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Miscellaneous - 75 MILL ROAD 4/30/2018
North Andover Board of Assessors Public Access Page 1 of 1 f North Andover Board of Assessors 9 ow' # o .At,9 � HSe roperty Record Card ,ocation: 75 MILL ROAD )wner Name: ti SUH, YEONG JE HAI SUE SUH )wner Address: ,75 MILL ROAD _ City: NORTH ANDOVER State: MA Zip: 01845 Jeighborhood: 5-5 Land Area: 1.18 acres Jse Code: 101 -SNCL -FAM -RES ',"Total Finished Area: 3040 saft Total Value: _ 4 L►TL'STEAR 526,100 _ 526,100 Building Value: 327,400 327,400 Land Value: ti 198,700 198,700 Market Land Value: 198,700 Chapter Land Value: ale Price: ,;'452,500 ;Sale Date: 11/10/2000 Lrms Length Sale Code: Y -YES -VALID Grantor: ANDREW KINGSWOOD .ert Doc: Book: ;105918 YPage: 0119 http://csc-ma.us/PROPAPP/display.do?linkld=1896538&town=NandoverPubAcc 3/6/2012 DelleChiaie, Pamela From: Pelletier, Joan [Joan. Pelletier@NEMoves.com] Sent: Thursday, March 29, 2012 11:02 AM To: DelleChiaie, Pamela Subject: COC - 75 Mill Road, North Andover Pamela, Thank you so much! Have a great day! Joan Joan Haggerty Pelletier, CRS, GRI, ABR, CBR, SRES COLD WELL BANKER RESIDENTIAL BROKERAGE 305 North Main Street, Suite 102 Andover, MA 01810 Office (978)475-2201 Mobile (978)360-0624 Fax (978)475-4575 From: DelleChiaie, Pamela jmailto:pdellech(cotownofnorthandover.comj Sent: Thu 3/29/2012 10:20 AM To: Pelletier, Joan Subject: COC - 75 Mill Road, North Andover To: Joan Pelletier Real Estate Agent Dear Joan, Per your request of yesterday, I have scanned the COC (Certificate of Compliance) for 75 Mill Road, along with the Title 5 Report dated 2/27/12. Now that the work has been done to make the Title 5 go from Conditional Pass to Pass, the COC is good for two years from the date indicated. Please call with any questions. Pamela DelleChiaie Health Department Town of North Andover 1600 Osgood Street I Bldg. 20 1 Suite 2-36 North Andover, MA 01845 Phone 978.688.9540 Fax 978.688.8476 Email Pdellechiaie@townofnorthandover.com Web www.TownofNorthAndover.com PUBLIC HEALTH DEPARTMENT Town of North Andover (ommunity Development Division Cenificate of Compliance As of ,larch 28, 2012 This is to cert that a SA `IIS TA C`IO RT INS 1PE C2ION Was completed for the: ftfitcement o a 1500 Galton Septic Zan Tor an On Site Wastewater P4osa(Swtem 0Y.- Warren y:Warren (Pearce at: 75 MIT &ad Parcel ID :210/107.C-0081-0000.0 NorthAndover, 910 01845 The Issuance of this certi cate shad not be construed as a guarantee that the On Site Sewage Disposa(System wifffunction satisfactorily. r' Sinn 7 Sa r, R,L (Pu6fic Y-feath Director 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com Page 1 of 1 W rO m. rz M A 0 M.' zo A m http://mud.attach.mail.ymail.com/us.f393.mail.yahoo.com/ya/securedownload?mid=1_318... 3/28/2012 Ilk, J2 VIE I fly zsr Al 'Id L7, 4 m >Z 1710 An > z fe, rc Z m Z 0 < m 7u -vv I I 0 0 r 4 ¢ g�'rt�Cr'b�j� • PUBLIC HEALTH DEPARTMENT Town of North Andover (ommunity Development Division Cenificate of Compliance As of Warcfi 28, 2012 This is to cert that a SA`IIS FACIORT INSPEC2IOV Was completed for the: ftfacement of a 1500 Gaffon Septic tank For an On Site Wastewater osaCS, ► e 'By: Warren Tearce at: 75 Wiff&ad Parcel ID :210/107.C-0081-0000.0 jr, orthAndover, NA 01845 The Issuance of this certificate sharf not be construed as a guarantee that the On Site Sewage Disposa(System wifffunction satisfactorily. r` S 4n T S u 3 er, R9 SS/ (Pu6Cic YfeaCth Director 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com 1 1W PUBLIC HEALTH DEPARTMENT Town of North Andover (ommunity Development Division Certificate of Com Ciance As of Warch 28, 2012 This is to cert that a S,4 IS FACIORT INSPECTION Was completed for the: ftGxcement o a 1500 Gaffon ,Septic 2a k For an On Site Wastewater P;i posa[System By, Warren Tearce at: 75 WiIrRQad Parcel ID :210/107.C-0081-0000.0 North Andoven mA 01845 The Issuance of this certificate shaff not be construed as a guarantee that the On Site Sewage IDisposaCSystem wiCCfunction satisfactorily. rj. ` n T Sa er, R (Pu6fic YfeaCth Director 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com 6041 MORTFr • : Town of North Andover s� r HEALTH DEPARTMENT ,SSACNUStS j CHECK #: DAT -1 LOCATION: H/O NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ZTit5 Inspecto�0101169) Tite 5 Report$� ❑ Other. (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer 6441 OpTI� � �'" r� L a � 3 _ e� Town of North Andover `�'•�,,,,; ..,' HEALTH DEPARTMENT s'SACMUSt� CHECK #: �DAT l� /O �� LOCATION: H O NAME: CONTRACTOR NAME:' 1 .. Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ L ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ . ❑ Swimming Pool $ ❑ Tobacco $ ❑ TrashlSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $� C,'Title 5 Report ❑ Other•. (Indicate) $ � � W,/ - Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer WAHKF- V R PEARCE JR / DBA PEARCE Towa of North. Andover CITIZENS BANK 75 Mill St Title 5 filling 75 Mill St Title 5 filing fee TOWN OF NORTH ANDOVER HEALTH DEPARTMENT \ 3/22/2012 6314 50.00 50.00 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. '�3,©t �fr ,Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for ary merits ^ 75 Mill Street /I ;V Property Address Yeon Je Suh �� J/ Owner's Name North Andover MA 01845 2/26/2012 Cityrrown 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: Warren Pearce Jr Name of Inspector Pearce Construction Company Name 196 Park St Company Address North Reading City/Town 978-664-5264 Telephone Number B. Certification MAR " 2012 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT MA State SI1959 License Number 01864 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 ❑ Needs Further Evaluation by the Local Approving Authority /2 R a -M -2012 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 of 17 4 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 Mill Street Property Address Yeong Je Suh Owner's Name North Andover MA 01845 2/26/2012 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 ❑ ND (Explain below): Tank appears to be leaking. This is a 2 piece tank and the fluid level is down to the seal level. Tank should be replaced. t5ins - 11/10 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 Mill Street Property Address Yeong Je Suh Owner's Name North Andover MA 01845 2/26/2012 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ 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 • 11110 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 75 Mill Street Property Address Yeong Je Suh Owners Name North Andover MA 01845 2/26/2012 CityfTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y day flow t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17 Comrrionwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , 75 Mill Street the system is within 400 feet of a surface drinking water supply Property Address ❑ Yeong Je Suh ❑ Owner Owner's Name information is the system is located in a nitrogen sensitive area (Interim Wellhead Protection required for North Andover MA 01845 2/26/2012 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 �I Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 75 Mill Street Owner information is required for every page. 0 Property Address Yeong Je Suh Owner's Name North Andover Cityrrown C. Checklist MA 01845 State Zip Code 2/26/2012 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 t5ins - 11/10 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 Mill Street Owner information is required for every page. Property Address Yes ❑ No Yeong Je Suh Yes ❑ No Owner's Name Yes ❑ No North Andover MA 01845 2/26/2012 Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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 Water meter readings, if available last 2 ears usage 9 ( Y 9 (9Pd))� 268 Detail: 2-2-2010 to2-2-2012 192,984 gallons Sump pump? ❑ Yes ® No Last date of occupancy: 11/2012 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 11110 Tide 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 75 Mill Street Property Address Yeong Je Suh Owner Owner's Name information is required for North Andover MA 01845 2/26/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date 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: pumped 12/7/05 by J's septic, BOH records gallons ® 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 - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 75 Mill Street Property Address Yeong Je Suh Owner Owner's Name information is required for North Andover MA 01845 2/26/2012 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: Installed in 1981 per as built 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): D' f t t I II f I 1 1/2 feet Istance rom pnva a wa er supe y we or suc Ion Ine. feet Comments (on condition of joints, venting, evidence of leakage, etc.): All OK inside Septic Tank (locate on site plan): 9.. Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ 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: 10'6" by 5'8" by 5' deep Sludge depth: 6" t5ins -11/10 Title 5 Official Inspection Farm: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM " 75 Mill Street Property Address Yeong Je Suh Owner Owner's Name information is required for North Andover MA 01845 every page. Cityfrown 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 2/26/2012 Date of Inspection 24" o„ How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet tee is good, outlet tee is PVC. Fluid level is low from no use and exMtration at the seal area (2 piece tank). Structurally the tank appears OK. There is a solid scum line at the normal operating level. 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 • 11/10 Date Tide 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 75 Mill Street Property Address Yeong Je Suh Owner's Name North Andover MA 01845 2/26/2012 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: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ No Alarm in working order: Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ❑ Yes ❑ No " Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 11/10 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 Mill Street Property Address Yeong Je Suh Owner's Name North Andover City/Town D. System Information (cont.) MA 01845 2/26/2012 state Zip Code Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D -box is level and distribution is equal. There is 1 inlet and 2 outlets. D -box is empty from no use but appears strucurally in good shape. There is 2" of solids in the D -box.. 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 • 11/10 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 75 Mill Street Property Address Yeong Je Suh Owner owner's Name information is required for North Andover MA 01845 2/26/2012 every page. Cityrrown D. System Information (cont.) State Zip Code Date of Inspection Type: ® leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system 6 Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No surface sign of problems. No evidence of back up in the D -box. Camera inspection of pits showed them to be dry. All piping apeared to be in good shape. 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 s •Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 75 Mill Street Property Address Yeong Je Suh Owner Owner's Name information is required for North Andover MA 01845 every page. City/Town State Zip Code 2/26/2012 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 • 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Owner information is required for every page. t5ins • 11110 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 75 Mill Street Property Address Yeong Je Suh Owner's Name North Andover MA. 01845 Cityfrown State Zip Code Date of Inspection 2/26/2012 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 Tdia 5 Official 6ispection Form: Subsutrace 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 Mill Street Property Address Yeong Je Suh Owner's Name North Andover CitylTown D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: MA 01845 state Zip Code 2/26/2012 Date of Inspection 10' below grade, 3' below system feet Please indicate all methods used to determine the high ground water elevation: r ►/ ►1 Obtained from system design plans on record If checked, date of design plan reviewed 1981 as built Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: Review Files ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Data from 1981 as built. Test hole data from design plan from 1981. Site slopes down to the rear to a wet area at an elevation considerably lower than the bottom of the system. The site was built up for the house and septic system. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17 -Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M z•'' 75 Mill Street Owner information is required for every page. t-roperry Haaress Yeong Je Suh Owner's Name North Andover City/Town MA 01845 State Zip Code 2/26/2012 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 - 11110 Title 5 Official Inspection form: Subsurface Sewage Disposal System - Page 17 of 17 r :k North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES -/ la LOCATION INFORMA I N ADDRESS: �5 ,� p' INSTALLER:L4, m 11 6 %�el DESIGNER: jv �,� ✓� �'� PLAN DATE: BOH APPROVAL DATE ON PLAN: MAP: LOT: INSPECTIONS / � TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: SEPTIC TANK ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered U Building sewer in continuous, grade, on compacted firm base ❑� Cleanouts per plan 0 Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ gallon tank has been installed loading Monolithic tank construction !Wat_A�ihfnfbss of tank has been achieved by ting -inlet tee installed, centered under access port Comments: Outlet tee installed, centered under access port (gas baffle/effluent filter) inch cover to within 6" of final grade installed over one access port ,Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ gallon Pump Chamber installed ❑ loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION -BOX ❑ Installed on stable stone base ❑ H-20 D -Box ❑ Inlet tee (if pumped or >0.087foot) ❑ Hydraulic cement around inlet & outlets ❑ Observed even distribution ❑ Speed levelers provided (not required) Comments: DelleChiaie, Pamela From: Weiguo Zhou [zhouw555@hotmail.com] Sent: Tuesday, March 06, 2012 2:56 PM To: DelleChiaie, Pamela Subject: RE: I.R. - 75 Mill Road, North Andover, MA - Title 5 Dear Ms. Dellechiaie, Thanks for your help! Weiguo Zhou From: pdellech(a)townofnorthandover.com To: zhouw555@hotmail.com Date: Tue, 6 Mar 2012 14:46:41 -0500 Subject: I.R. - 75 Mill Road, North Andover, MA - Title 5 To: Weiguo Zhou 978-319-4224 Dear Mr. Zhou, I pulled the file for 75 Mill Road here in North Andover, and there is no new updated information. Please note, however, that a Title 5 Inspector has 30 days to submit a Title 5 report to our office, so we just have not received it yet it appears. You may want to ask the current homeowner who did the Title 5 inspection, and get their phone number to find out some information. Best Regards, PameCa. DefCeChiaie Departmental Assistant I Community Development Division I Health Department Town of North Andover -1600 Osgood Street I Bldg 20 1 Suite 2-36 1 North Andover, MA 01845 t Office - 978-688-9540 12 Fax - 978-688-8476 1 Website-http://www.townofnorthandover.com/Pages/index Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more information please refer to: http://www.sec.state.ma.us/pre/preidx.htm. Please consider the environment before printing this email. a �i Commonwealth of Massachusetts Map -Block -Lot 107.00081 BOARD OF HEALTHPermit No ------------- North Andover - BHP -2012-05 - 41 ---- ----------------- P.I. FEE F.I. $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Warren Pearce Jr. to (Upgrade -SEPTIC TANK-SHEA 1500) an Individual Sewage Disposal System. at No 75 MILL ROAD as shown on the application for Disposal Works Construction Permit No. BHP -2012-054 Dated March 22, 2012 --------------------------------------------------- ----------------------------------------------- Issued On: Mar -22-2012 BOARD OF HEALTH • 5."' Commonwealth of Massachusetts Map -Block -Lot -- 107.00081 BOARD OF HEALTH ----------------------- North Andover CERTIFICATE OF COMPLIANCE Ito THIS IS TO CERTIFY, That the Individual Sewage Disposal System (Upgrade -SEPTIC TANK -SHE by Warren Pearce Jr. --- _Jr -------------------------------------------------------------------- Installer at No 75 MILL ROAD 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. 13HP-20127054 Dated ---March 22, 2012 ----------- ----------------------------------------- Printed -On: ------Mar-22-2012- --- --------------- -- ---------------------- -- BOARD OF HEALTH O` MORi// 7h i l/ Town of North Andover �'•�, o :: HEALTH DEPARTMENT 'SSACNUSt4 CHECK #:(1�DATE:�-- LOCATION: j, Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Tras4lSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic -Design Approval $ EJ/J Septic Disposal Works Construction (DWC) $ / � ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other: (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. IC�iI Application for Septic Disposal System Construction Permit - TOWN OF TODAY'S DATE $ 250.0 — F e 'r 2 . -Component Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system* ❑Re air or replace an existing on-site sewage disposal system* Repair or replace an existing system component — What? /4/�/�l ✓�S A. Facility Information 7 -s A t ( Address or Lot # City/Town 2.- *TYPE OF APTIC SYSTEM*: ❑ Pump gravity (choose one) ***If pump system, attach copy of electrical permit to application*** ❑ Conventional System (pipe and stone system) ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your 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. Name Address (if different from above) City/Town C - sok State Zip Code Telephone Number 3. Installer Information ple_��Q'o Name Name of Company Address ✓� � RJ 6(3- City/Town (3-City/Town State Zip Code Ciel.[. qZ� 31(;—Q) gO Telephone Number (Cell Phone # if possible please) 4. Designer Information Name Address City/Town Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit Page 1 of 2 J40Rt# Application for Septic Disposal System A Construction Permit — TOWN OF TODAY'S DATE r �$ 250.00 –Full Repair ORTH ANDOVER, MA 01845 $125.00 - Component s,C� PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: residential Dwelling or ❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation until a Certificate of Compliance has been issued by this Bo of He th. ame Date Board of Health Representative) Date Disapproved for the following reasons: For Office Use Only: z 1. Fee Attached? Yes No 2. Project Manager Obligation Form Attached? Yes No 3. Pump System? If so, Attach copy of Electrical Permit Yes— No 4. Foundation As -Built? new construction ronl : Yes No (Same scale as approved plan) / 5. Floor Plans? (new construction only: Yes— No v—/ Application for Disposal System Construction Permit • Page 2 of 2 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: A \ (Address of septic system) For plans by Relative to the application of 00k_ - name) Dated o ay s ate And dated With revisions dated I understand the following obligations for management of this project: (Engineer) (Original ate (Last revised date) 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner, contractor, project manager, or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or My company, a. Bottom of Bed — Generally, this is the first (VS inspection unless there is a retaining wall, which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection — Engineer must first do their inspection for elevations, ties, etc. As -built of verbal OK (or e-mail to: healthdel2t@townofnorthandover.com) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system, all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade — Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation) and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all ,persons involved are also possible 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board of Health staff or consultant. d. Installation of tank, D -Box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer, I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner. general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: (Today's Date) (Name — Print ame — Signe 475-7820 DEPARTMENT OF COMMUNITY DEVELOPMENT AND PLANNING 1 1 ESSEX ST. ARGEO PAUL CELLUCCI Governor Property Address: 7!r ANDOVER, MA 01810 I" — -- .,..._ -..r. a,.. s COMMOiN'VdEALTH OF MASSACHUSETTS EXECUTWE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CEE TjIFICATIO �// /k /,(` Name wrier J' Address of Owner: Date of Inspection: �- Name of Inspector: (Please Print) 1 am a DEP approved system inspector pur jant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: ></ / Q✓ S�+7`/ G- MaBing Address: �(l � f / / , 90P S I- Telephone Number: A -7 'I,. 4 -2 / TRUDY CORE Secretary DAVID B. STRUHS Commissioner CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this address and.that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs FurtVqr Evaluation By the Local Approving Authority _ Fails Inspector's Signature: (' Date: zo The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)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. . NOTES AND COMMENTS revised 9/2/98 i i Page l of 11 ;1 Printed or Recycled Paper ' 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 'roperty Address: 175' /Vi d lecl f Date oP Date of Inspection: it INSPECTION SUMMARY: Check A, B, C, o/ D: A. SYSTEM PASSES. I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. 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 complying septic tank as approved by the Board of Health. I 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). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced 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 revised 9/2/98 Page 2of11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: 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 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. G 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I 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 (approximation not valid). 3) OTHER revised 9/2/98 Page 3of11 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:(/A�rw+ A/0 '4r/a v vPv Owner: Date of Inspection: A 'Pi's D. SYSTEM FAILS: V Yotj m st indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described 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 orctogged 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. r P _ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the 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 I 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" 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 exist: 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 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: U Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yeses No Pumping information was provided by the owner, occupant, or Board of Health. _ 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. _ As built plans have been obtained and examined. Note if they are not available with NIA. t _ e The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non -sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. . _ 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. The size: -and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H... _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)] The facility owner (and occupants, if different from owner) were provided with information on the proper.maintanan"-of SubSurface Disposal Systems. revised 9/2/98 Page 5ofII 'roperty Address: Owner: Date of Inspection: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION I FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.ddbedroom. Number of bedrooms (design):_ Number of bedrooms (actual): Total DESIGN flow Number of current residents: Garbage grinder (yes or no):' Laundry (separate system) (y'es or no): If yes, separate .inspection required Laundry-tystem inspected (ye � or no) Seasonal use lyes or no):—ju Water meter readings, if available (last two year's usage (gpd): Sump Pump lyes or no): -1,16 Last date of occupancy: j Ce U.)/j� f s� COMMERCIALANDUSTRIAL:. Type of'establistiment: Design flowz'y gpd 1 Based on 15.203) J Basis of.design flow Grease trap present: (yes or no)_ /?t LIdustrial Waste Holding Tank present: (yes or no)_ Non -sanitary wastedischarged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy< GENERAL INFORMATION PUMPING RECORDS and source of information: I System pumped as part of inspection: (yes or no) t If yes, volume pumped: gallons Reason for, pumping: f TYPE pF� SYSTEM l �s Septic tank/distribution box/soil absorption system; Single cesspool ;' h Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank' Copy of DEP °Approval Other APPROXIMATE AGE of all components, date installed (if known) and source of information: 2 Yy/ Sewage odors detected when arriving at the site: (yes or no)� revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: Owner: p Date of Inspection: QT t� }� y �G 77/-7 BUILDING SEWER: j (Locate on site plan)p rr Depth below grader Material of construction: v'I ast iron _ 40 PVC _ other (explain) Distance from private water supply well or suction line Diameter_ Comments: (condition of joints, venting, evidence of leakage, -etc.) SEPTIC TANK:_' *6'? (locate on site plan) )+ 2 ff Depth below grade:6 4, Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _ (YeslNo) r Dimensions: ,�Q �r -,4- Sludge Sludge depth: tr Distance from top of sludge to bottom of outlet tee or baffle-'I� rr Scum thickness: ,11 Distance from top of scum to top of outlet tee or baffler Distance from bottom of scum to bottom of outlet tee or baffle:/ How dimensions were determined: '0 -'o ate/ % c.- 'omments: (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.) GREASE TRAP: ! ,/ (locate on site plan) !,t/%, J%(" Depth below grade:_ Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: t Scum thickness: r. r E r . -• 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: (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.) a revised 9/2/98 Page 7of11 4 t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icorttinued) Iroperty Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ f — Material of construction: _concrete metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in workr ing order: Yes No — — Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: .t�� (locate on site plan) Depth of liquid level above outlet invert: 1 ( a, Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ (locate on site plan) 114. 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.) revised 9/2/98 Page 8oftl SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (c%ontinnuuued) 'roperty Address:/ �% �(.✓ �/ Date of Inspection: PG SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excav io not required, location may be approximated by non -intrusive methods) If not located, explain: Type: leaching pits, number.► leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number: r. Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) CESSPOOLS: _ (locate on site plan)% Number and configuration: % Depth -top of liquid to inlet invert: Depth of solids layer: )epth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: E inflow (cesspool must be pumped as part of inspection) f Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: /�/ i t (locate on site plan)Y,4 f{J�f' - P Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9of11 e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address:��� lwner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) revised 9/2/98 Page 10 of 11 3 i Sf� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C F SYSTEM INFORMATION (continued) operty Address: Jwner: Date of Inspection: NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate SITE EXAM Slope Surface water Check Cellar p Shallow wells Estimated Depth to Groundwater O Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data i Deep Describe how you established the High Groundwater Elevation. (Must be completed) / ,sfss+, _i'i_�tfj C/ �. �/� GrGr.!/�.-/ ,✓ri!/ G_U� T `�,... s� revised 9/2/98 Page II of 11 1 r Commonwealth of Massachusetts City/Town of NO. ANDOVER System Pumping Record Form 4 M yvey`e 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. RECEIVE r r 6/03 3 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): 11/7/05 Date Cesspool(s) 4. Effluent Tee Filter present? ❑ Yes R No 5. Condition of System: 6. System Pumped By: Benjamin Shute Name J's Septic & Drain Company 7. Location where contents were disposed: GLSD DEC 0 7 2005 TOWN OF NORTH ANDOVER HEALTH DEPAPTA=&m LN State State Telephone Number 2. Quantity Pumped: canons ❑ Tight Tank 01845 Zip Code Zip Code 1500 Septic Tank If yes, was it cleaned? ❑ Yes ❑ No H79 406 Vehicle License Number 11/7/05 Date System Pumping Record • Page 1 of 1 A. Facility Information Important: When filling out 1. System Location: forms the computer, use 75 MILL RD. only the tab key Address to move your NO. ANDOVER cursor - do not City/Town use the return key. QJENNIFER 2. System Owner: SUH 'ed0f Name Address (if different from location) City/Town B. Pumping Record r r 6/03 3 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): 11/7/05 Date Cesspool(s) 4. Effluent Tee Filter present? ❑ Yes R No 5. Condition of System: 6. System Pumped By: Benjamin Shute Name J's Septic & Drain Company 7. Location where contents were disposed: GLSD DEC 0 7 2005 TOWN OF NORTH ANDOVER HEALTH DEPAPTA=&m LN State State Telephone Number 2. Quantity Pumped: canons ❑ Tight Tank 01845 Zip Code Zip Code 1500 Septic Tank If yes, was it cleaned? ❑ Yes ❑ No H79 406 Vehicle License Number 11/7/05 Date System Pumping Record • Page 1 of 1 S i =FORM.0 , -LOT RELEASE FORM INSTRUCTION T Is form Isused to verify that all necessary approvals/permits from Boards and De rtntshaving jurisdiction have been obtained. This does not relieve the applicant a /or amdouvner from compliance with any applicable or requirements. :APPLICANT FILLS OUT THIS SECTION********* tA'PPLICANT Sia A 90 E'%Z S LOCATION: Assessors Map Number SUBDIVISION STREET `J 5- m I L L (,PI:iONE q -36S Z PARCEL LOT (S) ;,/ST. NUMBER *************OFFICIAL USE ONLY************ RECOMMaWTIONS OF TgWI AGENTS: CONSERVATION ADMINI$TRATOR DATE APPROVED DATE, REJECTED - COMMENTS TOWN PLANNER DATE /APPROVED �4 DATE REJECTED COMMENTS FOOD INSPE TOR -HEALTH DATE APPROVED DATE REJECTED IC INSPECTOR -HEALTH TE APPROVED - SDATE REJECTED COMMENTS6 "► -. PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Job No. 8s 3 ,3 (-,, l o so .00 1so 1 This plan was not prepared from an instrument survey. Offsets and distances shown should not be used to establish property lines. This plan is Intended for mortgage. purposes only. I certify that the structure shown on this Plans . in conformance with the zoning setbacks in effect at the time of construction. I certify that the parcel shown is �o T located within a flood hazard area' as depicted on FEMA Flood Insurance Rate Maps for Community No, 1-1) (n 9R OF Mq� ti P Zi S E `pro ,L LZI MORTGAGE LOAN INSPECTION LOCATION:�/_, z- _.e �� SCALE: DATE: REGISTRY: NO ; TITLE REFERENCE: PLAN REFERENCE:__ COREY & DONAHUE, INC. Engineers & Surveyors 198 Cambridge Rond, Woburn, MA 01801