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Miscellaneous - 745 FOSTER STREET 4/30/2018 (2)
No Andover J&S Development dba 1600 Osgood St Stewart's Septic Building 20 Suite 2-36 Andover Septic No. Andover, Ma 01845 58 South Kimball Street 9 -Apr Disalvo 400 Winter St Bradford, MA 01835 Date Name & Address Gallons Comments 5 -Apr Andriolo 37 Birch Lane 1500 Good Sullivan 47 Boxford St 750 Good 6 -Apr Saplenza 40 Sterling Ave 1500 Heavy bottom 9 -Apr Disalvo 400 Winter St 1500 Good 10 -Apr Sarano 265 Hay meadow Rd 1500 Xxxsolids 12 -Apr Lind 575 Winter,-. Ise 1500 Good 16 -Apr Distefano 3-5& Raleigh Tavern Lane 1000 HG Walsh 58 Paddock Lane 1500 Good 18 -Apr Schrader 35 Woodberry Lane 1000 Good Ahlhdm 48 Hawkins Lane 1000 Good 19 -Apr Barrett 235 Candel Stick Rd 1500 Good 20 -Apr Harold 453 Forest St 1500 Good Duffy 67 Shirwood Dr 1500 Good Zoll 333 raeligh Tavern Lane 1500 Good 23 -Apr Haffeners Car wash 564 Chickering Rd 2000 red tank 25 -Apr Valle 58 Evergreen Dr 1000 Good 27 -Apr Lucas 39 deer meadow Rd 1500 Good 1000 Good (: f!!f= HAY 18 20119 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT RECEIVED Commonwealth of Massachusetts a v City/Town of NORTH ANDOVER JUN 1 C 2014 System Pumping Record [HEALTH WN OF NORTH DEPARTMENT w Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out forms 1. System Location: on the computer, use only the tab key to move your Address cursor - do not NORTH ANDOVER use the return City/Town key. 2. �a System Owner: rewn Name 7y5 f%skf Z) V Address (if different from location) City/Town Ma State State Telephone Number Zip Code Zip Code B. Pumping Record —/ 1. Date of Pumping /000 Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. Sy_stem,Pumped By: "61 Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant. 20 So. Mill Bradford. Ma 01835 Signature of Hauler Signature of Receiving Fac, i Date Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts RECEIVE2101�'� W City/Town of No Andover System Pumping Record HAY ,M Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When 'jam filling out forms 1. System Location: on the computer, U use only the tab key to move your Address cursor - do not No Andover Ma 01845 use the return City/Town State Zip Code key. 9-11 2. System Owner: e-( Name renin, Address (if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Dae Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. m Pum d Name Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's P Facility Vehicle License Number 20 So. Mill Bradford, Ma 01835 Date Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 North Andover Board of Assessors Public Access Q t N� pTN Iii ^y e� CHU t Click Seal To Return Search for Parcels Search for Sales Summary Residence Detached Structure Condo Commercial t Page 1 of 1 Prnnprty Rponrll C'arll Location: 745 FOSTER STREET Owner Name: HOWARD, PAUL Owner Address: 745 FOSTER STREET City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 5 - 5 Land Area: 2.00 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 1352 sqft ASSESSMENTS Total Value: Building Value: Land Value: Market Land Value: Chapter Land Value: CURRENT YEAR 362,300 157,400 204,900 PREVIOUS YEAR 380,000 175,100 http://csc-ma.us/PROPAPP/display.do?linkId=1516548&town=NandoverPubAcc 6/15/2010 ` 0' t' -20 O �^ t H � �D coca inewKw . 1' PUBLIC HEALTH DEPARTMENT Community Development Division CE127IF'IC47E O(FCOqVLPLIANM As of: June 30, 2010 ,This is to cert that the individual subsurface disposal system received a SA7ISEAC'T01RT 15VSTEC 10X of the: ft&cement of a Component: Oistridution Box and BaffCe Foran On Site Sewage�DisposaCSystem By. Peter Breen 745 TosterStreet tap -90,A; Parcef-007 NortFcAndaver, 9VA 01845 'The Issuance of this certificate shall not 6e construed as a guarantee that the system will function satisfactorify. Susdn 2'. Saute Public 9feafth Di 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com TRANSMISSION VERIFICATION REPORT TIME 06/15/2010 11:26 NAME HEALTH FAX 9786888476 TEL 9786888476 SER.# 000B4J120960 DATE,TIME 06115 11:26 FAX NO./NAME 9786898740 DURATION 00:00:24 PAGE(S) 02 RESULT OK MODE STANDARD ECM + 'try Commonwealth of Massachusetts 04'ir.,+o ;•e. �� O Board of Health North Andover DISPOSAL., WORKS CONSTRUCTIO Permission is hereby granted Petr 13toen 11 ---:-- ------------------------------------------------------- --------- to (Repair-DISTRIBUTIONe Disposal BOX �c $F>�T�1✓) an Individual SewagSystem. / "- z Z> at No 745 FOSTER STREET--- ------------------------------------------------ --------------------------- I as shown. oto. tl).e application for Disposal. Works Ootasnlction Perm. It No. BI -IP -2010-060 Dated lime 15, 2010 Issuecl. On: Jun -l.5-2010 Board of Ileal °a?, Application for Septic Disposal System - AConstruction Permit—'I'0�1N OF Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. VQ 1i It OR1 H Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system* pair or replace an existing on-site sewage disposal system* Repair or replace an existing system component — What? A. Facilitv Information 5 Address or Lot �/. Ali' do L/ el -t- �4- Cown 2.- *TYPE OF SEPTIC SYSTEM*: ❑ Pump ❑ Gravity (choose one) ***If pump system, attach copy of electrical permit to application*** TODAY'S DATE :00 — Fu epair 125.00 - Comp nent & x 4 &FF (e. ❑ Conventional System (pipe and stone system) ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D -Box Present) S.A.S. 2. Owner Information Name G -F 2% 1 f 0 fa -/1-. Address (if different from above) /V. q City/Town State Zip Code Telephone Number 3. Installer Information Q rC--V ` N:Z�-r� 6ffart� k c C Name �7 7 !� Name of Company Address W� .4 g y ,g- rK ® c City/Town State Zip Code 1 2 F 965' 2.578 Telephone Number (Cell Phone # if possible please) 4. Designer Information Name Name of Company Address City/Town State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 Application for Septic Disposal System pConstruction Permit -'TOWN OF ORTH ANDOVER. MA 01845 PAGE 2®F2 A. Facility Information continued.... 5. Type of Building:tDesidential Dwelling or ❑Commercial B. Agreement TODAY'S DATE 00 — Full Repair 125.0 - Component The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andov , and not to place the system in operation until a Certificate of Compliance has been issu �dkthis Boar of Health. //, �5 Name Date Applic ion Approved y: (Board of Health Representative) N Date Application Disapproved for the following reasons: �a a e �b D For Office Use Only: L Fee Attached? Yes Z, No 2. Project Manager Obligation Form Attached? Yes No 3. Pump Svstem? If so, Attach copx of Electrical Permit Yes No 4. Foundation As -Built? (new construction ronly): (Same scale as approved plan) Yes No 5. Floor Plans? (new construction only): Yes No Application for Disposal System Construction Permit • Page 2 of 2 DelleChiaie, Pamela From: DelleChiaie, Pamela Sent: Thursday, June 23, 20113:34 PM To: 'ssjmeaney2@aol.com' Subject: Well Water Testing Guidelines Attachments: 20110623134702023 (2) Importance: High Follow Up Flag: Follow up Flag Status: Flagged To: Jack Re: 745 Foster Street Attached are guidelines for well water testing with regard to 745 Foster Street. According to DPW, there are no records for water, so it appears to definitely be a well although we do not have those records in the files back that far. Pamela DelleChiaie Departmental Assistant I Community Development I Health Department Town of North Andover 1600 Osgood Street I Bldg 20 1 Suite 2-36 North Andover, MA o1845 9 Office - 978-688-9540 0 Fax - 978-688-8476 0 Email - pdellechiaieotownofnorthandover.com `6 Website httD://www.townofnorthandover.com/Pates/index "We can never see the path of our life if we are too busy focusing on the pebbles under our feet "--Anonymous If you are happy with the customer service you have received from town departments, please let us know ...feel free to complete the general Comment Form (link below): http://www.townofnorthandover.com/Pages/NAndoverMA WebDocs/contact a 0 I I�LBEI 10 NO � o ff , ao Aodas 3 � -t ' blip 3 y.og1It'd hoc bo `� Taracw11 4 zI I CU 12 'fb b b0 i A. o cd 'd'd' 1.,dam' ° O N'N�v�i++ h ao 0-15-0 Vic+Rw a� Coe 44 b 0 44) os - UO a, c� cn C a °E 1g u� TO �W g� 3 _C N O� 4J 0 bjj' O ._uvEoOL_ sc �. fj0 p W.1 - �� ;8 : 9 1!0� , '18, � 1104 Q 04 Ot O � •� • 'd O 4 Tt p O xi O V ,�, '� C rn b w F+ --yy bp'� t� rh rh SDG 8 x . 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OTJ l°L W O b O fE T- Q L a. �+• "• Commonwealth of Massachusetts City/Town of System Pumping Record NORTH ANDOVER 41 Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date i accordance with 310 CMR 15.351. RECEIVED City/Town State Zip Code Telephone Number B. Pumping Record , 2. Quantity Pumped: G�— --- 1. Date of Pumping Date Gallons 3. Type of system: ❑ Cesspool(s) [/Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes W/No 5. Condition of Syste If yes, was it cleaned? ❑ Yes /No 6. System Pumped By: MCirc _-- -- ----- — - �� Z`�_-_ - -- - - -� i�..C,� �1'1 - vehicle License Number Company 7. Location where contents were disposed: Signature of Hauler — Date Signature of Receiving Facility J — — Date 15form4.doc• 03/06 System Pumping Record • Page 1 or 1 A. Facility Information JUN -4 2011 Important: When filling out forms on the(� 1. System Location: 15..___ Fo5S cf TOWN OF NORTH ANDOVER HEALTH DEPARTMENT computer, use only the tab key to move your Address cursor • do not —Nov4� _— CitylTown State Zip Code use the return key} 2. System Owner: Name different from location) — �+�+^ Address (if City/Town State Zip Code Telephone Number B. Pumping Record , 2. Quantity Pumped: G�— --- 1. Date of Pumping Date Gallons 3. Type of system: ❑ Cesspool(s) [/Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes W/No 5. Condition of Syste If yes, was it cleaned? ❑ Yes /No 6. System Pumped By: MCirc _-- -- ----- — - �� Z`�_-_ - -- - - -� i�..C,� �1'1 - vehicle License Number Company 7. Location where contents were disposed: Signature of Hauler — Date Signature of Receiving Facility J — — Date 15form4.doc• 03/06 System Pumping Record • Page 1 or 1 � Commonwealth of Massachusetts RECEIVED city/ I own of �lt1G 5 Z010 _ System Pumping Record NURTH ANDOVER Form 4 TOWN OF NORTH ANDOVER ti HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. 6. System Pumped By: jrn�a l an -- -- — -7 b b-1 Vehicle License Number I�nyi fdn rnel��a I_ Company 7. Location where contents were disposed: Signature of Hauler Signature of Receiving Facility �— --- Date Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 A. Facility Information Important: When filling out 1. System Location: forms on the �T ------.—...-- — -- - -- - -- ---- computer, use only the tab key to move your _.1—-_.—_� -- AddressM! \^ 0C V @ 1 `(1U o_vL�_ 1 cursor - do not 1 V _ City/Town State Zip Code use the return key. 2. System Owner: Name different from location) Address (if ------.._.._—._.-- City/Town State 617 ---- Zip Code Telephone Number B. Pumping Record 000 1. Date of Pumping Date 2. QuantityPumped: p Gallons 3. Type of system: F-1L� Cesspool(s) �,/ Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): -- 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: jrn�a l an -- -- — -7 b b-1 Vehicle License Number I�nyi fdn rnel��a I_ Company 7. Location where contents were disposed: Signature of Hauler Signature of Receiving Facility �— --- Date Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 745 Foster Street Property Address Paul Howard Owner Owner's Name information is North Andover MA 01845 6-9-2010 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately HOUSE A B A -C=29' A -D=32'6" A -E=69' B -C=31' B -D=34'6" B -E=57' LTD E t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 577 Main Street�`''1°'"" Hudson MA 01749 JUN 'j 9010800-499-1682 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT, WIND Rl VER ENVIRONMENTAL TITLE V OFFICIAL INSPECTION PROPERTY ADDRESS: 745 Foster Street PROPERTY OWNER'S NAME: Paul Howard PROPERTY OWNERS ADDRESS: Same DATE OF INSPECTION: NAME OF INSPECTOR: June 9, 2010 Greg Fuller Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. _ ILS rertan Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 745 Foster Street Property Address Paul Howard Owner's Name North Andover City/Town MA 01845 6-9-2010 State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Greg Fuller Name of Inspector Wind River Environmental Company Name 163 Western Ave. Company Address Gloucester City/Town 978-282-7315 Telephone Number B. Certification MA State SI4986 License Number 01930 Zip Code I certify that I have. personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Np$ds Further aluation by he Local Approving Authority Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 745 Foster Street Property Address Paul Howard Owner Owner's Name information is North Andover MA 01845 6-9-2010 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 745 Foster Street Property Address Paul Howard Owner Owner's Name information is North Andover MA required for every page. City/Town State B. Certification (cont.) B) System Conditionally Passes (cont.): 01845 6-9-2010 Zip Code Date of Inspection ❑ 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 ® Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): No outlet baffle or T. Old baffle has corroded away. Distribution box needs replacement due to severe corrosion. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 745 Foster Street Property Address Paul Howard Owner's Name North Andover MA 01845 6-9-2010 City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a- public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than'/2 day flow l5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17 E Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 745 Foster Street Property Address Paul Howard Owner Owner's Name information is required for North Andover every page. Cityrrown MA 01845 6-9-2010 State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered.a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 745 Foster Street Owner information is required for every page. Property Address Paul Howard Owner's Name North Andover MA 01845 6-9-2010 Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): [ci X t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 745 Foster Street Property Address Paul Howard Owner Owner's Name information is required for North Andover MA 01845 6-9-2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 2 Number of current residents: Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Well water. Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Currently. Last date of occupancy: y Date 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? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 745 Foster Street Property Address Paul Howard Owner's Name North Andover City/Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: MA 01845 State Zip Code Date General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Owner. 6-9-2010 Date of Inspection ® Yes ❑ No 1000 gallons Pump truck / Measured / plans To check tank's structural integrity. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins - 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 745 Foster Street Property Address Paul Howard Owner Owner's Name information is North Andover MA 01845 6-9-2010 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: N/A Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: Material of construction: ® cast iron ® 40 PVC ❑ other (explain): 2' feet 25' Distance from private water supply well or suction line. feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good clean joints. Excellent venting. No evidence of leakage of any kind. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal Tank on hill. Inlet cover is 1' Bq 1' to 4' feet ❑ fiberglass ❑ polyethylene ❑ other (explain) Outlet cover is 4" Bg. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 9'8" L x 5'W x 68" H 12" Sludge depth: t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Commonwealth of Massachusetts w - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 745 Foster Street Property Address Paul Howard Owner Owner's Name information is North Andover MA 01845 6-9-2010 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle N/A ( Corroded off) Scum thickness 2'• Distance from top of scum to top of outlet tee or baffle N/A (Corroded off) Distance from bottom of scum to bottom of outlet tee or baffle N/A (Corroded off) How were dimensions determined? Sludge judge / Rod / Ruler. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Service annually. Inlet baffle in good condition. Outlet has corroded off, nedding replacement with a sanitary tee. No evidence of leaking into or out of tank. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: t5ins • 09/08 Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 745 Foster Street Property Address Paul Howard Owner information is required for every page. Owner's Name North Andover MA 01845 6-9-2010 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 -a_ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 745 Foster Street Property Address Paul Howard Owner Owner's Name information is North Andover MA 01845 6-9-2010 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D -box is level and distribution to outlet equal. Moderate to severe carryover. Field covered, needs to be water snaked to remove sludge from lines. D -box is corroded and needs replacement. Leaking evident around leach line inverts. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: _ ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 745 Foster Street Property Address Paul Howard Owner Owner's Name information is required for North Andover MA 01845 6-9-2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields 1 - 20'x 40' number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil appears clean and dry. No signs of hydraulic failure, no ponding, no damp soil. Grass and ferns over field. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 745 Foster Street Property Address Paul Howard Owner information is required for every page. Owner's Name North Andover City/Town MA 01845 State Zip Code 6-9-2010 Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 745 Foster Street Property Address Paul Howard Owner Owner's Name information is North Andover MA 01845 6-9-2010 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 4'+/- Estimated depth to high ground water. feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record ■ 14 If checked, date of design plan reviewed: Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Checked all abutting properties: No signs of high ground water. Found 8" deep hole down hill from field in wooded area. No signs of ground water. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 745 Foster Street Property Address Paul Howard Owner Owner's Name information is required for North Andover MA 01845 6-9-2010 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 1000 G kt - St~PTr� TANi9 ARF -A•. l9.-7 4 ACTZES r. 7L4� F051eg Si QT -Vwd Ume LF, VA -r 1010.4'5. I NV PIPE OUT OF HSE 1 ;.L 4 f .4a LOT LN V_ PIPE I NTO T.o i4 L i,, 4 IK►v P1PEDLrjDFT,ojjtL izg. 73 I N V- PI PE I NTO D P)OX i t-cr •-. =1 'N. V. E7MO OE: PI PEE �� P -i{ f Lt� -a j? G4 LE f °y� ., J 4zr3s �"r, - 24 F2AI1tV- GC�E�,►.In,S ASSvcI©.i`ES ^• r..-* , , ,� � t�S C-st NEE S � i DelleChiaie, Pamela From: DelleChiaie, Pamela Sent: Thursday, June 23, 20113:34 PM To: 'ssjmeaney2@aol.com' Subject: Well Water Testing Guidelines Attachments: 20110623134702023 (2) Importance: High Follow Up Flag: Follow up Flag Status: Flagged To:;ac Foster Street Attached are guidelines for well water testing with regard to 745 Foster Street. According to DPW, there are no records for water, so it appears to definitely be a well although we do not have those records in the files back that far. Pamela DelleChiaie Departmental Assistant I Community Development I Health Department Town of North Andover 1600 Osgood Street I Bldg 20 1 Suite 2-36 North Andover, MA 01845 2 Office - 978-688-9540 Fax - 978-688-8476 (] Email - pdellechiaiePtownofnorthandover.com Website . bM://www.townofnorthandover.com/Pages/index "We can never see the path of our life if we are too busy focusing on the pebbles under our feet. "— Anonymous If you are happy with the customer service you have received from town departments, please let us know ...feel free to complete the general Comment Form (link below): http://www.townofnorthandover.com/Pages/NAndoverMA WebDocs/contact TOWN OF NORTH ANDOVER NORTH Office of COMMUNITY DEVELOPMENT AND SERVICES a o ""•° `�"oma HEALTH DEPARTMENT,- 1600 EPARTMENT 1600 OSGOOD STREET; Building 2-36 NORTH ANDOVER MASSACHUSETTS 01 45 �9s °""° "P4sy S CRUS Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director �a � �r7(S' 978.688.8476 - FAX D -BOX ❑^/ Installed on stable stone base�`�` L^/ Inlet tee (if pumped or >0.08'/foot) Lv Hydraulic cement around inlet & outlets Observed even distribution Speed levelers provided (not required) Comments: SOIL ABSORPTION SYSTEM ❑ Bottom of SAS excavated down to soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 3/4-1 Y2" double washed stone installed ❑ 1/8-1/2" (peastone) double washed stone installed ❑ Laterals installed and ends connected to header ❑ Laterals vented if impervious material above ❑ Orifices @ 5 & 7 o'clock positions ❑ Gravel -less disposal systems: type, number and location as per plan ❑ Elevations of laterals installed as on approved plan ❑ 40 Mil HDPE barrier installed ❑ Retaining wall (boulder / concrete / timber/ block) [IFinal cover as per plan Comments: Oct c, 'Y�i ih16 Wastewater System Documentation — Feb 2006 Page 3 of 6 ',' :o',a Commonwealth of Massachusetts a Board of Health North Andover 1Ss:�CNus� DISPOSAL WORKS CONSTRUCTIOL--------i Permission is hereby granted Peter Breen ------------------------------------------------------------------------------- - to (Repair -DISTRIBUTION BOX & BAFFLE) an Individual Sewage Disposal System. at No 745 FOSTER STREET as shown on the application for Disposal Works Construction Permit No. BHP -2010-060 Dated June 15, 2010 ------ ----------------------------- Issued On: Jun -15-2010-----, Of - - ------ ----------- Board of Heal / N E Qt •I&O RT" Commonwealth of Massachusetts Map -Block -Lot ----------------------- Q Board of Health Permit No `a aNorth Andover BHP -2010-0609 .. i.... .. P.I. FEE �SsacHuF.I. $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Peter Breen to (Repair -DISTRIBUTION BOX & BAFFLE) an Individual Sewage Disposal System. at No 745 FOSTER STREET as shown on the application for Disposal Works Construction Permit No. BIR-2upAo_ Dated June 15, 2010 ------------------- FILE COPY --------------------------------------- I ssued On: Jun -15-2010 Board of Health Commonwealth of Massachusetts Map -Block -Lot X39 ,"So �a.`,Md10 4afiftid Q -. Board of Health North Andover �S ••�14 -,a� CERTIFICATE OF COMPLIANCE At„ u{ THIS IS TO CERTIFY, That the Individual Sewage Disposal System (Repair -DISTRIBUTION BOX by ---Peter-Breen ---------------------------------------------------------- ------------------------------------------------------ Installer at No _745 -POSTER -STREET has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. _BHP -2010-060_ Dated _ _ _ - - - June 15,_ 2010 - - - - - - - --------- Printed On: Jun -15-2010 Board of Health G f NORTy , 5052 Town of North Andover '+�'••;; :o ::. HEALTH DEPARTMENT ,SSACNUstt CHECK #: DATE: 5� LOCATION: 19, H/O NAME: CONTRACTOR NAME: 7P� 0- -",-7 Type of Permit or License: (Check box) ❑ Animal ; $ ❑ Body Art Establishment, $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ $ $ $ $ $ $ $ $ $ $ SEPTIC Systems: ❑ Septic - Soil Testing —` $ ❑ Septic - Design Approval $ [3Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) $�� ///,z, ealth A& Initials White - Applicant Yellow - Health Pink - Treasurer ❑ 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 $ [3Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) $�� ///,z, ealth A& Initials White - Applicant Yellow - Health Pink - Treasurer ❑ Septic - Soil Testing —` $ ❑ Septic - Design Approval $ [3Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) $�� ///,z, ealth A& Initials White - Applicant Yellow - Health Pink - Treasurer 745 Foster Street, North Andover, MA 01845 - Prudential Howe & Doherty, REALTORS® Page 1 of 3 7 �,� Sion In Pwdenfiat � '�' New User? Sin U Howe &Doheny,! REALTORS* 1, 1 Boston, MA M My Portfolio I My Search l(Online Seller AdvantagesmiI Resources About Home Contact hU Featured Listings I Area Inventory the future of real estate. Now. To learn more about this property, use Contact or call (978)857-1500. Chris Doherty SEE THIS PROPERTY Make an appointment to see this property with a local sales professional Next Steps Request a Home Tour Send Property to a Friend Save to My Portfolio Make an Offer M print 745 Foster Street, North Andover, MA 01845 go to map ® Share Search for nearby listings r----- --- -- -- -- Y` i_f -- r View Flood Map View More Photos Estimated Monthly Payment ............ ............... _....................... ._......... .---.......... Asking Price($): $354,900 Down Payment($): $70,980 Interest Rate: 30 yr. fixed @ 6% i n/a Calculate . . ............ ........ .. Monthly Payment: ............... -.............. ......_........... $1,702 Price: $354,900 Bedrooms:3 Bathrooms: 2/0 Garage:2 Square Ft: 1,352 Lot Size: 2 Price Per sq/ft for this property: $262 Average Price Per sq/ft for this area: $195 Median Home Price for North Andover, MA: $399,900 Year Built: 1979 MLS Number: 71215551 Property Type: Single Family Subdivision: n/a Status: For Sale Pru ID: PRU6P4E8 Property Information School District: n/a Live Date: Apr 13, 2011 Area Location: n/a County: Essex Map Page: 90 Peace And Tranquility Are Yours In This Absolute Move -In Condition Ranch. Enjoy 3 Seasons In The 15 X 16 Screened In Porch Overlooking 2 Acres Of Privacy. Bring Your Hot Tub! Large Eat - In Kitchen With Sliders To Deck. Family Room Features Wood Burning Fireplace. Brand New Heating System (2010), Title V Approved. Heated Lower Level Workshop Can Be Converted Back To A Garage. This Home Is Bright, Cheery And Very Manageable. Move In And Enjoy Life! General _ ...... ._............. ........................ Total Rooms: ............. 5 .._.............._... .............. Bedrooms: 3 Full Bathrooms: 2 Garage Capacity: 2 Garage Description: Under Parking Features: Off -Street Parking Spaces: 8 Fireplaces: 1 Square Footage: 1,352 Square Footage Public Record Source, Room Dimensions Bathroom 1: 8X7 Bathroom 2: 6X5 Bedroom 2: 15X10 Bedroom 3: 12X12 Family Room: 20X12 Kitchen: 20X12 Master Bedroom: 14X12 Other 1: 22X11 Exterior Comments .... ..._...................... ................................... Exterior Features: Enclosed Porch, Deck, Storage Shed, Screens Interior Comments _....._......_. ............_.............. .._...-................. ....... ........... ... ........... -....... ... Interior Features: Cable Available Basement Features: Full, Interior Access, Garage Access Flooring: Tile, Wall To Wall Bathroom 1 Full Bath Carpet Description: http://pruhoweanddoherty.com/details/start.aspx?propid=0050071215551 &VIP=C1assTruli... 7/19/2011 745 Foster Street, North Andover, MA 01845 -Prudential Howe & Doherty, REALTORS® Page 2 of 3 Bathroom 1 Level: First Floor Bathroom 2 Level: First Floor Bedroom 2 Level: First Floor Bedroom 3 Level: First Floor Family Room Level: First Floor Kitchen Level: First Floor Master Bedroom Wall To Wall Carpet Description: Other 1 Level: Basement Bathroom 2 Full Bath Description: ._..--.............. ... Bedroom 2 Wall To Wall Carpet Description: Frame Bedroom 3 Wall To Wall Carpet Description: Family Room Fireplace, Wall To Wall Description: Carpet, Bay / Bow / Lead Paint: Box Window(s) Kitchen Description: Stone / Ceramic Tile Asphalt/Fiberglass Floor, Dining Area Master Bath: Yes Master Bedroom First Floor Level: Year Built: Other 1 Room Workshop Name: Year Built Source: Construction No ........... ._..--.............. ... ..................... ............ Basement: ._............. Yes Construction Frame Currently Used As A Materials: Exterior: Vinyl Foundation: Poured Concrete Lead Paint: None Roof: Asphalt/Fiberglass High School: Nahs Home Owners Shingles Style: Ranch Year Built: 1979 Year Built Actual Year Built Source: Public Record Description: 2011 Equipment Appliances: Range, Dishwasher, Cooling System: Wall Ac Disposal Cooling Zones: 1 Electric Features: 220 Volts, Circuit Breakers Energy Features: Storm Windows, Heat Zones: 2 Storm Doors Heating: Forced Air, Propane Hot Water: Electric, Tank Sewer And Water: Private Water, Private Utilities Available: For Electric Range, For Sewerage Electric Oven, For Electric Dryer, Washer Hookup, Icemaker Connection Property Listing Agent: Peggy Patenaude Listing Provided Prudential Howe & Courtesy Of: Doherty MLS Number: 71215551 Lot Comments ................... ......._.-.................-...._........ - ......... _---.._........... Acres: 2 Beachfront: No Lot Description: Paved Drive Road Type: Public, Paved, Publicly Maint. Additional Information Adult Community: No Disclosure, No Disclosures: 1 of The Garage Stalls Elementary School: Kittredge Currently Used As A Workshop. LI Has Electric Heat. High School: Nahs Home Owners No Association: Middle School: Nams Tax Amount: $4,872 Tax Year: 2011 Neighborhood Map r� n and a Wildcat ,� ' Show Nearby Clear Mao Forestb' s A Local Schools rta�p w �e ❑ B Grocery Stores ` • ❑ C Parks • y c Map data 02011 Google http://pruhoweanddoherty.comldetailslstart.aspx?propid=0050071215551 &VIP=ClassTruli... 7/19/2011 745 Foster Street, North Andover, MA 01845 -Prudential Howe & Doherty, REALTORS® Page 3 of 3 D Restaurants ❑ E Gas Stations Driving Directions To this location I From this location My Account My Search My Portfolio Resources Online Seller Advantagesm About Terms of Use Privacy Policy © 2011, An independently owned and operated member of The Prudential Real Estate Affiliates, Inc. Prudential is a service mark of The Prudential Insurance Company of America. Equal Housing Opportunity. Q ©2011 MLS Property Information Network, Inc. All Rights Reserved. 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The data relating to real estate properties on this website was last updated as recently as July 18, 2011 11:08 AM CST REALTOR@ -- A Registered collective membership mark that identifies a real estate professional who is a member of the National Association of REALTORS@ and subscribes to its strict Code of Ethics. U.S. Pat. 7,333,943 Andover, Arlington, Bedford, Belmont, Boston, Burlington, Cambridge, Concord, Dover, Duxbury, Gloucester, Lexington, Lincoln, Manchester -by -the -Sea, N. Andover, Needham, Somerville, Stoneham, Sudbury, Swampscott, Watertown, Wayland, Wellesley, Weston, Winchester • http://pruhoweanddoherty.com/details/start.aspx?propid=0050071215551 &VIP=ClassTruli... 7/19/2011 PUBLIC HEALTH DEPARTMENT (ommunity Development Division C(FR7IFICA7E Off' C0914J)(I0NCE As of: June 30, 2010 This is to cert that the individua[su6surface disposal system received a SA`Il'STAC`IORT INSPECY ON of the: ft&cement of a Component: Distrid ution Box and Ba f f �e For an On Site Sewage Disposa[System . By. Peter Breen At: 745 (Foster Street Lap -90.A; (ParceC-007 Nortk Andover, 9Y.A 01845 ,The Issuance of this certificate shad not be construed as a guarantee that the system -will function satisfactorify. usdn T Sa , Pu6C�c IfeaCth Jai; 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com V Driving Directions from 1600 Osgood St North Andover, Massachusetts to 745 Foster St ... Page 1 of 2 I Sorry! When printing directly from the browser your directions or map may not print MAVOU"EST correctly. For best results, try clicking the Printer -Friendly button. 40 To Starting Location Ending Location 1600 Osgood St 745 Foster St North Andover, MA 01845-1048 North Andover, MA 01845-1433 Total Travel Estimate: 18 minutes / 7.56 miles Fuel Cost: Calculate MAP 11YEST r arRMRr�, t St •40 80o mt {f\ Chadwick }✓fzaooft, Poigd I y f Johns > W � f pond Hoveys Rx9d Willow Rd ri 81 s � Vest Bvxi rd s L,}-'Lakey Ct]ChfGflwWiG,k Wilell' �1 02010 MapQue#t Portions 02010 N%1w7EQ 40- 1600 Osgood StEdit North Andover, MA 01845-1048 Start out going SOUTH on 1. OSGOOD ST/MA-125 toward ORCHARD HILL RD. 2. Turn SLIGHT RIGHT onto SUTTON 1.4 mi 0.1 mi http://www.mapquest.com/maps? 1 c=North+Andover& i s=MA& l a=1600+Osgood+St& 1 z... 6/16/2010 Driving Directions from 1600 Osgood St North Andover, Massachusetts to 745 Foster St ... Page 2 of 2 745 Foster StEdit North Andover, MA 01845-1433 Total Travel Estimate: 18 minutes / 7.56 miles Fuel Cost: Calculate Directions and maps are informational only. We make no warranties on the accuracy of their content, road conditions or route usability or expeditiousness. You assume all risk of use. MapQuest and its suppliers shall not be liable to you for any loss or delay resulting from your use of MapQuest. http://www.mapquest.com/maps?lc=North+Andover&l s=MA& l a=1600+Osgood+St& 1 z... 6/16/2010 ST. 3. Turn RIGHT onto TERMINAL RD. 0.1 mi 4 Turn RIGHT to stay on TERMINAL 0.2 mi RD. 5. Turn LEFT onto SUTTON ST. 0.1 mi 6. Turn LEFT onto OSGOOD ST/MA- 125/MA-133. 0.2 mi tag 7. Turn SLIGHT RIGHT onto GREAT POND RD/MA-133. Continue to 2.9 mi follow MA -133. 8. Turn RIGHT onto MAIN ST. 2.4 mi 9. Turn RIGHT onto FOSTER ST. 0.2 mi W —1 - - 10. - -- ------ ---- --- ---------- 745 FOSTER ST is on the LEFT. ---------- --- - ------ _.._ _ _-_ _ _ _. ... - ----- - 745 Foster StEdit North Andover, MA 01845-1433 Total Travel Estimate: 18 minutes / 7.56 miles Fuel Cost: Calculate Directions and maps are informational only. We make no warranties on the accuracy of their content, road conditions or route usability or expeditiousness. You assume all risk of use. MapQuest and its suppliers shall not be liable to you for any loss or delay resulting from your use of MapQuest. http://www.mapquest.com/maps?lc=North+Andover&l s=MA& l a=1600+Osgood+St& 1 z... 6/16/2010 1600 Osgood St, North Andover, MA 01845 to 745 Foster St, Boxford, MA 01921 - Goo... Page 2 of 3 1600 Osgood St, North Andover, MA 01845 1. Head east toward MA -125 S/Osgood St @2. Turn right at MA -125 S/Osgood St About 2 mins 1 3. Turn left at MA -133 E/Great Pond Rd Continue to follow MA -133 E About 3 mins 4. Continue onto Washington St About 2 mins r5. Turn right at Main St About 5 mins go 374 ft total 374 ft go 1.1 mi total 1.2 mi go 1.7 mi total 2.9 mi go 1.1 mi total 4.0 mi go 2.4 mi total 6.4 mi http://maps.google.comlmaps?f=d&source=s d&saddr=1600+Osgood+Street,+North+And... 6/16/2010 1600 Osgood St, North Andover, MA 01845 to 745 Foster St, Boxford, MA 01921 - Goo... Page 3 of 3 6. Turn right at Foster Rd Destination will be on the left 745 Foster St, Boxford, MA 01921 go 0.2 mi total 6.7 mi These directions are for planning purposes only. You may find that construction projects, traffic, weather, or other events may cause conditions to differ from the map results, and you should plan your route accordingly. You must obey all signs or notices regarding your route. Map data ©2010 Google Directions weren't right? Please find your route on ma s. oo le.com and click "Report aproblem" at the bottom left. http://maps.google.comlmaps?f=d&source=s_d&saddr=1600+Osgood+Street,+North+And... 6/16/2010 JV.1L YKUt'1L� & PER TION TEST DATA �7,a%%�� North Andz)ver,I�?ss. No. &Street Lot No. Loc./Subdiv. Plan Investigator"oo4�jbse SOIL PROFILES ?' Elev. 2. Elev. 3. Elev. 4'Elev. 0 0 0 0 �J Benchmark Elevation 2 2 Ties to Test .Pits 2 3 3 5 6 1 2 _= 5 6 4 3 4 5 6 --------- — Start Saturation - 7 8 9 0 7 8 9 10 Location Datum Z r olation Tests-Date 7 8 91I 10 Pit Number 1 2 3 4 5 Start Saturation Soak -Mins. Start Test -Time PLOP ofS- Drop of 61' -Time ?� bins. lst. 3"Dro Mins.2nd 3"Dro — Percolation Rate �e Notes & Sketches oa Back ,i And -1, (,1 - 1 2 3 Loc. / S k)-L>d i v, Loc./St)->div, Plan, Investigator Observer rt Saturation SOIL PROFILES -DATE 1. Elev. 2. --- Elev. 3. Elev. ----_ ns.- a'Elev. — 0 0 0 Ft Test -Tine — of 3" -Time. 2 2 2 of 6't--* Ties to Test Pits 3 s.lst 3"Drop .2nd 3"Drop 3 — — 3 — s & S}- 4 -- — — 4 4 _' 3enchma rk elevation pit t_a oak -Mi t a rop ro r, of 5 6 7 8 9 10 Location Datum _ Percolation Tests -Date 5 6 7 8 9 10 Nunber e 1 2 3 4 S rt Saturation ns.- Ft Test -Tine — of 3" -Time. - of 6't--* -- s.lst 3"Drop .2nd 3"Drop - — — s & S}- -- — — — etches on Back i Board of Health North AndoveriNass. LVED DATE n, OK i IZ SEPTIC SISTEK INSTAU ATICN CHECK LIST �ppc�w.p� LOT ERCAVATIMK FAIL a 1. Distance Tot a. Wetlands b. Drains c. Well '2. Water Line Location 3. No PVC Pipe A. Septic Tank a. Tees - Length & To Clean Out Covers b. Cement Pipe to Tank On Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Equal Amounts c. No Back Flow b. Leach Field or Trench a. Dimensions b. Stone Depth c. Capped Eads d. Clean Double Washed Stone 7. Leach Pits a. sions b. Sto a Depth c. SP ash Pads d. Taiew e.Ment Pipe to Pit - Both Sides f. lean Double Washed Stone /8. No garbage Disposal 9. Final Grading Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System c. Location with Regard -to Pere Test d. Elevations e, Water Table b _PPROV ED DtkTE PROVIDED Title 5 Reg. 2.5 IF ail I l T . - Reg. 6 i�q ANDOVr;R .RD Or HEALTH /_ 00 rot DISAPPROVED DATE TIME REASON %klivSa /✓ submitted plan must show as a minumum: the lot to be served area, dimensions, lot //,abutters) (Planning Board -files) location and log of deep observation holes -distance to ties location and results of percolation tests -distance to ties s & calculations showing required design calculation leaching area location and dimensions sf system .(including reserve area) existing and proposed contours -location of any wet areas within 100 of the sewage disposal system o r disclaimer (check wetlands-mappinE surface and subsurface drain's within 100' of sewage disposal system or disclaimer location of any drainage easements within 100 of sei•.age disposal system or disclaimer (planning board files) -known: sources_ of --water_ supply with= -n; 200' -01 Sewage disposal- sys-tem= or_-rop--disclaimer- Iocati osed--well to serve=- the -lot ('100' -on-: of anyp from leaching facility) r- location -of water lines- on property (10' from. leach= facilities) location of benchmark driveways garbage disposers no PVC. is to be used in construction a profile of the system (elevations of basement, Pl. pipe septic tank, distribution box -inlets and outle:- distribution. -field piping and any other elevations) f maximum ground water elevation in area of sewage di, systemFn ineer or (s) plan must be prepared by a Professional g other professional authorized by law to prepare suc plans S,eptic Tanks 3) Capacities 150% of flow, water table, tees, of tees, access, pumping% - b Cleanout �. -- Cleanoom cellar wall or in -ground swimming pool d 25'- from subsurface drains depth) 51 Z .®2 w CY NORT14827 j O ` • Town of North Andover «�;S ;; :o :•s� ` HEALTH DEPARTMENT SAC14USt CHECK #: DATE: LOCATION: H/O NAME: CONTRACTOR N Type of Permit or License: (Check box) ❑ Septic - Soil Testing ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type.. $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice i $ ❑ 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 Spector $ itle 5 Report $ ❑ Other: (Indicate) $ n Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: n y S �zc C—: r� S t Owner's Name: b:(— C O u -P Owner's Address: _ fl Ll Fb5To� Sl— N8, r. Date of Inspection: i(�. Name of Inspector: (please print) Company Name: N. T. White�Enterprises, DBA HomePro Northshore Mailing Address: P.Q. Box 101 Rowl Py, Ma_ n7g69 Telephone Number: (978)948-8428 CERTIFICATION STATEMENT I certify that I have personally inspected.the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and.maintenance.of on site sewage disposal systems. I am a DEP approved system inspector pursuant to S tion 15.340 of Title 5 (310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails. Inspector's Signature: m- AkDate: J,)<Ao 1-- 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. OF 14 ©f VjEAj-, . . Notes and Comments ��'��"""�� ""This report only describes conditions at the time of Inspection and under the conditions of use at that time. This inspection does not address how the systems -will erio m in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I 1 s OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS -SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 17 u;, 1" 05TTE - Sr N, At,-,DoUC-N Owner: r_ Co uQ Date of Inspection: i Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section b A. Sy m 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.. .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 substantia! infiltration or exfiltration or tank failure is imminent. System will pass inspecam if the existing tank is replaced \v;i.: a complying septic tank as approved -by the Board of Health. *A metal septic tank will puss 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 of i or high static water level in the distribution box due io broken oc:: obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s).are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ND explain broken pipe(s) are replaced obstruction is removed 2 ". Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: �W �— FGST>= N, Rt✓DouE� Owner: (� Cwe Date of Inspection: cc. 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 sy tem 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(l)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: Cesspool or privy is .within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone .1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: '. Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: `� F03wrR _5-" Owner: L C o vP Date of Inspection: 311cx. D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes No ���ackup 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 _ tquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow �e uired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number f times pumped _ ::�;y portion of the SAS, cesspool or privy is below high ground water elevation. y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. portion of a cesspool or privy is within a Zone I of a public well. y portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private., water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or leaf than S ppm, provided that noother failure criteria are triggered. A copy of the analysis must be attached to this form.] VO (Yes/No) The system fails. I have determined that one or More of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the faihue. E. Large Systems: To be considered a large system the system must serve a fieffity with a design flow of 10;000 gpd to 15,000 gpd. You must indicate either "yes" or "no" to each of the following:. (The following criteria apply to large systems in addition -to -die criteria above) N yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system'has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. It .4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ri � 1"'Gn (4 fvocj U EF Owner: —J�(- C a Date of Inspection: Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes o Pumping information was provided by the owner, occupant, or Board of Health _ Zwere any of the system components pumped out in the previous two weeks? -ll — 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 partof 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 ? 7the�—bal Were theseptic tank manholes uncovered, opened, and the interior of the tank inspected for the condition es 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: Yes o Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] % Page 6 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .iPART C SYSTEM INFORMATION Property Address: 0 q,C EoMt,,7 Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL 2 Number. of bedrooms (design): J Number of bedrooms (actual): -3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):c- Number of current residents: Does residence have a garbage grinder (yes or no):�S Is laundry on a separate sewage system (yes or no): Na [if yes separate inspection required] Laundry system inspected (yes or no): Seasonal use: (yes or no): fvtJ Water meter readings, if available (last 2 years usage (gpd)): L L. Sump pump (yes or no): Nv Last date of occupancy: -'► LL p C G� P tEp COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): Rpd Basis of design flow (seats/persons/sgft,etc.): Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): Non -sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER (describe): 1 GENERAL INFORMATION Pumping Records Source of information: LDST Was system pumped as part of the inspection (yes..or no).: neo If yes, volume pumped: _gallons -- How.,was quantity pun a determined? Reason for pumping: TYP OF SYSTEM Septic tank, distribution box, soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank _ Attach a copy of the DEP approval _ Other (describe): im Approximate age of all components, date installed if known and source of information: on MATtca r=RoM 0Lt. uE� F�n�o PA 9i )e-SPBC:0.A,+`ZFPaRT Were sewage odors detected when arriving at the site (yes or no): N4' Page 7ofII OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Pi sr lam. I�Nc�uE� Owner: Date of Inspection: BUILDING SEWER (locate on site plan) I Depth below grade: _y Materials of construction: — cast iron _40 PVC other (explain): Distance from private water supply well or.suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: _ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass polyethylene —other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): — (attach a copy of certificate) Dimensions: Sludge depth: /ij �b Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: I rl If Distance from top of scum to top of outlet tee or baffle: 6 �f Distance from bottom of scum to bottom of outlet tee or baffle: r� How were dimensions determined: ll,,C-JR5 0j P ST(c ►L wt Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): _ 'TpwU. D--, &-5 A,167–NEe6D Its BJE 9— 1 A-' LF ---V- 4 q' -;V Z 13 0, �rU Gcr� 4.r-OfTtC;A, -TANK N- SfC,N PT- O t: (6k, t/JF(Ti GREASE TRAP: _(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 Page 8 of I 1 OFFICIAL INSPECTION FORM='NOT'FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSITM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 04S-- 3T N, Adv %A Owner: co�P Date of Inspection: 3b A OGl TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) 41 %L i Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Continents (condition of alarm and float switches, etc.): 17 _r S fi' LGw c' oAl) E 61 LSZ 0-91/ 1 G /i - Iev_)f9E b E 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.): _ n Lr� �u C�tDcn�c'� o r. Q�� Gz fti otl oc;, c3 C— D -t3 - PUMP CHAMBER: (locate on site plan) ' GV Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of pump chamber, Condit (o i;fp!*and appurtew=es, etc. : i . v Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: � y j Fo- 1 t=n n IVDaUFK Owner: A L C v Date of Inspection: _ iL SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: aching trenches, number, length: I / leaching fields, number, dimensions: 3 3 7 `1 -57 t overflow cesspool, number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 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 or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (locate on site plan) ov/A Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 9 ' " v Page 10 of 11 OFFICIAL INSPECTION FORM —:NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTIgM INSPECTION FORM FART. C. SYSTEM INFORMATION (continued) Property Address: y5 E051 an 5-1- ", ANDOUEN Owner: c.._ Cp, LAP Date of Inspection: f LLJikf, I 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. 10 I S `7 6 10 M C V Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: L_ u Date of Inspection: f 0&' SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water Of feet Nc, F -c- A-0 Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked with local excavators, installers- (attach documentation) Accessed USGS database -explain: --/— PO 5-T ja 1 x,51G xr You must describe how you established the high ground water elevation: _ h404 M 44 T i TLS 'jT— i ti 5PFc-71 c A, (J�Dt�� NEW ENGLAND ENGINEERING SERVICES INC MAR ' 6 2003 March 6, 2003 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT: 745 Foster Street, North Andover, MA Dear Sirs: Enclosed is a copy of the Title V report for the above referenced property. The system PASSED our inspection. If there are any questions please call me at my office, 686-1768. Sincerely Benjamin C. Osgood, Jr. 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 7q5- / o 0Z 572Er i Ua2ili AjJ00uC2 /h19- Owner'sName: CIN17ith 1, )+RNoG,p BFFKIuG Owner's Address: -71 S- (-y,5TE(4 s� 20 fJO(LTM Aay0ouCf-m19 Date of Inspection: ? 16 L o 3 Name of Inspector: (please print) e n sR•►� „o i� s q �a Company Name: t tGw �ry/.,.LRAJD fW64Aj �t(LIN 4� Mailing Address: o D 2tu i 0t (LTH A,,jpaye A- inti Telephone Number: Tib- 6 8--17 6 CERTIFICATION STATEMENT 7rgq�TO z V OF R,ORT1;: AEW 0, / MAR - 6 2003 L.. 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. Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: &.= C T / Date: 2 � � The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and comments Sc`r 1zEcJ.ue,v0 it70 &. s IN goyb ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 7 `%� ��os;z �z 5-rA&5`1� Ato 2TY A AI POOH tZ-. U4 - Owner: 6ynOV1119 i ARWL-P 6fi-AtN6— Date of Inspection: Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: V/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: On more system components as described in the "Conditional Pass" section need to eplaced or repaired The em, upon completion of the replacement or repair, as approved by the Boar f Health, will pass. Answer yes, no or not d ined (Y,N,ND) in the for the following .statemen . If "not determined" please explain. The septic tank is metal an ver 20 years old* or the septic tank ether metal or not) is structurally unsound, exhibits substantial infiltra n or exfiltration or tank failure . imminent. System will pass inspection if the existing tank is replaced with a complyin septic tank as approv y the Board of Health. *A metal septic tank will pass inspection if is structurally so d, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years of ' availabl . ND explain: Observation of sewage backup or out or high is water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, ed or uneven distrib 'on box. System will pass inspection if (with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or repla ND explain: e system required pumping more than 4 times a year due to broken or ob cted pipe(s). The system will pass inspection if (with approval of the Board of Health): ., broken pipe(s) are replaced obstruction is removed ND explain: 'Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 7 41.5- 1� S S R - ND AIR ANnOL)- 4 AAA Owner: C�N"►1c1►4> R;�1J�� D gr�ktro� Date of Inspection:) f 3 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(l)(b) that the stem is not functioning in a manner which will protect public health, safety and the envi"ment: _ 1 or privy is within 50 feet of a surface water Os�pool or privy is within 50 feet of a bordering vegetated wetland or salt m 2. System will fail Walesa a Board of Health (and Public Water Su ier, if any) determines that the system is functioning in a man er that protects the public health, ety 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 urface water suppl . _ The system has a septic tank and S d the AS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS a SAS is within 50 feet of a private water supply well. _ The system has a septic tank andAS and the SikS is less than 100 feet but 50 feet or more from a private water supply well**. Meth used to determine stance **This system passes if the ell water analysis, performed DEP certified laboratory, for colifor{n bacteria and volatile or c compounds indicates that the wl free from pollution from that facility and the presence of nia nitrogen and nitrate nitrogen is eq�attach to less than 5 ppm, provided that no other failure criteria triggered. A copy of the analysis must be o this form. 3. Other: 'Page 4 of 11 OFFICIAL INSPECTION FORINT -- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: )" Ery A nj o O u c 02 AAA Owner: cy"- ?o4 3 A,�N��� t314K.►'� G - Date of Inspection: 3 b 0 3 A System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes No ✓, Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _✓ Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow _✓1 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the SAS, cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be onsidered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 1Rd• You must indi either "yes" or `bio" to each of the following: (The following crit apply to large systems in addition to the criteria above) yes no _ _ the system is within 400 of a surface drinking water suppl — _ the system is within 200 feet of a tri to ce drinking water supply _ the system is located in a nitro en sensitive ar (Interim Wellhead Protection Area – IWPA) or a mapped Zone II �publicpply well If you have an estion in Section E the system i nsidered a significant threat, or answered "Yes" in Section D above the large system has failed. The owner or open of any large system considered a significant threat under Section E or failed under Section D shall upgrade the em in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the artment. Page 5 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: '7X15 Fzbs i c r2 sz 2C r —A2f?Xu Anj-0(51CV- MA Owner: ayAj"fKi4 S h-jL1�0L.p 9 AIV G - Date of Inspection: 77, j b „ 3 Check if the following have been done. You must indicate `Syes" or "no!' as to each of the following: Yes No _ Pumping information was provided by the owner, occupant, or Board of Health ✓ Were any of the system components pumped out in the previous two weeks ? _ Has the system received normal flows in the previous two week period ? Have large volumes of water been introduced to the system recently or as part of this inspection ? _ Were as built plans of the system obtained and examined? (If they were not available note as N/A) _ Was the facility or dwelling inspected for signs of sewage back up ? Was the site inspected for signs of break out ? _ Were all system components, excluding the SAS, located on site ? Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? _ _ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no Existing information. For example, a plan at the Board of Health. _ ZDetermined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: ? 45' Fos- P- Cl 2CE oo L_iNU Qr/,,o ooF ✓L AAA Owner: C. Yn/ i K m i f,#v knu 6— Date of Inspection: 7,i b 10 3 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example:110 gpd x # of bedrooms): H5'0 &f A Number of current residents: 7 Does residence have a garbage grinder (yes or no): JE -5, Is laundry on a separate sewage system (yes or no): !1!* [if yes separate inspection required] Laundry system inspected (yes or no):lVO — 2ecoAucNo "uA,0 ay 5e- -qco i N '70 ssP;�� sys;ern. Seasonal use: (yes or no): aL Water meter readings, if available (last 2 years usage (gpd)): w z i -- Sump pump (yes or no): Lo Last date of occupancy: elc, rrE COMMERCIALIMUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): _ Qpd Basis of design flow (seats/persons/sgft,etc.): Grease trap present (yes or no): Industrial waste holding tank present (yes or no): Non -sanitary waste discharged to the Title 5 system (yes or no): _ Water meter readings, if available: . Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: ?v M fit` D .2 `; F0 2 s /}&-o Was system pumped as part of the inspection (yes or no): N,7 If yes, volume pumped: gallons — How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM A Septic tank, distribution box, soil absorption system _ Single cesspool _ Overflow cesspool Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) _ Tight tank _ Attach a copy of the DEP approval — Other (describe): Approximate age of all components, date installed (if known) and source of information: .-IMM4uEP )q77 PFA As ROI L"7— Were i Were sewage odors detected when arriving at the site (yes or no): Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: -74S i�bsj-c,2 N60 --N ANDo 2 Owner: Cyn? � K0 s A•2/ML-9 gf}Kt+v Date of Inspection: _ 3 ) �0 3 BUILDING SEWER (locate on site plan) Depth below grade: 36 Materials of construction: ✓ cast iron _40 PVC other (explain): Distance from private water supply well or suction line: 35-1 Comments (on condition of joints, venting, evidence of leakage, etc.): ?I PC A_'�o i< j &V&P iN 811-SC'U' 141 SEPTIC TANK.^ ._4 (locate on site plan) Depth below grade: 6 - Material of construction: [concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) Dimensions: f o v c &-&L- t,oti s Sludge depth: Zµ Distance from top of sludge to bottom of outlet tee or baffle: Z 6 Scum thickness; Z " Distance from top of scum to top of outlet tee or baffle: (� i Distance from bottom of scum to bottom of outlet tee or baffle: /9 " How were dimensions determined: M iA s w j2 F- s r1 c 4 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): ` _TF}N)k IkJ &V00N, eeAje(IG jl' TG�S /N' `t'OcJ a7 GREASE TRAP: 4koocate on site plan) Depth below grade: Material of construction: concrete _metal _fiberglass _polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: `7 HS f;�,s Et- S~2c C r Owner: GYAriH► MbLD e->aKtAJ6— Date of Inspection: o 3 TIGHT or HOLDING TANK: W (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other(explain): Dimensions: Capacity. gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: D 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.): 13 D lAi . o/4 Co" D 4 ►2 ft?E fi✓t_j f-'�IZO -41, k OJ3F 7-,gAIX M05T' M05T DF 77Ye FCO w- P-rCVMc-N3) ;"SrA"A---(101Q of A NES .D - v'OX io Coila C 1 01vE0v1c► J15 i Q1,QunatJ. PUMP CHAMBER: 1! (1" (locate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 7 N,S ST/L F� i� Owner: e y/U-�/tif i 1VNc7 i -p OW IAI N6 - Date of Inspection: 31 G)z> SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: leaching trenches, number, length: leaching fields, number, dimensions: / Of X SY ' I- c He It r -i 6l a overflow cesspool, number: innovativetalternative system Typetname of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 1111Ea of le/ELD 5/i, 0 L (2 F, I NS PFGi1 a N o F -e'iv.v� )NDrcA�S ii IS 6-LEI4N fFnJD PIZy w'-ili Q Poo Di CESSPOOIS: 1V11' (cesspool must be pumped as part of inspectionxlocate on site plan) Number and configuration: Depth — top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY:,4/ (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.): F Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 7 y5 1:bd/�/? ST/L ToIT5Y . hvpou 2 ,v,A Owner: CYN'NiA ; tv4lozp $q14 w 6— Date of Inspection: 6_ 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 27` Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 7 `/S -A&-s)-7W s; Vo a -IV Aly , o o r2 M.4 Owner: CYI-j-,yt4 r' ")'Z v0&P agKIN(,— Date of Inspection: a/ 6- 63 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water _j(;7_ feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked with local excavators, installers- (attach documentation) A` Accessed USGS database --explain: You must describe how you established the high ground water elevation: - S)TF of !-c4clt frte�� �5 /c7 f�8�•; iLi#4Dwa, -54A04pSiNJ9IcW-i-F JCYI JU ININ WaterTable r SSP ' -9 --7 1997 aepuc uumpumce, me affilliate of Thomas E. Neve Assoc., Inc. September 2, 1997 North Andover Board of Health ,inti M.,;., ctwe 30-)Choo` tA-C,pp—t North Andover, MA 01845 Attn: Sandra Starr Re: Sanitary Disposal System Inspection 745 Foster Street - Mabel Wilkinson Dear Ms. Starr: In accordance with the Commonwealth of Massachusetts, Department of Environmental Protection, State Environmental Code (Title V), 310 CMR 15.301, paragraph 7, please find attached a "Subsurface Sewage Disposal System Inspection Form" for your records. If you have any questions regarding this report or any of its contents, please do not hesitate to contact this office. We thank you, in advance, for your continued cooperation in these matters. Very truly yours, SEPTI MPLIANCE, INC. Paul Cardone Certified Septic Inspector Attachment N.Andlet.sam • SYSTEM INSPECTORS • • SOIL EVALUATORS • • ENVIRONMENTAL ENGINEERS - 447 Old Boston Rd., US Route 1, Topsfield, MA 01983 Tel (508) 887-8586 Fax (508) 887-3480 Septic Compliance, Inc. affilliate of Thomas E. Neve Assoc., Inc. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: Mabel Wilkinson Address of Owner: 745 Foster St., North Andover, MA (if different) 01845 Date of Inspection: August 19, 1997 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: 1./ Passes Conditionally Passes Needs further Evaluation By the Local Approving Authority Fai Inspector's Signature: Date: 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: http://www.mapetstate.ma.us/dep (mised04"s/9') 447 Old Boston Rd., US Route 1, Topsfield, MA 01983 Tel (508) 887-8586 Fax (508) 887-3480 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 745 Foster St., North Andover, MA 01845 Owner: Mabel Wilkinson Date of Inspection: August 19, 1997 INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: X 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: 745 Foster St., North Andover, MA 01845 Owner: Mabel Wilkinson Date of Inspection: August 19, 1997 B) SYSTEM CONDITIONALLY PASSES (continued) The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): Broken pipe(s) are replaced obstruction is removed 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: 745 Foster St., North Andover, MA 01845 Owner: Mabel Wilkinson Date of Inspection: August 19, 1997 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: 745 Foster St., North Andover, MA 01845 Owner: Mabel Wilkinson Date of Inspection: August 19, 1997 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 04n5/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CHECKLIST Property Address: 745 Foster St., North Andover, MA 01845 Owner: Mabel Wilkinson Date of Inpsection: August 19, 1997 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) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CHECKLIST Property Address: 745 Foster St., North Andover, MA 01845 Owner: Mabel Wilkinson Date of Inpsection: August 19, 1997 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Yes Pumping information was provided by the owner, occupant, or Board of Health. Yes None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. Yes Asbuilt plans have been obtained and examined. Note if they are not available with N/A. Yes The facility or dwelling was inspected for signs of sewage back-up. Yes The system does not receive non -sanitary or industrial waste flow. Yes The site was inspected for signs of sewage breakout. Yes All system components, excluding the Soil Absorption Syste, have been located on the site. Yes The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of SCUM. Yes The size and location of the Soil Absorption System on the site has been determined based on: Yes The facility owner and occupants (if different from owner) were provided with information on the proper maintenance of Subsurface Disposal System. Yes Existing information. Ex. Plan at B.O.H. Determined in the field (if any failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] Page 7 of 18 (revised 04/25/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 745 Foster St., North Andover, MA 01845 Owner: Mabel Wilkinson Date of Inpsection: August 19, 1997 RESIDENTIAL Design flow: Number of bedrooms: Number of current residents: Garbage grinder (yes or no): Laundry connected to system (yes or no): Seasonal use (yes or no): Water meter readings, if available (last 2 year usage (gpd): Sump Pump (yes or no): Last date of occupancy: occupied COMMERCIALANDUSTRIAL: FLOW CONDITIONS 450 g.p.d./bedroom for S.A.S. 3 1 no no dry -well no no Type of establishment: Design flow: Grease trap present (yes or no): Industrial Waste Holding Tank present (yes or no): Non -sanitary waste discharged to the Title 5 system (yes or no). Water meter readings, if available: Last date of occupancy: OTHER (Describe): Last date of occupancy: Page 8 of 18 (revised 04/25/9' gallons/day SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 745 Foster St., North Andover, MA 01845 Owner: Mabel Wilkinson Date of Inspection August 19, 1997 GENERAL INFORMATION PUMPING RECORDS and source of information: . Owner told me she has tank pumped once a year System pumped as part of inspection (yes or no): If yes, volume pumped: 1,000 gallons yes Reason for pumping: To check tees or baffles, to check for run back, to check for leaks, to check structural integrity of the tank. TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) [If yes, attach previous inspection records, if any] UA Technology etc. Copy of up-to-date contract? Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: 18 years of age 7-3-79 system design Sewage odors detected when arriving at the site (yes or no): no BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction cast iron 40 PVC other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) (revised 04/25/97 - Page 9 of 18 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 745 Foster St., North Andover, MA 01845 Owner: Mabel Wilkinson Date of Inspection: August 19, 1997 SEPTIC yes TANK: (locate on site plan) Depth below grade: 8" Material of construction: concrete metal Fiberglass Polyethylene Other (explain) X If tank is metal, list age Is age confirmed by Certificate of Compliance (Yes/No) Dimensions: 8'0"x 5' 1 "x 5'4" Sludge Depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: I'10" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 9" Distance from bottom of scum to bottom of outlet tee or baffle: 1'5" How dimensions were determined: on-site Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) We recommend tank be pumped once every two years, baffles were in good shape, liquid level was good, structural integrity was good, no sign of leaks. Page 10 of 18 (revised 04/25/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 745 Foster Street North, Andover, MA 01845 Owner: Mabel Wilkinson Date of Inpsection: August 19, 1997 GREASE TRAP: N/A (locate on site plan) Depth below grade: Material of construction: Concrete Metal 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: Fiberglass Polyethylene Other (Explain) Comments: (Recommendations for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: Material of construction: (revised 04/25/97) N/A (Tank must be pumped prior to, or at time of, inspection) Concrete Metal Fiberglass Polyethylene Other (explain): Page 11 of 18 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 745 Foster Street North, Andover, MA 01845 Owner: Mabel Wilkinson Date of Inspection: August 19, 1997 TIGHT OR HOLDING TANK (continued) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in working order Yes; No Date of previous pumping: Comments: (Condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: Yes (Locate on site plan) Depth of liquid level above outlet invert: Even Comments: (Note if level and distribution is equal evidence of solids carryover, evidence of leakage into or out of box, etc.) Box was level distribution was equal no signs of carryover no apparent leaks in or out of box. Page 12 of 18 (revised 04/25/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 745 Foster St., North Andover, MA 01845 Owner: Mabel Wilkinson Date of Inspection: August 19, 1997 PUMP CHAMBER: N/A (Locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (Note condition of pump chamber, condition of pumps and appurtenances, etc.) SOIL ABSORPTION SYSTEM (SAS): Yes (Locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain Type; Leaching pits, number: Leaching chambers, number: Leaching galleries, number: Leaching trenches, number, length: Leaching fields, number, dimensions: 1 field 33' x 27' Overflow cesspool, number: Alternative system: Name of technology: Page 13 of 18 (revised 04125/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 745 Foster St., North Andover, MA 01845 Owner: Mabel Wilkinson Date of Inspection: August 19, 1997 SOIL ABSORPTION SYSTEM (SAS){continued): Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) dry none none brown grassy area CESSPOOLS: N/A (Locate on site plan) Number and configuration: Depth -top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: Inflow (cesspool must be pumped as part of inspection): Comments (Note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 14 of 18 (revised 04/25/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 745 Foster St., North Andover, MA 01845 Owner: Mabel Wilkinson Date of Inspection: August 19, 1997 PRIVY: N/A (Locate on site plan) Materials of construction: Depth of solids: Dimensions: Comments (Note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 15 of 18 (revised 04MI97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 745 Foster St., North Andover, MA 01845 Owner: Mabel Wilkinson Date of Inspection: August 19, 1997 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent references, landmarks or benchmarks. 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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 745 Foster St., North Andover, MA 01845 Owner: Mabel Wilkinson Date of Inspection: August 19, 1997 DEPTH TO GROUNDWATER Depth to groundwater: 9' no water feet observed Please indicate all methods used to determine High Groundwater Elevation: X Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) X Determine it from local conditions Check with local Board of Health X Check FEMA Maps X Check pumping records Check local excavators, installers Use USGS Data Descirbe in your own words how you established the High Groundwater Elevation. (Must be completed) I took it off of design the system is'nt that old, checked maps , looked at surroundings , the system is in what appears to be a built up area. Page 17 of 18 (revised 04/25/97) r r t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Company Address Certification Statement Paul Cardone Septic Compliance, Inc. 447 Boston Road, Topsfield, MA 01983 (508) 887-8586 I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and maintenance of on-site sewage disposal systems. Check one: M Inspector's Signature: Date: Copies to: I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15.303.. Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15.303. The basis for this determination is provided in the FAILURE CRITERIA section of this form. Buyer (if applicable) Approving authority: (revised 04/25/97) August 22, 1997 No. Andover Board of Health 745 Date. .�� ��.......... pf o 0 TOWN OF NORTH ANDOVE p : PERMIT FOR GAS INST TION 5 SSMC MUSEt This certifies that .. lf�.s 1 -A °:.. .,�' ��`?C'� . has permission for gas installation .. ...1J. k ...`........... . in the buildings of ...K. �`f ..�� ........................ . at ... .�) ........ , rth-Andover, Mass. Fee..3?..... Lic. No...f Ud �..`. �' ...... `� ... . GAS'INSPECTOR Check # c-/,1 3 I. MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) G N. ANDOVER , Mass. Date: 11/2/2010 City, Town Permit# Building Owner's AT: Location 745 FOSTER ST Name PAUL HOWARD New I, Plans Submitted Renovation ❑ Yes ❑ No 9 Type of Occupancy: Replacement ❑ RESIDENTIAL (Print or Type) Installing Company Name: E. Osterman Propane, Inc. Address 22 Legate Hill Road Sterling, MA 01564 Check One: Certificate ® Corp. 042553302 ❑ Partnership ❑ Firm/Company Business Telephone 978-422-0204 Name of Licensed Plumber or Gasfitter hA.�s�e�rsfGE G e t/C—W 145 I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. I have informed the owner or his agent that I do not have liability insurance including completed operations coverage. Signatuw of owner/Agent I have a current liability insurance policy to include completed operations coverage. 12 By Title City/Town APPROVED (OFFICE USE ONLY) TYPE LICENS . Signature of Licensed ❑ Plumber Plumber or Gasfitter ® Gasfitter ❑ Master A, / . ❑ Journeyman License Number