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Home My WebLink AboutMiscellaneous - 75 LOST POND LANE 4/30/2018,. MAP # PARCEL # "STREET' ONSTRUCTIp.N A.PPROV HAS PLAN REVIEW FEE .BEEN PAID? / YES NO PLAN APPROVAL: DATE `L9 / APP. BY DESIGNER: PLAN DATE. CONDITIONS WATER -,SUPPLY: PERMIT WELL TESTS: COMMENTS: S� WELL D R Z LLER._ CHEMICAL bnC�aE RI� A I BACTERIA II DATE APPROVED DATE flPPRUVED DATE APPROVED FORM U APPROVAL: APPROVAL TO ISSUE � NO DATE ISSUED /eI z115� BY' CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NO ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: BY: ZL1-.NSSfl4LAT.I4N �.j •2(i•r 1i �A fr^- •,1.. /'Yl:- 7 ', a,--.r•^..��i x.1:.TA. {;—�' �. . - `THE ( 'lz IS INSTALLER LICENSED? NO 4 t . ` `.TYPE OF CONSTRUCTION: - REPAIR 'CONSTRUCTIDN:-,.`CERTIFIED NEW PLOT -PLAN REVIEW YE NO '.� CONDITIONS OF:. APPROVAL YES NO ( (FROM FORM U) l: `ISSUANCE OF DWC PERMIT / YES NO 0S�6Q� DWC PERMIT N0. a INSTALLER: BEGIN,•I NSPECT I ON 0: ' - , !- ..::.-':-,.EXCAVATION, INSPECTION: ; NEEDED: _ PASSED ;CONSTRUCTION INSPECTION: NEEDED: AS BUILT PLAN SATISFACTORY: YESs APPROVAL. TO BACKFILL: DATE: BY " '�FINAL•GRADING APPROVAL: DATE /Z//� BY � DATE:AAIA� BYAll FINAL CONSTRUCTION APPROVAL: ._ 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. AM Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 75 Lost Pond Lane Property Address Ginay Tannenbaum Owner's Name North Andover City/Town MA 01845 State Zip Code 1/29/2016 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information Inspector: RECEIVED , W� ,x q 19 b Neil J. Bateson FEB Q 9 2016 Name of Inspector Bateson Enterprises Inc. 70WN OF NORTH ANDOVER rnn nTR AMIT Company Name HrAfi i i EE -A 111 Argilla Road Company Address Andover MA J7ra rr, Q�81 k K .: +✓, A. a;: City/Town State Zip Code 978-475-4786 S 1 15 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below .is true, accurate and.complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems t:am.a.DF__-approved-,system. irxspe'ctorpurs�uant10 Section 15:3`40of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Eurther Evaluation by the Local Approving Authority I 1/29/2016 Inspector's lignature Date a 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 wiifi perform in the future under the same or different conditions of use. t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 75 Lost Pond Lane Property Address Ginay Tannenbaum Owner's Name North Andover City/Town B. Certification (cont.) MA 01845 State Zip Code 1/29/2016 Bate of inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or -repaired. The system, upon.completion of the -replacement lar-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 exfiltratiem-or tank fai#ure is: imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y � ❑ N ❑ ND (Explain below): t5ins • 3113 Title 5 official Inspection Form: Subsurface Sewage Disposal System •Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 75 Lost Pond.Lane Property Address Ginay Tannenbaum Owner's Name North Andover MA 01845 1/29/2016 City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/aJPrms arQ repaired, B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to ,protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 3f13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Foran - Not for Voluntary Assessments 75 Lost Pond Lane Property Address Ginay Tannenbaum Owner owner's Name Information is required for every North Andover MA 01845 1/29/2016 page. City/Town State Zip Code Date of Inspection 13. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning'in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply, ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins • 3113 Title 5 official inspection Form: Subsurface Sewage Disposal System •Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 75 Lost Pond Lane Property Address Ginay Tannenbaum Owner Owner's Name information is required for every North Andover MA 01845 1/29/2016 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply, ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17 I Commonwealth of Massachusetts ugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 75 Lost Pond Lane Property Address Ginay Tannenbaum Owner Owner's Name information is required for every North Andover MA 01845 1/29/2016 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Z 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 been determined based on: this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not approximation of distance is unacceptable) [310 CMR 15.302(5)] available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 660 t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 75 Lost Pond Lane Property Address Ginay Tannenbaum Owner owner's Name Information is North Andover required for every page. City/Town D. System Information Description: MA 01845 State Zip Code 1/29/2016 Date of Inspection Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundrysystem inswoted? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Yes Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): 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 • 3113 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t 75 Lost Pond Lane Property Address Ginay Tannenbaum Owner Owner's Name information is required for every North Andover MA 01845 page. City/Town State Zip Code D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: Date 1/29/2016 Date of Inspection Pumped two years ago, owner 1500 gallons Measured tank Inspect tank & tees ® Yes ❑ No ® 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 • 3/13 Tito 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System. Form - Not for Voluntary Assessments 75 Lost Pond Lane Property Address Ginay Tannenbaum Owner Owner's Name Information Is North Andover MA 01845 required for every page. City/Town State Zip Code D. System Information (cont.) 1/29/2016 Date of Inspection Approximate age of all components, date installed (if known) and source of information: 21 years old, 12/1/1995, as built plan Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): ❑ Yes ® No 2 feet Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" PVC through wall to septic tank, 3" PVC in house, no leaks visible. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 1 feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10' x 5'x4' Sludge depth: 4" t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C 75 Lost Pond Lane Property Address Ginay Tannenbaum Owner Owner's Name information equire tifor a North Andover MA 01845 required for every page. City/Town State Zip Code D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 29" 411 8" 11" 1129/2016 Date of Inspection How were dimensions determined? Tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid level§ es related tc outlet invert, evidence Qf leakage, etc,); Pumped septic tank. No inlet tee. Outlet tee ok. Depth of liquid at outlet invert. No evidence of Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete 1 ❑ 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 • 3/13 Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 75 Lost Pond Lane Property Address Ginay Tannenbaum Owner Owner's Name information is required for every North Andover MA 01845 1/29/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid leyel; as relate to 94% inyert, gyidenq* gf leakage. et0, 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 Dimensions: Capacity: gallons Design Flow: Alarm present: Alarm level: ❑ polyethylene ❑ other (explain): gallons per day ❑ Yes ❑ No 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 - 3113 Title 5 official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 75 Lost Pond Lane Property Address Ginay Tannenbaum Owner's Name North Andover MA 01845 1/29/2016 City/Town State Zip Code' e — 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 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D -box level & distribution equal. No evidence of leakage. Evidence of carryover, pumped d -box to clean, P -box cQver brQken, replaced it, Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Foam - Not for Voluntary Assessments 75 Lost Pond Lane Property Address Ginay Tannenbaum Owner Owner's Name information is required for every North Andover MA 01845 1/29/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches 3 trenches 46' number, length: long ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No Sig n of ponding to surface Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 75 Lost Pond Lane Property Address Ginay Tannenbaum Owner owner's Name Information is required for every North Andover MA 01845 1/29/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc,), Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 75 Lost Pond Lane Property Address Ginay Tannenbaum Owner's Name North Andover MA : 01845 1/29/2016 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 W t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 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 75 Lost Pond Lane Property Address Ginay Tannenbaum Owner's Name North Andover MA 01845 1/29/2016 City/Town D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: State Zip Code Date of Inspection 4 feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: 11/17/1994 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Design Plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: As per test pit data on design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3f13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked 1/29/2016 Date of Inspection ® 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 • 3/13 Tide 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 75 Lost Pond Lane Property Address Ginay Tannenbaum Owner Owner's Name Information is required for every North Andover MA 01845 page. City/Town State Zip Code E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked 1/29/2016 Date of Inspection ® 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 • 3/13 Tide 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Summary Record Card generated on 1/29/2016 11:37:59 AM by Karen Hanlon Town of North Andover Tax. Map # 210-1043-0219-0000.0 Parcel Id 16538 75 LOST POND LANE GINAY TANNEBAUM 75 LOST POND LANE NORTH ANDOVER, MA 01845 Page 1 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 0.68 Acres FY 2016 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until GINAY TANNEBAUM Payor 75 LOST POND LANE NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 18002.0 - 75 LOST POND LANE Last Billing Date 1/6/2016 3180031 03 Cycle 03 Active UB Services Maint. Account No. 3180031 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 45.60 /1 UBWeter Maintenance Account No. 3180031 Serial No Status Location Brand Type Size YTD Cons 13242254 a Active 00 METE METE w Water 0.63 0.63 615 Date Reading Code Consumption Posted Date Variance 12/14/2015 1058 aActual 12 1/20/2016 -16% 9/11/2015 1046 a Actual 14 10/16/2015 29% 6/11/2015 1032 aActual 10 7/24/2015 -27% 3/18/2015 1022 a Actual 15 4/28/2015 32% 12/15/2014 1007 aActual 11 1/15/2015 -16% 9/16/2014 996 a Actual 14 10/15/2014 31% 6/12/2014 982 a Actual 10 7/16/2014 -2% 3/14/2014 972 aActual 10 4/11/2014 -11% 12/.16/2013 962 aActual 12 1/17/2014 6% 9/13/2013 950 a Actual 11 10/15/2013 -42% 6/14/2013 939 a Actual 18 7/24/2013 45% 3/20/2013 921 a Actual 14 4/22/2013 12% 12/13/2012 907 aActual 11 1/9/2013 0% 9/19/2012 896 a Actual 12 10/15/2012 16% 6/18/2012 884 a Actual 10 7/16/2012 -15% 3/20/2012 874 a Actual 12 4/14/2012 2% 12/19/2011 862 aActual 12 1/17/2012 -42% 9/16/2011 850 a Actual 21 10/13/2011 81% 6/13/2011 829 a Actual 11 7/20/2011 0% 3/15/2011 818 a Actual 11 4/13/2011 -15% 12/15/2010 807 aActual 13 1/12/2011 -86% 9/16/2010. 794 a Actual 94 10/15/2010 389% 6/14/2010 700 a Actual 18 7/15/2010 -4% 3/18/2010 682 a Actual 20 4/14/2010 5% 12/14/2009 662 aActual 18 1/12/2010 -36% 9/16/2009 644 aActua1 31 10/15/2009 -7% 6/10/2009 613 a Actual 29 7/20/2009 31% 3/17/2009 584 a Actual 24 4/29/2009 -35% 12/15/2008 560 aActual 36 1/20/2009 35% : Commonwealth of Massachusetts City/Town of . System Pumping- Record Form 4 DEP has provided this form for use -by local Boards of Health. Other forms may be used, but the information, must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility. Information 1. System Location• eRig �oufld eft / Right rear of house, Left / right side of house, LeftRight side of buil ind ng, Left / Right froS2 Left Left / Right rear of building, Under deck Address tq S City/Town State Zip Code 2. System Owner. Name' Address Qr different from location) Citylrown State( ✓ ON a _ [ el Zqc Telephone Number .B. Pumping Pecord 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type -of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yep o If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Neil. Bateson Name ' Bateson Enterprises Inc' Company 7. Locayon-Khere contents -were disposed: F5821 Vehicle License Number Date t5form4.doe- 06/03 System Pumping Record • Page 1 of 1 � O 01 N O•C O C� V COp � CY) O Ul c 4) w z cir -r o�.c-rio 12-a�i o Ql)Z Q ~t c acs �� •Lo I Ncoto Ql) \_ •� O� L O � � � �'� icc��•� '�o'� .off O wo I� o z J O � as W Q) �� Oho �t-O QOQO \\Q)Q)N oz c U)o o�oi�ui� � 0000 00zac °m II q �m Qm Qm �d- j�� II II 064� 4� �6 Lrj� �Q) 0Q0 m �m QLQ � Qm C)(J� f) w ®� L -ro oc.o cc cj U N 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: 70 Lost Pond Road_ _North Andover_ Owner's Name: _Tom Murphy_ Owner's Address: 70 Lost Pond Road_ North Andover, Ma. 01845_ Date of Inspection: _2/22/2002_ Name of Inspector: Neil J. Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, Ma. 01810_ Telephone Number: _( 978 ) 475-4786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fail &:&� Inspector's Signature • ' Date: _2/22/2002_ The system inspector shall submi 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: After inlet tee was install in septic tank by Peter Breen, the septic system now passes Title 5 Inpection. T0,r,,N OF NORTH Al Dy, / ROA+RD OF HEALTH i ****This report only describes conditions at the time of inspection and under the conditi FsaMer �t ani time. This inspection does not address how the system will perform in the future under th di 2Y conditions of use. FORM - U - LOT RELEASE FORM Z0 INSTRUCTIONS: This form is used to verify that all -necessary approval/ permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. APPLICANT�1 r..�r2.� ��:Ae—Y.� PHONE i ASSESSORS MAP NUMBER LOT NUMBER 4 p—� SUBDIVISION LOT NUMBER .—� STREET _ ��d,,v STREET NUMBER //6 ............................................................................ OFFICIAL USE ONLY ....ERNE... .............................................................. RECONB ENDATIONS OF TOWN AGENTS DATE APPROVED CONSERVATION ADNE NISTRATOR DATE REJECTED CONRVM TTS DATE APPROVED TOWN PLANNER DATE REJECTED COI�� DATE APPROVED FOOD INSPE FOR -11R.AL DATE REJECTED DATE APPROVED S P TOR - HEALTH + DATE REJECTED COMMENTS PUBLIC WORDS - SEWER / WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTNIENT DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR Feb -07-01 07:42A Pinzer (810) 816-4289 . P_02 Feb -07-01 07:43A Pinzer 1 .i 10'0` 810 816-4289 P-03 +_ II- CFL I v, CIL 4 ( 4'6' 2 8' 2'0' 6'9` 8 9- I I 1 � - - - �- - �� Yto� X 35• 5'91t• X 4r ` x O r` C7 _ PTl O - z 2V _ w.r..� •. ma k- 4114' 3'9' 3'6' Z Q ^r: cs ra' u R of 3b• 2WX.4'9" o S'8' 3 0' 28' 38' 2'x1' 4'9' �_- 110` U'6* t* FARMERS PORCH se 6 6' 3'6` 110- CO 38'0' -P N C4 J a C 0 C �.0 O CIS C � m C-) to —C'j CL n CO) d 'v O CD n Z N! -a CD o y CL r C) 1= CO) acc -0 �o CD C2 v CD 0 CL Q CD CD CD O CD vo � C CDCD CA W O O I CO COD � CA v O � O Z O O CD d y Cr a C 0 C �.0 O N y = Q CL CD m O m C-) to —C'j CL n CO) =r'O y d 0 ..► .O -r CD y T CD =r = m �1 O W y O --q = m y ^�✓ 'O CD O O y, : A � = H co a O CD m y Cl) D O d y Cr m to y CO3 : 0 W y CD = m AN V to , N O n. = C-3 CO) o CD „F . C., CD :z y -� 0: m moo: m o �5 c 0 1' Tin d° w G x r w C G El C, �n t3 O -< x O ID d 0 E Town of North Andover . OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES N d LU 0 LL C O ~ E J W O O = Z Z H O W h in E h- O Q a� � N H o O a M AO N z U v N W tx T t] N LA OtA LA +�+ "I J N C U N Q Q C .o L -W > t1 > = 0 (') O LL tY Q n QO Bt <W0 0 Q Z o v Z ZO ND_ a b 4- m W w O C pCe F m p _ Z o N r W C C m O Q N b -Z L tv O t1 O c LA �• �i p N U 0 N ,t�A O J ` U Q Q cn tY t1 C a - LL .� tt�... ,e •r0 plans for the site le following reasons: s groundwater at 64 Please address with basement elevations. of system which will :ate to call the Board BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Julie Pa rino D. Robert Nicetta Michael Howard Sandra Starr Kathleen Bradley Colwell DATE__ Oe r / Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEES PERMIT # DATE RECEIVED APPLICANT _ D QVC )�,gVJ)&-,D ASSESSOR'S MAP ADDRESS ENGINEER / VC1/& ADDRESS PARCEL # LOT # STREET .LD 5 ✓� �a lzl b ,9 PLAN DATE _ z1a, /� REVISION DATE CONDITIONS OF APPROVAL: APPROVED DISAPPROVED M\1 50 le G o F 6F' 94-91q IN D I G 01-6 PLAN REVIEW CHECKLIST ADDRESS �/,T j/�� ENGINEER GENERAL ,/ 3 COPIES STAMP v LOCUS ✓ NORTH ARROW i/ SCALE v CONTOURS(/ PROFILE(/ SECTION BENCHMARKS SOIL & PERCS ELEVATIONS WETS. DISCLAIMER L-1"' WELLS & WETS WATERSHED?'g DRIVEWAY�lev) WATER LINE L�-' FDN DRAIN L� SCH4 0,z TESTS CURRENT? Z/ SOIL EVAL SEPTIC TAN MIN 1500G .17 INVERT DROP GARB. GRINDER/U(O (+200% EDF) 25' TO CELLAR ✓ MANHOLE ELEV GW # COMPS. D—BOX SIZE # LINES 3 FIRST 2' LEVEL STATEMENT INLET 1410.0 Z - OUTLET l j BZ = Z6 (2 " OR . 17 FT) TEE REQ' D? LEACHING MIN 660 GPD? (// RESERVE AREAv 4' FROM PRIMARY?L"""�2% SLOPE 17 100' TO WETLANDS �100' TO WELLS ��'4' TO S.H.GW ( (5'>2M/IN) 35' TO FND & INTRCPTR DRAINS�325' TO SURFACE H2O SUPP 4' PERM. SOIL BELOW FACILITY. MIN 12" COVER FILL? (25' if above natural elev; 101if below) BREAKOUT MET? TRENCHES / MIN 660 gpd SLOPE (min .005 or 6"/1001) �SIDEWALL DIST. 3X EFF. W OR D (MIN 6') C—' -RESERVE BETWEEN TRENCHES? L--- IN FILL?A%i MUST BE 10' MIN. `-'—' 4" PEA STONE? .%/ VENT? /y'�i (>3' COVER; LINES >501) BOT + SIDE <Jc Z- X LDNG 1p� = TOT % (L x W x #) (DxLx2x#) (G/ft2) Copyright 0 1995 by S.L. Starr THOMAS E. NEVE ASSOCIATES, INC. Engineers . Land Surveyors . Land Use Planners 447 Boston Street US Route 1 TOPSFIELD, MASSACHUSETTS 01983 (508) 887-8586 FAX (506) 887-3480 TO Sandy Starr, R.S., C.H.O. Board of Health North Andover, MA LETTER OF T RANSMIT T AL DATE 929195 JOB NO. 1276-11 ATTENTION Sandy Starr RE: Lot 11 — Lost Pond Lone WE ARE SENDING YOU XAttached ❑ Under separate cover ❑ Shop Drawings Prints ❑ Copy of Letter ❑ Change order ❑ Plans the following items: ❑ Samples ❑ Specifications COPIES DATE I NO DESCRIPTION 4 Revised 9126195 1276— 11 Sanitary Disposal System for Lot 11 Lost Pond Lane Pre ored By Thomas E. Neve Associates, Inc. THESE ARE TRANSMITTED as checked below: ❑ For Approval ❑ Approved as submitted Resubmit 4 copies for approval ❑ For your use ❑ Approved as noted ❑ Submit copies for distribution ❑ As requested ❑ Returned for corrections ❑ Return corrected prints ❑ For review and comment ❑ FOR BIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS Dear Sandy: Please find enclosed 4 prints of c revised septic design for Lot 11 Lost Pond Lane. The revised system has been designed to accommodate the provisions as stated in the new Title V. The previously submitted design for this lot was designed under the old code. If you should hove any concerns or questions please do not hesistate to call us. Thank you, in advance, for your time in reviewing this matter. COPY TO David Kindred SIGNED Ci e �- Steven Saraceno, E.I. T. Engineer In Training F, U' ? j I � ' j lam' zzz ............ ................. M L.1 7A - LY 1- I A ............ ................. M L.1 I �� '�` itit��t r �� s�� "` I r �"�,¢ +'� � � �' 1 `"'1 .i.�"S� !.K "ix"4 � a.y+i" .a' • �� D'� � "�'�7`"` ,y. S �` � �xf '� F io _'� .., i exls� r +1 �R-. a C -s r 17 �,�,e' kMb +.y ash• i rt�fs �` d'pt# rFl�. L:• '� A,#G '+t4+..A �' e SyR �¢ v t �. re i � � � S%�;.nl .�; � �' xt>. Sys ina `�''� � t • �. 'r = c MMM M-U"glilr�� 1■PV��a/1 aau�ur � 110 MMc!a�� I� '=A7►ia■■CM II�� —mm IMMM I ■■MI/1 111Amml►SM�� M G:��rmmi �l�iL�I►�l�i� C�►`�GIlMM/lNl�l� il/f►�t�/7�1�� Mmm� Mt`J M!!.\ N1�{Na��m a1�7►/MM M``�lrim��►7wu��MM MMr/��rs ■■M��ar�s��r�� 1 � MMMM �C�rlMMM�rait Mm MMm MM��l1■ r�mmmm��l� IMIMMMM�� MMM�� ®MM Mi=MM aM �mm��a�� M�� n � TUI`" CA N ^� J c i ''� ri r r .li�l.'�;u i Pjt',�yF 1 { �� Rif , g,.�,.tr ,1 t�t+�yp? yt<<4dltr x .E�fr;�!irx ttl;7tjt! ". +fel r-, triE is :•' .d r: : r r i�� _,r'r r { vItr1•r+%1 %r�a�(�lt rt tt • T. MMM M-U"glilr�� 1■PV��a/1 aau�ur � 110 MMc!a�� AlrmEi\M MM mm '=A7►ia■■CM II�� —mm IMMM MMM�:al�l� on MM ■■MI/1 111Amml►SM�� M G:��rmmi �l�iL�I►�l�i� C�►`�GIlMM/lNl�l� il/f►�t�/7�1�� Mmm� Mt`J M!!.\ N1�{Na��m a1�7►/MM M``�lrim��►7wu��MM MMr/��rs ■■M��ar�s��r�� MMMM �C�rlMMM�rait Mm MMm MM��l1■ r�mmmm��l� IMIMMMM�� MMM�� ®MM Mi=MM aM �mm��a�� M�� i ''� ri r r .li�l.'�;u i Pjt',�yF 1 { �� Rif , g,.�,.tr ,1 t�t+�yp? yt<<4dltr x .E�fr;�!irx ttl;7tjt! ". +fel r-, triE is :•' .d r: : r r i�� _,r'r r { vItr1•r+%1 %r�a�(�lt rt tt • T. --- --------- LI i ol1 rj\ Id i i r i� i� j �� i� V '� z !� � I I t� TV nn C-1 I 'JK --- --------- LI Oi_T-19-1995 11:39 THOMAS E. HE�JE ASSOC:. From: Steven Saraceno To: Sandra Starr Company: North Andover, Board of Health Re: Lot #11, Lost Pond Lane Message: Date: October 19, 1995 Time: 11.41 AM FAX #: (508) 688-9542 Dear Sandy: This fax is in response to your disapproval of the sanitary disposal system for the above referenced lot. Your concerns in your letter were as follows: 1 - Soil Log OP 94-9A shows groundwater at 64" 2 - A Benchmark with 75' of the proposed system, which will remain during construction. To address your first concern, the field notes that I have on file for OP 94-9A does not show groundwater at 64 it does however, state that mottling was observed throughout. Steve D'Urso has informed me that these are relic mottles, in the knoll, and that you and he had discussed this matter when you were out on the site. For your second request, a benchmark within 75' of the system will be installed prior to the construction of the system. Please call me with any concerns, as we are anxious to get this system approved for our client. Thank you for your time in reviewing this matter. Sincerely, Steven Saraceno, Ell Engineer in Training VOICE: (508) 837-8586 FAX: (508) 887-3480 P.01 TOTAL F.r1