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Miscellaneous - 742 BOXFORD STREET 4/30/2018 (2)
Dhvner inlbrmafion is required for every page. Important: When filling out foi":ns on the computer, use only the tab Ivey IX) move your cx.mor o do not lase the return Ivey. Commonwealth of Massachusetts lritle 5 Official Inspection IFooirm Subsurface Sewage eDisposal.System Form - Not for Voluntary Assessments Property Address Ee Y' Y^ 1 S _ isarae .7 cayfrovm state Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms nue not be alt r .4ag P Y way. Please see completeness checklist at the end of the -form. C A. General Information 1. Inspector: Name of Inspector Company Name Company Address Cityffoyin Teleph ne Number B. Certification IP5 T 110il 71.5 V LA- 6 09 L State_ Zip Code 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 ❑ Needs Further Evaluation by the Local Approving Authority InsotVors Signature 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. ISins • 03113 Me 5 Offtlel Inspection Fom Subsurface Sewage DlepoW System • Pegg 1 of 17 Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspec:ti®n (Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address City/Town B. uertltication (cont.) 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" br "not determined" (Y, N, ND) forthe Ilowing statyements. If "not determined, " please explain. The septic tank is metal and over 20 years old* or the sept tank (whether metal or riot) is structurally unsound, exhibits substantial infiltration ore tration or tank failure is imminent. System will pass inspection if the existing tank is replacedwit a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it js"'structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less,,than 20 years old is available. ❑ Y ❑ N ❑ Wz( xplain below): Title 5 Official Inspection Fpmt Subsurface Sewage Disposal System • Page 2 of 17 t5in5 • tl3113 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address — Owner Information is Owner's Name required for every page. Citylrown State7_Ip 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 El 11N ❑ ND xp/Iain below): ❑ distribution box is leveled or replaced ❑ Y 11 N ND (Explain below): ❑ The System required pumping more th system will pass inspection if (with a o ❑ broken pipe(s) are replad ❑ obstruction is removdd� 4 times a year due to broken or obstructed pipe(s). The gal of the Board of Health): ❑ Y U N ❑ ND (Explain below): ❑ 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 nvironment. 1. System will pass unless Board of Health deterr�1 nes in accordance with 310 CMR safety and t that the system is not functioning�jrt'a manner which will protect public health, safety and the environment: �'" ❑ Cesspool or privy is within 50 fed(of a surface water ElCesspool or privy is within_M feet of a bordering vegetated wetland or a salt march rsina .03113 Title 5 official Inspectlon Form Subsurface Sewage Disposal system • Page 3 of 17 Owner Information is required for every page. Isins - 03/13 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 �-a- -? dX-, I1rj lz� -�_ Property Address Owner's Name City/Town B. Certification (cont.) State Zip Code Date of Inspection 2. System will fail unless the Board of Health (and Public: Water Supplier, if any) deterimes 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 systern (SAS)he SAS is within 100 feet of a surface water supply or tributary to a:surface wat supply. EJThe system has a septic tank and SAS and the SAS is withiM a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS isA ithin 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 anal is, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presencd of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other a'ilure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: P J D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ E?� 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 ❑ 0" 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection l� Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;Lperty Address — Owner Information is Owner's Name required for every page. Cityfrown 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 Bess 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.] ❑ ❑ This system is a cesspool serving a facility with a design flour 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 eaf the following, in addition to the questions in Section D. r Yes No ❑ ❑ the system is within 400 feet `'Pf', surface drinkiing water supply El El the system is within 200 fe5et of a tribt.itary to a surface drinking water supply ❑ ❑ the system is locate:0in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA or �rfiapped Zone II of a public water supply well If you have answered "yes" to any uestion in Section E the system is condidered a significant threat, or answered "yes" in Section D ove the large system has failed. The owner oroperator of any large system considered a signific t threat under Section E or failed under Section D shall upgrade he system in accordance wit 10 CMR 15.304. The system owner should contact the appropriate regional office of the Department. I51ns • 03113 Tille 5 Official Inspection Form Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official In _ spection Fore Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Information is Owner's Name required for every page.City/7own 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? This size and location of the Soil Absorption System (SAS) on the site has been determined based on: u ❑ 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): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 1H 7 �t:�>i✓4 r�-. �- t5in5 • 03113 Tille 5 Oficial Inspection Form subsurface Sewage Disposal System • Pape 6 of 17 a Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspections Form Subsurface Sewage Disposal System f=orm - Not for Voluntary Assessments Owner's Name City/Town D. System Information Description: State Zip mode Date of Inspection Number of current residents: Does residence have a garbage grinder? ❑ Yes t No Is laundry on a separate sewage system? [if yes separate inspection required) ❑ Yes ff No Laundry system inspected? 1 I� ❑ Yes ❑ No Seasonaluse? !!! ❑ Yes LJ 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.,et Grease trap present? Industrial waste holding tank present?/ Non -sanitary waste discharged t the Title 5 system? Water meter readings, if available: Yes ❑ No DatC�cu�S. <3a110ns per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No tSins - 03/13 Title 5 Official Inspeotlon Form Subsurface Sewage Disposal System • Paye 7 W f 7 Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Forrmi Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Cityrrown u. system Information (cont.) Last date of occupancy/use: Other (describe below): State Zip Code Date of Inspection uate General Information Pumping Records: Source of information; IJ 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: It 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): 15ins - 03113 Title 5 Official Inspection Forth Subsurface Sewage Disposal System • page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address -- Owner Information is Owner's Name --` 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: Were sewage odors detected when arriving at the site? ❑ Yes ❑/ No Building Sewer (locate on site plan): Depth below grade: -� Material of construction: feet 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.): t5ins • 03113 Septic Tank (locate on site plan): Depth below grade: Material of construction: concrete ❑ metal If tank is metal, list age: ❑■ feet ❑ polyethylene ❑ other (explain) years Is age confirmed by a Certificate of Compliance? (attach a cagy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth Title 5 Offidal Inspection Form Subsurface Sewage Disposal System • Page 9 of 17 r Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspecti®n Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Cityrrown State Zip Code D. System Information (cont.) Septic Tank (cont) Date of Inspection 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 U How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): lQ J " C Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness Distance from top of scum to Distance from bottom of,-1/cur Date of last pumping: EN of outlet tee or baffle feet ❑ polyethylene ❑ other (explain) to bottom of outlet tee or baffle rsi s . r,aiia Date TWO 5 Olticlal Insimdon Form Subsurface Sewage Disposal Syslefn • Pape 10 of 17 a— Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Formi Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address vW11G1 5 IVGrllti 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 Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Capacity: Design Flow: Alarm present: Alarm level: Date of last pumping: Comments (condition of Pumped at time of inspection) (locate on site plan): ❑ fiberglass ❑ Pf`yethylene ❑ other (explain) gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date float switches, etc.): ` Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No csins • 03113 Title 5 Of clal Inspection Form Subsurface Sewage Disposal System • Page 11 of 11 �r �y Owner information is required for every pane. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property City/Town u. bystem Information (cont.) State Zip Code Date of Inspection Distribution 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, etc.): i _��� it i � � 'Y' �r-' 1\� fir`•, lL�---�`�..—HS�f <� � L'} ti J 1� ti — 42 hisl ILL Pump Chamber (locate on site plan): Pumps in working order: j ❑ Yes ❑ No Alarms in working order:11Yes ElNo Comments (note condition of pump chamber, Gond' ' n of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 03113 Title 5 OKdal Inspection Form Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts Title .5 Official Inspection Fora Subsurface Sewage Disposal S stem Form - Not for Voluntary Assessments Property Address Owner Information is Owner's Name — -- required for every page. City/Town State ZIP Code Date of Inspection D. System Information (cont.) Type: I y TypeEriame of itechnology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): r. i v Cess Fools cess ool must b P ( p pumped as part of inspection) (locate on site plan) Number and configuration Depth - top of liquid to inlet invert Depth of solids layer /J Depth of scum layer Dimensions of cesspool f Materials of construction Indicati f on o gioundwater;tfiflow ❑ Yes ❑ No t5i0s • 03/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System I Page 13 of 17 leaching pits number: ❑ leaching chambers r number: ❑ leaching galleries number.- umber:❑ 0 leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative s stem y TypeEriame of itechnology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): r. i v Cess Fools cess ool must b P ( p pumped as part of inspection) (locate on site plan) Number and configuration Depth - top of liquid to inlet invert Depth of solids layer /J Depth of scum layer Dimensions of cesspool f Materials of construction Indicati f on o gioundwater;tfiflow ❑ Yes ❑ No t5i0s • 03/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System I Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form p � n7 Subsurface Sewage Disposal ystem Form - Not for Voluntary Assessments Property Address Owner Information is Owner's Name required for every pale. CitylTown 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 fail e, level of ponding, condition of vegetation, etc.): 15ins - 03113 Ttlle 5 Official Inspection Fprm Subsurface Sewage Disposal Syslem • Page 14 of 17 Commonwealth of Massachusetts 'Title 5 Official Inspection Form Subsurface Sewage Disposal Syst m Form - Not for Voluntary Assessments < Nroperty, Address Owner — Information is Owner's Name required for every page. City/ Iown 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: LJ hand -sketch in the area below 13 �� �tk I It, D drawing attached separately } io Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 15 of 17 t5ins • 03113 r_ Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 15 of 17 t5ins • 03113 Owner Information is .required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .� _ �'�41rd Address Owner's Name Cityr town D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells / Estimated depth to high ground water: State Zip Code feet Date of Inspection 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 u 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 USG$ database - explain: You must describe how you established the high ground water elevation: 3, D I r rAA I � �i �_ t-' t�. "r t � t✓ L� cif -F- I CS Before filling this Inspection Report, please see Report Completeness Checklist on next page. tslns • 03111Title 5 OtScial InSTmodlOn Form Subsurface Sewage otsposal System • page 16 of 17 Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Forme Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner's Name Cityfrown State Zip Code Date of Inspection E. Ree/port Completeness Checklist lJ 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 Ltd' Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i5ins - 03173 ntlu 5 OhSdal Inspection Form Subsurface Sewage Disposal System • Page 17 of 17 .a Gf ,MONTH 1y 7962 3: • +.o , o of h l 9 • . Town of North Andover HEALTH DEPARTMENT ,SSwCNN`+t� CHECK #: a.96 8 DATE:: O/7 LOCATION: H/O NAME: CONTRACTOR NAME: u Y. Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ Title 5 Report p6,,55 $50- 0 .5a ❑ Other. (Indicate) $ Head Agent Initials White - Applicant Yellow - Health Pink - Treasurer Owner information is required for every page. J-- J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 742 Boxford Street Property Address Dionne Torre Owner's Name No. Andover City/Town MA 01845 State Zip Code 06/19/07 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your Benjamin C. Osgood Jr. cursor - do not Name of Inspector use the return key. New England Engineering Services, Inc. Company Name Q 1600 Osgood Street Suite 2-64 Company Address No. Andover MA 01845 rein City/Town State Zip Code 978-686-1768 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 /o�2 Inspect s Signature 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. 742 Boxford St No Andover.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 742 Boxford Street Property Address Dionne Torre Owner's Name No. Andover MA 01845 06/19/07 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: 10/1'have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If "not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 742 Boxford St No Andover.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 742 Boxford Street Property Address Dionne Torre Owner's Name No. Andover MA 01845 06/19/07 City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 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. 742 Boxford St No Andover.DOC • 08/06 Title 5 Official Inspection Form. Subsurface Sewage Disposal System • Page 3 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 742 Boxford Street Property Address Dionne Torre Owner's Name No. Andover MA 01845 City/Town State Zip Code B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): 06/19/07 Date of Inspection ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No El F?r ❑ 2' ElLJ 742 Boxford St No Andover.DOC • 08106 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than'/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: Any portion of the SAS, cesspool or privy is below high ground water elevation Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 742 Boxford Street Property Address Dionne Torre Owner's Name No. Andover City/Town B. Certification (cont.) MA 01845 State Zip Code D) System Failure Criteria Applicable to All Systems (cont.): Yes No 06/19/07 Date of Inspection ❑ [R' Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ V 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. ❑ [a/ 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: Tobe 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 ❑ 51,' the system is within 400 feet of a surface drinking water supply ❑ 2r, the system is within 200 feet of a tributary to a surface drinking water supply ❑ 21-- 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. 742 Boxford St No Andover.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 742 Boxford Street Property Address Dionne Torre Owner Owner's Name information is required for No. Andover MA 01845 06/19107 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 El D Were any of the system components pumped out in the previous two weeks? R ❑ 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? 2 ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ,/ 2'-- I� ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? [2"- ❑ Were all system components, excluding the SAS, located on site? 0---- ❑ 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. ❑ Q— 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)] 742 Boxford St No Andover.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 15 1 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 742 Boxford Street Property Address Dionne Torre Owner information is required for every page. Owner's Name No. Andover City/Town D. System Information State 01845 Zip Code 06/19/07 Date of Inspection Residential Flow Conditions: Number of bedrooms (design): J-2> Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Last date of occupancy/use: Date Other (describe): yso ❑ Yes No ❑ Yes No ❑ Yes [K No ❑ Yes ❑ No L.r e L C__ ❑ Yes K No C v rr I� - Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No 742 Boxford St No Andover.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 15 Owner information is required for every page. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 742 Boxford Street Property Address Dionne Torre Owner's Name No. Andover City/Town D. System Information (cont.) State 01845 06/19/07 Zip Code Date of Inspection General Information Pumping Records: Source of information: ►►►oc !7 Yf'l ;?o04- Pe2-- 2-at4 Was system pumped as part of the inspection? If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: E. Septic tank, distribution box, soil absorption system ❑ Yes ® No ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): Approximate age of all components, date installed (if known) and source of information: 0 - ' t ✓t 119 Z P e/L- a o i -f Q -e c�D �—D s Were sewage odors detected when arriving at the site? ❑ Yes X No 742 Boxford St No Andover.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 15 Commonwealth of Massachusetts Title 5 official Inspection Form �s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �t ,M 742 Boxford Street Property Address Dionne Torre Owner Owner's Name information is required for N0. Andover every page. Cityrrown MA 01845 State Zip Code 06119/07 Date of Inspection D. System Information (cont.) Building Sewer (locate on site plan): r� Depth below grade: Y feet Material of construction: 9 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.): 1 L L_Q045 0V, 1ti 2,41IF A 4F M I Septic Tank (locate on site plan): Depth below grade: Material of construction: concrete ❑ metal 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) ❑ Yes ❑ No ----------------------------------- ----------------------------------------------------- Dimensions: Sludge depth: 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 How were dimensions determined? 15C-) C,4t -3^JS Lt t/ Z19 .4, 1 I Z I f ," E.95 2 E SZ c b( 742 Boxford St No Andover DOC - 08/06 Title 5 Official Inspection Form. Subsurface Sewage Disposal System • Page 9 of 15 Owner information is required for every page. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 742 Boxford Street Property Address Dionne Torre Owner's Name No. Andover City/Town State 01845 06/19/07 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.): TANK 1 N C. -O a O G.> r-1 0 11-1c vt . Ga J c r e- i Z a .7t- t t-:- 1C -- i% t n� I*nr— G9r-+ D ImeW . 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 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): 742 Boxford St No Andover.DOC - 08106 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 15 ' Commonwealth of Massachusetts t�F w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 742 Boxford Street Property Address Dionne Torre Owner information is required for every page. Owner's Name No. Andover MA 01845 City/Town State Zip Code D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Desi n Flow 06/19/07 Date of Inspection g 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 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.): X E 7" Cso O D �o ,.� D. i1 u n_ N G✓ D f/t t� o r LC rj-g, 0 Cwt% I N o 2 -- c t+- 4.y s? 2 L 0-11 Q� Pump Chamber (locate on site plan): Pumps in working order: Alarms in working order: ❑ Yes ❑ No ❑ Yes ❑ No 742 Boxford St No AndoverDOC- 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments +Q` 742 Boxford Street Property Address Dionne Torre Owner Owner's Name information is required for No. Andover MA 01845 06/19/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: X leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Typelname of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): o K�v o o s nA 44L c ✓ r o e .A u- o c- r.- 19 �� 6k u•v�1suA-- 0&4 742 Boxford St No Andcver.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 15 ' Commonwealth of Massachusetts w Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 742 Boxford Street Property Address Dionne Torre Owner information is required for every page. Owner's Name No. Andover City/Town D. System Information (cont.) 06/19/07 Date of Inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 742 Boxford St No Andover.DOC • 08106 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 742 Boxford Street Property Address Dionne Torre Owner Owner's Name information is required for No. Andover MA 01845 06/19/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. ------------------------------- J N Q $-',X-Fz) Sr D c5Ti4n�Gt S 2q Z t. Lt 742 Boxford St No Andover.DOC - 08106 Title 5 Offcial. Inspedon Form: Subsurface Sewage Disposal System - Page 14 of 15 Commonwealth of Massachusetts EFE�w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 742 Boxford Street D. System Information (cont.) Site Exam: Check Slope Surface water l ,aAjiF Check cellar iv—> r u,., D it Shallow wells v_on/C Estimated depth to ground water: 01845 06/19/07 Zip Code Date of Inspection N Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record ti If checked, date of design plan reviewed: t� Al- '-`"l o Bs C2clA Date Eli[ 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: nom, 5 iL I S �A L H 0 �' r4- � l l.l.. (c`� f? 4 S r/o'j-A P 9 A s e v►ti �.T- r s P —a! w'� f ivo s - P�� P P'TS 8 o i iD "-5 CL 2L 48 c c a3F1 � �%�-� t n i � c� 0 A L., All '> w/. 742 Boxford St No Andover. DOC - 08/06 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System - Page 15 of 15 Property Address Dionne Torre Owner Owner's Name information is No. Andover MA required for every page. CitylTown State D. System Information (cont.) Site Exam: Check Slope Surface water l ,aAjiF Check cellar iv—> r u,., D it Shallow wells v_on/C Estimated depth to ground water: 01845 06/19/07 Zip Code Date of Inspection N Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record ti If checked, date of design plan reviewed: t� Al- '-`"l o Bs C2clA Date Eli[ 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: nom, 5 iL I S �A L H 0 �' r4- � l l.l.. (c`� f? 4 S r/o'j-A P 9 A s e v►ti �.T- r s P —a! w'� f ivo s - P�� P P'TS 8 o i iD "-5 CL 2L 48 c c a3F1 � �%�-� t n i � c� 0 A L., All '> w/. 742 Boxford St No Andover. DOC - 08/06 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System - Page 15 of 15 T I z C" F—I rn W -4 rri M x rn fA ci z zp zE i ra ( z rl pq tj iris "V m M r1i r m I . I i ............ ................ ........................ Ii ............................................... ^ rrl Z C" F—I rn W -4 rri M x rn fA z zp zE W EZ ❑ rl pq tj iris IC vCr "V m M r1i r m I . I i ............ ................ ........................ Ii ............................................... ^ rrl Z a" W -4 rri M x z zp zE W rri 0 rl pq tj z rm 0 C3 ?U ii 5.1 m �s W n z m 3. rrxi W zp rn r pq tj IC ....................... . I ...................... ..." ....... m �s W n z m dd 3QIS d3 IVOIdAl HSdS SSVIO 931vinSNI Q3XI4 AMNIA Mai 8312 vne M 3Ms V3 IVMd&L usrs ��MU KWMMi M IoM k u t ■ ( § ® � � � $ U ■ E O J a k � j m j k ■ § ® � � $ U 3 2 6 0 2 k Sm 0 cm0 ;E Ag, B & a_ ■ 3 \ � CD § 2 a k � § z z z Sm 0 cm0 ;E Ag, B & a_ �V(a 'C, Sf..#L,d OWNER 3iit a nz �� u� z`rr nt �EzvieE 78 689 7404 2 Sawyer Street .,,Cel � 78-273-9097 Methuen, MA 01844 978 889-9305 DelleChiaie, Pamela From: DelleChiaie, Pamela Sent: Tuesday, February 26, 2008 4:08 PM To: Sawyer, Susan Subject: 742 Boxford Street - MTBE Issues Importance: High Hi, A Mark Sheperd from the Bistany Adjustment Service is looking for information on 742 Boxford Street. The file is not in the general files or in our septic files. This is the home that had the renters and the oil leaking issues in their water, etc., and Shepherd is looking for information for insurance purposes. His number is: 978.273.9097. I told him that when I find the file, I would copy the contents and e-mail it to him. I have his business card. gag! Ragwzdg, P.1*0.0a IVO&Mo diAia Health Department Assistant Town of North Andover 1600 Osgood Street Building 2o, Suite 2-36 North Andover, MA o1845 9978.688.9540 - Phone A 978.688.8476 - Fax http://www.townoffiorthandover.com healthdept@toivnofnorthandover.com DelleChiaie, Pamela From: Sawyer, Susan Sent: Thursday, February 28, 2008 11:40 AM To: DelleChiaie, Pamela Subject: RE: 742 Boxford Street - MTBE Issues I am sure there are a lot of chicken scratch notes. If it needs some organizing let's do it before it goes out since it is a legal issue. Did they need a true and attested file or just a copy?? I would assume regular unless he asks. Thx From: DelleChiaie, Pamela Sent: Wednesday, February 27, 2008 12:29 PM To: Sawyer, Susan Subject: FW: 742 Boxford Street - MTBE Issues Importance: High Found the file. Do you want to look through it before I scan and send to this guy?? P -----Original Message ----- From: DelleChiaie, Pamela Sent: Tuesday, February 26, 2008 4:08 PM To: Sawyer, Susan Subject: 742 Boxford Street - MTBE Issues Importance: High Hi, A Mark Sheperd from the Bistany Adjustment Service is looking for information on 742 Boxford Street. The file is not in the general files or in our septic files. This is the home that had the renters and the oil leaking issues in their water, etc., and Shepherd is looking for information for insurance purposes. His number is: 978.273.9097. I told him that when I find the file, I would copy the contents and e-mail it to him. I have his business card. 1900RagAtdB, Pa�BBA D¢l��aG�!liwi¢ Health Department Assistant Town of North Andover 1600 Osgood Street Building 20, Suite 2-36 North Andover, MA o1845 19978.688.9540 - Phone A 978.688.8476 - Fax http://www.townofnortbandover.com healthdept@townofnorthandover.com Page 1 of 3 Grant, Michele Subject: FW: Test Results ----Original Message ----- From: Ken _Torre@Countrywide.Com[mailto:Ken_Torre@Countrywide.Com] Sent: Monday, October 22, 2007 1:34 PM To: Grant, Michele Subject: FW: Test Results Michele: Here is the rest of the results. With the exception of high MTBE levels, everything else is clear. I am very concerned about the MTBE and am wondering how it got in the well and if there have been other cases in North Andover. I am going to call you as well as to what we should do next. Regards, Ken Torre SVP, Revenue Pricing Management WLD - Financial Administration 818-316-8262 Office 8511 Fallbrook Ave 92-593-8262 intemal Mail Stop: WH -82 West Hills, CA 91304 From:Cindy Wooldridge Sent: Friday, October 19, 2007 1:39 PM To: 'ken torre@countrywide.com' Subject: Test Results Hi Ken, I just spoke w/ the lab and they said that they should have the Volatile Organic Scan back on Monday. I will forward them to you as soon as I get them. Mary has called inquiring about them. I haven't spoken with her though, she left me a voicemail. 10/22/2007 It L7 9, .t N . rd rd v 9r► 1 v y d J 'J f' �U L 4 t� rA 7 . rd v 9r► 1 � .� d J L �U L 4 . rd v 9r► 1 � .� d 14 J (� d 14 y I m Page 1 of 4 Grant, Michele From: Grant, Michele Sent: Thursday, November 08, 2007 11:12 AM To: 'Ken_Torre@Countrywide.Com' Subject: RE: Test Results Good Morning Ken, FYI ... A gentleman by the name Larry Immerman will be in contact with you this morning regarding the re -testing of your well. He is from the "Field Response Unit" within DEP. If you have any questions please let me know. Thanks Michele E. Grant Town of North Andover -----Original Message ----- From: Ken Tone@Countrywide.Com[mailto:Ken_Torre@Countrywide.Com] Sent: Thursday, November 01, 2007 11:18 AM To: Grant, Michele Subject: RE: Test Results The state told me that because the EPA has not settled on what levels are considered hazardous, they recommended I do the following: I monitor the well over the next year, getting samples every two months to see if the levels begin to drop. They want me to do this over the next year. If the levels do not drop, then to contact them again. Other than that, there is nothing more that will be done. In regardsto my tenants, II have set them up with bottled water delivery, and am installing a water titter system to filter out some of the impurities. They are aware of the situation and are ok with it since they will be using the well water for washing and bathroom use only_ Ken Torre SVP, Revenue Pricing Management WILD - Financial Administration 818-316-8262 Office 8511 Fallbrook Ave 92-593-8262 Internal Mail Stop: WH -82 West Hills, CA 91304 "Grant Michete"<mgrant@townofnorthandovercom> TO CKen Torre@Counbywjde.Com> cc 11/01/2007 07:24 AM 11/8/2007 Subject RE: Test Results Page 2 of 4 Hi Ken, Just a quick e-mail to see where you are with the state. Is there any new news. Speak to you soon. Michele -----Original Message ----- From: Ken_Torre@Countrywide.Com [mailto:Ken Torre@Countrywide.Com] Sent: Monday, October 22, 2007 1:34 PM To: Grant, Michele Subject: 'FW: Test Results Michele: Here is the rest of the results. With the exception of high MTBE levels, everything else is clear. I am very concerned about the MTBE and am wondering how it got in the well and if there have been other cases in 'North Andover. I am going to call you as well as to what we should do next. Regards, Ken Torre SVP, Revenue Pricing Management WILD - Financial Administration 818-3165262 office 8511 Fallbrook Ave 92-5935262 0ntemal Mail Stop: V4-82 West (tills, CA 91304 From:Cindy Wooldridge Sent: Friday, October 19, 20071:39 PM To: 'kentorre@cwuntrywide.cwm' Subject: Test Results Hi Ken, I just spoke wl the lab and they said that they should have the Volatile Organic Scan back on Monday. I will forward them to you as soon as I get them. Mary has called inquiring about them. I haven't spoken with her though, she left me a voicemail. 11/8/2007 Page 3 of4 l _ Y Thank you, Cindy W. This message is intended only for the use of the Addressee and may contain information that is PRIVILEGED and CONFIDENTIAL. If you are not the intended recipient, you are hereby notified that any dissemination of this communication is strictly prohibited. If you have received this communication in error, please erase all copies of the message and its attachments and notify us immediately. From:Qndy Wooldridge Sent: Tuesday, October 16, 200712:35 PM To: 'ken Lorre@oountrywide.com' Cc: 'MacDonald, kevin Subject: First Part of Test Results Hi Ken, Here are the preliminary test results. As mentioned on the phone, we are still waiting for the volatile organic scan to come back Once I received that, I will email those results to you as well. Please be sure to submit your payment as soon as possible. We are not in the practice of giving test results without receiving ,payment. Thank you for your understanding, Cindy W. Cindy L. Wooldridge Service and Installation Coordinator 150 S. Main Street Middleton, !Ma 01949 Phone: (978)777-8330 Fax (978)777-8385 This message is intended only for the use of the Addressee and may contain information that is PRIVILEGED and CONFIDENTIAL. If you are not the intended recipient, you are hereby notified that any dissemination of this communication is strictly prohibited. If you have received this communication in error, please erase all copies of the message and its attachments and notify us immediately. 11/8/2007 MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza Boston, Massachusetts 02108.1904 (617) 723.3800 Ma Only (800) 392.6108, FAX (800) 851-8424 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch.139, Sec.3B NORTH ANDOVER HEALTH DEPT NORTH ANDOVER TOWN HALL NORTH ANDOVER MA 01845 e 1 G 811512012 127 2012 1 �_I LWNf3FNeO�Rp'1�l�A�r�l:., v�1� ��s�-stye._ Re: Insured: C742 OAQUIN C. D DIONNE TORRE Property Address: B0XF D STREET, NORTH ANDOVER, MA 01845 Policy Number:10 2 Type Loss: Water Damage: All Other Water Damage Date of Loss: 0810212012 Claim Number: 303772 Claim has been made involving loss, damage or destruction of the above captioned propert, which may either exceed $1000.00 or cause Massachusetts General Laws, Chapter 143, section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. MPIUA Claims Division CMA00021 MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza FAU-00 ECEIVEDBoston, Massachusetts 02108.1904 (617) 723.3800 Ma Oniv (800) 392.6108, FAX (800) 851.8424 6 212 81312082 TOWN OF NORTH AND VER Form of Notice of Casualty Loss to Building HEALTH DEPARTMENT Under Mass. Gen. Laws, Ch. 139, Sec.36 NORTH ANDOVER HEALTH DEPT. NORTH ANDOVER TOWN HALL NORTH ANDOVER MA 01845 Re: Insured: Property Addre Policy Number: Type Loss: Date of Loss: Claim Number: CMA00021 JOAQUIN C. AND DIONNE TORRE 742 BOXFORD STREET, NORTH ANDOVER, MA 01845 1016862 Water Damage: All Other Water Dao3ag 0810212012 303510 Claim has been made involving loss, damage or destruction of the above captioned propert, which may either exceed $1000.00 or cause Massachusetts General Laws, Chapter 143, section 6 to be applicable. If any notice under Massachusetts General Laws Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. MPIUA Claims Division MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza Boston, Massachusetts 02108.1904 (6171723-3800 Ma Only (800) 392-6108. FAX (800) 851.8424 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch.139 Sec.313 NORTH ANDOVER HEALTH DEPT. NORTH ANDOVER TOWN HALL NORTH ANDOVER MA 01845 1211812013 RECEIVE=D DEC 301 ?013 TOWN OF NORTH ANDOVER HEALTH )DEPARTMENT Re: Insured: JOAQUIN C. AND DIONNE TORRE Property Address: 742 BOXFORD STREET, NORTH ANDOVER, MA 01845 Policy Number: 1016862 Type Loss: Water Damage: Plumbing Systems Date of Loss: 1 211 71201 3 Claim Number: 319029 Claim has been made involving loss, damage or destruction of the above captioned propert, which may either exceed $1000.00 or cause Massachusetts General Laws, Chapter 143, section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139 Section 313 is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. MPIUA Claims Division CMA00021 Distance ACRES TOT _END _AR MAP_PAR_1D HOUSE -NUM PAR_ADD_2 PAR_ADD_ST OWNER 01 1/8 Mile (660 feet)- 1.006 L020 105.A-0018 754 _NAME BOXFORD STREET HART, DAVID R 1/8 Mile (660 feet) 7.220 7.080 105.A-0017 729 BOXFORD STREET SIMMONS, JEFFREY M CAROLYN P E 1/8 Mile (660 feet) 2.755 2.830 105.A-0026 725 BOXFORD STREET GLASKO, JOHN & BRENNEMAN, KA 1/8 Mile (660 feet) 1.110 1.030 105.A-0022 730 BOXFORD STREET VOKE, BRIAN P LAURIE A VO 1/8 Mile (660 feet) 1.335 1.530 105.A-0023 0 BOXFORD STREET GREEN, PETER KERRY BREEI 1/8 Mile (660 feet) 2.106 1.570 105.A-0002 770 BOXFORD STREET GREEN, PETER KERRY BREEI 1/8 Mile (660 feet) 0.967 1.020 105.A-0021 742 BOXFORD STREET DIONNE & JOAQUIN TORRE 1 /8 Mile (660 feet) 3.333 4.060 105.A-0006 0 BOXFORD STREET SIMMONS, JEFFREY M CAROLYN P 1 /8 Mile (660 feet) 49.585 6.000 105.A-0001 115 OGUNQUIT ROAD BREEN, PETER R KERRY M BRI 1/4 Mile (1,320 feet) 12.049 9.500 105.A-0007 0 BOXFORD STREET COFFEY, BARBARA L 1/4 Mile (1,320 feet) 9.452 13.400 105.A-0009 0 {,flC-Y_S-TREEO------K-I4q4W--DGE,MARS If,* - 1/4 Mile (1,320 feet) 15.427 16.890 105.A-0005 0 BOXFORD STREET SIMMONS, JEFFREY M CAROLYN P E 1/4 Mile (1,320 feet) 1.415 0.000 000.0-0053 Number Null 1/4 Mile (1,320 feet) 7.220 7.080 105.A-0017 729 BOXFORD STREET SIMMONS, JEFFREY M CAROLYN P E 1/4 Mile (1,320 feet) 4.175 3.330 105.A-0003 0 3 BOXFORD STREET RI BREEN, PETER R KERRY M BRI 1/4 Mile (1,320 feet) 0.923 0.960 105.A-0027 35 BRGeKYHBWFR 1/4 Mile (1,320 feet) 0.956 1.030 105.A-0029 65 BRSei-VIEW-DPdVE-BRACK-EN-R7-J tAB CATHERINE? 1/4 Mile (1,320 feet) 0.745 0.770 105.A-0028 53 , 1/2 Mile (2,640 feet) 4.453 4-770 105.0-0026 545 BOXFORD STREET KLIMENKO, ALEXANDRE G ELENA A KLI 1/2 Mile (2,640 feet) 4.606 4.640 105.CX027 557 BOXFORD STREET KIM, SANG GON & KIM, RAN 1/2 Mile (2,640 feet) 5.598 5.780 105.0-0028 0 BOXFORD STREET WESLIE REALTY OR TOWN OF 1/2 Mile (2,640 feet) 10.105 9.700 105.0-0006 595 BOXFORD STREET WILSON, WALTER A 1/2 Mile (2,640 feet) 88.836 83.300 105.A-0010 0 ---LAC-YSTREE'P---KIrFRED6E-MARJ0R1EV -- - 1/2 Mile (2,640 feet) 1.036 1.000 105.0-0004 585 BOXFORD STREET BROGAN III, CHARLES C & DEBORA 1/2 Mile (2,640 feet) 1.017 1.170 105.0-0003 562 BOXFORD STREET HOPPING, CHARLOTTE L 1/2 Mile (2,640 feet) 0.913 1.020 104.B-0183 155 L -7A DUNCAN DRIVE SCANLON, MICHAEL R KATHLEEN C 1/2 Mile (2,640 feet) 0.957 L080 104.B-0184 143 DUNCAN DRIVE DURGIN, SCOTT A KIMBERLY S 1/2 Mile (2,640 feet) 1.221 2.050 105.CX007 615 BOXFORD STREET MURPHY, JAMES C. MURPHY, LY 1/2 Mile (2,640 feet) 1.738 1.000 105.0-0023 624 BOXFORD STREET BRADSHAW, RICHARD V JOYCE ANN 1 1/2 Mile (2,640 feet) 0.862 0.920 105.A-0033 50 -BR-OOKVIFW-DRIVE-&VANGEI>IST-A; ANGEL -O 1/2 Mile (2,640 feet) 0.978 1.000 090.A-0069 104 --BR9GK-VIE-W-HR-W.E--C-RON3N-MARS-KAg.EN 1/2 Mile (2,640 feet) 0.988 0.770 090.A-0013 100 BROOKV•IEW-DR-YVE-BE°AUDON, DA.L-E-B------------BEAUDGIN; L 1/2 Mile (2,640 feet) 0.936 0.980 105.A-0031 86 -BR00K-i•BW---DR^IV•E-�RS0N-3GE•L-i -IMBERhY T• 1/2 Mile (2,640 feet) 1.070 1.110 105.A-0032 70 -BROOKVJFW DRIYd-LAMBO, NICHOLAS -V - 1 /2 Mile (2,640 feet) 0.854 0.860 090.A-0067 118 BROOKV4E-VW-DRIVi� -BBT-I-ERBRODT ,JAY T CHERYL -BAR 1/2 Mile (2,640 feet) 1.113 1.160 090.A-0068 110 -BR.OOKVI•EW-DRIVE=SWEENEY-4R;-R0BERTE n:GEUA-SWI 1/2 Mile (2,640 feet) 0.683 1.000 104.13-0182 167 DUNCAN DRIVE SEELEY, EARLE B KATHRYN M 1/2 Mile (2,640 feet) 2.146 2.000 105.0-0079 594 BOXFORD STREET HANSSEN, BRYAN M KERRY A HAI 1/2 Mile (2,640 feet) 1.239 1.260 105.0-0025 537 BOXFORD STREET PALISIN, TERRANCE J 1/2 Mile (2,640 feet) 19.991 22.190 105.0-0022 602 BOXFORD STREET GORTON, WILLIAM ANNE GORT( 1/2 Mile (2,640 feet) 1.180 1.220 090.A-0054 106 ROCKY BROOK ROM WAISNOR, ANNE M JON D WAIST, 1/2 Mile (2,640 feet) 0.813 1.140 090.A-0051 93 ROCKY BROOK ROM DRURY, MATTHEW F NICOLE E DR 1/2 Mile (2,640 feet) 1.123 1.150 090.A-0052 88 ROCKY BROOK ROM MILLIARD, ROBERT P SUSAN A PAR 1/2 Mile (2,640 feet) 0.918 1.030 090.A-0002 16 OGUNQUIT ROAD LACEY, WILLIAM J MARY H LAC 1/2 Mile (2,640 feet) 1.016 1.080 C90.A-0061 151 ROCKY BROOK ROM BALLERINI, DANTE M COLLEEN M 1 1/2 Mile (2,640 feet) 0.929 1.060 090.A-0059 139 ROCKY BROOK ROM CHICKO, FRANK A RHONDA M C 1/2 Mile (2,640 feet) 0.975 1.050 090.A-0053 107 ROCKY BROOK ROM MYRIE, HUNTLEY B. MYRIE, CARC 1/2 Mile (2,640 feet) 0.260 2.000 090.A-0076 100 OGUNQUIT ROAD BREEN, PETER R KERRY M BR] 1/2 Mile (2,640 feet) 3.255 2.000 090.A-0077 70 OGUNQUIT ROAD BREEN, PETER R KERRY M BRI 1/2 Mile (2,640 feet) 1.481 1.240 C90.A-0063 93 BROOKNIEW-DRIVE--AURA; JOHN J 1/2 Mile (2,640 feet) 1.221 1.210 C90.A-0065 111 BR9Gi-VIEW-DRIVE-WATKINS, JOHN A --C-HERY-L-A-W 1/2 Mile (2,640 feet) 0.926 0.930 090.A-0064 105 ,BRAOKV]EW DR4VE-HDDLIN,-S4=FVEA1 F M{C-HFi ,1 E 1/2 Mile (2,640 feet) 0.911 0.930 090.A-0066 117 BR9GKW}EW-DRI•V•E-N1KGL-GP49UbOS-NIC-H0LAS -T-&d0 1/2 Mile (2,640 feet) - 1.167 1.170 090.A-0050 79 ROCKY BROOK ROM KOCHANSKI, PAUL F. KOCHANSKI, 1/2 Mile (2,640 feet) 0.938 1.110 090.A-0049 67 ROCKY BROOK ROM HUAPAYA, JAY CAROLYN Hl 1/2 Mile (2,640 feet) 0.962 1.D30 105.A-0030 79 BROOKVIEW DRIVE CAIN III, EDWARD A KATHRYN J ( 1/2 Mile (2,640 feet) 3.400 3.450 090.A-0028 101 ROCKY BROOK ROM PULASKI, KENNETH J SUSAN S PUL VNER_2 OWNER_ADDR OWNER_CITY VEIJWNER_ZIl'OT_FIN_A'OTAL_RMR_BEDROOM'ULL_BATHIALF_BATHXT_WALL _'EAR _BUIL3FF_YEAR_B 754 BOXFORD STREET NORTH ANDOVI MP 1845 2392 7 4 2 1 FB 1979 1983 IMMONS 729 BOXFORD STREET NORTH ANDOVI MP 1845 2378 6 3 2 1 FB 1975 1980 725 BOXFORD STREET NORTH ANDOVI MP 1845 4114 9 4 2 1 BK 1998 1998 KE 730 BOXFORD STREET NORTH ANDOVI MP 1845 4445 11 5 3 2 FB 1982 1987 4 770 BOXFORD STREET NORTH ANDOVI MP 1845 0 0 0 0 0 0 0 4 770 BOXFORD STREET NORTH ANDOVI MP 1845 3465 10 4 3 1 FB 1978 1985 742 BOXFORD STREET NORTH ANDOVI MP 1845 3299 8 4 2 1 FB 1979 1980 IMMONS 729 BOXFORD STREET NORTH ANDOVI MP 1845 0 0 0 0 0 0 0 IN 770 BOXFORD STREET NORTH ANDOVI MP 1845 0 0 0 0 0 0 0 32 SILSBEE ROAD NORTH ANDOVI MP 1845 0 0 0 0 0 0 0 "^6K- i; W-R6.RI3-BOXFORD ------ :"..,4.9121 0 0 0 0 0 0 0 IMMONS 729 BOXFORD STREET NORTH ANDOVI MP 1845 0 0 0 0 0 0 0 0 0 0 0 0 0 0 IMMONS 729 BOXFORD STREET NORTH ANDOVI MP 1845 2378 6 3 2 1 FB 1975 1980 :EN 770 BOXFORD STREET NORTH ANDOVI MP 1845 0 0 0 0 0 0 0 35-BR08iWIFW-DRWE— NORTH ANDOVI MP 1845 3320 11 4 3 1 FB 2000 2000 I-BRACK-EN----65-BROOKV-IEW-DRfVE NORTH ANDOVI W 1845 3038 9 4 2 1 FB 1998 1998 1 53 -DRIVE NORTH ANDOVI MP 1845 3446 9 4 4 1 FB 1998 1998 vIENKO 545 BOXFORD STREET NORTH ANDOVI MA 1845 2205 8 4 2 1 FB 1978 1980 557 BOXFORD STREET NORTH ANDOVI MP 1845 1939 7 4 1 1 FB 1977 1980 NORTH ANDOVEF 4 MASON STREET #67 PEPPERELL MP 1463 0 0 0 0 0 0 0 595 BOXFORD STREET NORTH ANDOVI MP 1845 2464 9 5 2 1 FB 1974 1980 — BRE)0RVIEW-ROAD- BeXfeRD MF 1921 3012 0 0 0 0 0 0 585 BOXFORD STREET NORTH ANDOVI MP 1845 2345 8 4 3 0 FB 1989 1989 562 BOXFORD STREET NORTH ANDOVI MP 1845 811 4 2 1 0 FB 1969 1975 SCANLON 155 DUNCAN DRIVE NORTH ANDOVI MP 1845 2914 8 4 2 1 FB 1983 1987 7URGW 143 DUNCAN DRIVE NORTH ANDOVI MA 1845 2128 7 4 2 1 FB 1982 1987 4N L. 615 BOXFORD STREET NORTH ANDOVI MP 1845 2492 8 4 2 IAV 2000 2000 RADSHAW 624 BOXFORD STREET NORTH ANDOVI MP 1845 2133 6 3 1 1 WS 1971 1975 ----- -50BROOKVIEW-DRIVE .a-M45 3130 8 4 3 1 FB 1999 1999 104-BRQQK.V.IFAW R W 'J0RZH.-kNPGVi-MA-1845 2794 8 4 2 1 FB 1998 1998 ENISE-C---------I00-BROOKVIEW-DR VT VOR-T41-A DGVI-MA4845 3130 9 4 2 1 FB 1999 1999 %4Y-ERSON-----86-BR6BK-VIEW DRIVE NOR�T44A,NDOV4=W-1845 3228 9 -4 3 0 FB 1999 1999 '0-3RQQ 5 3514 8 4 2 1 FB 1998 1998 UZAK ----------- 448-BROOKVVIEW-DRIV£ NORTH-AND@V44vlP-1845 2808 9 4 3 I FB 1999 1999 !ENE-Y--X40-BROO ORTH-A-ND9VI-W-1845- 3224 9 4 3 1 FB 1999 1999 3EELEY 167 DUNCAN DRIVE NORTH ANDOVI MF 1845 2090 7 4 2 1 FB 1983 1987 4SSEN 594 BOXFORD STREET NORTH ANDOVI MP 1845 2440 8 4 2 1 FB 1999 1999 537 BOXFORD STREET NORTH ANDOVI MP 1845 2054 8 4 2 1 FB 1979 1980 )N 602 BOXFORD STREET NORTH ANDOVI MP 1845 783 5 2 1 0 WS 1948 1962 OR 106 ROCKY BROOK ROAD NORTH ANDOVI MP 1845 2752 9 4 2 1 FB 1996 1996 URY 93 ROCKY BROOK ROAD NORTH ANDOVI MP 1845 3012 10 4 2 1 FB 1996 1996 E 88 ROCKY BROOK ROAD NORTH ANDOVI MP 1845 3040 9 4 2 1 FB 1997 1997 EY 16 OGUNQUIT ROAD NORTH ANDOVI MP 1845 2854 9 4 3 0 FB 2000 2000 SALLERINI 151 ROCKY BROOK ROAD NORTH ANDOVI MP 1845 3264 8 4 2 1 FB 1995 1995 HICKO 139 ROCKY BROOK ROAD FORTH ANDOVI MP 1845 3104 11 4 2 1 FB 1997 1997 ,LYN COLLINS 107 ROCKY BROOK ROAD NORTH ANDOVI MP 1845 2927 9 4 2 1 FB 1996 1996 iEN 770 BOXFORD STREET NORTH ANDOVI MP 1845 0 0 0 0 0 0 0 iEN 770 BOXFORD STREET NORTH ANDOVI MA 1845 0 0 0 0 0 0 0 PF 93-BRO9KVIEW DR 3380 9 4 3 1 FB 1999 1999 \TKINS '44-BR09KV4E V4DRKV£�QYI-M,a-IS45 3159 9 4 3 1 FB 1998 1998 4A--DEA+i - m5-BR9OK-VIEW-FNt4V£ NORTH-ANDOV1-MP-1845 3393 10 4 2 1 FB 1998 1998 il?B QKV4EW-I)P— .E NOR 11 ANDOVI : v" 1845 3180 9 4 2 1 FB 1998 1998 SHELLY A. 79 ROCKY BROOK ROAD NORTH ANDOVI MP 1845 3204 10 4 2 1 FB 1996 1996 PAPAYA 67 ROCKY BROOK ROAD NORTH ANDOVI MP 1845 3806 10 4 2 1 FB 1996 1996 RECELIUS 79 BROOKVIEW ROAD NORTH ANDOVI MP 1845 3130 9 4 2 1 FB 1999 1999 %SKI 101 ROCKY BROOK ROAD NORTH ANDOVI MP 1845 3072 8 4 2 1 FB 1999 1999 } .t ,� A.0 9 L let 130 Y 1 .16.2007 11:52 9766920023 LITTLETON ROAD, WESTFORD, MA 01886 Rcpod Number: A 109143 Client: THORSTENSEN #5085 P,001 /001 (M)692-8395 FAX(978)692-0023 1 -800 -649 -TEST Report Datc: • 10/8/07 Sample Information: Atlas WFrtar Systems (NI)' 742 Botsford St ISO South Main St. N. Andover,MA Middleton MA 01949 Sampled by: Client Bate Received: 10/5/07 Date Sampled: 10/5/07 C..e .ifi to f AW st Test Parameter UPA Limit Rd._`_�'�I.r1k Units Total Coliform (P) 0 0 per10Om1 Fecal Coli form/F coli (P) 0 Absent perl0Oml .Arsenic (P) 0.01 110.002 M91 Calcium Not Spec. 49.3 rnyl. Cropper (S) 1-3 0.03 219/1- t;/LIron Iran(S) 0.3 e0,01 mg/L i,ead (P) 0.015 •.0.001 Tng/J. Magaesiu n Not Spec. 9.7 m9JL Manganese (S) 0.05 <4.01 mg,/L Potassium Not Spec. U.6 mg/L Stxi6mi See Note . 196 mg/I, . Alk-,dWty (S) Not Spcc. 152 invi Ammonia -N Not Spec. 0.03 ntg/L Chloride (S) 250 # 370 ME , Chlorine Not Sane. <O-02 mgJJ., Color (S) 15 0 CPU conductivity Not Spcc. 1300 urnhus/cm t•'luoride (S) 4.0 0.41 111ga. Hardrtoss Not Spec, 163 MAI Nitrat(>N (P) 10 0.15 rng/L Nitrite -N (P) 1 •=0.05 ing/L Odor 3 2 TON PH (S) (i.5 -S.5 7.3 SU Sulphate (S) 250 24.2 mg/L Turbidity Not Spec. 0.60 Sediment• pos/ncg neg LC�CRdS: (i')-J'r ww.y BPA Standard, (S)—Secoudary L'PA Standard, I/ Exweds FPA Limit, 'fNl'C=TOo Niunerous to Count, * Background Bacteria Noted, ' — F.xcerds Advisory Limit Sodiurrr Advisory Limits, Mass. 20, NH -250. Michael 1'. Carlson, for Thorstensen Laix/rdtory Inc. CT.22.22. 2/0y0A7�06: 3�8n9,786992200.0,,233 t/i'A6FJ'(�%� e1A c./�L!/�4 (YWAi�%� �J 66 LITTLETON ROAD, WESTFORD, MA01886 Report Number: A109143 Ac. Atlas Water Systems (M) 150 South Main St. N Middleton MA 01949 nate Sar:npled: 10/5/07 1tL um, 1,1,2,2-Tetracb1oroedtane •- 'EPA 524.2 04)khioropropanc -- NJ) MUMl3'1'L.R MCI. R*FSTJJ. T Benzeno 5.0 0,8 Cmbon Teunchloride 5,0 ND 1,1-D1cWortwthy1cnc 7_0 M I,?-Dichlometha>ae 5.0 ND p -T) i0lordDeuzene 5.0 ND Trichlorocthylcnc 5.0 NI) 1,1.,1-Tlichloi -ne 200. ND Vinyl Chloride 2-0 NI) MonmMorobenzeae 100. ND olrtho-UlcWorobutimac 600. NT) trans-1,2-DichlorwAhylcnc 100. ND cis-1,2-Dieblomethylene 70.0 NL) 1,2-Mchloropropane 5.0 ND Fdaylbenzeae 700. ND Styrene 100. ND TetTachk"ethylene 5,0 ND Toluene 1000. ND XyloneacNal) 10000. NI) Dichloromethane 5.0 ND .I,2,4-Trichlorobenzette 70.0 ND 1,1,22=1Tichlorocthanc 5-0 ND Chlorolorm - ND Bromodichloromethanc - M) Chlurodibran-mmethane - ND Rrrnnofotpa. • ND nt-llichlorobcnzenc _ ND. Dibromonaedulle _ ND 1,1-Ulchloropropene 1,1-Dichloroethane _ NI) % Recovery ofinternal Standar&: 4-13romo>luorobcnct:nc 91 1,2-DichlorobcnzLmc-d 95 Detection Limit: 0.'5 ue/l. Subcontracted to Mass DEP Lab MA072_ THORSTENSEN x5130 P.001 1001 (978) 692-8395 FAX (978) 692-0023 1-800-6496TEST Report Datc: . 10/20/07 vOLI 742 Boxford St N. Andover,MA Sampled by: Clic,-nt PARAMF.TF.R MC;T. 1tL um, 1,1,2,2-Tetracb1oroedtane •- ND 04)khioropropanc -- NJ) Chkwomethane - ND T3romomethane Nn 1,2,3-Trichloropropanc - ND 1, 1, 1,2-Tetracltioroethane ND Chloroethane NT) 2,2AAchloropmpane ND a-Chlorotoluene ND p-Chlurotolucnc - "N1) Brornobonzcne - NU 1,3-Dich1oropropeiie - ND 1,2,44ximethylbenzene ND 1,2,3-Tr1chlorobenzono _ ND n-Propylbcnrcne _ ND n-Rutylbenzene ND Naphthalane NT) Hoxachlorabutadiene - NU 1,3,5-Trimethy1bett7.ene - ND p-Isopropyltoluene ND lsopropylbtmzLne - NT) t-Butylbenzcnc stx:-ButyTbt.�n CM FluoroTrichloromethane McWorodlfluotomethane ND Bron(u:hloromcthanc - ND *Methy1T'ettiatyl3utyM- et - 240 N).)=None Deteaed MCL Maximum Contamination T-evel Restd[J art: in uvJL *MTBF. (Optional) Michael P. Carlson- for Thorsten.wi Labor•atnry Tnc. a d r A ti _2.�� o - (� O o 0 o a d r A ti _2.�� o - (� O o o 0 a' � d •*, N x CD CD Oo �p 3 Q i:w fD ° 'A C 0 w m � o O o �e 0 a I o 0 to � o m a 0 ve 0 _2.�� o H y v I• C (� o 0 a' � d •*, N x CD CD Oo � coo N CD J Q n X V _2.�� H y v I• C o 0 a' � d •*, N x CD CD Oo � coo N CD J Q ° 'A C 0 o O o �e 0 a I o 0 to � �, of W. z IL O O W ID V I s� ° 0 o z CD 001 v �• What adverse health effects are associated with exposure to MtBE? Page 1 of 1 Answer ID What adverse health effects are associated with exposure to MtBE? 1605 Last Updated 11/29200511:07 AM Q uestion What adverse health effects are associated with exposure to MtBE? Answer There are no data on the effects on humans of ddnldng MtBE-contaminated water. In laboratory tests on animals, cancer and noncancer effects occur at high levels of exposure. These tests were conducted by inhalation exposure or by introducing the chemical in oil directly to the stomach. The tests support a concern for potential human hazard. Because the animals were not exposed through drinldng water, there are significant uncertainties about the degree of risk associated with human exposure to low concentrations typically found in drinking water (Fact Sheet: Drinldng Water Advisory: Consumer Acceptability Advice and Health Effects Analysis on Methyl Tertiary -Butyl Ether (MtBE), 822-F-97-009) L')s L-- P/+ m -2-1Z,1 2� v� 3 r5--(d�'3 tl C.2- V^ C- " l ,V�.-.� i/l V 1 a Tla Lf L= l_ http://safewater.custhelp.comlcgi-bin/safewater.cfglphplenduserlpmt_adp. php?p_fagid=l ... 10/22/2007 i mpftmug Embummahm R©Q Uoa alummR What is MTBE? MTBE (methyl tertiary butyl ether) is a chemical added to fuel to make it burn more cleanly and efficiently. In the 1990s, many states required the addition of MTBE to gasoline in order to meet federal clean air mandates. MTBE is a flammable liquid with a distinctive, disagreeable odor, somewhat like a sweet solvent. Leaking gasoline storage tanks and spills are the leading source of MTBE contami- nation in water. The US Geological Survey has found MTBE in ground water in 24 states. However, in studies to date, only about one percent of water that tested positive for the contaminant demon- strated levels higher than 20 parts per billion. What are the health effects of MTBE? There is no published data on the effects on people who ingest MTBE. Studies with rats and mice suggest that it may be a possible cancer-causing agent and may cause gastroin- testinal irritation, liver and kidney damage and nervous system effects. How do l test for MTBE? Due to the widespread use of MTBE in fuel, reports of the chemical in ground water are increasing. The U.S. Environmental Protection Agency (EPA) has placed MTBE on the drink- ing water contaminant candidate list for future evaluation. Your local health department or state environmental agency may be able to tell you if MTBE has been found in water in your area. If you live near a gas station in a state where MTBE is used, you should probably test for the chemical. Also, MTBE in drinking water has a nasty smell, a sure sign to test for the additive. A test for MTBE costs about $150 per sample. The EPA recommends a maximum level of MTBE of 20 parts per billion to control odor and 40 parts per billion to prevent adverse taste. Meeting these control levels also will protect against adverse health effects. What is the treatment for MTBE in drinking water? While the EPA currently does not offer treatment recommendations, air stripping in packed tower aerators and granular activated carbon (GAC) filters is used frequently to remove other volatile organics from drinking water. Contact your state health department or well professional for guidance. eficare info on MTBE September 2003 l�weiica information on MTBE Page Z For more information on your ground water Your local well contractor, health department, cooperative extension service and state environmental or natural resources department can provide more information about ground water in your area. Check the telephone directory or search the web under "water wells" or "government agencies." For more information about wells and other welicare° publications welicare® is a program of the Water Systems Council (WSQ. WSC is a national nonprofit organization dedicated to promoting the wider use of wells as modern and affordable safe drinking water systems and to protecting ground water resources nationwide. Contact us at 202-625-4387 or visit www.watersystemscouncii.org Other wellcare® publications: A Consumer's Guide to Water Wells A Consumers Guide to Well Testing & Disinfection wellcare® Info Sheet: Home Drinking Wafter Treatment Devices wellcare® Info Sheet; Water Quality—arsenic, bacteria, chromium, iron, MTBE (methyl tertiary butyl ether), nitrates, radon, radium, sulfur and TCE (trichloroethylene) Other organizations you may want to contact: Water Quality Association 630.505.0160 www.wqa.org The Ground Water foundation 800.8584844 wwwgroundwaterorg American Ground Water Trust 603.228.5444 www.agwt.org National Ground Water Association 800.551-7379 www.ngwa.org This publication was developed in part under Assistance Agreement No. X-82849101-1 awarded by the U.S. Environmental Protection Agency. It has not been formally reviewed by EPA. The views expressed in this document are solely those of WSJ. EPA does not endorse any products or commercial services mentioned in this publication. Well water naturally better... Contact your local water well pratessional How much MTBE is too much? Most people can taste and smell MTBE in very small amounts. According to EPA's Drinking Vater Advisory, EPA reviewed health effects studies in 1997 and noted that drinking crater with MTBE levels of 20 to 40 'pans per NNW (acceptable taste and odor) would probably not pose health risks. MTBE at 20 ppb in Rater is about the same as one drop in 500 gallons of water. EPA has efforts underway to fill some of the data gaps on health effects of MTBE and the extent of its occurrence in drinking water supplies. Current data on MTBE levels in ground and surface waters indicate, widespread:and.numerous detections at low levels of MT.B>r However,-:m:studies to date, only about one rcent of ffe und:and surface water testing positive for M'I'BE'fias levels;h%ghetthari20 ppb. Leaks and spills from storage tanks hale"caused a limited number of drinking water wells to have high concentrations of MTBE. Keep in mind that gasoline contains many chemicals, some of which could be in higher concentration in your water and a much more serious health concern. Immediately contact your local health officials if your water tastes or smells suspicious, and remember to test! A Checklist for identifying MTBE problems Do you need to take further action concerning MTBE? If you answer "no" or "unknown" to any of the questions in the following checklist, you should get more information (see the resources at the end of this brochure). if a question does not apply to you, just skip it. Yes No Unknown Have you tested your well water in the last 12 months? If gasoline is sold or stored within 1 mile of your well, have you tested your water specifically for MTBE at least once? Have you asked the health department if there is any known - groundwater contamination reported in your community? If you have an underground fuel storage tank (UST), have you tested the tank for leaks in the last 12 months? if you have an above -ground fuel storage tank (AST), have you tested the soil around the tank to determine if there have been leaks, drips, or spills? If you have an AST, is it protected with concrete containment and do you closely monitor the tank for leaks, drips, and spills? If you have either an AST or UST, do you have procedures to prevent leaks, drips, or spills and as well as methods to clean them up innnediately? If there has been a vehicle accident or other instances of fuel spills on or . near your property, have you tested for MTBE since those occurrences? - Have you tested your water upon recognizing a change in taste, smell, or appearance? If you use gasoline -powered equipment, do you prevent leaks, drips, and spills and do you clean them up immediately? a z 0� �m yF ��q O p y 00 c7o k� �, •oO So a o_ . v C IQ 0 J _ a O o m'n y� °o� o.. `J° o y 21 � C� N Tlo m N o 77eD fD C17 R ,7 W n O m CD � A CD CD J 5 � d C C 1 a z 0� �m yF ��q O p y 00 c7o k� �, •oO So a o_ . v > IQ 7 aay-y<°�;NW a O o m'n y� °o� o.. `J° ?N oo 21 � 3 N Tlo O fD C17 R ,7 W n O m CD �. � CD CD J O O S CC4 ro o�2'n- O� - FT C C 1 » y7 S y cv co w p = S 5 W o 0 two a o `ii .UQ i o 'X 00 ! o N CD a m.� •� N '�7 a y o �I K y C aro n 9x a c r� �I N � a o n > IQ ICD � O w, id o rn O Tlo CD �. � CD CD J w a 1 o o W O A C7 o `ii .UQ N o 'X 00 ! o o �I K y C aro a u M cr 0 IT Z .G > IQ ICD � O w, id o O Tlo CD Q+ I w a 1 o o O A C7 o `ii .UQ N o 'X 00 ! o o C I IT Z .G > IQ ICD � O w, id o O CD w a 1 IT Z .G > C ICD � O w, id o o z Z w, id o o z tl Iv Page 2 of 3 Thank you, Cindy W This message is intended only for the use of the Addressee and may contain information that is PRIVILEGED and CONFIDENTIAL. If you are not the intended recipient, you are hereby notified that any dissemination of this communication is strictly prohibited. If you have received this communication in error, please erase all copies of the message and its attachments and notify us immediately. From:Cindy Wooldridge Sent: Tuesday, October 16, 200712:35 PM To: 'ken_torre@countrywide.com' Cc: MacDonald, kevin Subject: First Part of Test Results Hi Ken, Here are the preliminary test results. As mentioned on the phone, we are still waiting for the volatile organic scan to come back. Once I received that, I will email those results to you as well. Please be sure to submit your payment as soon as possible. We are not in the practice of giving test results without receiving payment. Thank you for your understanding, Cindy W Cindy L. Wooldridge Service and Installation Coordinator 150 S. Main Street Middleton, Ma 01949 Phone: (978)777-8330 Fax: (978)777-8385 This message is intended only for the use of the Addressee and may contain information that is PRIVILEGED 10/22/2007 (click on "search" then select `Petroleum Product Management' or "Private Drinking Water Supply" under the Household Topic Search to find worksheets developed in your state or region). To find program contacts in your state, click on the "Resources" button on this web site, or call 608-262-0024. MOW wrMw umd ca mam by Betsy Tice andover consultants inc. 7 J ro�es.s�ro(nal &gzneers �ar� V urve�gors TO : NORTH ANDOVER HEALTH DEPARTMENT TOWN HALL NORTH ANDOVER , MASS. EIGHT TILTON STREEV METHUEN, MASSACHUSETTS' 01844 (617) 687-3828 December 2, 1977 RE : SUBSURFACE SEWAGE DISPOSAL SYSTEM LOT 3. BOXFORD STREET NORTH ANDOVER,NIASS. I:HEREBY CERTIFY THAT I HAVE INSPECTED THE CONSTRUCTION OF THE DISPOSAL SYSTEM AT LOT 3 , BOXFORD STREET, NO. ANDOVER, MASS. , AND THAT THE LOCATION AND ELEVATIONS ARE AS SHOWN ON THE AS BUILT DRAWING DATED NOVEMBER 29, 1977• ANDOVER CONSULTANTS, INC. WILLIAM S. MacLEOD REGISTERED SANITARIAN r,t`r 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. *`**,**Q*****APPLICANT FILLS OUT THIS SECTION APPLICANT �� / f h0 JIS)' PHONE �54FJ' G LOCATION: Assessors Map Number q0 PARCEL A'`ex" SUBDIVISION LOT (S) STREET ST. NUMBER_�_ ..,.,►******, t**"******""***"*********OFFICIAL USE ONLY**** �►„***'�*,� RECOMMENDATIONS OFF TOVIAGENTS: NSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED Ij4 DATE REJECTED - COMMENTS FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED C PECTO -HEALTH DATE APPROVED DATE REJECTED COMMENTS r' PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT ` FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE N �l Ior . a�Q c �• n 0 v 0 n s< 3 rt D 0 rf I lD nAnvv rt A rt (D O C 3 � � tD 3 rt � {all m W l9 O J9 rt O C 'O O H CD CJ D f9 c 3 �Irt A 7� 1 Ior . SOIL PROFILE & PERCOLATION TEST DATA Town/City No.&Street 12®� 'Cl Lot No. `. Loc./Subdiv. Plan Owner 1Gx. 4 Investigator �G'c„-��c�/� Observer T SOIL PROFILES-DATE3/a �1,71 N 1' Elev. �' Elev. 3' Elev. 4'Elev. 0 0 0 0 3 4 4\6 0 7 9 4 i 5 6 4 7 8 9 2 3 4 5 6 7 8 9 2 3 4 5 6 7 8 9 10 10 �._ 1 10------�-- 10 _ Benchmark Location Elevation Datum Percolation Tests -Date Pit Number 1 2 3 4 5 Start Saturation Soak -Mins. Start Test -Time / Drop of 3" -Time / Drop of 6" -Time JAD :vim Mins.lst 31'Dro Mins.2nd 3"Dro Notes & Sketches on Back Frank C. Gelinas & Associates, North And. WELL DATABASE ADDRESS: ' AGE OF ,NtLL: WELL DRILLER: WELL PERtiiiT,T: WELL LOCA"IiON: --SWELL PERiN= DATE:- _ DEPTH OF WELL: TYPE OF W��.L: a._ DRILLED b. DUG c. L V;�NOWN _TYPE OF WATER BEARING ROCK_ WA= ANALYSIS: DAT-HIG fi EM Y IR N. Y - N OTf CONTAiYENANTS: Y N WELL. DATABASE N ADDRESS: AGE OF WELL: 'WELL DRILLER: ' ..WELL PERN= T: WELL L0CA%-17. ` �J WELL PERNET DATE: DEPTrI OF LL TY -PE OF W -ELL: a- DRILLED b. DUG c. UINF2L CWN TYPE OF WATERBEARLNG ROCK. WATER ANALYSIS DAT:: HIGH ti/ ANGANESE: Y N HIGH IRON: Y N OTHER CONTAlA,NTS: Y N Septic compliance,°Inc. Title 5 Systeminspector Soil Evaluator n F. PaulCardone 447 Boston St., Topsfiela, Massachusetts 01983 (978) 887-8586 (978)'681-0726' .,,' 2 i.F �^—.^�:.a.-•_4s��e."��".„e^c,'h.-k..a.,r,�ry�""n.,� .�c�!y— -� �i-.c.i-;� /f..���-1�1�i�r.I.rJ♦�-�1�rr11♦ •I' Septic Comp ance, Enc. affilliate of Thomas E. Neve Assoc., Inc. February 18,1998 North Andover Board of Health FS 23 Town Hall 30 School Street North Andover, MA 01845 Attn: Sandra Starr, Health Agent Re: Sanitary Disposal System Inspection 742 Boxford Street- Edward Parolisi Dear Ms. Starr: In accordance with the Commonwealth of Massachusetts, Department of Enviromental Protection, State Enviromental Code (Title V), 310 CMR 15.301, paragraph 7, please find attached a "Subsurface Sewage Disposal System Inspection Form" for your records. If you have any questions regarding this report or any of its contents, please do not hesitate to contact this office. We thank you, in advance, for your continued cooperation in these matters. Very truly yours, SEPTIC MPLIANCE, IN . Paul Cardone Certified Septic Inspector Attachment • SYSTEM INSPECTORS • • SOIL EVALUATORS • • ENVIRONMENTAL ENGINEERS 447 Old Boston Rd., US Route 1, Topsfield, MA 01983 Tel (508) 887-8586 Fax (508) 887-3480 •1' Septic Compliance, Inc. affilliate of Thomas E. Neve Assoc., Inc. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 742 Boxford St. No. Andover, Ma. 01845 Address of Owner: Edward Parolisi (if different) Date of Inspection: February 10, 1998 Name of Inspector: Paul Cardone I am a DEP approved septic inspector pursuant to Section 15.340 of Title 5 (3 10 CMR 15.000) Company Name, Septic Compliance, Inc. Address and 447 Old Boston Road, Topsfield, MA 01983 Telephone Number: (508) 887-8586 Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance. of on-site sewage disposal systems. The system: Passes W Conditionally Passes Needs further Evaluation By the Local Approving Authority Fa' Inspector's Signature: Date: 7 p? The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Page 1 of 18 • SYSTEM INSPECTORS • • SOIL EVALUATORS • • ENVIRONMENTAL ENGINEERS DEP on the:World Wide Web: hq-//www.rnagnet.state.maus/dep (revised 04/25/97) 447 Old Boston Rd., US Route 1, Topsfield, MA 01983 Tel (508) 887-8586 Fax (508) 887-3480 - F ' NI 7I. 1310 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM: INSPECTION FORM PART A. CERTIFICATION (continued) Property Address: 742 Boxford St. No. Andover, Ma. 01845 Owner: Edward Parolisi Date of Inspection: February 10, 1998 INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES:. XX I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. 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. Indicate yes, no, or not determined (Y,N, or ND). Describe basis of determination in all instances. If "not determined", explain why. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced Page 2 of 18 (revised 04/25/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM_ PART A CERTIFICATION (continued). Property Address: 742 Boxford St. No. Andover, Ma. 01845 Owner: Edward Parolisi Date of Inspection: February 10, 1998 B) SYSTEM CONDITIONALLY PASSES (continued) The system required pumping more than four times ayear 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 C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS THE BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. Cesspool or privy is within 50 feet of a surface water. Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximate not valid.) Page.3 of 18 (revised 04/25/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 742 Boxford St. No.Andover, Ma. 01845 Owner: Edward Parolisi Date of Inspection: February 10, 1998 C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH (continued): 3) OTHER D) SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s) Number of Times Pumped (revised 04/25/97) Page 4 of 18 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART A CERTIFICATION- (continued Property Address: 742 Boxford St. No. Andover, Ma. 01845' Owner: Edward Parolisi Date of Inspection: February 10, 1998 D) SYSTEM FAILS (continued) Yes No Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface.water supply or tributary to a. surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exists: Page 5 of 18 (revised 04/25/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A, CHECKLIST Property Address: 742 Boxford St. No. Andover, Ma. 01845 Owner: Edward Parolisi Date of Inpsection: February 10, 1998 E) LARGE SYSTEM FAILS (continued): 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). The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. Page 6 of 18 (revised 04/25/97) FOWA 4 • SYSTEM Ft.J JING RECOR^ Commonwealth of Masscichusztts DECEIVED " Rr ,Massachusetts MAY 15 2006 fe?71 pij!'Ti in Record �_� „�RTH ANDOVER �iStt 1 Wi1Ct -7y2- �50fv- . N�N�u4 019 ystem ocauon ,vt F� l y o o /( (JP Type Emergency O Routine,,E No Yes Q Svp6c TznS * 'No ❑ Yes Ctasp� �I. Q - c -Osoutiry Pumped; ' / S _ _ jai'on, Dare c ' Pumping•. �S Q-,an BO RACZ.'EK.'S Permit s f _ S% stci• Pumped by (Company): _ ._ Conic- ;s irmsterrcd to: ------------ C,+nt. its disposed at: Pumper Signature Cone :tion of systerriothcr comments: / ov Nraorty roa„ , owns �S BUILDING COMMISSIONER OR INSPECTOR OF BUILDINGS Town Hall No. Andover, MA 01845 RE: AMERICAN CLAIMS SERVICE MULTI -LINE ADJUSTERS April 13, 1994 BOARD OF HEALTH OR BOARD OF SELECTMAN INSURED: Edward Parolisi PROPERTY ADDRESS: 742 Boxford St. POLICY NUMBER: HP1036117 LOSS OF: 2/28/94 Water FILE/CLAIM NUMBER: 5356 Claim has been made involving loss, damage or destruction of the above captioned property which may either exceed $1,000.00 or cause Massachusetts -General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include.a reference to the captioned insured, location, policy number, date of loss and claim file number. P a j Paul D. Jackson Claims Representative On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. April 13, 1994 Date (; i€ APR 1 5 1994 r 50 SALEM STREET, BUILDING A, LYNNFIELD, MASSACHUSETTS 01940 TELEPHONE: (617) 245-9516 • FAX: (617) 245-1077 FORM 4 SYSTEM PUNIPCNG UWPD . HEALTH Commonwealth of Massachusetts Massachusetts ti NOV — 5 a ,S stem i�'um in Record ystem ocation �yste n v✓ner PV) 3 a�OCLV� S �` 15 j Out � 4 f- i E ❑ Routir e Type Emergency Y Yes ❑ S(,ptic Tank: No ❑ Yes --�' Cesspc .D1: No ❑ Date c Pumpine: Quanti�I gallons Pumped: S%sten: Pumped by (Company): Permit �: Conic AS transferred to'. Cont_ its disposed at: Daic Pumper Signature k� Con,,-ition of systerrvother comments: k -- t DFP APPROVED FOR -Ni • 12107195 MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza Boston, Massachusetts 02108-1904 (617)723.3800 Ma Onlv (800) 392-6108, FAX (8001851.8424 Form of Notice of Casualty Loss to Building Under Mass. Gen, Laws, Ch. 139, Sec.36 NORTH ANDOVER HEALTH DEPT. NORTH ANDOVER TOWN HALL NORTH ANDOVER MA 01845 Re: Insured: JOAQUIN C. AND DIONNE TORRE Property Address: 742 BOXFORD STREET, NORTH ANDOVER, MA 01845 Policy Number: 1016862 Type Loss: Windstorm Other than Hurrcane or Tornad Date of Loss: 0112012013 Claim Number: 309279 Claim has been made involving loss, damage or destruction of the above captioned propert, which may either exceed $1000.00 or cause Massachusetts General Laws, Chapter 143, section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. MPIUA Claims Division CMA00021 112312013