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HomeMy WebLinkAboutMiscellaneous - 80 CHRISTIAN WAY 4/30/2018 (2)0 1 r , of,� RT .,� 6331 . O • Town of North Andover HEALTH DEPARTMENT sACHU`+t /j CHECK #: 1 DATE: I� LOCATION: I H/O NAME:,jri icy CONTRACTOR NAME:1'Y 4�.CIIY�,, Type of Permit or License: (Check box) ❑ Swimming Pool ❑ 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) $ ❑ ?� Title 5 Inspector Title 5 Report $ $ ❑ Other. (Indicate) $ (k) Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer 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. _ 1__ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Christian Wa Property Address James Sherlock Owner's Name North Andover Cityrrown MA 01845 State Zip Code 4/16/2013 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: Neil J. Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover City/Town 978-475-4786 Telephone Number B. Certification MA State S115 License Number MAY 2 0 2013 TOWN OF NORTH ANDOVER HE HDEPARTMFNT 01810 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 F rther Evaluation by the Local Approving Authority 4/16/2013 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Christian Wa Property Address James Sherlock Owner's Name North Andover MA 01845 4/16/2013 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: After permit from Board of Health, install in tank, d -box & replace five broken pipes, inspection from Board of Health, septic system 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 I Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Christian Way Property Address James Sherlock Owner information is required for every page. Owner's Name North Andover Cityrrown B. Certification (cont.) MA n1 RAR 12/4/2012 State Zip Code Date of Inspection B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ 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 sant marsh t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Christian Way Property Address James Sherlock Owner Owner's Name information is required for every North Andover MA 01845 12/4/2012 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) u 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Septic'tank leaking, pipe to d -box crushed, d -box leaking & corrosion holes & four leach pipes t-ri ichari 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 % day flow t5ins • 09108 Tiffe 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 80 Christian Way Property Address James Sherlock Owner Owner's Name information is required for every North Andover MA 01845 12/4/2012 page. City/Town 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. ❑ Z 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 ❑ F-1 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 a El Area system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 09/06 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 5 of 17 t<L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 80 Christian Way 12/4/2012 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): 600 t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Property Address James Sherlock Owner Owner's Name information is required for every North Andover MA 01845 page. CityrFown State Zip Code C. Checklist 12/4/2012 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): 600 t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Christian Way Property Address James Sherlock Owner Owner's Name information is North Andover required for every page. Cityrrown D. System Information Description: MA 01845 State Zip Code 12/4/2012 Date of Inspection Sump pump? ❑ Yes ® No Last date of occupancy: September 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 Number of current residents: No 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Yes Detail: Sump pump? ❑ Yes ® No Last date of occupancy: September 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 - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Christian Way Last date of occupancy/use: Other (describe below): 01845 12/4/2012 Zip Code Date of Inspection 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: Date Last year, owner gallons ❑ Yes ® No 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 - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Property Address James Sherlock Owner Owner's Name information is required for every North Andover MA page. Cityfrown State D. System Information (cont.) Last date of occupancy/use: Other (describe below): 01845 12/4/2012 Zip Code Date of Inspection 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: Date Last year, owner gallons ❑ Yes ® No 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 - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Christian Way Property Address James Sherlock Owner Owner's Name information is required for every North Andover MA 01845 12/4/2012 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: 25 years old, 7/23/1987, as built plan Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): 1.6 Depth below grade: fee 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 thru wall. 3" PVC in house, no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal n feet ❑ Yes ® No ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list ager years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) 10'x5'x4' Dimensions: Sludge depth: N ❑ Yes ❑ No t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 80 Christian Way Property Address James Sherlock Owner Owner's Name information is North Andover required for every page. City/Town D. System Information (cont.) MA 01845 State Zip Code Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle N/A 12/4/2012 Date of Inspection 1" Scum thickness Distance from top of scum to top of outlet tee or baffle N/A= Tank leaking Distance from bottom of scum to bottom of outlet tee or baffle N/A 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 ok. Outlet tee ok. Liquid level in tank 1' below invert, evidence of leakage. Outlet pipe to d -box crushed. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: t5ins - 09/08 Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 80 Christian Way Property Address James Sherlock Owner Owner's Name information is North Andover required for every page. Citylrown MA 01845 State Zip Code 12/4/2012 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 ❑ --ther (explain): Dimensions: Capacity: Design Flow: gallons gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins - 0908 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Christian Way Property Address James Sherlock Owner Owner's Name information is North Andover required for every page. Cityrrown D. System Information (cont.) MA 01845 12/4/2012 State Zip Code Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 2"below inverts 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.): Liquid level in d -box 2" below inverts. Evidence of leakage. Evidence of solid carryover. D -box cover broken, replaced same. Four out of five leach pipes crushed. 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 • 09/08 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 80 Christian Way D. System Information (cont.) Type: Property Address ❑ James Sherlock Owner Owner's Name information is required for every North Andover page. Cityrrown D. System Information (cont.) Type: ❑ leaching pits ❑ leaching chambers ❑ leaching galleries ❑ leaching trenches ® leaching fields ❑ overflow cesspool ❑ innovative/alternative system MA 01845 State Zip Code 12/4/2012 Date of Inspection number: number: number: number, length: number, dimensions: number: 1 field 25' x 44' 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 • 09/08 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 80 Christian Way Property Address James Sherlock Owner Owner's Name information is North Andover required for every page. Cityrrown MA 01845 State Zip Code 12/4/2012 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 • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 80 Christian Way Property Address James Sherlock Owner Owner's Name information is required for every North Andover page. Citylrown MA 01845 State Zip Code 12/4/2012 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 a D --Dr- ✓ �aD =� 6 t5ins • 09/08 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 80 Christian Way Property Address James Sherlock Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells MA 01845 State Zip Code 12/4/2012 Date of Inspection 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: 3/19/1984 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked. with local Board of Health - explain: Design plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: As per test pit data on design plan shows water 5' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Christian Way Property Address James Sherlock Owner Owner's Name information is required for every North Andover MA 01845 page. Citylrown State Zip Code E. Report Completeness Checklist 12/4/2012 Date of Inspection ® 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 • 09108 ,Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 t Summary Record Card generated on 12/12/2012 1:14:42 PM by Karen Hanlon Town of North Andover Tax Map # 210-104.D-0136-0000.0 Parcel Id 16822 80 CHRISTIAN WAY SHERLOCK JR., JAMES F 80 CHRISTIAN WAY N. ANDOVER, MA 01845 Page 1 Class 101 Single Family Property Type. 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.02 Acres FY 2013 UB Mailina Index Name/Address SHERLOCK JR., JAMES F 80 CHRISTIAN WAY N. ANDOVER, MA 01845 UB Account Maint. Account No Cycle Bldg Id. 17764.0 - 80 CHRISTIAN WAY 3170428 03 Cycle 03 UB Services Maint. Account No. 3170428 Service Code MISCFEE ADMIN FEE WTR WATER UB Meter Maintenance Account No. 3170428 Brand Serial No Status YTD Cons 36388108 a Active b Badger Date Reading 9/12/2012 720 6/12/2012 635 3/13/2012 616 12/12/2011 597 9/13/2011 576 6/7/2011 478 3/7/2011 453 12/8/2010 434 9/9/2010 362 6/8/2010 62 3/9/2010 5 2/6/2010 0 2/6/2010 5037 12/11/2009 5027 9/8/2009 4961 6/9/2009 4844 3/16/2009 4792 12/8/2008 4766 9/10/2008 4712 6/6/2008 4551 3/10/2008 4402 12/12/2007 4381 9/6/2007 4313 6/19/2007 4172 3/15/2007 4123 12/12/2006 4096 9/13/2006 4069 Trouble Code:03 .' 6/19/2006 - 3965 Type Loan Number Active/Inact. From Payor Occupant Name Active/Inactive Last Billing Date 10/2/2012 Active Rate Charge Multiplier/Users 0.635/8 7.82 1/ 01 ALL METER SIZE 436.37 /1 Until Location Brand Type Size YTD Cons ERT HH b Badger w Water 0.63 0.63 715 Code Consumption Posted Date Variance a Actual 85 10/15/2012 343% a Actual 19 7/16/2012 1% a Actual 19 4/14/2012 -11% a Actual 21 1/17/2012 -77% a Actual 98 10/13/2011 268% a Actual 25 7/20/2011 27% a Actual 19 4/13/2011 -73% a Actual 72 1/12/2011 -75% a Actual 300 10/15/2010 415% a Actual 57 7/15/2010 288% a Actual 5 4/14/2010 -100% n New Meter 0 4/14/2010 -100% r Replacement 10 4/14/2010 -75% a Actual ; 66 1/12/2010 -45% a Actual 117 10/15/2009 110% a Actual 52 7/20/2009 131% a Actual 26 4/29/2009 -56% a Actual 54 1/20/2009 -64% a Actual 161 10/10/2008 -1% a Actual 149 7/16/2008 618% a Actual 21 4/11/2008 -66% a Actual 68 1/22/2008 -61% a Actual 141 10/12/2007 250% a Actual 49 7/20/2007 76% m Manual estimote 27 4/16/2007 -3% .a Actual 27 1/19/2007 -75% a Actual 104 10/20/2006 64% a Actual 76 7/10/2006 93% PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 4/16/2013 This is to certify that the individual subsurface disposal system has been installed in accordance with the provisions of Title 5 of the State Environmental Code: Repair of Tank and D -Box By: Todd Bateson At: 80 Christian Way Map 104D Lot 0136 North Andover, MA 01845 1 Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. r Michele Grant Public Health Agent 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com 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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Christian Wa Property Address James Sherlock Owner's Name North Andover Cityrrown MA 01845 State Zip Code 12/4/2012 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information Inspector: Neil J. Bateson Name of Inspector Bateson Enterprises Inc. 111 Argilla Road Company Address Andover Ma 01810 Citylrown State Zip Code 978-4754786 S11 Telephone Number License Number nc17M12 B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 12/4/2012 lnspectoriSignatur4J Date The system inspector shall submit a copy of this inspection reportto the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 09/08 Title 5 Official Inspeckn Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Christian Wa Property Address James Sherlock Owner's Name North Andover MA 01845 12/4/2012 CityrFown 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 filtration 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 0 N Tank ❑ ND (Explain below): t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 F. u North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 80 Christian Way MAP: 104D LOT: 0136 INSTALLER: Todd Bateson DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS Tank and D -Box TANK INSPECTION: 4/16/2013 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 ® Building sewer in continuous grade, on compacted firm base ® Cleanouts per plan ® Bottom of tank hole has 6" stone base ® Weep hole plugged ® 1500 gallon tank has been installed H-10 loading ® Monolithic tank construction ® Watertightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port r I Q Comments: PUMP CHAMBER Comments: CONTROL PANEL Comments: DISTRIBUTION -BOX Comments: ® Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ® Hydraulic cement around inlet & outlet ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 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 ❑ Watertightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement ❑ Installed on stable stone base ❑ H-20 D -Box ❑ Inlet tee (if pumped or >0.08'/foot) ❑ Hydraulic cement around inlet & outlets ❑ Observed even distribution ❑ Speed levelers provided (not required) SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder / concrete / timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel -less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = FINAL GRADE ❑ Loamed ❑ Seeded ❑ Cover per plan Comments: DOCUMENTS NEEDED ❑ Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer ❑ As -Built Plan .................................................................................................................................................. Reference No: BHJ-2013-000024 ................................... Permit No: BHP -2013-0611 ................................... Department: North Andover BOARD OF HEALTH ......................................................................................... Account No: 1001001.1.5.0510.00 Fee Type: ........................... Receipt NO: REC-2013-001280 DWC-Component Repair PERMIT .................................... ........................................................ ................................ Paid By: Paid in Full On: Tue Apr 02,2013 ................................... SHERLOCK, JAMES F, JR MARY C SHERI, ......................................... Received By: ................................................. Check No: 7320 ................................... Lisa Blackburn ........................................................ ................................ Amount: DEPARTMENT'S COPY ........ $125.00 . :::..:: ........... ................................................................................................................................................ .. .................... j P • Sw��°� Commonwealth of Massachusetts s BOARD OF HEALTH orth Andover CERTIF CA OF COMPLI E THIS IS TO CERTIF That the Indi 'dual Sewage Disposal S tem (Re ir) Map -Block -Lot by--- - Todd Bateso ----- ---- --- ......... _- ---- ------------------------ ----- ---- - --ler-------- - ---------- --- 0 80 CHRISTIAN has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. -BHP--20-1-3---06 1 Dated April -02,-2013 --------------------------- --------------------------- Printed On: Apr -02-2013 BOARD OF HEALTH - ------------------------------------ -- • awl«' , Commonwealth of Massachusetts Map -Block -Lot BOARD OF HEALTH Permit NO North Andover - BHP -2013- - 0611 - -------------------- FEE $125.00 -------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd Bateson to (Repair) an Individual Sewage Disposal System. at No 80 CHRISTIAN WAY - --------------------------------- - - - - - - - as shown on the application for Disposal Works Construction Permit No. 13HP-2013-061 Dated --Apr-i-1-02-,-20-13 -------------------------------- ---------- Issued On: Apr -02-2013 BOARD OF HEALTH �f yURT1{ 1 Application for .Septic Disposal System 3' :.+ . " '• o� aConstruction Permit - TOWN OF TODAY'S DATE OL �. °..,,° .• ,SSACMUSE4 ORTH ANDOVER, MA 01845 $ 250.00 — Full Repair -Component Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer, use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key to move your [v]'IZepair or replace an existing system component — What? .-r- /AN� 2ex cursor - do not use the return key. A. Facility Information j Reg 6kt-" _5 ! r ffA�1 W/ -Y Address or Lot # Cityrrown APR 0 2 2013 3 2.- *TYPE OF SEPTIC SYSTEM*: E] Pump ravity (choose one) TOWN OF NORTH ANDOVER. HEALTH DEPARTMENT ***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. Owner Information 5'her L DUL. Name Address (if different from above) Alo, t Atk ✓.e i� City/Town 1011¢- )I ? Y� State Zip Code 973' -'f3Al- /ZG 7 Telephone Number 3. Installer Information Name Name of Company !1 / 14rcy' l/A Pz,,2, Address City/Town State Zip Code q7 V YIS a 743 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 r''it = TOW' 9 G/—�--I-'� TODAY'S DATE $.250.00 - Full Repair $125.00.- component PAGE 2OF2 A. Facility.Information continued.... 5. Type -of Building: esidential 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 Issue by this Board of Health. Nam Data Application A, roved B .(Board of Health Representative) Name Date G/y t Appli ti Disapproved. r the following reasons For Office Use Only: I. ''Fee Attached?: Yes No Z.- ProjectAfartager Obligation Form Attached? M ' 3.: EM -0 ? Ifsol Attach copy ofElectricRl Permit' No 4. Foundation As Built.? (hew construction -ronly)r Yes_ No (Sam.- scale as approved plan) — S. FloorMws? (hew construction. only). Yes_ No ApplR titin tor -Disposal Oysterih:t~onstruction Pennft Rage 2 of 2 SEP' IC SYSTEM.INSTAI. E 'PROJE'� �' WAgMENT OBLIGATIONS As the.North Andover.licensed installer for the consteuction f4s.the septic system' for.the property at. 8© G J. For plans by (Address of septic system) Relative to the:application of !�� ` And dated (in'staller's name) Dated H—d-- I3 o s ae With revisions dated (Last revised date) I understand the following obligations for management of Ibis project: 1. As the installer, I am .obligated to obtain all permits and Board of fHealth approved plans: prior to ;perfomung any'work on a site: T must have the' antiroved lilans and the petrnit on site when any work is cin n 2. As the installer,.I,must'call for any and all.inspt~ d6ns: I£ 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. b F: applicable - 3,`' As .tli► ststatler, I atn required to. have .the Oecessaty work �cQmpleted priof .to the .applicable inspections as tii�r`lisrman 't'ri'dt reAii�8t111 an 1tiS ection without comliletlon of the items in accordant itic4cated below, �nZ peal - a s in 0. fine levied st:me.and of niv cotnbanv: a B tri tSf B.edenerail , this' is the €xst . 1 ` : i;�s ectiom txnloss. there is a� retaining wall, which y�.P.. shoulii•be dri ii :� t: The'instalTok:iriust�tp pest tBe iiispectios but does. not have to be present. . b, `nna' ct1'�ri Inspection — Engineer taus't'first cla them inspection for elevations; ties, etc. As-biiilti of verbal (or e-mail•tigo:1Q-Qorthandover.�om): from the engineer must be submitted to -..the.Board-ofHealth, after.;ak&lnstaller.calls fpr:an inspection time. Installer must be present for this inspection, With -a puthp system, ail electrical �vok;tnust be ready and able to cause- .to ,arork arid; alarni :to function.. , c, Fina _ �staller must reque0 inspection tvheh 4 grading'is compltte. Installer'does not have to be 4. As -the installer,'I un%ler nd that only I-puy ptttorm the work'(otherthan :rim,pk excavation) and'i ani required to complete the installation of the syst erYi identified in th . attached application for. installation: If .er 5. G. As the.instiller,•I understand that'l /11A'111Y V1' \r'Y RLQ. waVV YVVVJ V1v, .. .on=;lite 'during the.per&imance .of the following construction. steps: a: Det=q natrort that.the proper efevadan of the exrea'wa don has been reached. A Inspection oftbe`sand and store to be used. c. Frnaf mspectlou by Board ofHealth staffor consultant. d Installation., of tank, D Box pipes, stone, vent, pump chamber, rctariirrg wall and other components. . Undersigned Ilceased Septic. In$taller: (T'oda'y Date).. William F. Weld Governor Trudy S. Coxe Secretary, EOEA David B. Struhs Commissioner Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection Metro Boston/Northeast Regional Office TOW BOOAFRD OF HEAL 01VER/ AUG SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: QO Address of Owner. Date of W • A"`d'vs r MA (If different) Name of Inspector. 1� AN MA�'R� zt w t E P Company Name, Address and Telephone Number. C1oo3 43�— 39 j> , r_ K !�• c Zt -rc—" t e l- IJ 6 l ra �icR Cq 5a L -#J r W t tptz+,e A W l+ 03o�d l I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of 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: Inspector's Signature: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR. 15.303. Any failure criteria not evaluated are indicated below. B] 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 exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) 10 Commerce Way • Woburn, Massachusetts 01801 a FAX 9 Telephone 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 (revised 8/15/95) . 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner- Date wnerDate of Inspection: B] SYSTEM CONDITIONALLY PASSES (continued) The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS 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 SALTY 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 supply 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 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. D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. 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). (revised 8/15/95) 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. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontinped) Property Address: Owner: Date of Inspection: D] SYSTEM FAILS (continued): 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 FAIR: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 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 H 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. ' PART B CHECKLLST Check if the following have been done: Pumping information was requested of the owner, occupant, and 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 N/A. 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. XAll system components, excluding the Soil Absorption System, have been located on the site. (revised 8/15/95) 5 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 or approximated 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 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property address: *50 CV -1-N yi-far.. v�'w� / -1.1 iP�►nt�o.ln, r' owner: a %h Sw. < bc.lti Date of Inspection: (%.,o lct�. FLOW CONDITIONS RESIDENTIAL: Design flow: ons ! Lo....l K %O a (� Number of bedrooms: Number of current residents: Garbage grinder (yes or no):�_�5 Laundry connected to system (yes or no): Y67 s Seasonal use (yes or no): Ao Water meter readings, if available: N 1 R Last date of occupancy: PRQ'N3'A1T COMMERCIAIJINDUSTRIAT- 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, if available: Last date of occupancy: OTHEM (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: L-hsT 1?uM PED N 101q,5 N a tt. System pumped as part of inspection: (yes or no) * - AS S If yes, volume pumped: _L45pp gallons Reason for pumping: et)j W e(?— ALe QV t?4T 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) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: C1 Sewage odors detected when arriving at the site: (yes or no) As�0 (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properly Address: Qd f.L►.r 1 tib' i a�H►. �fJ c+-�, IJ. AnV e Owner: v tiVV' I:Aki Date of Inspection: Q I l0 (Q 6 SEPTIC TANS _ (locate on site plan) Depth below. grade: �IC.Vfr Material of construction: _Kconcrete _metal _FRP —other(explain) Dimensions: zo ' ' **-L-") Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 3 5 Scum thickness: 344 u Distance from top of scum to top of outlet tee or baffle: (a 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, structural integrity, evidence of leakage, etc.) GREASE TRAP: IJOt�� (locate on 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, structural integrity, evidence of leakage, etc.) (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properly Address: go Glum s+( ay.r- Owner-: q I w r lo. k Date of Inspection: Cfr 71GHT OR HOLDING TANK. 140W t (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 BOR v (locate on site plan) rf Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) 'D -box e_I %..J/ 4a ff 'fl-'QSCac, Lo cnJr�.d d.�Pr-oxZw►s..ta,lu � � u . A•e Loc.J CereLtie.. PUMP CHAMBER:_J�O►. - (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: W o.y $ t-4. Ano­&ev a r - Owner -T'% vA '6t%2 r toc t.0 Date of Inspection -g % t o(q (. / SOIL ABSORPTION SYSTEM (SAS): ✓ (locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length:—�— leaching fields, number, dimensions•. i k A -5 overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) Q0 lata.. m � :ea wre. CESSPOOLS: vaa-w E (locate on site plan) Number and configuration: Depth -top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: _WOE (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 8/15/95) 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (cold) Property Address: go c.1��: ��: ar.. W o.,.W. N .J L e - Owner: Z" L h S Ptil = l 04.(.4 Date of Inspection: %I l o i g f. SE=H OF SEWAGE DISPOSAL SYSTKV: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' taam%U100T %oN pjox l.6Ac. N r -161.D. 'f'Aw1K kx���N tz.wWL.C.ti 4 (revised 8/15/95) DEPTH TO Depth to groundwater:_feet method of determination or approxin (revised 8/15/95) 12 • ,r LOT 3 44)640 145.00 f•�, t CHRIST�A�� VAM NP, F A Zkk •s .� ri n't �w 3tr S ..._ fS�1`�� ONi ^ .•'r �� 5 rl.f'.;i•s71•..'. iI)" •.^^''fi�nn . S l ' .�/� �.. �11:_� j F IV'! A I it JILT 1G 7.78r 1 . v '+166►'78:�U %�1 I'`(�TMT THE 5FPTtC "SYST�. IU WAS INSTALED- A_> S 0 _ .. _ 7175 0 9 Pow • Town of North Andover HEALTH DEPARTMENT SACNUSf CHECK #: DATE: LOCATION: 11 t 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 Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $� Title 5 Report ��. $�U ❑ Other: (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Commonwealth of Massachusetts 9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Christian Way Property Address 6 Debbie Doorack Owner owner's Name information is required for North Andover MA 01845 11/25/2014 every page. 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. Important: When filling out A. General Information forms on the 2p�4 computer, use 1. Inspector: only the tab key ANDOVER to move your Neil J. Bateson Ur NURj�R7Y�EN� cursor - do not Name of Inspector ►" Ali v use the return HE key. Bateson Enterprises Inc. Company Name VQ 111 Argilla Road Company Address Andover MA 01810 City/Town State Zip Code 978-475-4786 S115 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs F rther Evaluation by the Local Approving Authority 11PA, /� 11/25/2014 lnsp#tof Si nature 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 w Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System - Page 1 of 17 Owner information is required for every page. t5ins - 3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Christian Way Property Address Debbie Doorack Owner's Name North Andover Cityfrown B. Certification (cont.) MA 01845 State Zip Code 11/25/2014 Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" 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): Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 V Commonwealth of Massachusetts , uWn Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Christian Way Property Address Debbie Doorack Owner Owners Name information is required for North Andover MA 01845 11/25/2014 every page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/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 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 80 Christian Wa Property Address Debbie Doorack Owner's Name North Andover MA 01845 11/25/2014 City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 % day flow t5ins • 3113 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t 80 Christian Way Property Address Debbie Doorack Owner Owner's Name information is required for North Andover MA 01845 11/25/2014 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No El ® 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 of 17 . ' . Commonwealth of Massachusetts Title 5 Official Inspection Form • v� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Christian Way Property Address Debbie Doorack Owner Owner's Name information is North Andover MA 01845 11/25/2014 required for every page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 600 t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts VUTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Christian Way Property Address Debbie Doorack Owner owner's Name information is required for North Andover every page. Cityrrown D. System Information Description: Number of current residents: MA 01845 11/25/2014 State Zip Code 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 Industrial waste holding tank present? Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage 9 ( Y 9 (gPd))� Yes No Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 ` . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Christian Way Owner information is required for every page. Property Address Debbie Doorack Owner's Name North Andover MA 01845 11/25/2014 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: Pumped 2012, owner 1500 gallons Measured tank 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments F 80 Christian Way Property Address Debbie Doorack Owner Owner's Name information is required for North Andover MA 01845 11_/25/2014 every page. City/Town t5ins • 3113 State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 27 years old, 7/23/1987, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 1.8 feet r 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 .8 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'x 5'x 4' Sludge depth: 2" ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Owner information is required for every page. t5ins - 3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Christian Way Property Address Debbie Doorack Owner's Name North Andover Cityrrown D. System Information (cont.) MA 01845 11/25/2014 State Zip Code Date of Inspection Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness 3" 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 12" 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. Depth of liquid at outlet invert. No evidence of leakacie. Inlet cover has riser 1" deep. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness ❑ fiberglass 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: feet ❑ polyethylene ❑ other (explain): Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17 ' . !L\ Commonwealth of Massachusetts QmMia Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth - Not for Voluntary Assessments UIV 80 Christian Way Property Address Debbie Doorack Owner Owner's Name information is North Andover MA 01845 11/25/2014 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Christian Way Property Address Debbie Doorack Owner Owner's Name information is required for North Andover MA 01845 11/25/2014 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D -box level & distribution equal. No evidence of leakage. Evidence of carryover, pumped d - box to clean. 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 - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Owner information is required for every page. t5ins - 3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Christian Way Property Address Debbie Doorack Owner's Name North Andover MA 01845 11/25/2014 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® r leaching fields 25'x 44' number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No 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 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 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 80 Christian Wa Property Address Debbie Doorack Owner's Name North Andover MA 01845 11/25/2014 Cityrrown 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 80 Christian Way Property Address Debbie Doorack Owners Name North Andover MA 01845 11/25/2014 Cityrrown 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 t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 Owner information is required for every page. Commonwealth of Massachusetts `title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Christian Way Property Address Debbie Doorack Owner's Name North Andover Cityrrown D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar MA 01845 11/25/2014 State Zip Code Date of Inspection ® 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: 3/19/1984 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Design plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: As per design plan test pit data 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 80 Christian Way Property Address Debbie Doorack Owner information is required for every page. Owners Name North Andover Cityfrown MA 01845 State Zip Code 11/25/2014 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 • 3/13 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 ° • Summary Record Card generated on 11/25/2014 1:36:48 PM by Maureen McAuley Town of North Andover Tax Map # 210-104.D-0136-0000.0 Parcel Id 16822 80 CHRISTIAN WAY ROBERT & DEBRA DOORACK 80 CHRISTIAN WAY NORTH ANDOVER MA 01845 Page 1 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.02 Acres FY 2015 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until ROBERT & DEBRA DOORACK Owner 80 CHRISTIAN WAY NORTH ANDOVER MA 01845 SHERLOCK JR., JAMES F Previous Customer Inactive 7/12/2013 80 CHRISTIAN WAY N. ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 17764.0 - 80 CHRISTIAN WAY Last Billing Date 10/3/2014 3170428 03 Cycle 03 Active UB Services Maint. Account No. 3170428 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 175.13 /1 UB Meter Maintenance Account No. 3170428 Serial No Status Location Brand Type Size YTD Cons 36388108 a Active ERT HH b Badger w Water 0.63 0.63 985 Date Reading Code Consumption Posted Date Variance 9/10/2014 990 a Actual 38 10/15/2014 -22% 6/9/2014 952 a Actual 47 7/16/2014 121% 3/11/2014 905 aActual 21 4/11/2014 -14% 12/12/2013 884 aActual 25 1/17/2014 -24% 9/12/2013 859 a Actual 23 10/15/2013 -62% 7/10/2013 836 f Final Bill 112 7/11/2013 4266% 3/14/2013 724 a Actual 2 4/22/2013 -1% 12/12/2012 722 aActual 2 1/9/2013 -98% 9/12/2012 720 a Actual 85 10/15/2012 343% 6/12/2012 635 a Actual 19 7/16/2012 1 % 3/13/2012 616 a Actual 19 4/14/2012 -11% 12/12/2011 597 aActual 21 1/17/2012 -77% 9/13/2011 576 a Actual 98 10/13/2011 268% 6/7/2011 478 a Actual 25 7/20/2011 27% 3/7/2011 453 a Actual 19 4/13/2011 -73% 12/8/2010 434 aActual 72 1/12/2011 -75% 9/9/2010 362 a Actual 300 10/15/2010 415% 6/8/2010 62 a Actual 57 7/15/2010 288% 3/9/2010 5 a Actual 5 4/14/2010 -100% 2/6/2010 0 n New Meter 0 4/14/2010 -100% 2/6/2010 5037 r Replacement 10 4/14/2010 -75% 12/11/2009 5027 aActual 66 1/12/2010 -45% 9/8/2009 4961 a Actual 117 10/15/2009 110% 6/9/2009 4844 a Actual 52 7/20/2009 131% 3/16/2009 4792 a Actual 26 4/29/2009 -56% 12/8/2008 4766 aActual 54 1/20/2009 -64% L;0 6 06ed . 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U Date. ,,ORTM TOWN OF NORTH ANDOVER PERMIT FOR MECHANICAL INSTALLATION a D r r L This certifies that �: r' (�... �.' i �....................... has permission for mechanical installation . ;�............... . r in the buildings of ............�......... at .,.- .,i ... . f...... .:...�... }%{ ., North Andover, Mass. Fee. ,' `Lic. No..%.'!..... ......... !,{............. GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 6 S f4ill 4 t ' Client#: 74206 ROYALAIRSY ACOW. CERTIFICATE OF LIABILITY INSURANCE DATE(MWDOMM OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 9/2612014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE. ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this Certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER HUB International New England C%NT CT Certificates Dept PHotrE — — - -- Arc yo, E>a�: 978 657.5100 _ [� K�. $66 475-7959 289 Ballardvale St Wilmington, MA 01887 E-MAIL __......---- AD .. Ess, nee.certificates@hubinternationaLcom —_ _ INSURERS) AFFORDING COVERAGE MAIC # 97$ 657-rJi OO INSURER A: Travelers Indemnity Co of CT INSURED Royal Air Systems, Inc ,NSURER e; Hanover Insurance Company INSURERc:lndependence Casualty ins Co 210 Main Street INSURER D: Safety indemnity Insurance Co North Reading, MA 01864 ._ INSURER E: INSURER F. -^ ...........�-- .1w r,v,v,. lwmtacn: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE13EEN ISSUED. TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. lNSR ADDL SUER LTR TYPE OF INSURANCE NSR D ' POLICY NUMBER. '--- APWDD/YYYY MWODYIYE�IY LIMITS GENERAL LIABILITY 68074990754 D912812014 09128/201 EACH OCCURRENCE s 1 OOO OOO COMMERCIAL GENERAL LIABWTYDAMAGE T RENTED PREMISES Es occil D S 300,00 � CLAIMS�MADE L_ `J OCCUR oe MED EXP (Any ono Person) $5,000 _ PERSONAL & ADY INJURY 511000000 GENERAL AGGREGATE Is2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: :PRODUCTS-COMPiOPAGG s2,000000 X POLICY PRO- 1 LOC $ D. AUTOMOBILE LIABILITY 1710990 9/28/201.4 09/28/201 O sodden SINGLE IMiT 1,.000,000 ANY AUTO BODILY INJURY (Per person) $ ALL OWNED X SCHEDULED AUTOS AUTOS BODILY INJURY (Peracddenq S X NON -OWNED HIRED AUTOS X AUTOS I l PROPERTY DAMAGE -- 1Per academe,_ B X UMBRELLA UAB X OCCUR UHNA104686 9/28/2014 S 09/28/201 EACH OCCURRENCE $1000000 c— EXCESS LUte CLAIMS -MADE AGGREGATE $1.000.000 u DED. X RETENTION S55000 S C WORKERSGOMPENSAILIT AND EMPLOYERS' LlA81LnY1 WCI00110901 �0/10120141D/101201 WC STATIf 0TH - X FR YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICE JMEMSER EXCLUDED? � , NIA tt� E.L, EACH ACCIDENT $1 ,000 000 (Mandatory In NH) Hyp, describe under i E.L. DISEASE - EA EMPLOYEE $11,000,000 DESCRIPTION OF OPERATIONS below _ E.L. DISEASE - POLICY LIMIT $1,000,000 A MTCargo 68074990754 9/2812014 09/28/2015 25,000 A Installation 68074990754 912812014, 09/2812015 25,000 DESCRIPTION OF OPERAT101,13I LOCATIONS f VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) Blanket Additional Insured Status and Waiver of Subrogation in favor of Certificate Holder on the general and auto liability policies as respects to operations of the named insured when required by executed contract prior to any loss/claim. Evidence of Coverage. CERTIFICATE HOLDER CANCELLATION Evidence of Coverage Only SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE % 19BB-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) 1 of 1 The ACORD name and logo are registered marks of ACORD 9S1222316/M1222239 MC005 2 Fail, Then Detach Along An $ 6 4 SNEER ISSUES THE FOLLOW F'N%0"11At- ASTER-UNRESTRICTED Rift S 3 3 YSTEk...Tkc 00 0 M Iq > A P-jimel 'mm m 3 ROYAL 0 1f,4.' YtTttiS l N ST 3 EADINGxwJM 01864-31 30� 1r O/.8 16 X933 52 0 0 1101-:444ERV .14 L Commonwealth of Massachusetts -110 0 0 . Department of Public Safety 10 M (D or 48 CHESTNUT ARTHUR A PICKETT Pipefitter Master License: PM -002596 S s N READING M& OI Can-unissioner Expiration: J OMI/2015 ' PLUAB.ilff'% ZT6ISF I z HE, j' SSUES T 5� E AS,,A, UFjOURNE jf� GASF -ITTE MAN, ARffdfR A. PICKET -f -JR I-V 48H ST ..,c E 'TW ft � T' RNG 018 2864 /0 1 75 i AL �nrric��#$� Project ect Summa Job: Date: 4/15/2015 Entire House By: Project Information For: Perry 80 Christian way, North Andover, MA 01826 Notes: Weather: Boston, MA, US Winter Design Conditions Outside db Inside db Design TD Summer Design Conditions 0 °F Outside db 75 °F Inside db 75 °F Design TD Daily range Relative humidity Moisture difference Heating Summary 2700 2700 Structure 61177 Btuh Ducts 0 Btuh Central vent (0 cfm) 0 Btuh Humidification 0 Btuh Piping 0 Btuh Equipment load 61177 Btuh Infiltration Method Construction quality Fireplaces Simplified Average 0 Heating Cooling Area (ft') 2700 2700 Volume (ft) 24300 24300 Air changes/hour 0.32 0.16 Equiv. AVF (cfm) 130 65 Heating Equipment Summary Make 0 Trade Use manufacturer's data Model Btuh AHRI ref 1.00 Efficiency Heating input Heating output Temperature rise Actual air flow Air flow factor Static pressure Space thermostat 0 AFUE 0 Btuh 0 Btuh 0 °F 1689 cfm 0.028 cfm/Btuh 0 in H2O 88 °F 73 °F 15 °F L 50 % 31 gr/Ib Sensible Cooling Equipment Load Sizing Structure 33421 Btuh Ducts 0 Btuh Central vent (0 cfm) 0 Btuh Blower 0 Btuh Use manufacturer's data y Btuh Rate/swing multiplier 1.00 ton Equipment sensible load 33421 Btuh Latent Cooling Equipment Load Sizing Structure 1961 Btuh Ducts 0 Btuh Central vent (0 cfm) 0 Btuh Equipment latent load 1961 Btuh Equipment total load 35382 Btuh Req. total capacity at 0.70 SHR 4.0 ton Cooling Equipment Summary Make Trade Cond Coil AHRI ref Efficiency Sensible cooling Latent cooling Total cooling Actual air flow Air flow factor Static pressure Load sensible heat ratio Bold/italic values have been manually overridden Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. 0 SEER 0 Btuh 0 Btuh 0 Btuh 1689 cfm 0.051 cfm/Btuh 0 in H2O 0.94 2015 -Apr -1510:51:01 wrightsOft Right -Suite® Universal 2015 15.0.15 Right J® Mobile Page 1 ...\wstmp\bag2f7f6-6d57-48bg-839e-413eee77857b.rup Calc = MJ8 Front Door faces: N Orightsoft• Right -J® Worksheet Job: Entire House Date: 4/15/2015 By: AL 1 Room name Entire House First Floor 2 Exposed wall 300.0 It 160.0 It 3 Room height 9.0 It d 9.0 It heat/cool 4 Room dimensions 50.0 x 30.0 ft 5 Room area 2700.0 ft' 1500.0 ft' Ty Construction U -value Or HTM Area (ft') Load Area (ft') Load number (Btuh/ft'-°F) (Btuh/ft) or perimeter (ft) (Btuh) or perimeter (ft) (Btuh) Heat Cool Gross N/P/S Heat Cool Gross N/PtS Heat Cool 6 Vy 12C-Osw 0.091 n 6.82 2.13 540 458 3128 976 270 229 1564 488 �-G 1D-c2ow 0.570 n 42.75 19.01 82 0 3491 1553 41 0 1746 776 12C-Osw 0.091 a 6.82 2.13 810 667 4555 1421 450 362 2467 770 1Dc2ow 0.570 a 42.75 60.87 122 0 5201 7405 68 0 2866 4108 11 11DO 0.390 a 29.25 11.08 21 21 614 233 21 21 614 233 12C-Osw 0.091 s 6.82 2.13 540 478 3263 1018 270 249 1699 530 1D-c2ow 0.570 s 42.75 32.80 41 0 1746 1340 0 0 0 0 11DO 0.390 s 29.25 11.08 21 21 614 233 21 21 614 233 Vjl 12C-Osw 0.091 w 6.82 2.13 810 688 4698 1466 450 383 2611 814 1-G 1 Dc2ow 0.570 w 42.75 60.87 122 0 5201 7405 68 0 2886 4108 C 16B-19ad 0.049 3.67 2.54 1500 1500 5512 3815 300 300 1102 763 F 19A-Obscp 0.295 8.31 1.62 1500 1500 12467 2427 1500 1500 12467 2427 61 c) AED excursion 101 0 Envelope losstgain 50492 29291 30656 15251 12 a) Infiltration 10686 1040 5699 555 b) Room ventilation 0 0 0 0 13 Internal gains: Occupants Q 230 3 690 3 690 Appliancestother 2400 2400 Subtotal (lines 6 to 13) 61177 33421 36356 18895 Less external load 0 0 0 0 Less transfer 0 0 0 0 Redistribution 0 0 0 0 14 Subtotal 61177 33421 36356 18895 15 Dud loads 0% 0% 0 0 -0% 0% 0 0 Total room bad61177 33421 36356 18895 Air required (cfm) ( ( I 16891 1689 I 10041 955 Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. w r1gWhtsQiFt a 2015 -Apr -15 10Pge Right-Suite®Universal 2015 15.0.15 Right J® Mobile Page 1 \wstmp\ba92f7f6-6d57-48b9-839e-413eee77857b.rup Calc = MJ8 Front Door faces: N t• Wrightsoft' Right -J® Worksheet Job: Entire House Date: 4/1512015 By: AL 1 Room name Second Floor 2 Exposed wall 140.0 ft 3 Room height 9.0 ft heattcool 4 Room dimensions 40.0 x 30.0 ft 5 Room area 1200.0 ft' Ty Construction U -value Or HTM I Area (ft') I Load I Area I Load number I (Btuhtft°-°F) (Btuh/ft) or perimeter (ft) (Btuh) or perimeter Heat Cool Gross NIPIS Heat Cool Gross N/PIS Heat Cool 6 Vjl 12C-0sw 0.091 n 6.82 2.13 270 229 1564 488 L—G 1Dc2ow 0.570 n 42.75 19.01 41 0 1746 776 12C-0sw 0.091 a 6.82 2.13 360 306 2087 651 1 Dc2ow 0.570 a 42.75 60.87 54 0 2316 3297 11 11130 0.390 a 29.25 11.08 0 0 0 0 Vel 12C-0sw 0.091 s 6.82 2.13 270 229 1564 488 � –:t1 Dc2ow 0.570 s 42.75 32.80 41 0 1746 1340 11D0 0.390 s 29.25 11.08 0 0 0 0 VY 12C-0sw 0.091 w 6.82 2.13 360 306 2087 651 L—G 1Dc2ow 0.570 w 42.75 60.87 54 0 2316 3297 C 166-19ad 0.049 3.67 2.54 1200 1200 4410 3052 F 19A-Obsco 0.295 8.31 1.62 0 0 0 0 61 c) AED excursion 10 Envelope losstgain 1 19835 14040 12 a) Infiltration 4987 485 b) Roomventilation 0 0 13 Internal gains: Occupants @ 230 0 0 Appliances/other 0 Subtotal (lines 6 to 13) 24822 14525 Less external load 0 0 Less transfer 0 0 Redistribution 0 0 14 Subtotal 24822 14525 15 Dud loads -0% 0% 0 0 Total room load 24822 14525 Air required (cfm) I I I 6851 7341 Calculations approved by ACCA to meet all requirements of Manual J 8th Ed wrlgh�aft• 2015 -Apr -15 10Pge Jgt..c..ca Right-Suite6� U nNa ersal 2015 15.0.15 Right J® Mobile Page 2 \wstmp\ba92f7f6-6d57-48b9-839e-413eee77857b.rup Calc = MJ8 Front Door faces. N NAME: Meghan Perry PHONE: 1-978-979-0348 DATE: ADDRESS: $0 Christian Way other: 03-26-15 TOWN: North Andover, MA 01845 E-IVIPUL meghaneperry@gmail.com Pg. 1/1 We hereby submit specifications and solutions for: Furnishing and installing a new high efficient central heat pump system for your home. Condensing unit will be installed outside the home on anew pre -cast pad- adAir Airhandler will be installed in the attic. It will be hung from the roof rafters with 3/8" threaded rod Underneath will be an emergency drain pan, gravity drain, EZ trap, and float switch Installation of an outdoor temperature sensor to shut down the heat pump at 35 degree outdoor temperature. All. drain piping needed All. refrigerant piping needed All line -hide on exterior of the house to conceal piping. Fabrication, insulating; sealing, and installation of all necessary duct work up to .Mass state sheet metal code. Two zone control package, Two new programmable thermostats. All wiring needed All electrical wiring to the existing electrical panel. Electrical permit and inspection. Sheet metal permit and inspection. Complete startup and tests. A one year service contract on all new products. System Description , ,2LO pate Lexington DSZC18 heat pump condenser VT COST- 17.5 SEER, 12.5 EER Solution Lexington "FTC variable speed air handier I9,09$.00 Rebates: $250.00 Cool Smart rebate. Will receive after job is complete and balance Is paid in full. Guarantee and warranty information: This installation includes a 10 year unit replacement warranty, limited lifetime compressor and 10 year parts warranty. A 100% performance guarantee. A one year service contact on all new products.. We propose hereby to furnish material and labor — complete in accordance -with the above specifications, we accept option # 46.,-e- for the sum of: $ l 4 (DO Payment to be as follows: o Financing initial 1/3 down, 1/3 at the start, 1/3 upon completion All material is guaranteed to be as specified. AN work to be completed in a professional manner according to standard practices, Any alteration or deviation from above involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. Title to the equipment to remain with Royal Air Systems, Inc. until the final payment is made. All agreements contingent upon strikes, accidents, or delays beyond our control, owner to carry fire, tornado and other necessary insurance. Our worker Is fully covered by Worker's Compensation Insurance. Acceptance of proposal: The above prices; specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. This Proposal may be withdrawn if not accepted within 15 days from the above date, x Customer Wceptance si nature DATE Royal Air Systems, Inc. Authorization Signature Date 4- 0 u c ro �i W 0 U) Lf) 70 0 Co FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ***************Applicant fills o t this section***************** L,,,�=CANT: J � � F��c/ �- Phone LOCATION: Assessor's Map Number Parcel Sub 'v/�ision /�/ Lot(s) 0--AStreet l- �eld,-7 YI �'v St. Number v " Use Only************************ RECOrMENDATIONS OF TOWN AGENTS: Conservation Administrator Comments Town Planner Comments Date Approved Date Rejected Date Approved Date Rejected Date Approved Food Ins_ector-Health Date Rejected Date Approved % q Septic Inspector -Health Date Rejected Comments IAJa RDUA>A SDL— /f X 34 Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date '.N 4 i..�iro" T'. - -�-_ iye ate• •.:, FND JSE OUTLET .NLET XITLET :X ' INLET OX CL MIT 208,50 LOT 3 44,a40 � i 0 .r 143,^0 EL EVAT10N 172.81 170.55 16.13 !68•37 157.98 167.78 I6; -,.7S CHRIS-TiAN V AY 5,31 ��-C-t(��ST; PLAN SHOW �t*J,B 2FACE-SEWMAGE S.LT LXATI al-LOT3 CHRI'l-, IANA/AY -tee t{. rr-t — — -_. , , .r 143,^0 EL EVAT10N 172.81 170.55 16.13 !68•37 157.98 167.78 I6; -,.7S CHRIS-TiAN V AY 5,31 ��-C-t(��ST; PLAN SHOW �t*J,B 2FACE-SEWMAGE S.LT LXATI al-LOT3 CHRI'l-, IANA/AY -tee t{. rr-t — — -_. Town of North Andover, Massachusetts Form No. 1 BOARD OF HEALTH 19 MAPPLICATION FOR SITE TESTING/INSPECTION Appl.j_cant NAME ADDRESS TELEPHONE Site Location Engineer NAME ADDRESS. TELEPHONE Test/Inspection Date and Time F CHAIRMAN, BOARD OF HEALTH Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. P -URD OP NOJ�JH 4AJpOVEI^�IMA, S5 a L -o -r 3 c- h c, -T,,4 1-i w��y SPL i C,4tiJ I L� WEc,t_ ,�P�ovCD D�'C Wrl c Sy STE,l V'S1 6,k) 4pn�ovt� ' 2- �7-7� APR�NW6 AuTliol'�,Try COAJPITWJ5 = �15APPIZpVEp IN"►E R�ASoNS = PL 3 6 q SCPT"( C SV ST67M I lu STA U-ATIOA J al�gl f.� L X4V4T(c,�,J Arc x-10 Q 0455 [] F4it- ���T F[NAil IV5P6: TIO/-) Di3TE Z- 2 S - V AVP(Tjo1)A1, 1nj5Fz.i joys X11=- koy) DISIJW)' ovF,D Rj�6'50 tis FV AL APPC`6' VAL DA►C AP> RWVJG /6u HnRi F\/ I --t 53 crt 145 -CO X% CHRISTIAN kti AY ELEVATION TG 5 ANO 172.61 t 'lj-,E` FLET 1705 �► i �,i..r-_T toy -13 CLJTLFT Ti I [-- (1NN LL l 16M� D E 3 � G,Ji1.. 167.7$ E!"7) FIFI D IEC -,73 r -SS, k SCE ScV. ESE DISPOSAL L-7) S-! E[,,.. AS Blu'f L:I U)CAT I ON LQ ► 3 CHR I AN V% AY � AjY -,I-RL jT I DATE 1.21_)-67 I CET; iFY TAT R1 C SF6 ,-IC .3N StI-71.1 t 1S 1F .STALI-ED AS SHOM- TI P"At r -h DF T1 F SYSi Z:ta PREPARED EY— Design Y—Dell gn C L "I i or /I A r (-l'o l I � l'4,J 161,01 C%'�--��i% i.� ��� ! �r� /� � - - � L �i <� G �! fo • � . S lam- �';� � r�� I _;'_ '� r � ` s-'%:_!C/ire-,+f-s'.•�' ���(/�u� '/ti ��::,,.r i����.a�_�--i t���_./, r �L\ Commonwealth of Massachusetts _ W City/Town of No.Andover a System Pumping Record Form 4 M DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. P1,4 ` A. Facility Information `01� Important: When filling out 1. System Location: forms the computer, use only the tab key Address to move your No.Andover Ma 01845 cursor - do not use the return City/Town State Zip Code key. 2. System Owner: Name OL Address (if different from location) City/Town State Zip Code Telephone Number B. Pumping Record /1. Date of Pumping 16-12-11 2. Quantity Pumped: Gallons Date Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): TONFAL H DEPARTMENN OF NORTH V7 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. '.ystem Pumped By: I— JZ U -M lI 7/ Nv me Stewart's Septic Service Company 7. Location where contents were disposed: Vehicle License Number Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Dto Signature of Recei g Facilityate t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 TOWN F NORTH AN'DOVEP, UA tlOJ SYS M PUMPINQ RECOfU, .1 T a I rM vwNUF, & ADD - SS 0 /Z& lee��71c80 Gw2ea�i IJA I r. VY FVMMNO: Q T 0 1 MM LVL-AT10N ...-QUANTITY PLIMPSD: C k:tWOOL: NO YiS/Sopuc I,Lnk: Nu y fs NA rvRE op SERVICE: Kou,rtNE.,,_ Qb3bAVA'nGN3: OOOD CONDITION Fula, 'M COVER JUN 0 3 2005 Kmyy OiXF.,Ms itomAMBS IN PLC AL, LWN OF H LA.CKFIP_LD pLjNBACK TOHEALTH DEPART,74,EN VER "C3381YE SO IDS Ll.... ... .SOLID CARRYOVER, FLOODED OTHER EXPLAIN ay Pwnpo4 by .......... t-:vm rmns rKAN,4yw(Kfso ru s .,.`.y7i,�jj�.�ijl(}''�':���.Ll��i�:�?�`r�n�.���:'�,•,���t\r:nk,�},��,��,�y�1�^��,(r�t:;;�%; '::?•.. - ;,,��.�, ;:y. 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Y 1 o/'/,..;• H' raciilry lnfo M—atlon location; .. 400 f101 CI7/T a+ 6M n . Vii/ �• .jYtit, y ;, ,' i. �•J:.,'.,',� ,.l '. � y, •. , , ,; ftr,.�,rS��,'•i1;:72''' S �16m .".r. ,�' '�"1/.Odrµ�.(114Uftrtnl',rcvn,•bcaUon) �I" 1. � f:' •�'� . (: .. ... �' ['pumping Ragord 1. 081 o! Pum,pinp . 1. oil �' .. i r• .6C /� 3. TYpa o! eyslem;..'CD$00C C Ten,, —1 ,� �� :•Q %O;har (das•�ri �1 Is•,I Ter, o " Off. _ Emuen.l Too Flllo(,P�p�ent? [' Yv9 no ,r 89, n'B I; n `` ,.��:'i'i :(r1 s.;;, aj11" (�t{� ,; .• Y 9 C•'98 9Q? —D4.1 YeS . . . . . . . . . . . . Vi � '. �•, ;r%^��'�.'�fil� ��' 4 7Y ;'' '' �, � r � Jcon�i nuT:;er '�(1.''i ..,J,'.l'�.JVv4 1Y'�'{(',.�`�• 'll on. Where oor!lenla'ware dl9poseo: ,,•' ,,,�'- •�), :Ili;,. ,. \ C =:.'�•mess.gov/dep!weler/apprOvaJs/161orma.n��naL�s�ecc �tl� 1 0- T^ '