsmit t, :y6(ti ��t3tt �;rt�•Nci:i:i tr: i • :(ti:li:3�i':a i�-soy:' Fli"Ic1',s, :•� ;+•_ r' •, • , 'lis►iptq�r a� (zjti�i�lt�:�h�ad • **t* .4»eramsY ti itc�itai�ttzdr ��• This report only describes conditions at the time of inspection and under the k6nditions 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. Title 5 Inspection Form 6/15/2000 page I'. k�, f Page•2 of 11 Y" ,rti r. OFFICIAL iNSR +'KION' 'ORtVi11TOTt ORVOLUNTARY ASSESSMENTS SiJ�SU;,'pSA+;YST�M INSPECTION FORM RM:CAT1Qrj jc n ued) r ' r v.i ;�.Y"t Property Address: Owner: Date of Inspection-, t.; +'t1.„f:F;�. .r.� . Inspection Summa�Y.it.ryryr Stec oA / AL Y r 1 tg'all of Section D Passes r y! �}, A. System _� ? �, ,;;� b��” �;', �.M lw+�,! ' ; ;:.,�'•�, � ., •' �� , 7� 0rIy 4 5 _Z1have not found aA o fi ` y tipA;lY�ligl! indicat4s tbat'gny. of the failure criteria described in 310 CMR 15.303 or in 310 GMR:1S�304 Y¢st, ,►y#'aaluro criteria' Ant ?+aluated are indicated below. 71 Comments: j" ._ r t t B. System Conditionally One or more system tpponergjs described iti;lhe ?` ditionaj'Pass" section need to be replaced or re aired. The s ste P y m, upoAotnpletion Qffile replaceanent o 'eppproved by the Board of Health, will pass. Answer yes no of dete ; i� (Y N xp or n rmnq ) :irt the. for tue following statements. If "not determined" please explain. . ' � , mix � r �'� � r;!},E ' y 14e septic �i Y � }'rel, i4 tkri.a, i� � , r' z i3t;Sr P ?l1e}d .R or of 1��tlpd�`ac'(whether metal or not) is structurally unsound; exhibits sub t' °'`' f� F ,� , Q11,oi,,4,*1 ge is:imminent. System will pass inspection if the existing tank is replaced I4 MP Y1a r taolc 'al?I 1' 'l?y d- Board of Health. •A metal septic tank will-pass A } structurall uzi of leakin an *Mun ` - Y A g d if a Certificate of Compliance g „ �aM indicatin the tank 1 le t. . ; . ?� qhs ,?tQ� avatilab 5�`k','3';•.;`. , _: '• '. °, fir.;" ^'y' �;;r...q.�.y� ,.�, z;:���:i�'',;.'�. litlabn�l'• • ND explain: cal to f'•F1! :?r?Yc='fids+ 1'�t11u - Observation of sows e.brl $;1�rre 4ttt or, 'high stc water level in the distribution box due to broken or obstructed pipe(s),pr.d a System will pass inspection f PP • i (with approval of Board ofHeallh)r,�„; ,�'�: �Ri�k;� R,tPc(s) at�&:�%���?�fi�rar`u �uli ►, , +c; NaP !.iU 3aifla liar.., t. placed, :iiu t}fir. ails U�tRi s{'i ji{i ;ia �1+i i?(rt 9rdYf{l ('i,�t NI) explain. a.-'.11 .. `� ,��,.•!s•s,•{`;�;I: s�,'���;r, yy�' �;:�u.• ,r 4 r.'+� ., .y$. ;;2 �r�,j ..i. The system required putts �ttg #fir sthaA a'tunes a y dtte,tp,brokcn or obstructed pipe(s). stem will ass inspection TM= The system P pe qn if (wxthtapp Ir •. ar bro ptpg(s) are rep s= A+ 1b 'on" is removed .�� `fit# '1 - t r � � l,�i,t,' .i<:'r•.;Ji:�a '�o ,rFawa'9,tllt'�'�;�,'�!���, ��t�r�v)'z�cl flr�{i�ll`((Q�ty�i�•�t:s :� , ND explain: .:,; : i :.,1 �.�; ;, ; • . ,,£ j y,s, �r t' Page 3 of I I OFFIC �"(SPg . NF'Or,IVOT'FOR VOLUNTARY ASSESSMENTS SUBS A( SFwWAGRDI$F ?SAU SYSUM INSPECTION FORM PART1'A All CFS. + CAT1ON Q4tiuued) Property Address: Lr _ Owner: Date of luslection: C. Further Evaluatiou is "uired by the 004rd of Haalt4; Conditions exist which m9uiM Yitlua<ia� by the $oarEiof Health in order to determine if the system is failing to protect public health, Safety or tl;p cavirotument. 1. System Will Pass gWesl Boar of'-HeWth 49t0ra1nes in mance with 310 CMR 15.303(l)(b) that the system is not funcoquingi11,1man =Wb';h wA1 protect Public health, safety and the environment: Cesspool or Prlvyis-wi*in 4 lW,;QfAWfM Wateris xod :f',,, _._. Cesspool or privy is within 50 fW of a bord9* vogctated we or a salt marsh 916114Vp `'a 1"V14 \uolad .ta�ti„••�: ;� '.�#dW b.ta.tc} t � ti ; it1 ^rt<i �d i t v, !} r,+ •;! ;. sutliU 1q �(It,t�t i sft'Yi 9R : .4 u 1'3 J: t Q'1; r1+llrr+ st , 2. System will fail unless the PO4rd Of Health (and Public Water Supplier, if any) determines that the system is functioning In a numer fiat prat The publl .bealth, safety and environment: .11'. •t .j;4gJt. '".•�'+' 41"ovhq Gan ty sl V ,q— lite sy*m Wwrption system (SAS) and the SAS is within 100 feet of a surfacc wow sgpPiy. ar UtutaQ► to a'surfa supPly;t'' .:gyp ,�,,. '. r_ � .lf+tt+;'t7 :1#3n;la"�`r iN�,' I�t+Jw:►i .il l5i'iti�IlU9 ?iri .'�apr ��+r;f .' , --F� a'F'?S aithcrS�S is withip a Zone 1 of a public water supply. I:,ti ��.ls,► R': tilt l�^hi'tp'rt rrsg4 t" ustfi u�.i 'a c►q t':et1r° :'f .r The system has a "Ptic t Atd. ,,=43bM$AS'is withiu_S0 feet of a private water supply well. The $Y*M W Pl PtiutaAk aJQd!SA& and the E,AS4 less.tban 100 feet but 50 feet or more from a Private WPf AITPIY wcU0'%,M4od used to detgrutino disftea r - , **This system passes if the Well water analysis, performedet a DEP certified laboratory, for coliform bacteria and volatile• organic compounds indicges that the wen is free from pollution from that facility and the presence of ammonia AiM*en and niAPM is equal to or less than 5m provided that no other �1�.Q itRis are � A109,py of tho anakwis.must be auacW,to this form. ' 3. Other: Y1-' ;til . t•i•Ef1tYi, . a , , V �. i s,,t�'fI Cif. I+r!":: +�1f ��tf` JI +1 /, n.r}.•.� LA`t'lr<1 4:X, alit, �Jr,II7 t • - t iti0 tttr�t' is edit: �{ a a1: ��l$t3sJ 1 it f+:..JdYa ;,;.12 ;�, t iJ1J:+. � f ., � • h�]? t7t�J1�(�f J;j7Fi'(tt4 �.Q'tnJr,'tgyr�'tU :tin•,;t, ^4•� .l,;ftt�r cr , 4f u u:.}ti4 1u11013'.l7 C31.'ri.lq.:. , , -Page 4 of 11 OFFICIAL;'iQ 4:;�pT.FO .VOLUNTARY ASSESSMENTS SUBS Y ,; .p'STEM.INSPECTION FORM 1 ,� D • � >i�(,�; ��ns � � �� � h. ITI�•A1�41�'(cQnpnued) �s.' �. Property Address: Owner: :,,f,•.� :.. .• ;; Date of Ins _ • { ....._.... . :._,yin r t,A•'4•�• F . ,, ;; •:,',. � , L�,� � ` � S`� ;ti: �_ }'�'��� � � � ' ��x ,tiTl�.�•� t�•�ts,ct4 -,. ' D. System Failure Crite;ap You mus ilidicate 4:y�s-,Q�� ?"t No!t* l t>a,4peCtlons.� ' a • , (S�t� �Vl, 9 4"IVrV;+ `• Yes K Itt , y'{R ,Bacicuprofsc a ..•. 8 ! vfl YW{ S +st compo iitjdue+to overloaded or clogged SAS or cesspool il, ,, Dischargcorlpq�iAg�p clogged SAS.cr� Vn`"T d or surface waters due to an overloaded or Stat1C ! ;; J'"`' ►r .1� liquid ley�el >p:ttu]!tiou boxtbaYo'4tytlet"invert due to an overloaded or clogged SAS or cesspool ° w •:''a.:ts 1lgsviof a_.l�y t�a� : Liquid de tli to Required p. ism.. 4,51 — t`b"•f law iAXGtt,or available volume is less than %day flow p P� t t} C;R ii} the est y r OT due to clogged or obstructed pipe(s). Number oftimes putgpedes _Z Any portion of , S � 3 _ e, . tO, cwessp�pl'c privy is beloW,Itipii ground water elevation. Any portion of Mp ] or On lvithin'100 gaVpf #.surface water supply or tributary to a surface watcrsuPltlyut 0iW �+•ild� .'i4y, ,I - �y portion�ofVA, *?W1 b a#a.�i4 jix�€a'publi� well. .-.lC Y portion pf ccsspr l { pflY is wubm Sp feet Qf`Ij prlvW water supply well. , Faly porfQfi40f►a PPP -Wo ase 41*0Q l �bNt greater than 50 feet from a private water supply well wtth Ao �q;ter gtXYais�[This,system passes if the well water analysis, performed al's )?I 'c rt a t{akj,FStgry,,for;9W°orm bacteria and volatile organic compounds ladicpa'!'!'p011tltiAA%hg�t�tliat";faellity and the presence of ammonia nitrogen and pitc�k iitrogi## gqual to or lejq:than I ppm, provided that no other failure criteria ;:are Mae red„►A�pp�►� SiSJmust1k )#aebed'to this form.] i • ""j i. f ,t>` ,�*F �•c•Yyi:;4� .�,5' ti :�y kart (Y"o) T4e•ayst;q, i�I ;tiped.tbaot'grw�e•of the above failure criteria exist as .. described in 3„ 10 9 03G foto 41s 4 ,1W1S fbe ,system owner should contact the Board of healthto e: t t jQz � ( at ' !O c ailure. T(r�4T}i Y4rtA�'.7n► �RZ;137�:3�1 niebriu E. Large SysteIRS:k;) w:lx} ;li,tt l 'or r in+ ta:irlll t:a, To be considered a � ` T �e ' k � J;erj'e & li vilth a -design flow of 10,000 gpd to 15,000 You s tit ib »Ft ,i t t to { s'. must indicate either !dyes, Rr;" no to of the Ifo owin (The following criteria a . Pp]X�l,;ldr�e s}�"W"'. it�.additi6 t 'criteria above) yes no r �a•xr :�• s SIG{� i..• e system is wi 40 ` r �._...K�pRlx,_ �.. • � { ��w� � •.r �'i+:^'r.•1r ' "' � *�� OROi �`y 1 the system is i �, —..W 4 ''�, rte} k� :� f �, �•* �x np�, �Watcrsupply ' J'is�d.4 r, :F7• c+�JY`�f.V'•`if , ¢' ..:� •'tY3, . +. y.,'j'••'' . .. the system is locat .iti Aitipg% CAs. _) area (Interim Vf�ellhead Protection Area — IWPA) or a mapped Zone II of a pubbF w S stip y Drell. f. t ,• e �, If you have answered �!► k..: t°'!X gkloA,im,Sectiatt it the systci is colisidered a significant threat, or answered "Yes" in Section D above #ie,lacgo' �+stem ]1 :fa}1ed, '!� 'pyvnW'o -operator of any large system considered a significant threat under Secttop isfailgd.0 Or r Section D sball•upMde. the system in accordance with 310 CMR 15.304. dile syg;m owner should cpgt thC`.a,l?Rm . P nBiRnal office of the Department. G�,a s Page -5 of 11 . :,p .. =`f�.� ', vY.I • .'r' .+fit ,. .! Property Address: Owner: —AJ -12Z Date of Inspection: WPV M1-;VUT R -VOLUNTARY ASSESSMENTS .USP.OSAUSYSTEM INSPECTION FORM if the following have been done.You must ind to each of the Yes No t �' y�•{r ;; :� .r--, / ` Vii•' Pumping a�. ✓ j lUd4d bYft 9wnj1 ;4 VRV% or Board of Health Were an of the ' Y system compolietits•pumped out in the previous two weeks ? '•.,`t...a.,• fit ��• .:;.._..;,,;r�:+r:..I' _ Has the systet4 t'eceivcd pormal flows in the previous two week period ? ���-' � • fir•+' :-`�":��� s; ' • .`., •- -' •..�:'-r,;;-". Have large voligm of wow intrad y aced to tlt� s�+stem recently or as part of this inspection ? _ Were as built plans of. obtained and exatoinedZ.(lf they were not available note as N/A) i•,r t:,, i• `• ,.�r. �, t .. li..;_• f Was the acility �iwed for signs p.11'agc back up ? Was the site inspc�cw� for $igos'of break out ? s ` "��.,�,. s�;;`_ �.<<;:+�;�,�?:1:"� "Y" ..• - :.batt �7•wxr,),r.,., r., . Were all system compopents; excluding the SAS' Ipqpjj Site ? _ 7_ Were the septic tan1G mopholes uncovered, opened,' and the interior of the tank inspected for the condition of the baffles or tecs, matq* / Of consuatio i Uf liquid, depth of sludge and depth of scum ? Was the facility owWtudif maintenancef ,. % owner) p information on th provided with info n a proper subsurface sewga dispQs1 rygtenns ?* „ `� �y• • �� ` ,iUi � r �'- • kms••- +mr�({•++}r+}•..-. .. • ••' �,:;:.' ` "�.. T'baltjtii7�a'ab ik�lti2lij`i(11�FSGit1 •:r.. �' '. . The size and 16ciifio4 of 00 $oil Absorption $�tt„� ���$) on the site has been determined based on: Yes nor Existing inforwatiotLFQr examlet',p plan 4i,the B9 r of Health. -.1—I_ Determined ui * field if jj •y .rr r• t is unacceptable310 Q the critm# rolated to Part C is at issue approximation of distance .. #Ij �;��;c1ii4��Fi+,t}�a:�17777777�i:Ai`Jcl•(i i:�TS1�i gsli�td• �;Z•, , E '. ' � ' r� .. t'.� •.fit `. � •?� ' , :! ;• . .�� ,. ' `�� � ' •j��lt[�t•FS'lt��'ilt5 �'U J�iltU7 itr�q ��,wOtS:} is , ., r •'.1 1 '!••..•. ?.;t •'!�r Vit" '•}" :s. .+��ryn la.tf} i -'Page 6 of 11 OFFICUL IDISM-PTIONF-0RM,�NOT',. -VOLUNTARY ASSESSMENT SUBSTJI�FA . , OISPOS 0 S s i1- - �'(STEM INSPECTION FORM ART INFORMATION INFATION Property Address: 11 t Owner: Date • ��--i.;;'�w+=-:—,,,: of Inspection: x. IDENTIAL CONDITIONS RES + ^{4`"1�' '� '�' Number of bedrooms �"t'nim of bedroom s DESIGN flow based oti'3 101 p e 11Q gpd X # of bedrooms): .Number of current residents.•:.,i'..y FCS •i,� :• �:9"r- Does residence have a e Is 8gAdC� (ygi:Orno)�: Laundry system inspect $4 AyM �r.W40 � =[if yqI6eparate inspection required] Seasonal use es dyes Ox Qo)`^, i a>t .� (y or al w wt u�ave•aq t�di 111po. ii,r . Water meter readings, if MOO* (W 2 Y0= usago (gpcl)Sump Pump (yes )' Last date f occu or cy.o)., �t„ ) Pan :,,fir _• ,• :. ';; �,,:,{, COMMERCIrr�nLi�r//}�•����T��/:iifTc�it�'�t��s�.�,�ci��3ti��x7�tssa�a��z��:11�s{i��:,:'f=•.,. - Type of establishiueqV•`*' Design flow (baseecion 314 CMR 151203)..".- Basis of design flow (seats/porsQ*sq Grease trap present (yos'or no) •' ' �` Industrial waste holding tank present (ye;i or no Non -sanitary waste discharged to dw-Tido 5! system (yes or no): • ' Water meter readings, if ay$ilabl':?.;:�� •;ria. !!cy iii rl;afrE".n��.�F�+ `•its; Last date of occupancy/usp; dj:..�. x .. � v 7 _ : r . t OTHER.ir,r�, (describe): ,, 'Z ► ,.••.,,,,F,.h13A r; rriirh hi���itits ritrt�s��'=f{i3tarr; ��. r+:kitrii��,Ki k't(dvt.GrF E I.0FORMATION';i �a;;• Pumping'Records :y ••H+ , '}� ',:r:;,. Source of infbfmation: - `'`>{ r :•S':k;.�;,.; � • ..f : . �, ,. Was system pumped as thq iaspeo 4A_(+es or q): " If yes, volumepumped: Ono 4.-4Q1ir► Wks u p' ...ri rmined? Reason for uumoin¢:,,,,:ti Lllw,./XI"r=%�ir'. ;:� q r .... plunped dere .-� TYPE SYSTEM ` ' : �� N^•, AeSeptic tank, distribution ,- L _ ~soilibpippt system s�il''�,�t Single cesspool -- Privy F-P4Q(:,tycoi +t ttisEl+ i :zfi iY i of .b rf��t €x�JCi7a etu; i r i �. .s. , Shared system (Yes or i) (if-yes.y ploys laspeetion;ecords, if any) InnovativdAlternativo t ljnglpgy, A a copy of ftCW=t operation and maintenance contract (to be obtained from system owtie�)' Q' -- Tight tank Attach a rppy ofbe, t�DEQ! aPP , �{r/$�. 9,', 'V, , ,J `r .• ?{r," Other de t. , r •' r}s .? ; • ,z, r; y Y 'x _. ( scribe): `-'' 1= �: -, • � : - !`;_. ' . Approximate age of all comnentsinformation: r d lAownA1`source of Were sewage odors detecW,whcu Anivuthesite (yes or no:' Page 7 of 11 OFFICIAL IN&P,EeI'I41 F"r NQUOR VOLUNTARY ASSESSMENTS Si7BSUUA"-',$TLW-AGEMIU.OSAU�SYSTEM INSPECTION FORM ..r ., PAIITiC' kY SY41 M, INF01MA 'ION (continued) Property Address: '%1�� Owner: Date of Inspection: UQ, ' .. :�'x;97•'• ,. .ivy `"�:' . BUILDING SEWER 16 r_mit t 4tv Depth below grade:49 Materials ofconstructi9m I) ;Ngn'�l�r'�Q.j ) y, •�othet� a :.:. (XP Distance from private watef sup�glrQpi}r. O • , Comments (on condition ofrjoiats,' yentiag,. cc of leakes0tc.).. SEPTIC TANK: (locate on site plap)'r3; (GZ a', Depth below grader Material of construction: tre e �metal�fbergl polyett►ylene _other(explain) , . If tank is metal list age: IS age coitfMO by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) Dimensions: _,,[�.•'i' 'jiiialQ h.f',f no :��.xii)(bxi:xl� r=' Sludge depth: Distance from top of s �udge to bottom of optlet tee or baffle; Scum thickness:''r:� .�e�vtixipsTor�ilyt3. Y,�lsup^ z�al�t: c Distance from top of scum to'top Qf outlet tee or bathe:, ! ,f i� ... Distance from bottom of setp>l, .t ' bQ a tgF o rA-. D 'How were dimensions determine � Comments (on pumping recoilenclon&; inlFt and putlet wor bafle condition' structural integrity, liquid levels as related to outlet invert, evidFnce •af kekWe,';tc ); ��.csi��l•� � ��� est GREASE TRAP• o :stte•�lan gs 1AA ,"s;wug3ti Depth below Material ofcons--�.�:�::::.... traction, cotuiate ;;,, tnetl � . fiberglass ;,polyethylene _other (explain): Dimensions: t; Scum thickness: Distance from to of sc of Qutlot:teq or baffle: Distance from bottom of 0 b9'd, qutlei tee or baiil - Date of last pumping: Comments (on pumping reConatgepdatjgtlsl'inlet and -outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evi00;0.af leakagC, y 3.4 Page 8 of 11 OFFICIAL INS1R PIONFORM :: NOT 1F R VOLUNTARY ASSESSMENTS SUBSURTiACR"SEWAGEi'DISPOSAL"4YSTEM'INSPECTION FORM PARTX(Aq SYSTEM INFORMATION (continued) Property Address; A Owner: Date of Inspection: TIGHT or HOLDING TANK; (Wk must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete 'metal.l-fi;,j 4b`rgiasspolyethylene other(explain): Dimensions: Capacity: ons Design Flow eallous/day _: Alarm present (yes or no): Alarm level: Algm j4 working ordei (yes or no): Date of last pumpmg: Comments (condition of Tl — 'and float switches, etc.): . to el., +t: tflU,s� DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above Quoit invert: !r allt}:d zr� Comments (note if box is level and distr_ioutiou to outlets equal; any evidence of solids carryover, any evidence of leakage into or out of box, etc.): / dlse nK`�t.'C�'� `�4,V I .)ti '{}l,/i :li l�i%±� a�IM �t►'ik4� Ml �i ti ' 01 PUMP CHAMBER.� on V site ` OCate flan Pumps in working order r no): ' ' �J. , .— Alarms in working order (yo; or no); Comments (note condition of pump G11aW 4, condition of pumps and appurtenances, etc.): Page 9 of 11 . O 'FICIAL, I11i$FCT,�QNTPRN XQ'nFJDR VOLUNTARY ASSESSMENTS SU$SVAFAC SkW,.AC* )DlSrOSA,I,, SYSTEM INSPECTION FORM PARM'I SYS AKMORMTI.QN &ontinued) Property Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): V (locate on site plan, excavation not required) If SAS not located expigiA jy r , +,,, �r, w?tj c�,,ri t :.: i s� w c:,.► a,4 vbo Tyle leaching pits, number; ping chambers, number. leaching galleries, number. leaching trenches, number, len : /[ leaching fields, number, dimensi 4 overflow cesspool, number. imnovativelalternativo system TypOname of technology: Comments (note condition of soil, sips of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): CESSPOOLS:cesspool must be pumped as part of inspoctionXiocate on site plan) Number and co Euration; 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 49), Comments (note condition of-soi4 signs of hydt We fedure, level of ponding, condition of vegetation, etc.): PRIVY:4 ovate on site plats) -„ Materials of construction; Dimensions: Depth of solids: Comments (note condition of soil, sighs of 11ydraulic Wum, level of ponding, condition of vegetation, etc.): 9 1 Page 10 of 11- - r OFFICIAL, INSPECrI1 o DrFOW4. gOTFOR-VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAG SPOSAL;SYSTEgINSPECTION FORM PART:QaI SYME1Vl.IMORNATION (continued) Property Address: Owner: MA j Date of Inspection: JJU 0941AVI*sa,nalq 414 ut; a4:.s+ui1' SKETCH OF SEWAGE DISPOSAL $XSM Provide a sketch of the sewage disposal syskm WIV*8 006 tQ At least two pemment reference landmarks or benchmarks. Locate all wells within,100 fmtl,�-* P)l1b.4W4W suPplXkAtm the building. atttNe, C.f • ;: ,��U� ynu�b ,ani111iu'�i4 i�y.71 �� tulisi ��fu�b�{d #o zr .: , Page 11 of l I OFFICIAL INSPZGTION FORM = NOT FOR VOLUNTARY ASSESSMENTS SUBSURFAC9*,U VAC�R.OISPOSAL SYSTEM INSPECTION FORM FPART C' " EM INFORMATION (continued) Property Address: y% Owner: t }, Date of Inspection: j'°•i SITE EXAM Slope „ Surface water Check cellar Shallow wells... irA , *s :/ r.t f{ t i .•`.tz�Y �rD �;f,,' tri }�"h"4• 2 r, c.�' + , . t 7i! fT..; r r,�t, �r 7S .. 7'yZ 1 i I, lr. Estimated depth to ground, ,ik Please indicate (check) all methodstonne the high rpµnd water elevation: btained from system design platy on`tard . If checked; date of design plan reviewed: Observed site (abutting pmgc0Y*W.440p holo: witbut 15Q Ieet of SAS) Checked with local B l' Checked with local excayatgri;"nstUres! (Mach documeption) Accessed'USGS databaap-oiait' ;:'%' •_�, er` You musst� describeou established the hl�b ground water elevation: /� 11►/G , ! �a� i�eN: �+ . "Awi..a/1.- iQ.i %� d/1 • ' /A A 14.4n��YD. n� CA t GILBERT REA 44 Rea St. NO. ANDOMI R, MA 01845 Phots '66882.9684 . - 1rC•tN la t. l .}l SHEET NO. 0 CAICVLAT90 /Y._ _ DATE CNECKEP 6Y DATE _ SCALE a1 `r4 i;efxrtc, 'Its � i . ........ .. . Ken,, Te, $,04, "7ill 7 7c,6 A 17 C-00 c- . i • 08;23,02 FRI 1+:43 FAX 978 854 9$73 NoR'I'H ANDOVER DAM• a• W .r1W �pto VMV1Rb1N•r W 1 i N N N V N N N N N N N N N N n 1 M o r I .6C7j! �iN.6rCJN.►+ W N i 1 � M �VN1 V1 w0 ;1414N NNNN �J J V Vyii�iN �p V W V wwww��km M C3 V N W- A ao.1Vo�c a0 �iyNiVv�.►�jN�V0VW rpt/► •WNW�r+j' W.0 r q� m rV�'10 VW1m R ar�l�}1VY'1 N �p14 Nir�NyWf4-m •, iv OW Fm �WPyyMW{r��Pi XVyy11Ni`N� /F•i CWP WC �' mNM!�pi1V1V1 N aw�IDC.tq©cwwoOw• I� y •=�io��ii�f'oow�so� w r♦yl J •� i V1 0 f� wl %n 4A i r,A •0 0� 4� T v�1AV'sVIV'1• i70�Q©�� H N 1 N-401 � 0Ao W r4 A 46 NW r WWN•M1HN vwnCOA NR �W ii O�• w� r V P � ."�•R'":Mir';. zoul �I1+eT=I M Date: � Town. of North Andover, Watorshed Septic Sysi servicing Report Homeowner: _ (&0 cklW_ Pumper : Street : T�,� �/, Address: Phone 1� 1:_ Phone Nature of Service: Routine Emergency _ Observations: Good Condition Full to Cover` Baffles in Place I'l Leachfield Runback Excessive Solids Heavy Grease �►►((' Jppp(jjj\ 1 00tJ Other (Explain) Description of Work; Comments: GILBERT REA 44 Rea St. NO. ANDOVER, MA 01845 Phone 682-9864 joa -73 S7— SHEET NO. OF CALCULATED BY CHECKED BY DATE .� v — DATE - PRODUCT 204.ees Inc.. Gmtm, Mass. 01471 go Vis! 3� ,ki :y r � �Ar 1 -7-5 9,u&(ve\,\j - a O 9(k ��d�cfra C ('-2z-15- -7! Z -Z C j r r)_ Td See [ 7-1 i- -5 d- �-- (4R� of ti ��Th Ati POVE)'� , MA . A FU CAti T SA v 0 WAtE� 50ppVt QF(j )Wlj ❑ ojELL ,�P ouCDIYJT6 SS � StPT"Ic Sy s Tom► PE -s -►&O ,—.....__.. ,.� PPi{ov t�D �15APPK�VED ��45oNS = DwL 2 DAr�� APROvwG /unlo�iry PIA&) DESS &A.)6 t aAv UN V7 1AF, 6 c7 4v4T(ol,j )tiSPt�GTlo&j Colov)To)JS 5tPV(6 SYSTEM t J S -W U-ATlOAJ �ArE-ll�--i�/JSS El FAIL (�l5(�F.crlon� P(PE Ff2,t)xA t tock IA)Ybc TjoAj5 C1�-any) RFO'50 rvs FVAL APP )VAL DAT -C 1-0 T/30t� Ll Pry SS `O R)L APPi�ovvJ6 6u 09/25/2013 10:31 FAX 19787412012 A&ASERVICES Department of Public Health & Department of Labor NOTIFICATION OF DELEADING WORD Alt ucctions of this form must be completed in order to comply with the notification requirements of M.G.L. C. 1116197, 454 CMR 22.00 and 105 CMR 460.000, as most recently amended Contractor performing project Chris ZOrZy License 0 DC000440 Exp. Date 6/7/2014 Lead Paint Inspector eon Mlsoh ADDRESS OF PROJECT: Date of Inspection 9/23/13 License A IM984 Exp. Date Street Address 75 Rlvervlew Street Apt. Number City North Andover, MA Zip 01845 Property Owner John Tortorelli Address 73 Riverview Street, No. Andover, MA Telephone Number 978-500-5096 Deleading Method!@ Wet/Dry Scraping []Demolition MCovering Tf "Othce' selected, pleaee Check one: Dwelling is multi -family ❑ Heat Gun ❑ Caustics Other Single-fumilY� 0 Liquid Encapsulant 0 Replacement Olhe1--L=— Start Datc 10/7/2013 Completion Date 10/8/2013 When will work be done: AM x PM X (Specify times on site) Weekends" Project Supervisor Name Willie Woods License # DS3534 Exp. Date 11 /6/13 Worker's Compenmation Policy Number 0243M815 Carrier Traveler's In case of emergency contact Chris Zorzy 7 el. M f 976 )741-0424 (Contractor's Representative) DE1YADING CONTRACTOR 14002/002 The undersigned hereby states, under the pains and penalties of perjury, that he/she has read and understood the Commonwealth of Massachuxetts Deleading Regulation -4, 454 CMR 22:00, and the Lend Poisoning Prevention and Control Regulation", 105 CMIZ 460.000, and that the information contained in this notification is true and correct to the best of his,P?er knowledge and belief Company Address Telephone Number OVER4 NG This sketch was drawn for mortgage inspection purposes only and is not to be recorded, or co strued as an instrument survey, it should be further understood that if an instrument survey is accomplishe at a later date we will not be responsible for any changes that occur. This mortgage inspection is based upon technical standards as adopted by the Massachusetts Association of Land Surveyors and Givill Engineers Inc. alb .0, !,v N .ti MORTGAGE INSPECTION SKETCH PEt61 Y County, Mass. in .Qr� ' - c "' owned by _Bm:jamirt. Y, Sands00 - '� Date: _.�ij) i2..r.19$5— :A„n Book No.1_ Page No. 0 L.C. Cert. No. _.... _..... . __.._..._. tSti 0: if In my professional opinion the building and ,s lot lines shown on this plan are approximately JOHN � located On the ground as shown hereon and THOMAS z•rh't- that'llhey have conformed to the Zoning Laws 1 111Of th;o � p at thr: time I COn'rtfuCi10� 0��� * G .� On this date,._._. `-. �Y. �5. - I certify SUIRtSu� that to the best of my knowledge and belief the 6k t �.. parcel 85 shown does fa!I within the Flood -� Plain as shown on the FEMAfFIA National FI od / Insurance Prooram Maps dated _ (�- Ze $ ,, .. Y'en�a.a .--• • erg -'��� v YUNIT9 ENGINEERING CO. IN �__ Holbrook, Massachusetts 021113 w_ rltsncy-. 1. rnv J i h f !s n h MORTGAGE INSPECTION SKETCH PEt61 Y County, Mass. in .Qr� ' - c "' owned by _Bm:jamirt. Y, Sands00 - '� Date: _.�ij) i2..r.19$5— :A„n Book No.1_ Page No. 0 L.C. Cert. No. _.... _..... . __.._..._. tSti 0: if In my professional opinion the building and ,s lot lines shown on this plan are approximately JOHN � located On the ground as shown hereon and THOMAS z•rh't- that'llhey have conformed to the Zoning Laws 1 111Of th;o � p at thr: time I COn'rtfuCi10� 0��� * G .� On this date,._._. `-. �Y. �5. - I certify SUIRtSu� that to the best of my knowledge and belief the 6k t �.. parcel 85 shown does fa!I within the Flood -� Plain as shown on the FEMAfFIA National FI od / Insurance Prooram Maps dated _ (�- Ze $ ,, .. Y'en�a.a .--• • erg -'��� v YUNIT9 ENGINEERING CO. IN �__ Holbrook, Massachusetts 021113