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Miscellaneous - 78 VEST WAY 4/30/2018 (3)
p 4. 1PI 00 m 1 D PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 2/1/16 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Complete Repair of D -Box By: Todd Bateson At: 78 Vest Wav Map 104.B Lot 0170 North Andover, MA 01845 this cern ca , §haRAot be gonstrued as a guarantee that the system will function satisfactorily. MichHe Grant Public Health Agent 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com �=a X .J #A Commonwealth of Massachusetts Title 5 Official Inspection Form j Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Vest Way Property Address Shaun Milliken 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. VQ ISI Owner's Name North Andover MA 01845 12/21/2015 City/Town 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: FEB o 12016 Neil J. Bateson - Rnn-• r,nnvrt') Name of Inspector Bateson Enterprises Inc. HEALTH CEP%R VrDJ Company Name 111 Argilla Road Company Address Andover MA 01810 Cityfrown State 978-475-4786 S115 Telephone Number B. Certification License Number 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 JJ141 12/21/2015 Inspe6torrs Signature V 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 - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 r� Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Vest Way Property Address Shaun Milliken Owners Name North Andover MA 01845 12/21/2015 Cityfrown 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: After permit from B.O.H., install new d -box, inspection from B.O.H., septic now passes Title 5 Inspection. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 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. IGS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Vest Way Property Address Shaun Milliken Owner's Name North Andover MA 01845 11/18/2015 ► 5 Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any 4-e lea way. Please see completeness checklist at the end of the form. f0 ov A. General Information 1. Inspector: Neil J. Bateson RECEIVED b DEC 0 2 2015 j''�}��� Name of Inspector TOWN OF NORTH ANDOVER Bateson Enterprises Inc. HFAI TH DEPARTMENT Company Name 111 Arailla Road Company Address Andover MA 01810 City/Town State Zip Code 978-475-4786 S115 Telephone Number B. Certification License Number I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Nee s Fu her Evaluation by the Local Approving Authority f 11/18/2015 Inspecto s Si nature 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 • 3/13 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page t 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 78 Vest Way Property Address Shaun Milliken Owner's Name North Andover MA 01845 11/18/2015 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old" or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. " A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ® N ❑ ND (Explain below): t5ins • 3/13 Title 5 ficial Inspection Forth: Subsurface Sewage Disposal System - Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Vest Way Property Address Shaun Milliken Owner Owners Name information is North Andover MA 01845 required for every page. Cityrrown State Zip Code B. Certification (cont.) 11/18/2015 Date of Inspection ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are 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 • 3/13 Title 5 Official Inspection Forth: 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 78 Vest Way Property Address Shaun Milliken Owners Name North Andover MA 01845 11/18/2015 Cityrrown 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 -Box needs to be 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 Y2 day flow t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 ❑ ® 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Vest Way Property Address Shaun Milliken Owner Owner's Name information is required for North Andover MA 01845 11/18/2015 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 or 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 78 Vest Way Property Address Shaun Milliken Owners Name North Andover MA 01845 11/18/2015 Cityrrown C. Checklist State Zip Code 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): N/A Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): N/A t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Vest Way Property Address Shaun Milliken Owner's Name North Andover Cityrrown D. System Information Description: Number of current residents: MA 01845 State Zip Code 11/18/2015 Date of Inspection 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.) ❑ No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 9 ( Y 9 (gp ))� 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 - 3/13 Title 5 Official Inspection Forth: 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 78 Vest Way Property Address Shaun Milliken Owner Owner's Name information is required for North Andover every page. Cityfrown D. System Information (cont.) Last date of occupancy/use: Other (describe below): 11/18/2015 State Zip Code Date of Inspection Date General Information Pumping Records: Source of information: Pumped 2013, owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Measured tank Reason for pumping: Inspect tank & tees Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 3113 Title 5 official Inspection form: Subsurface Sewage Disposal System • Page 8 of 17 Owner information is required for every page. t5ins • 3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Vest Way Property Address Shaun Milliken Owners Name North Andover Cityrrown State D. System Information (cont.) 01845 Zip Code 11/18/2015 Date of Inspection Approximate age of all components, date installed (if known) and source of information: Original, owner. Outlet tee in septic tank was replaced 2004, B.O.H. info Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 1.6 feet Material of construction: ® cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" Cast iron through wall, 3" PVC in house, no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal M 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) Dimensions: 10'x5'x4' Sludge depth: C. ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts 'UWTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments * 78 Vest Way Property Address Shaun Milliken Owner information is required for every page. t5ins • 3/13 Owner's Name North Andover MA 01845 11/18/2015 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 27" Scum thickness 6" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 7" 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.): Pumped septic tank. Inlet tee ok. Outlet tee ok. Inlet cover has riser under patio blocks. Depth of liauid at outlet invert. No evidence of leakaae. 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: Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Vest Way Property Address Shaun Milliken Owner's Name North Andover MA 01845 11/18/2015 City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Capacity: Design Flow: Alarm present: Alarm level: Date of last pumping: ❑ fiberglass ❑ polyethylene ❑ other (explain): gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No 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 78 Vest Way Property Address Shaun Milliken Owner's Name North Andover Cityrrown D. System Information (cont.) MA 01845 State Zip Code Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11/18/2015 Date of Inspection 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. Evidence of carryover, pumped d -box to clean. D -box has corrosion holes, needs to be replaced. 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 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t 78 Vest Way Property Address Shaun Milliken Owner's Name North Andover Cityrrown D. System Information (cont.) MA 01845 11/18/2015 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 1 field 15'x 40' 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 sign 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 • 3/13 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 r 78 Vest Way Property Address Shaun Milliken Owner Owner's Name information is required for North Andover MA 01845 11/18/2015 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions 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 78 Vest Way Property Address Shaun Milliken Owners Name North Andover MA 01845 11/18/2015 Citylrown 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 i 15ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 78 Vest Way Property Address Shaun Milliken Owner Owner's Name information is required for North Andover MA 01845 11/18/2015 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >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: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database - explain: Essex County Soil Map. You must describe how you established the high ground water elevation: Essex County Soil Map, Sheet # 30, Paxton Soil, Water >6' deep Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins - 3/13 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 78 Vest Way rn Property Address Shaun Milliken Owner owner's Name information is required for North Andover MA 01845 11/18/2015 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins - 3113 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 I I V I. L J• L V I J 1 1.. J V 1 11! ••-. v. I I I &Am&y Room cad gonaated on tU230t512:459 PM by Mlaween McAuley pme Town of North Andover Tax Map # 210-104.B•0170-0000.0 Parcel Id 16492 78 VEST WAY MILLIKEN, SOPHIA 78 VEST WAY N. ANDOVER, MA 01846 Class 101 Singoe Family Property Type 1 Residential zoning2 1 Residential loning3 1 Resldentiol Size Total 1.01 Acres FY 2016 Up Malling Index NalnelAddress MILOKEN, SOPHIA 78 VEST WAY N. ANDOVER, MA 01645 UB AccounflImInL Account No Cycle Bldg Id. 11631.0 - 78 VEST WAY 3170496 03 Cycle 03 US Servi*rea Maint. Account No, 3170490 Servioe Code MISCFEE ADMIN FEE WTR WATER US Motor Maintenance Account No. 3170496 Multiplier/Users Serial No Status 11 35844525 a Aotive 11 Data Reading 81812015 995 6110/2015 912 3/1212015 867 12/1212014 853 8/1012014 828 6!912014 737 311112014 718 12/1212013 705 911212013 673 611112013 610 31*2013 571 1211212012 558 811212012 536 611212012 440 3113(2012 391 1211212011 379 9/13/7011 364 817/2011 294 317/2011 264 121812010 250 919/2010 219 618/2010 105 3/1012010 67 12)1112009 51 918/2009 34 71812009 0 6/812009 4714 3116/2009 4674 Mae 1/1212010 Type Loan Number Activelinact. From Payor Occupant Name Activelinective Lae Billing Rate 101812015 Active Rats 0.03616 01 ALL METER SIZE Locatlon ERT HH Code a Actual a Actual a Aotual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual e Actual a Actual a Actual a Actual n Now Meter m Manual estimate M Manual estimate Charge Multiplier/Users 7.82 11 425.95 11 /i'I 11 1 '- Brand 'type b Badger w Water Consumption Putted Date 83 10/1812015 45 7/24/2015 14 4/28/2013 26 111512015 91 10/15/2014 19 7/16/2014 13 4/1112014 32 1/1712014 53 1011512013 39 7/2412013 13 4/2212013 22 119/2013 96 10/15/2012 49 7/16(2012 12 4/14/2012 15 111712012 70 10/1312011 30 712012011 14 4(312011 31 1/1242011 114 10/1612010 38 7/15/2010 16 41140010 17 1/1212010 34 1011612009 0 1011312009 40 7/2((2009 36 4129/200.9 Until 'C' o r'j 3 u ,r) P >h 0 /-) i'%'b 1- d Qe� (rl II'f$ jallo�+j Situ 0.63 0,83 YTD Cons 961 Variance 82% 221% -421141 -73% 383% 46% -58% -48% 55% 210% •42% -77% 94% 313% -22% -77% 119% 107°/6 -5!% •721: 190% 135% -68% 0'144 0% 32% -7% Commonwealth of Massachusetts Mj C4/Town of . System P�mping.IRecord Form 4 DEP has provided this form for useby local Boards of Health. Other forms may Used, but the information• must be substantially the same as that provided here. Before using.this fom, Fheck with your local Board of Health to determine the form they use. The System Pumping Record must b6' submitted to the local Board of Health or other approving authority. A. Facility. Information 1. System Location: Left / Right front of house, Left / Rig rear f house, 0/ right dkklof hous Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address ClWTown State Zip Code 2. System Owner. Name Address (f different from location) Cilyrrown B. Pumping 1. Date of Pumping rd 3. Type -of system: ❑ ❑ Other (describe): � ut � State Zip Code r a Telephone Number a f Date 2. Quantity Pumped: Gallons Cesspool(s) Septic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yep No If yes, was it cleaned? ❑ Yes ❑ No, 5. Condition of Syst 6: System Pumped By: Neil. Bateson Name Bateson Enterprises Inc' Company 7. Location where contents -were disposed: IV 0=4.doc- 06/03 F5821 Vehicle License Number Date .r (a - System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts Map -Block -Lot 104.B0170 --------_-_- BOARD OF HEALTH Permit No North Andover - BHP -2015-0924 ---------------------- P.I. FEE F.I. $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd -Bateson to (Repair) an Individual Sewage Disposal System. at No 78 VEST WAY (R -1) ----------------------------------------------------------- ------------------- as shown on the application for Disposal Works Construction Permit No. BHP -2015-0.92 Daember 18, 2015 -- - Issued On: Dec -18-2015 �-- BOARD OF HEALTH Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. IFd� Application for S.eotic disposal Svstem Construction: Permit - TOWN OF NORTH ANDOVER$ MA 01845 a new on-site sewage disposal system' /a -/ a-- is TODAY'S DATE $ 250;00— Full Repair $425.00: - Component ❑ Repair or replace an existing onwsite sewage disposal' system= pair or replace an existing system component – What? A. Facility Information A Wt Address or Lot # s�.� CitylTown DEC 18 2015 2: *TYPE OF SEPTIC SYSTEM* TOWN OF NORTH ANDOVER ➢ ❑ Pump 0,Gravity (choose one) HEALTH DEPARTMENT —If pump sy , 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) ➢ ❑ Pressure Dosed (D -Box Present) S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES = (no further info. needed) NO = (installer must specify brand of friter before DWC issuance) Whstis the Make? 2. Owner Information What is dre Modc�9 Mame Address (if different from above) / Cityrrown l'tIf State Zip Code q8— Telephone Number 3. Installer Information iB,4T.�5d!✓ BATEuON ENITPORnll.-L ,fes Name dName of Company111 ARC" 1.;., , , L— ANDOVER, IV1A a 14,1 U Address Cityfrown 4. vest. r Name Address Cityfrown State q Zip Code 9'70© Telephone Number (Cell Phone # if possible please) Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 fo TOWN /S _ TODAY'S DATE $.250.00 , Full Repair $725.00;- Component PAGE 2OF2 A. Facility. Information continued.... 5. Type -of BuNding; B9esidential Dwelling or []Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore -described on-slte 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 T North Andover, and not to place the system 1n operation unf/l a Certificate of Compliance has been Issue by this Board of Health. AS Na Date lica n ApproB • (Boar , of He esentative) ame Date Application Disapproved. for the following reasons: ' For Office Use Only: 1 -Fee Attached? Yes No Z.• ProjectMgn-Iger Obligation Fonar Attached. Yes No ' Puma SEMMM? Ifsoj Attach copy ofElectrical Permit' 'es No 4. FbuadadonAs Built.? (hew construction-ronly); Yes No (Same scale as approved plan) —" S. F1oorPlw (hew construction, only): Y.es_ No Applfcmt(dn {or•p(sppsal 0y3tdM':06nstMC8Oh Penn- Rage 2 of 2 SBP', C .Md..T +ROf As 111e119�lbutovesS=edkiaarurr frs�ct#e tutsttc gsrf�•theaepiic tyetr fo2.che arc j tpa (Ad4iix atupik 19im •-1402pU= by ReLtiaa m tit�.tpp9� of �� ` 7�e�,�i _ {i�atir et'r mmte "�� hnd doled Doted �.ZaI `sem 1 = a - Wit tevidot I vadrrttaad the foDowbg ofiligatioas fart ttagemtatt Cows proicct: i. As the iast ua4 I m.obiig w i,p obtaia aIIpmgaits an4Boud aft apprd PbmoM M' �pet6omtg aap: as s e#� 3. At�ie.I.oaIlmpand sfl'p: Ttconturt,�araap Qt3terPM=M*ftocbftdvfth my comping9•aa� and the apstet�n is aofmdy, tip ftm Ae�st�il�t- ,,• aiet�d niti}ev�tsrti,wtnvn. s,�,N4iJL,i�i1�1..�.a,J.t.1:.IrN.�i...h... �Gt.s_�.s,._� �`_y:• :s"`•�E'J-' ._���� . t►.. ,I� l�feaak.�I"'st>�p-:tlsex �'ratrgt, •_� int t not bane to be pr�sctit: . miiaixtep {or ��t, eta a OIC (or ell is frarn tha ed 'ae Most • ba itibmitird•#o �is.8�'�.Iltal�, �: .• fsarm �fectipn. dine. 'Iarttllea it�ist bet f+ar b� a Ruth be tad able to coo POWT ti mid.vlumito- a •— ttiilec izmnegtzwbaptttloa li cn P «doei aot 4 As'the b. mltr/t;' I d that I,* ft',Vo&(WhwMiff� md'I aai tired m mpfete thgutisttitu of tits spstd•id%,s�x�plinet�diatioa: 'S.. 1SU t�iaadtite��i �derst� , I u �f t� ooas . a Deet�laadamt tliat.�ep�rreleAr'damr aftbr e�,csnvoetars,Qr�•,b�p �� - .. . b6 laspeIatoff aFtdr jWd readk a wd '1'irul�aapeo#anrbyBOW a.iaitt�rel�fforcoa8 dofmak,•la'.xi, st+orae, voaPFtaw 'watD►saGCotbar . b. Uadm.*WUmmdSeptic.br (gp . . 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: _78 Vest Way _North Andover-t(.,pF�orAtLT ! Owner's Name: _Shaun Milliken Owner's Address: _78 Vest Way_ _ North Andover, MA 01845_ 6 ' Date of Inspection: _4/7/2004 ` Name of Inspector: Neil J Bateson Company Name: Bateson Enterprises Inc.— Mailing Address: _111 Argilla Road_ _Andover, Ma. 01810_ Telephone Number: _( 978 ) 4754786_ 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 Inspector's Signature: Date: _4/7/2004_ The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments: ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _78 Vest Way_ _ North Andover — Owner: Milliken Date of fnspection: 4f7/2004_ Inspection Summary: Check AAC,D or E / ALWAYS complete all of Section D A. System Passes: _X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: _ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. _ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 78 Vest Way_ _ North Andover_ Owner: _Milliken Date of Inspection: _4/7/2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance _ _ "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 78 Vest Way _ — North Andover Owner: _Milliken Date of Inspection: 4/7/2004_ D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes No _ No Backup of sewage into facility or system component due to overloaded or clogg — ed SAS or cesspool No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool No Liquid depth in cesspool is less than 6" below invert or available volume is'/2 day flow. —No7 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _No Any portion of the SAS, cesspool or privy is below high ground water elevation. _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _ _No Any portion of a cesspool or privy is within 50 feet of a private water supply well. No Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design How of 10,000 gpd to 15,000 gild• 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) 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. Page 5 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: _78 Vest Way_ _ North Andover — Owner: _Milliken Date of Inspection: _4/7/2004 Check if the following have been done. You must indicate "yes' or "no" as to each of the following: Yes No Yes _ Pumping information was provided by the owner, occupant, or Board of Health No Were any of the system components pumped out in the previous two weeks ? Yes _ Has the system received normal flows in the previous two week period ? No Have large volumes of water been introduced to the system recently or as part of this inspection ? N/A _ Were as built plans of the system obtained and examined? (If they were not available note as N/A) Yes Was the facility or dwelling inspected for signs of sewage back up ? Yes _ Was the site inspected for signs of break out ? Yes_ _ Were all system components, excluding the SAS, located on site ? _Yes_ _ 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 ? _Yes_ _ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no _Yes_ _ Existing information. _ _No_ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: _78 Vest Way — North Andover— Owner: _Milliken Date of Inspection: 4/7/2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): _N/A_ Number of bedrooms (actual): _4_ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): _N/A_ Number of current residents: _3 Does residence have a garbage grinder (yes or no): Yes_ Is laundry on a separate sewage system (yes or no): _ No_ Laundry system inspected (yes or no): Seasonal use: (yes or no): No_ Water meter readings: Yes_ Sump pump (yes or no): _No_ Last date of occupancy: _Current COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sqft,etc.): Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): _ Non -sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: Pumped 2001, owner _ Was system pumped as part of the inspection (yes or no): Yes _ If yes, volume pumped: _1500_gallons -- How was quantity pumped determined? _Measured Tank Reason for pumping: Inspect Tank & Tees_ TYPE OF SYSTEM X Septic tank, distribution box, soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank _ Attach a copy of the DEP approval _ Other (describe): _ Approximate age of all components, date installed (if known) and source of information: 22 years old, owner Were sewage odors detected when arriving at the site (yes or no): _No Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 78 Vest Way- — North Andover_ Owner: _Milliken Date of Inspection: _4n12004 BUJIMING SEWER _ X _ (locate on site plan) Depth below grade: _18"_ Materials of construction: R cast iron _X_40 PVC _other Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): _4" Cast Iron thra wall. 3" PVC in house, no leaks visible SEPTIC TANK: X _ (locate on site plan) Depth below grade: 4"_ Material of construction: —X—concrete metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) Dimensions: _10' x 5' x 4' Sludge depth: 3' Distance from top of sludge to bottom of outlet tee or baffle: —24"— Scum 24"Scum thickness: _6" Distance from top of scum to top of outlet tee or baffle: _8" Distance from bottom of scum to bottom of outlet tee or baffle: _15"_ How were dimensions determined: _ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.):_ Pumped septic tank Inlet tee ok Outlet tee ok. No evidence of septic tank leaking. Depth of liquid at outlet invert. _ GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete metal fiberglass polyethylene —other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 78 Vest Way- — North Andover_ Owner: _Milliken Date of Inspection: _417/2004 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX. _X (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 level & distribution equal. No evidence of leakage out of d -box. Evidence of solid carryover, pumped d -box to clean_ PUMP CHAMBER: (locate on site pian) Pump in working order (yes or no): Alarm in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): , Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 78 Vest Way — North Andover— Owner: _Millken_ Date of Inspection: _4/7/2004_ SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: _ leaching trenches, number, length: X leaching fields, number, dimensions: _1 field 15' x 40' 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 oL Vegetation ok No sign of ponding to surface_ CESSPOOLS: (cesspool must be pumped as part of inspectionxlocate on site plan) Number and configuration: Depth — top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (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.): Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _78 Vest Way _ _ North Andover— Owner: —Milliken— Date illiken_Date of Inspection: ^4/7/2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Driveway Water Meter House B Porch A Deck A to Inlet = 2'9" A to Outlet =12'2" A to D -Box = 23'9" B to Inlet =14' 10" B to Outlet =15' 10" B to D -Box = 33'2" Septic Tank D - Boa E] 5' Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 78 Vest Way —North Andover— Owner: _Milliken Date of inspection: 4/7/2004_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water _ >6'_ Please indicate (check) all methods used to determine the high ground water elevation: _ Obtained from system design plans on record - If checked, date of design plan reviewed: _ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: _ Checked with local excavators, installers- (attach documentation) X Accessed USGS database -explain: Essex County Soil Map_ You must describe how you established the high ground water elevation: _Essex County Soil Map, Sheet # 30, Paxton Soil, Water >6' Deep. _ VVV111 LA CD a N • �xz La rZico `! r rr �1� '�' f Kywtito�vl,AwNrm•cao�a�cn�AwNr st � a ��,�; .. � - . � gx •_ rC-•NNNNNNNNNNNNNNNNNN ci ( 011 - Iz1@®@mmmm@mm@mmmmmmm ■C I ttrf „fo .AWWWWNNmNmNNmI•+mFrhmFm'mmmmmmm$s'Z. . G WNF+1 1 1 Ct! I 1.0 C0 SK,aWNF+C7�AWNh+,q.WNF+,AI T: OWWWWWWWWwwwwwwwwww 1 t" _ ti�lmmmµmmmmmmmmmµmmmM+ S s %O 9%WN.0%O0+.&ON CO I C) ryt M <?3N M.3i. � �:�� �� µf.►µKF+NNNNNNh+mmNmKm XII = ',•�N y f*1 ftCO �r xbx s �`; O+017'�7�0�0�]mWODO�F+NRIWN.A.AF► C 1 cn . �= a r NNNNNNh1NNNNNNNNNNF+ C;') I �'1 nmmmmmmmmmm©mmmmmm•o 11'110 i? a �, :�' t=7mmmmmmmmmmmmmmmmm� I c nY ` ZWWWNNh-wWNF-rIjF+mt9mm� I ► .`..: •b CAJ wwwwwwwwwwwwwNcvNNly O a _rn .j_ �{ a� ;a�•$r.. 31)�TT�lit11VIN�l1NF+61L9O.O�O�OOD `.T! k�1 •" 'a.� - �e�. QNm�017COF+17t11F+C�m�OT(J'7WNmW •A Z . i S�.AmyoOmi-•C�mmCTtSTNQ+�0�7�7.A ON R. u�wwwwwwwwwwwwwwNNNt� W r 0%ONcnv,wNcM"1"Lmm•o%0%0%0 M4=r s prNm�oyl+o�+7enF-cn V�Q� cnWM zt:r•- XIN%O.A©17m00F+Q%mmT(QNT�O �7'�7 •iflln ODNF+F+C7! WMIANmI+F+N17 4 ` i.� ��" �.�.� '+ . WCJI,AW�OmyCnCT�m,ACTCGTyNmW •d � _ . N W1 F+O►A N N 17TWWmN.AWNGDN.Ati1COr'>•WCA a • • • • • • . • • • • • • • • • • • 119 + W CJ I %0 001+ %O m to %016 cn a ca A N] � X! GON,AmCJtiOCn@mNCn,ACIOt+CT0 Irl S r 1 C C- H t m W c n mmmmmmmm@mmmmmmmmm # `_��{R. `�,�' ��' mmmmmmmmmmmmmmmmmm XI µ _ *�' boa, .�•, ©mmmmm@@C9mmmmmmmmm •■ 9 =� LM U1 lttllmfJlViNVtF+F+F+limen®6) 17 ,AzozC�O�CisiM J7tJ1C11@m@mmmmQ Irl .A i A)-Jt717-]mu"MCnCnmmmm©@mt9 trl w ��cn C7% �� � , �: " co � w w r N ,ra •A w ao W Cn t7o m 0,A,A @t+ No 0%Cn00-ON 4%+17®CTN4%C H ,t I+ N V IQ I -L CM CJS W 4 A o+,A w ,p -] ON N3 r ■ tt+ en 40 t+ -j e+,A m en Cn N OD ,A co r ON m ha CL �Ug s s . *"�kk ri=m r•"' � _ .. Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 78 Vest way, North Andover Owner: Milliken Date of Inspection: 4/7/2004 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Neil` J. Byeson Bateson Enterprises, Inc. fid William F. Weld Governor Argeo Paul Celluccl U. Gasmor B'0''o Commonwealth of Massachusetts ". Executive Office of Environmentol Affairs Department of W991 Environmental Protection Trudy Cox* Secretary David B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC'T'ION FORM PART A �, • . CERTIFICATION Property Address: Ve, Noy �U�� Address of Owner. Date of Inspection: _ t� 3�C1 VV (if different) Name of Inspector. Company Name, Address and Telephone Number. BATESON ENTERPRISES, INC. TEL (508) 475-1474 Excavating - Water & Sewer Lina - Septic Systems & Pumping Service FAX: (508) 475-5451 111 Argilla Ro 11 Andover Mass 01810 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: v Passes _ Conditionally Passes _, Needs Further Fvaluation By the Local Approving Authority F' Inspector's Signature: Date: 9-8-97 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) 7E'MPASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.30°. Any failure criteria not evaluated are indicated below. BI SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. 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, cracked, structurally unsound, shows substantial infiltration or exii1tration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a Fonforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Winter Street * Boston, Massachusetts 02108 a FAX (617) SWIG49 * Telephone (617) 292-55oo A ' is Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: V V e,4 aIwv Owner. M n. Date of Inspection. B] SYSTEM CONDITIONALLY PASSES (continued) 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(#) 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 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 piotect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and is within a Zone I of a public water irupply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more fmm 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. 3) OTHER (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: VeVQ4 V0'V-� \ bev96Q.,f Owner. Date of Inspection: D) SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defused 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. _ Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped 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. El LARGE SYSTEM FAILS: 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: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.. (revised 11/03/95) 3 P. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner. Date of Inspection: q'i Check if the follo have been done: information was requested of the owner, occupant, and Board of Health. _ 5.7t.oof he system components have been pumped for at least two weeks and the system has been receiving normal flow rates A l during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. NIA -As built plans have been obtained and examined. Note if they are not available with N/A. The ty or dwelling was inspected for signs of sewage back-up. Th-pystem does not receive non -sanitary or industrial waste flow The i was inspected for signs of breakout. excluding the Soil Absorption System. have been located on the site. _ All m components, ex g rp Y The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. size and location of the Soil Absorption System on the site has been determined based on existing information or pprmimated by non -intrusive methods. _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub - Surface Disposal System. (revised 11/03/95) 4 F" SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C LSYSTEM INFORMATION Property Address: Owner- Date wnerDate of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow:0 gallons Number of bedrooms: Number of current residents Garbage grinder (yes or no): Laundry connected to system (yes or no):�A6 Seasonal use (yes or no): Water meter readings, if available: Last date of occupancy: 63V(k� COMMERCIALANDUSTRLkU Type of establishment: Design flow:_,_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non -sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, davailable: --- Last date of occupancy OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: • System pumped as part of inspection: (yes or no) jLtS If yes, volume pumped:. 49V 7 Reason for pumping: %%XS(O�L TYPE RP TEM 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) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) (revised 11/03/95) 6 a- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address ylg Ut'C4 f ol� Avubovar Owner. Date of Inspection: SEPTIC TANK: &-' (locate on site plan) k Depth below grade: Material of construction: Zonrete _metal _FRP —other(explain) Sludge depth: (o " (iC� j q Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:_Q (1 Distance from top of scum to top of outlet tee or baffle: Vt Distance from bottom of scum to bottom of outlet tee or baffle: a Comments: (recommendation for pumping'eQndition of ink t and outlet tees or es, *?pth of liq�t id level rl relation to GREASE TRAP:j4jpye (locate on site plan) Depth below grade: Material of construction: _concrete _metal —FRP —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, struchiral integrity, evidence of leakage, etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Addr+eew'-f o QJ� Owner. Date of Inspection: V l�• u`1"L--> TIGHT OR HOLDING TANKV CV�e (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX._V (locate on site plan) Depth of liquid level above outlet invert: O ] L _� ►To�:JnZ�i�1.�r���'�.� " L���?:.���•rte i�'►� • . v .� -� PUMP CB:AMBER.i{�Ohe"-c-ACQLV (locate on site plan) V �J V Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 k I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued) Property Address: U I bJ4 v , Alkk� Owner. f, , �, �y S �3 Date of Inspection Z:7— ` �.J - SOIL ABSORPTION SYSTEM (locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Type= leaching pits, number: leaching chambers, number:, leaching galleries, number: �1 leaching trenches, number,length_� lea fields, number, dimensions: 1 x 40 v� overflow cesspool, number: Cndit�pnl6soilgns o;VIi CESSPOOLS: VAC (locate on site plan) Number and configuration: Depth -top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) of pondiuz condition of vei[etation etc.)_ 6 ('y 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.) (revised 11/03/95) 8 s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �"�Q , Alu,� Owner. Date of Inspection: �^ SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' B-�-V a = /U lQ a DEPTH TO GROUNDWATER Depth to groundwater:kA41 feet method of detemnination or apprmir .e --Es— -� (revised 11/03/95) 9 '' 13ATESON ENTERPRISES ING Septic Systems — Excavating — Water k Sewer Lines Title 5 Inspection Report i i i AtgniA mold Andover, Matieth0§6111 01816 (Sol) 06-1411 Property Address i! U vi Owner: Date of Inspection:—�3JC�'� My report contained hdkOin does riot ddnetitute d guarantee of future usage and the turictionality of the existing septic sy6tem► Such report issued herewith is merely bagod upon My bbbetVationsi and I hereby disclaim any fftthof bpdkatfbn of your current septic aygbbmi P to Of to Neil dt Sat"son Bate9dn ghterptisss thdi i If TO: FROM: NORTH ANDOVER, MASS C- 3 19 e2 - BOARD OF HEALTH DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at 1 7- e Vf,5 7` WAY North Andover, Mass. SITE LOCATION The grades and construction are as specified in apr plans and specifications dated /?i1 ACS lk 19-eL. by FR,41M CEL/N C Mo aG//a7`FS IAV((A eg. vr %neer/Reg; unitarian �TC- 114 s i M GRav< N D FLAN 92���N �E S _ / /V _ c ---A-0 64 N b /OLA ly L% 5 goo 33 ooG�.L• s�PT'�-T� Pfd Comm -i a T �Tli Town of North Andover, Massachusetts Form No. 1 NORTH AA BOARD OF HEALTH ��S LED ib q,Y� 19 O APPLICATION FOR SITE TESTING/INSPECTION Applicant - NAME ADDRESS TELEPHONE Site Location Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time Fee CHAIRMAN, BOARD OF HEALTH Test No. S.S. Permit No. % D.W.C. No.C.C. Date Plbg. Permit No. r G.L. C. 1310 s 40 and under Town of north Ando��er By La�,�, Chapter 3 Section -3 _5 -A & B-_- -___- -_-_- -J- • CITY/TOWN NORTH ANDOVER NAME Lacy Street Realty Trust CERTIFIED MAIL NUMBER PROJECT LOCATION: FILE NUMBER 242- 178 ADDRESS 200 Lacy Street North Andover, MA n _194;_ Address Lot 46 Vest.Way Recorded at Registry of North Essex Book 1600 page 147 Certificate (if registered) REGARDING: Notice of Intent Dated October 12, 1982 and plans titled and dated see condition eleven (11 THIS ORDER IS ISSUED ON (date) November 19, 1982 Pursuant to the authority of G.L. c. 131, s. 40, the North Andover Conservation Commission has reviewed your Notice of Intent and plans identified above, an has determined that the area on which the proposed work is to be done is significant to one or more of the interests listed in G.L. c.: 131, s. 40. Town of North Andover bylaws, Section 3.5 A & B Wetlands Protection. The North Andover Conservation Commission hereby orders that the following conditions are necessary to protect said interests and all work shall be performed in strict accordance with them and with the Notice of Intent and plans identified above except_wheresch -------- _u_plans_are--m-o-d-i--f-ied -b-y -ssaaiidd-c-o-n-d-i-t-i-o-n--s-. ------------------ CONDITIONS 1. Failure to comply with all conditions stated herein, and with all related statutes and other regulatory measures, shall be deemed cause to revoke or modify this order. . 2. This order does not grant any property rights or any exclusive privileges; it does not authorize any injury to priviate property or invasion of private rights. 3. This order does not relieve the permittee or any other person of the necessity of complying with all other applicable federal, state or local statutes, ordinances, by-laws and/or regulations. 4. The work authorized hereunder shall be completed within one (1) year from the date of this order unless it is for a maintenance dredging project subject to Section 5(9). This order may be extended by the issuing authority for one or more additional one-year uper application to the said issuing authority at least thirty �eriods 30) days prior to the expiration date of the order or its extension. 5. "_nv fill used in connection with t' is prc;ect shall be clean fill, ccntaining no trash, refuse, rubbish or debris, includ ng without limiting the generality of the foreZoind, lumber, bricks, plaster, w.i.re,lath, paper, carboard, pipe, tires, ashes, refrigerators, motor vehicles or parts of any of the foregoing. 6. No work may be commenced until all appeal periods have elapsed from the order of the Conservation Commission or from a final order by the Department of Environmental Quality Engineering. 7. No work shall be undertaken until the final order, with respect to the proposed project, has been recorded in the Registry of Deeds for the district in which the land is located within the chain of title of the affected property. The Document number indicating such recording shall be submitted on the form at the end of this order . to the issuer of this order prior to commencement of work. 8. A sign shall be displayed at the site not less that two square feet or more than three square feet bearing the works, "Massachuse Department of Environmental Quality Egnineering. Number 242- " 9. Where the Department of Environmental Quality Engineering is -requested to make a determination and to issue a superseding order, the Conser- vation Commission shall be a party to all agency proceedings and hearings before the Department. 10. Upon completion of the work described herein, the applicant shall forthwith request, in writing, that a Certificate of Compliance be issued stating that the work has been satisfactorily completed. 11. The work shall conform to the following described plans and additional conditions: 1. Notice of Intent and Environmental Data Form Dated October 12, 1982/ prepared by Flynn Associates P.C./nine (9) pages. 2. Plan titled "Plan Shaing Dwelling Location and Proposed Site Alterations, Location: Lot 46 Vest ,%av, ?Forth Andover" O,.%n.er: Lacy Street Realty Trust, Dated 10/12/82, prepared by Flynn Associates, P.C. 12. A row of staked hay bales shall be placed between all construction areas and wetland areas. This ro<<,, of hay bales sha11 re:1-ain intact until all disturbed areas have been stabilized to prevent erosion. 13. All disturbed areas shall be graded, loamed and seeded to provide restabilization of disturbed areas. After restabillzation, hay bales shall be removed and sedimentation shall be removed from areas of accumulation. 14. Al erosion prevention and sed -L-mentation protection measures found necessary during construction by the North Andover Conservation Commission will be implemented at the direction of the NACC or Highway Surveyor. 15. Any changes in the submitted plans, Notice of Intent, or resulting from the aforementioned conditions must be sub- mitted to the NACC for approval prior to implementation. If the NACC finds, by majority vote, said changes to be significant and/or deviate from the original plans, Notice of Intent or this Order of Conditions to such an extent that the -.interests of the Wetlands Protection Act cannot be protected by.this Order of Conditions and would best be served by the issuance of additional conditions, then the NACC will call for another public hearing within 21 days, at the expense of the applicant, in order to take testimony from all interested parties. Within 21 days of the close of said public hearing, the NACC will issue an amended or new Order of Conditions. 16. Any errors found in the plans or information submitted by the applicant shall be considered as changes and procedures outlined for changes shall be followed. 17. The provisions of this Order shall apply to and be binding upon the applicant, its employees, and all successors and assigns in interest or control. 18. Prior to the issuance of a Certificate of Compliance, the applicant shall submit a letter to the Conservation Commission from a registered professional engineer certifying that the Work is in compliance w th the plans referenced above and the conditions stated above. 19. Members of the NACC shall have the right to enter upon and inspect the premises to evaluate compliance with this Order of Conditions. 20. Accepted engineering and construction standards and procedures shall be followed in the corapietion of the project. �1. Issuance cf these con3itions CCe� ,got i_ ± ar}- [:� T-._tply cr certif - that the site or do[•,T15t ea?n- areas [.-•i1l iiOt be subject to flooding, storm damage, or any other form of dariage due to wetness. ID ra I _ ..�'- 'F. .�!r_� v'r an%' �L "t residVnt.s of the city or to :n in F:hich such Jan d is located, are hereb•, notified of their right to appeal this order o the Department of Environ- mental Quality Engineering. provided the request is made in writing and by certified mail to the Department within ten (10) days from the issuance of this' order. /1 _ ISSUED BY NORTH ANnnvFR CONSERVATION COMMISSION On this 19th dof November 19 82before me personally appeared Anthony ffivagna to me known to be the person described in, and who executed, the foregoing instrument and acknowledged that he executed the same as his free act and deed. My Commission exp ires%� DETACH ON DOTTED LINE AND SUBMIT TO THE -ISSUER OF THIS ORDER PRIOR TO COMMENCEMENT OF WORK. To NORTH ANDOVER CONSERVATION COMMISSION (Issuing Authority) PLEASE BE ADVISED THAT THE ORDER OF CONDITIONS FOR THE PROJECT AT REGISTRY OF FILE NUMBER 242- , HAS BEEN RECORDED AT THE ON (DATE) If recorded land, the instrument number which identifies this transaction is If registered land, t e document number which identifies this transaction is Signed Applicant e or COL4SE.RVATION COMMASSiON .40"M ..�1, TELEPHONE 683-7105 Pursuant to the authority of the Wetlands Protection Act,. Massachusetts General Laws Chapter 131, Section 40, as amended, and the Town of North Andover's Wetland Protection By Law, the North Andover Conservation Commission will hold a Public Hearing on November .3, 1982 at 8:00 P.M. at the Town Building Meeting Room, 120 Main Street, North Andover, MA on the Notice of Intent of Lacy Street Realty Trust to alter land at Lot 46 Vest Way for purposes of constructing a single family dwelling and related site development. Plans are available at the Conservation Commission Office, Town Building, 120 Main Street North Andover, MA, on Tuesday_ from 12:00 noon to 2:00 p.m. and by appointment. run once in the N.A. Citizen Copies sent to: Planning Board — Board of Health Public Works Highway Dept. Applicant Engineer DEQE By: A. Galvagna Chairman on October 28, 1982.