HomeMy WebLinkAboutMiscellaneous - 83 LOST POND LANE 4/30/2018I 0 " c ,y -•Fr� a, . � -.. r t�r,+as. Yr r, t:K — ._L:—;:.ry�.�. � . `'t' 4�"^'; d�'"a' wC _ '�i �i ti ' _ ry, , .• t }..+s '�i tt,`:w �rY� r^ a- ' 1 y- 46?�.°,�'���,1 �`�y*�'iY'`�C��+���J,�'I. .. c C ff r -�, '" k �W, <t'�Ki7l' �l; �f j�r:• n �: .i�y�ic- r .�151..'�r, t , .. ... - t' ' 9a 'Y�1'fi ; k'• 1r� ' of t'�!' a : a s 4 �,. # MAP - 1` < S ,,..:,� , �� LOT# PARCEL # ...`. STREET - HAS PLAN REVIEW FEE .13EEN PAID? YES NO PLAN APPROVAL: DATE ��`/�- APP. BY DESIGNER: PLAN DATE. CONDITIONS WATER SUPPLY: TOWN WELL -PERMIT WELL TESTS: COMMENTS: CHEMICAL WELL DRILLER---.-__-_-____ DAZE APPROVED BRO IA I DA 1 E (1PPROVED BACTERIA II DATE APPROVED FORM U APPROVAL: APPROVAL TO ISSUE YES NU DATE ISSUEDT'/ / � 4L„ BY CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NU SEPTIC SYSTEM CONSTRUCTION APPROVAL CffV NO OTHER YES NU ANY VARIANCE NEEDED FINAL BOARD OF HEALTH APPROVAL: YES NO • t L r • _.'\f. T-. j-. — ia. T A I ; .. \_i•+ ••��,: ,.1 -:,i .. 7.• 1.��f11. x IS THE -INSTALLER LICENSED? ' + �+ YE5 - NO `TYPE OF CONSTRUCTION: NE REPAIR > — r MNEW'CONSTRUCTION: ,.... CERTIFIED PLOT PLAN REVIEW NO CONDITIONS OF:.APPROVAL YES NO (FROM FORM U) ` r `ISSUANCE OF DWC PERMIT YES NO DWC PERMIT N0. y.� INSTALLER: ..: : BEGIN .INSPECTION .' YES 0: ' EXCAVATION. INSPECTION: ;NEEDED: 7.1 t ''PASSED ... ��• .. ': •HY CONSTRUCTION INSPECTION: := NEEDEDt = //i, � ' AS BUILT KLAN SATISFACTORY: YES: . DATE: BY APPROVAL TO BACKFILL: " FINAL•GRADING APPROVAL: DATE r ALLBY sC/ C31 � O Llj w�j 78 76 14 Ld lb Q 1 O Q)oElbol° O^ c (b c c v, o c� Q co o ` o Zm 3 OR U O�ONNL-C) N >� 00 � Ln Q) N .;� ') "q- Q) 00 Do o ��6�6�6(-o�D4� cooi O`- 00� n03 Q) N-1114- 0000 � II � fl II ii II II II QU �U IQ Q) a' U � II II it II II II II 00� i O J c I Q� � Q Q o o o 25'® p tt` . C - - - - �Zl L Lo i � \ � � `-� SIJ • � C s� c Lf) -c-- � o � v O N `r. Fu -E# N- And 8d i a AUG 14 201Z TOWN OF NORTH ANDOVER HEALTH DEPARTMENT T= V INSPE`.1.0 ONS Dean G. Luscomb H & Sons P.O. Box 135 Middleton, Mei 01949 978-774-4065 Licensed Plumber #20285 SUBSURFACE SEWAGE DISPOSAL SYSTEM FNPSECTION FORM PROPERTY OWNERS NAME Ann- He n _ L L a L PROPERTY ADDRESS ne. N. ndQVe r 1v1A ADDRESS OF OWNER(I€ffiff=at) S Q DATE OF INSPECTION I A S -f of SA Q 1 o - NAME OF INSPECTOP, 'r) � l,(SC O QUALITY IS NUMBER ONE TO US. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 83 Lost Pond Lane Property Address Madden 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. Owner's Name North Andover City/Town MA August 2, 2012 State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Dean G. Luscomb II Name of Inspector Dean G. Luscomb II & Sons Company Name P.O. Box 135 Company Address Middleton MA Citylrown State 978-774-4065 S1848 Telephone Number B. Certification License Number 01949 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority ti Signature Date st 2. 2012 The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 of 17 Owner information is required for every page. �j Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Lost Pond Lane Property Address Madden Owner's Name North Andover MA August 2, 2012 City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: ChecIgB,C,D or E / always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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. JO 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Lost Pond Lane Property Address Madden Owner Owner's Name information is North Andover MA August 2, 2012 required for g every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ 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 salt marsh t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Lost Pond Lane Property Address Madden Owner Owners Name information is North Andover MA August 2 2012 required for g every page. 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: 0 ** 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: t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or ❑ ® clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Lost Pond Lane Property Address Madden Owner Owner's Name information is North Andover MA August 2, 2012 required for g every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) (� Yes No v ❑ ® 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 sys s, you must indicate either "yes" or "no" to each of the following, in addit on to the questions in Sectio Yes No ❑ ❑ the system is wi 1 400 feet of a surface i ing water supply ❑ ❑ the system is within 200 fe f utary to a surface drinking water supply ❑ ❑ the system is located in rogen s itive area (Interim Wellhead Protection Area — IWPA) or a ped Zone II of a p 'c water supply well If you have answered "yes" to an estion in Section E the system is idered a significant threat, or answered "yes" in Section above the large system has failed. The own r operator of any large system considered a si ' cant threat under Section E or failed under Section all upgrade the system in accordan ith 310 CMR 15.304. The system owner should contact the ropriate regional office a Department. t5ins • 11/10 / Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 0 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Lost Pond Lane Property Address Madden Owners Name North Andover MA August 2, 2012 City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 gpd a ')q n t t r 660 7, P, -e t5ins • 11110 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^M 83 Lost Pond Lane Property Address Madden Owner information is required for every page. Owner's Name North Andover City[Town D. System Information Description: Owner and town State Zip Code August 2, 2012 Date of Inspection Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): E Detail: �o A 2 �7 ga� hel �f Sump pump? Last date of occupancy: Commercial/industrial Flow Conditions: Type of lishment: Design flow (based on 0 CMR 15.203): Basis of design flow (seats/person .ft., etc.): Grease trap present? Industrial waste holding Non-sanita to discharged to the Title 5 system? ter meter readings, if available: Gallons per day ❑ Yes ® No ❑ Yes ® No ❑ Yes ® No ❑ Yes ® No town water 41 A ❑ Yes ® No Current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal Syst rn,-_Page 7 of 17 Commonwealth of Massachusetts f Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Lost Pond Lane Property Address Madden Owner Owner's Name information is North Andover MA required for every page. City/Town State Zip Code D. System Information (cont.) Las f occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Date August 2, 2012 Date of Inspection Pumped every 1-2 yrs - owner gallons No need at this time Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy 7010MI1110. ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 83 Lost Pond Lane Property Address Madden Owner information is required for every page. Owner's Name North Andover MA August 2, 2012 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: System was installed in 1996, 16 yrs old - owner and town Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): 39" feet Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Main line and joints are in very good condition with no signs of any problems. Septic Tank (locate on site plan): Depth below grade: / Material of construction: 29" feet ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) Precast rectangular concrete 1500 gallons If tank is ;:list : - yearsIs comed a Certificate of Compliance? (attach �Copy ofcertificate) ��o Dimensions: 5'Dx5'Wx10'L /f00 Sludge depth: 1" t5ins • 11/10 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 9 of 17 Owner information is required for every page. el t5ins • 11/10 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Lost Pond Lane Property Address Madden Owner's Name North Andover MA August 2, 2012 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 34" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? sticks and 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.): The septic tank and baffles are in very good condition. The solids in the tank are very light. The liquid in the tank is running at it's correct working heigth. The tank does not require pumping at this time. Trap (locate on site plan): Depth be rade: Material of construc ❑ concrete ❑ metal Dimensions: Scum thickness ❑ fiberglass Distance from top of scum to of outlet tee or baffle Distance from b�otto of scum to bottom of outlet tee or baffle Date of las " U1 I 1101"%4o Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 feet ME. other (explain): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Lost Pond Lane Property Address Madden Owner Owner's Name information is required for North Andover MA August 2, 2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Commen�rela ecommendations, inlet and outlet tee or baffle condition, structural liquid levutlet invert, evidence of leakage, etc.): ✓-" Nf Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): D ptly below grade: Material o`F,,c ❑ concrete Dimensions: Capacity: Design Flow: Alarm present: Alarm level: Date of last pumping: Comments (condition ❑ metal ❑ fiberglass ❑ polyethyyjerlie ❑ other (explain): gallons per day ❑ Yes ❑ No .Alarm in working order: / Date rm and float switches, etc.): ❑ Yes ❑ No * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Lost Pond Lane Property Address Madden Owner's Name North Andover MA August 2, 2012 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 Zero " 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.): The d -box is 44" below grade and is 16" x 16" square. it is structually sound and level. The liquid in the d -box is running at it's correct working heigth. The soil in this area is clean and dry with no signs of anv problems. Chamber (locate on site plan): Pumps in worrder: Alarms in working order: Comments (note condition of pump chamber, ❑ Yes ❑ No ❑ No ps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: S.A.S. was located by d -box and level area of yard and asbuilt drawi t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 83 Lost Pond Lane Property Address Madden Owner information is required for every page. t5ins • 11/10 Owner's Name North Andover MA August 2, 2012 City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: 5 ❑ leaching pits number: j❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 3 - 50' long ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The S.A.S. is in very good condition with no signs of any problems. The soil in this area is clean with no signs of ponding or breakout This area is covered with well maintained green grass. (cesspool must be pumped as part of inspection) (locate on site plan): Number and c u�Ion Depth — top of liquid Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of ruction In ' ation of groundwater inflow ❑ Yes ❑ Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Lost Pond Lane Property Address Madden Owner Owner's Name information is North Andover MA August 2, 2012 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)-. (locate on site plan): U Materials of Dimensions Depth of solids Comments (notdition of soil, signs of etc.): lic failure, level of ponding, condition of vegetation, t5ins - 11/10 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 For Subsurface Sewage Disposal SysVm Form - Not for Volunt Assessments 83 Lost Pond Lane Property Address 4�. U / Madden Owner's Name North Andover City/Town V nnn State Zip Code August 2, 2012 Date of Inspection D. System Informatio cont.) Sketch Of Sewage Di osal System: Provide a view of the sewage disposal system, including ties to at least two perma nt reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public r supply enters the building. Check one of the boxes below: O'hand-sketch in the area below ❑ drawing attached separately 3�(c a� �� 4owre, -2,3 P,,nd Q /U. R,�/d✓!/%lila c-•.t�y R ty lytt tri D;-'101 t5ins • 11/10 /, Po��� Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Lost Pond Lane Property Address Madden Owner Owner's Name information is required for North Andover MA August 2, 2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: / L_ ®Check Slope ,[�( �V "' / ® Surface water / Sf I�O�U 2-4 & �- ® Check cellar AA 54Ar p pµry�p ® Shallow wells K__ -b Ne_. Estimated depth to high ground water: 11.5' below grade 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. 5-14-93 & 4-25-95 Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Proposed asbuilt and permit on file ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database - explain: You must describe how you established the high ground water elevation: Deep hole test done 5-14-93 and 4-25-95 showed no ground water at 138" below grade and 140" below grade. The basement is 8' below the grade of the front yard where the system is located, with no water and no sump pump. Lost Pond sits to the far back of the property and is 24' below the grade of the front yard where the septic system is located. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 83 Lost Pond Lane Property Address Madden Owner Owner's Name information is g required for North Andover MA August 2, 2012 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist �f Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 08/0612012, 09:12 9786889573 WATER SEWER DEPT summery Roeotd Card generated an 816/2012 0:51;07 AM by Maureen McAuley Town of North Andover Tax Map # 210-104.B-0218-0000.0 Parcel Id 16537 83 LAST POND LANE MADDEN, ANNE 83 LOST POND LANE NORTH ANDOVER, MA 01845 Class 101 Single Family Zoning2 1 Residential Size Total 0.72 Acres FY 2013 UB MallincOndex Namo/Address MADDEN, ANNE 83 LOST POND LANE NORTH ANDOVER, MA 01845 UB Account Maint Account No cycle Bldg Id, 18001.0 - 83 LOST POND LANE 3180030 03 Cycle 03 UB Services Maint Account No, 3180030 Service code MISCFEE ADMIN FEE WTR WATER UB >Meter Maintenance Property Type ,Zoning3 Type Loan Number Activellnact. From Payor Occupant Name Active/Inactive Last Billing Date 7/9/2012 Active Rate Charge Multlpller/Users 0.635/8 7,82 11 01 ALL METER SIZE 153.70 11 Account No. 3180030 YTD Cons 0.63 0.63 621 Serial No Status Location Brand Typo 13242547 A Active .gg% 78% 00 METE METE w Water Bate Reading Code Consumption Posted Date 6/18/2012 1238 a Actual 34 7/16/2012 3/20/2012 1204 a Actual 22 4/14/2012 12119/2011 1182 a Actual 26 1/17/2012 9/16/2011 1156 a Actual 60 10/13/2011 8/13/2011 1096 a Actual 32 7/20/2011 3/1512011 1064 a Actual 20 4/13/2011 12/15/2010 1044 a Actual 29 1/12/2011 9118/2010 1015 a Actual 80 10/15/2010 6/14/2010 935 a Actual 33 7/15/2010 3/18/2010 902 a Actual 21 4/14/2010 12/14/2009 881 a Actual 27 1 /1 PJ2010 9/16/2009 854 a Actual 48 10/15/2009 611 a Actual 3/17/2009 771 a Actual 23 4/29/2009 12/15/2008 748 a Actual 28 1/20/2008 9/16/2008 720 a Actual 65 10/10/2008 6/10/2008 655 a Actual 38 7/16/2008 3/14/2008 617 aActual 22 4/11/2008 12/17/2007 595 a Actual 32 1/22/2008 9/14/2007 563 a Actual 79 10/12/2007 6/20/2007 484 a Actual 49 7120/2007 3/16/2007 435 a Actual 12 4/16/2007 12/13/2006 423 m Manual estimate 30 1/19/2007 MSG 9/19/2006 393 a Actual 72 10/20/2006 6/20/2006 321 a Actual 25 7/1012006 3/20/2006 296 a Actual 19 4717/2006 1/3/2006 277 a Actual 31 1/17/2006 9/15/2005 246 a Actual 59 10/14/2005 6/14/2005 187 a Actual 37 7/15/2005 PAGE 01/02 page 1 1 Residentlal 1 Residential Until Size YTD Cons 0.63 0.63 621 Variance 58% -14% .gg% 78% 31 1 .l J 60% -62% 168 e /o -26% -38% 19°k 65% -20% -53% 54% 73% -27% -63% 80% 296% -63% -55% 191% 9% -11% -58% 42% 90% COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 t%q 1 8 2003 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: _83 Lost Pond Lane_ _North Andover_ O Owner's Name: _Anne Madden_ Owner's Address: _83 Lost Pond Lane_ North Andover Cd Date of Inspection: 4/10/2003 Name of Inspector: Neil J. Bateson Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, Ma. 01810_ Telephone Number: _( 978 ) 475-4786 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority d"Fai Inspector's Signature: Date: _4/10/2003_ The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 83 Lost Pond Lane _North Andover— Owner: Madden Date of Inspection: 4/10/2003_ Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _83 Lost Pond Lane_ _North Andover— Owner: Madden Date of Inspection: 4/10/2003_ C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _83 Lost Pond Lane_ _North Andover— Owner: Madden Date of Inspection: 4/10/2003_ D. System Failure Criteria applicable to all systems: You must indicate "yes" or `%o" to each of the following for all inspections: Yes No _ No— Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _No_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ _No_ Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow _No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ _No_ Any portion of the SAS, cesspool or privy is below high ground water elevation. _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _ _No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either "yes" or "no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone 11 of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 83 Lost Pond Lane_ _North Andover— Owner: Madden Date of inspection: 4/10/2003_ Check if the following have been done. You mast indicate "yes" or "no" as to each of the following: Yes No Yes _ Pumping information was provided by the owner, occupant, or Board of Health No Were any of the system components pumped out in the previous two weeks ? Yes _ Has the system received normal flows in the previous two week period ? No_ Have large volumes of water been introduced to the system recently or as part of this inspection ? Yes_ _ Were as built plans of the system obtained and examined? (If they were not available note as N/A) Yes Was the facility or dwelling inspected for signs of sewage back up ? Yes _ Was the site inspected for signs of break out ? Yes_ _ Were all system components, excluding the SAS, located on site ? _Yes_ _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? _Yes_ _ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no _Yes _ Existing information. For example, a plan at the Board of Health. _No_ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: _83 Lost Pond Lane_ North Andover — Owner: Madden Date of Inspection: _4/10/2003_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): _4 4 — Number of bedrooms (actual): __ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): _660 Number of current residents: _3 Does residence have a garbage grinder (yes or no): _No Is laundry on a separate sewage system (yes or no): No_ [if yes separate inspection required] Laundry system inspected (yes or no): — Seasonal use: (yes or no): _No Water meter readings: Yes_ Sump pump (yes or no): _No_ Last date of occupancy: _Current COMMERCIALIMUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgft,etc.): Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): Non -sanitary waste discharged to the Title 5 system (yes or no): _ Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: _Pumped two years ago, owner_ Was system pumped as part of the inspection (yes or no): Yes_ If yes, volume pumped: _1500_ allons -- How was quantity pumped determined? _Measured tank_ Reason for pumping: _Inspect tank & tees TYPE OF SYSTEM X Septic tank, distribution box, soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ hmovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) — Tight tank _ Attach a copy of the DEP approval — Other (describe): Approximate age of all components, date installed (if known) and source of information: 7 years old. 7/17/1996. As built plan. Were sewage odors detected when arriving at the site (yes or no): _No Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 83 Lost Pond Lane_ _North Andover_ Owner: Madden Date of inspection: 4110/2003_ BUILDING SEWER (locate on site plan) X Depth below grade: _4'_ Materials of construction: _cast iron _X_40 PVC other (explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: X locate on site plan) Depth below grade: _3'_ Material of construction: —X—concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) Dimensions: 10' x 5' x 4' Sludge depth —6" _ Distance from top of sludge to bottom of outlet tee or baffle: 21"_ 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: _15"_ How were dimensions determined: Subtract scum & sludge depth to tee length. _ 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. No inlet tee or baffle. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. GREASE TRAP: _(locate on site plan) Depth below grade: _ Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _83 Lost Pond Lane _North Andover— Owner: Madden Date of Inspection: 4/10/2003_ TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: _X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: _0_ Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): _D -Box level & distribution equal. No evidence of leakage. Evidence of carryover. Pumped d -box to clean. PUMP CHAMBER: (locate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 83 Lost Pond Lane _ _North Andover— Owner: _Madden Date of Inspection: 4/10/2003_ SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ teaching chambers, number: leaching galleries, number: X leaching trenches, number, length: 3 trenches 50' long_ leaching fields, number, dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): —Soil ok. Vegetation ok. No sign of ponding to surface. CESSPOOLS: (cesspool must be pumped as part of in spectionxlocate on site plan) Number and configuration: Depth — top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): . Page 10 of 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _83 Lost Pond Lane_ _North Andover— Owner: Madden Date of Inspection: 4/10/2003_ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A to Tank = 4717" A to D -Box = 49'9" B to Tank = 28' B to D -Box = 32'8" Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 83 Lost Pond Lane_ _North Andover_ Owner: Madden Date of Inspection: _4/10/2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 4 feet Please indicate (check) all methods used to determine the high ground water elevation: X Obtained from system design plans on record - If checked, date of design plan reviewed: _4/25/1995 _ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked with local excavators, installers- (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: As per design plan_ 04/09/03 WED 14:37 FAX 978 688 9573 NORTH ANDOVER DPW IRI001 f% -r� ... 00 dr Lm F . ....... 0 Pa qG LA .7 Z c Cot 6-1 LA . r- 10LI1 0 jr ca T- co .7 cc Lm 1% 0 42 0 CC VI .OWC2 0 Ln V� CC Co 19tit SP. ol- I- CM CY �Al ul 0 0 a M LA Lm N r. 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Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 83 Lost Pond Lane, North Andover Owner: Madden Date of Inspection: 4/10/2003 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Neil J. 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This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION (D APPLICAN>014"110,0 o 117 6PHONE 79) - Ut -� 776,a LOCATION: Assessor's Map Number q E> PARCEL SUBDIVISION LOT (S) STREET_ �C v�'i o :� 1\ Ldp t �T. NUMBER ************************************®FFICIAL USE 1 it !� UMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR COMMENTS DATE APPROVED DATE REJECTED TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR -HEALTH !/ SEPTIC INSPECTOR -HEALTH ` COMMENTS ke e DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT M ez: % r q bL, .A_0 RECEIVED BY BUILDING INSPECTOR DATE Revised 9\97 jm Feb 20 03 01.0Gp t Hlackdog Builders MAYGH 51DING . AND GXPOW;ZE �', ;P1 6038990821 p.3 =1111 t■t MIrL � G,TP gHC GLP I 1 I — -- f — --r— j� I �?� .� aEv __.-- _ a 1 .. —-- —--^_ i v�i I � j I I I --- V I ----- 1171 4 I I .. 1•I�� � /i Feb 20 03 Ql i 06p Blackdos' Builders pop venom OIMENSION5 D_V5TlrD PER MAIN r- 50 T►fAT N1=1N WALLS / MAIN FLOOR WALLS 6838880821 X W-5- I PELLA #:M3 { EX -j- 5LIOER j R.O. 3'-I 314"IX 4'-5 3/4" ` 'N---,,-FRAMIc TILE F-A"LY (BOOM GNLIN& HO(54T 2X4 FURRED — C71, W' -/-) Q1A5F�NT WALL CQOPPW rztj!,7w RED �iM W-2' v t- FZ_ °NT OR (ENT Srvli.0 1 :El v,V b it ,'C. .c F; Town of North Andover NORTk Office of the Health Department Community Development and Services Division _ 27 Charles Street +oZ. North Andover, Massachusetts 01845 Fti Sandra Starr Health Director March 31, 2003 Mr. and Mrs. Madden 83 Lost Pond Lane North Andover, MA 01845 Re: Application for an addition to an existing home Dear Mr. and Mrs. Madden: Telephone (978) 688-9540 Fax (978) 688-9542 Your application for an addition at 83 Lost Pond Lane has been reviewed by the Health Department. The application was denied on March 31, 2003 for the following reasons: 1. ✓ Missing information 2. ✓ Passing Title 5 inspection of septic system may be required 3. Location of structure not acceptable To address the problem(s): If #1 is checked, please supply: a. Floor plan of the existing dwelling including the back porch or sunroom. All rooms must be accurately named; b. Certified plot plan showing house, septic system and proposed project in scale, including any associate grading. If #2 is checked: a. Have the septic system inspected by a certified Title 5 inspector to determine the size of the system and whether it is operating properly: OR b. Tie-in to municipal sewer. If #3 is checked: a. The proposed the project must meet all current Title 5 setbacks. Please feel free to call the Health Office at 978-688-9540 with any questions you may have. Sinc el r ian J. LaGrasse, Hea th Inspector Cc: Building Department File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535 w FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approva[s/permits from Boards and Departments having jurisdiction have.been obtained. This oes not relieve the applicant and/or landowner from compliance with any applicable ori equirements. x *****************************AFFL.ICANT FILLS OUT THIS SFC T ION*********************** I APPLICANT _�ku� /�la�-i PHONE LOCATION: Assessors Map Number /Oy PARCEL Z/g SUBDIVISION LOT (S) STREET /OS% f%11�1/%%�,�/�� ST. NUMBER_�J ********************************OFFICIAL USE O N LY* **"y *i`*' ********* ****7" RECOMMENDATIONS OF TOWN AGENTS: CA, CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS {illi L��hn�5 g re SrOr� f��UliOsc� �p�`ti 1 PLANNER COMMENTS FOOD INSPECTOR -HEALTH o SEPTIC INSPECTOR -HEALTH COMMENTS DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING iNSPECTOR DATE Revised 9197 jm CERTIFIED PLOT PLAN LOCATED IN NORTH ANDOVER, MASS. SCALE. -I"=40' DATE: 8/24/99 Scott L. Giles R. P. L. S. Frank. S_ Giles 50 Deer Meadow Road North Andover, Mass. I CERTIFY THAT OFFSETS SHOWN ARE FOR THE USE THE OFFSETS OF THE BUILDING INSPECTOR ONLY SHOWN COMPLY AND SUCH USE IS FOR THE WITH THE ZONING DETERMINATION OF ZONING BYLAWS OF CONFORMITY OR NON -CONFORMITY NORTH ANDOVER WHEN BUNT WHEN CONSTRUCTED. _- I 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 out this section***************** APPLI CANT : �l IN C Phone LOCATION: Assessor's Man Number `� Parcel/9c'%F/Z/S ?3r/ T - - -- Subdivision G Lots) Street 6 57 Z- St. Number 83 ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Date Approved Conservation Administrator Date Rejected Comments 10) «u-bk- Town Planner Comments Food Ins a tor -Health ep c nspector-Health Comments Date Approved Date Rejected Date Approved Date Rejected Date Approved / Date Rejected Public Works - sewer/water connections_ - driveway permit -, 77 -c -t) LO -?S " Fire Department "C-�f�— Received by Building Inspector Date THOMAS E. NEVE ASSOCIATES, INC. Engineers . Lend Surveyors . Land Use Planners 447 Boston Street US Route 1 TOPSFIELD, MASSACHUSETTS 01983 (508) 887-8586 FAX (508) 887-3480 TO Sandy Starr, R.S., C.H.O. Board of Health North Andover, MA WE ARE SENDING YOU (Attached ❑ Shop Drawings ❑ Copy of Letter LETTER OF TRANSMITTAL DATE 9/29/95 JOB NO. 1276— 10 ATTENTION Sandy Starr RE: Lot 10 — Lost Pond Lane ANDOVER/ MALI rl 1995 �3 t � t_s ❑ Under separate cover via [j Prints ❑ Plans ❑ Samples ❑ Change order ❑ following items: ❑ Specifications COPIES DATE Revised 9126195 NO. 1276-10 DESCRIPTION Sonitory Disposal System for Lot 10 Lost Pond Lone P e or d gy Thomas E. Neve Associates, Inc. '4 THESE ARE TRANSMITTED as checked below: ❑ For Approval ❑ Approved as submitted Jj Resubmit 4 copies for approval ❑ For your use ❑ Approved as noted ❑ Submit copies for distribution ❑ As requested ❑ Returned for corrections ❑ Return corrected prints ❑ For review and comment ❑ FOR BIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS Dear Sondy• Please find enclosed 4 prints of a revised septic design for Lot 10 Lost Pond Lane The revised system has been designed to accommodate the provisions as; stated in the new Title V. The previously submitted design for this lot was designed under the old code. If you should have any concerns or questions please do not hesistate to Coll us_ Thank you, in advance, for your time in reviewing this matter. COPY TO David Kindred SIGNED Steven Saraceno, E.l. T. Engineer In Training PLAN REVIEW CHECKLIST ��// ADDRESS Il -e7- /,Q�os�-�oyD 4649- ENGINEER X,!5:- � GENERAL 3 COPIES STAMP LOCUS NORTH ARROW SCALE CONTOURS Ll-' PROFILE SECTION �-� BENCHMARK ZI SOIL & PERCS ELEVATIONS WETS. DISCLAIMER WELLS & WETS J WATERSHED? DRIVEWAY Elev) WATER LINE L/ FDN DRAIN SCH40 c -/ TESTS CURRENT? SOIL EVAL '5, i� U,251j /S . STF9,ee SEPTIC TANK MIN 150OG .17 INVERT DROP GARB. GRINDER(+200% EDF) 25' TO CELLAR-'� MANHOLE ELEV GW # COMPS. - D -BOX SIZE # LINES 3 FIRST 2' LEVEL STATEMENT INLET/&, OUTLET = - A0 ( 2 " OR .17 FT) TEE REQ' D?_ LEACHING MIN 660 GPD? L----- RESERVE AREA Z--- 4' FROM PRIMARY?y 2% SLOPE 100' TO WETLANDS 6f- 100' TO WELLS4' TO S.H.GW (51>2M/IN) 35' TO F_ND-&--IWTRGRT$-DRAINS C---' 325' TO SURFACE H2O SUPP `-- 4' PERM. SOIL BELOW FACILITY � MIN 12" COVER I--� FILL? (25' if above natural elev; 10'if below) BREAKOUT MET? TRENCHES MIN 660 gpd SLOPE (min .005 or 6"/100') L------SIDEWALL DIST. 3X EFF. W OR D (MIN 6') L--- RESERVE BETWEEN TRENCHES?? IN FILL?- MUST BE 10' MIN. ---- 4" PEA STONE? [""' VENT? (>3' COVER; LINES >501) BOT JS'�'- + SIDE (L x W x #) Copyright 0 1995 by S.L. Starr c3C� (DxLx2x#) e"I X LDNG i �'c d = TOT 60'&,� (G/ft2) �- -= MAS E. NEVE ASSOCIATES, INC. sneers • Land Surveyors • Land Use Planners 447 Boston Street US #1 TOPSFIELD, MASSACHUSETTS 01983 (508) 887-8586 FAX (508) 887-3480 0��-A1.�C>Lpt i•�os=T1-� AM float E1z MR. WE ARE SENDING YOU AAttached ❑ Under separate cover via ❑ Shop drawings D( Prints ❑ Plans ❑ Copy of letter ❑ Change order ❑ 11R44EQ @IF MM"M0�411 DATE�12 1 1t 11 JOB NO. 12-1 b - l ATTENTIO,N.rcw, RE: Vi/7F��f�i � :��J � � �►NG L.n'r 11 — LOST PCM -1V l-At�sE 1�.Y ISE+b4 o z 915P12'T�- to ►'CAibf C7 ► rpt:., SK z_ S -r _-m F L-4 "-r t o,%C..O ST Pay D I ANfc Pv'C Pv etc 04-c�m45 'e • t- . pa ssD u Parres 1 %-�. 4 the following items: ❑ Samples ❑ Specifications COPIES DATE NO. DESCRIPTION 1�.Y ISE+b4 o z 915P12'T�- to ►'CAibf C7 ► rpt:., SK z_ S -r _-m F L-4 "-r t o,%C..O ST Pay D I ANfc Pv'C Pv etc 04-c�m45 'e • t- . pa ssD u Parres 1 %-�. 4 t� s lk sY o tSPA- IM-re:PA Ftrv- c -o-r I% u=s -r Ft�t-fl L_Pw-vr,_- THESE ARE TRANSMITTED as checked below: ❑ For approval ❑ Approved as submitted Resubmit 8 copies for approval ❑ For your use ❑ Approved as noted ❑ Submit copies for distribution ❑ As requested ❑ Returned for corrections ❑ Return corrected prints ❑ For review and comment ❑ ❑ FORBIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS C'9:40z- S P*-1V`t t PISA SE % t.-► b 45j"C.►. y,,t= fl Fu• -i 1_ (4) Pe-%t.3-rs o; -t-Hr_ 21E v 1 SIEt� SEP'Tt L G� S%C=111-4 VorL. LCxC t c . -IV} _' eCa r_t_Ec-T5 TE}+L co¢.���'t' r-oc�-c►cam rtjc�--Tr_ oma' c2 T%L"A,� A" -r Q es _G . At- --C>, PL-(--- - �i � � Es-� SASE � ►¢- t4-� Pet srS of-' t..c'T I% . 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