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Miscellaneous - 83 PENNI LANE 4/30/2018 (2)
I E f North Andover Board r '.ors Public Access Page 1 of 1 w f ,10RTot O +��ao a• �O �+Sy+Os�no .At,�9 .SgACMU Click Seal To Return Search for Parcels Search for Sales Summary Residence Detached Structure Condo Commercial roperty Record Card Location: 83 PENNI LANE Owner Name: TRIMBLE, WALTER J LINDA M TRIMBLE Owner Address: 83 PENNI LANE City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 7 - 7 Land Area: 1.10 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 2184 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 541,500 566,300 Building Value: 316,000 340,800 Land Value: 225,500 225,500 Market Land Value: 225,500 Chapter Land Value: http://csc-ma.us/PROPAPP/display.do?linkId=1466313&town=NandoverPubAcc 11/2/2009 • � V it i+f b HEALTW OEPA. RTME'NT city Development Division CYFRTI(FlCA Off' C0r1'.GIA9VCE As of: Novei.Inber 17, 2009 This is to certify that the iividual sukurface d4posa(system received a SA�IISFA 0RTl VSnC770Yof the: ft4wewnt of a Tankand Oistr 6ution Box Tor an Inarwdual'Sewage 0isposaCSystem By: Todd,Bateson t. 83 Venni .bane 9Vap-10Z (D farCel —TO 91ForthAndove 9 wA 01845 The Issuance of this certificate shaft not be construed as a guarantee that the system wiff function satisfactorify. c� Susan T Sawyer, R06A S Tu6CcWealth Director 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Commonwealth of Massachusetts Map -Block -Lot 1 07. D0070 --- ------- 0 Board of Health Permit No BHP -2009-0694 North Andover ----------------------- P.I. FEE F.I. $1 25 .00 DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd-B-ateson -------------------------- -------------------------------------------------------------- to (Repair -TANK & D -BOX ONLY) an Individual Sewage Disposal System. atNo-83-P-ENNI-LANE ----------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BBIR-2009-969. Dated ---Nove-mber-02-,-20-09 -COPY ------------------- I ssued On: Nov -02 -2009 ------ - F ILL F] ard of Health ";RT,H , Commonwealth of Massachusetts Map -Block -Lot 4� 107.DO070 ----------------------- Board of Health North Andover 0� CERTIFICATE OF COMPLIANCE THIS IS TO CERTIFYThat the Individual Sewage Disposal System (Repair -TANK & D -BOX ONL by... T-o-d-d—Bateson -------------------------------------------------------- ----------------------------------------------------------------------------- Installer atNo, 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. -BH-P-2009--069- _ Dated ... November 02, 2009 ----------------------- ----------------------------------------- Printed On: Nov -02-2009 Board of Health ---------------------------------------------------------------------------------- 4003 TH 0 I. , 'A Town of North Andover HEALTH DEPARTMENT S"CHUS CHECK I?ATE: LOCATION: H/0 NAME: ")ean CONTRACTORNA E: Type of Permit or License: (Check box) Massage Practice 0 Animal $ 0 Body Art Establishment $ 0 Body Art Practitioner $ 0 Dumpster $ 0 Food Service - Type: $ 0 Funeral Directors $ 0 Massage Establishment $ 0 Massage Practice $ 0 Offal (Septic) Hauler $ 0 Recreational Camp 0., Sun tanning 0 Swimming Pool $ 0 Tobacco $ 0 Tras4lSolid Waste Hauler $- 0 Well Construction $ SEPTIC Systems: 0 Septic - Soil Testing $ �D�Sepvtic sign Approval Sept! Disposal Works Construction (DWQ 0 Septic Disposal Works Installers (DWT) 0 Title 5 Inspector $ 0 Title 5 Report $ 0 Other (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return kkey.Q Application, foSeptic Disposal System /a - 3c Construction Permit -TOWN OF TODAYS DATE $40RTH ANDOVER MA 01845 $ 250.00 — Full Repair $125.00 - Component Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system* ❑ Re air or replace an existing on-site sewage disposal system* epair or replace an existing system component — What? 1,4,A - A. /4,A - A. Facility Information Address or Lot # Cityfrown O 4 . 0 C T 3 0 2009 2.- *TYPE OF TIC SYSTEM*:I HEALTH DEPARTMENT TOWN OF NORTH ANDOVER El Pump Gravity (choose one) ENT ***If ump system, attach copy of electrical permit to application*** onventional 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 Name Address (if different from above) A1.0 { /� CitylTown 3. Installer Information Name f f q -r14 L 0,q Address R o a/v Cityrrown 4. Designer Information Name Address Cityrrown 1*11!7- r D f rq,5-- State r Zip Code 17 5,47 P7 Telephone Number Name t F43N EN Y 7 [:_ PNC L' L c+` �. '+f Andover, po'A- ©-i 81 Q state �i Zip Cade Get l?0 8`�.27d-1 Telephone Number (Cell Phone # if possible please) Name of Company State Zip Code Telephone Number (Best # to Ready) Application for Disposal System Construction Permit • Page 1 of 2 s . Appiication"Jor Septic Disposal System Construction Permit - TOWN OF $40RTH ANDOVER, MA 01845 PAGE 2OF2 /o _ 3c)—o _q TODAY'S DATE $ 250.00 - Full Repair $125.00 - Component A.Eadility Information Conti ed.... 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 issued this Board of Health. /:57 7 Name Date Application Approved By: (Board of Health Representative) Name Date Application Disapproved for the following reasons: For Office Use Only: Z Fee Attached. Yes No 2. Project Manager Obligation Form Attached.; Yes No J. Pump Ssy tem? If so, Attach copy ofElectrrcal Permit Yes No 4. Foundation As -Built. (new construction ronly). Yes No (Same scale as approved plan) 5. Floor Plans? (new construction only): Yes No Application for Disposal System Construction Permit • Page 2 of 2 4 " . W • SEPTIG SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: f1 3 N tow-, t (Address of septic system) For plans by Relative to the application of ! d (Installer's name) And dated Dated a o ay s ate With revisioi I understand the following obligations for management of this project: 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans Prior to performing any work on a site. I must have the aper= oved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner, contractor, project manager, or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 3." As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Tide 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or my company a. Bottom of Bed — Generally, this is the. first (15) inspection unless. there is a retaining wall, which should be done.first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection — Engineer must first do their inspection for elevations, ties, etc. As -built of verbal OK (or e-mail to: healthdelt@townofnorthandover.com) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system, all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade — Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation) and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board ofHealth staffor consultant. d. Installation of tank, D -Box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer, I understand that I am solely responsible for the installation of the system as per the approved plans No instructions by the homeowner, general contractor, or any other persons shall absolve me of this oblation. Undersigned Licensed Septic Installer: 7 ame — not (Today's Date) e gn TOWN OF NORTH ANDOVER a� %&ORTH N Office of COMMUNITY DEVELOPMENT AND SERVICES 3 . 4' HEALTH. DEPARTMENT A 1600 OSGOOD STREET; Building 2-36 "� NORTH ANDOVER, MASSACHUSETTS 01845 "s3 ACHUSr"u 0'* � � Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION RM ION ADDRESS: �/�'/. /l �/� MAP: INSTALLER DESIGNER:? PLAN DATE: BOH APPROVAL DATE,O PLAN: INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: SEPTIC TANK LOT: ❑Existing septic tank properly abandoned ❑Internal plumbing all to one building sewer []Topography not appreciably altered ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading Monolithic construction ❑ Water tightness of tank has been achieved (Visual or Vacuum Test or Water. held for 24hrs) Inlet tee installed, centered under access port ❑ Outlet tee (gas baffle or effluent filter) installed, centered under access port ❑ 24" inch cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present ❑ Hydraulic cement around inlet & outlet Wastewater System Documentation — Feb 2006 Page 1 of 6 TOWN OF NORTH ANDOVER °4 �y°RTFJ q Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT «. 1600 OSGOOD STREET; Building 2-36 NORTH ANDOVER, MASSACHUSETTS 01845 �qs """° "•��te SACHUS .Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ Combo Tank installed. Size: ❑ 1000 gallon Pump Chamber installed H-10 loading Monolithic 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 ❑ 24" inch cover to within 6" of final grade installed over pump access port ❑ Water tightness of tank has been achieved Visual testing ❑ Hydraulic cement around inlet & outlet Comments: ADVANCED TREATMENT TECHNOLOGY ❑ Type of treatment device: Comments: ❑ Installed per manufacturers requirements ❑ All components working in accordance with manufacturer's requirements Wastewater System Documentation — Feb 2006 Page 2 of 6 TOWN OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT A «. 1600 OSGOOD STREET; Building 2-36 NORTH ANDOVER, MASSACHUSETTS 01845 "Ss CHUSeK`h Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476—.FAX D -BOX � 21/installed on stable stone base H Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets [observed even distribution Speed leveler provided (not required Comments: � kS SOIL ABSORPTION SYSTEM Comments: Bottom of SAS excavated down to soil layer, as providedon plan Size of SAS excavated as per plan Title 5 sand installed, if specified on plan 3/4-1 Y2" double washed stone installed 1/8-1/2" (peastone) double washed stone installed Laterals installed and ends connected to header Laterals vented if impervious material above Orifices @ 5 & 7 o'clock positions Gravel -less disposal systems: type, number and location as per plan Elevations of laterals installed as on approved plan 40 Mil HDPE barrier installed Retaining wall (boulder / concrete / timber/ block) Final cover as per plan Wastewater System Documentation — Feb 2006 Page 3 of 6 r 41 TOWN OF NORTH ANDOVER Nor+rk Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT p 1600 OSGOOD STREET; Building 2-36 NORTH ANDOVER, MASSACHUSETTS 01845 ACHUS Susan Y. Sawver, REHS/RS 978.688.9540 —Phone Public Health Director 978.688.8476 — FAX PRESSURE DISTRIBUTION El Comments: CONTROLPANEL Comments: -- inch manifold laterals installed with end sweeps size: material: Squirt test ft in height Equal distribution to all laterals orifice size inch as per plan ❑ Alarm & Pump are on separate circuits ❑ - Alarm sounds when float is tripped ❑ Location of control panel: ❑ Rated for exterior if placed outside Wastewater System Documentation — Feb 2006 Page 4 of 6 TOWN OF NORTH ANDOVER NORTH Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT ❑ J p 1600 OSGOOD STREET; Building 2-36 10 -- ❑ NORTH ANDOVER MASSACHUSETTS 01845 "SAC sgcHus Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX .CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Wastewater System Documentation — Feb 2006 . Page 5 of 6 Tank SAS Sewer ❑ Property line 10 10 -- ❑ Cellar wall 10 20 -- ❑ Inground pool 10 20 -- ❑ Slab foundation 10 10 -- ❑ Deck, on footings, etc 5 10 -- ❑ Waterline 10 10 101 ❑ Private drinking well 75 1002 50 ❑ Irrigation well 75 100 ❑ Surface Water 25 50 ❑ Bordering Vegetated Wetland , Salt Marsh, Inland / Coastal Banka 75 100 ❑ Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ❑ Trib. to surface water supply 325 325 ❑ Public well 400 400 ❑ Interim Wellhead Prot. Area ❑ Reservoirs 400 400 ❑ Drains (wat. supply/trib.) 50 100 ❑ Drains (intercept g.w.) 25 50 ❑ Drains (Other) Foundation 10 (5) 20 (10) ❑ Drywells 20 25 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Wastewater System Documentation — Feb 2006 . Page 5 of 6 TOWN OF NORTH ANDOVER f AORT►, Office of COMMUNITY DEVELOPMENT AND SERVICES °OZ. ° A HEALTH DEPARTMENT 1600 OSGOOD STREET; Building 2-36 NORTH ANDOVER, SMASSACHUSETTS 01845 ��qe rro �P��ty ACHUS Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX SYSTEM ELEVATIONS Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 HIGH Lateral 1 LOW Lateral 2 HIGH Lateral 2 LOW Lateral 3 HIGH Lateral 3 LOW Lateral 4 HIGH Lateral 4 LOW Lateral 5 HIGH Lateral 5 LOW INVERT ON DESIGN PLAN FIELD INVERT ELEV. Wastewater System Documentation — Feb 2006 Page 6 of 6 VAORT" Town of North Andover UV A I TU nVV A DTX4UVT SS CH CHECK#: LOCATION: H/O NAME: CONTRACT( 016 Type of Permit or License: (Check box) 0 Septic - Design Approval 0 Animal $ 0 Body Art Establishment $ 0 Body Art Practitioner $ 0 Dumpster $ 0 Food Service - Type. $ 0 Funeral Directors $ 11 Massage Establishment $- 0 Massage Practice $ 0 Offal (Septic) Hauler $ 0 Recreational Camp $ 0 Sun tanning $ 0 Swimming Pool $ 0 Tobacco $ 0 TrashlSolid Waste Hauler $- 0 Well Construction $ SEP77C Sustems: 0 Septic - Soil Testing $ 0 Septic - Design Approval $- 0 Septic Disposal Works Construction (DWQ $ 0 Septic Disposal Works Installers (DWl) $- 0 Title 5 Inspector $ 0 Title 5 Report $ Other Undicate)- Health Agent Initials White - Applicant . Yellow - Health Pink - Treasurer Q r TOWN OF NORTH ANDOVER NORTH ANDOVER, MASSACHUSETTS 01845 Permit Number 9—/ Date Issued //1O o2oo Expiration Date Jackie's Law Permit Ap Ii c tion �e Af Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended) THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Name of Applicant. ---- Phone Cell `o c� �7-.�1. Scr�✓ Street Address // r-, 67 7.r -- off- / 0 CiVrown MA ZIP Name of Excavator (if different from applicant) Street Address City/Town Name of Owner(s) of Property Street Address City/Town MA ZIP Phone Cell Phone Cell 97y G Ysr- 7'7� Description, location and purpose of proposed trench: Permit Fee Received NoYes Please describe the exact location of the proposed trench and its purpose (include a description of what is (or is intended) to be laid in proposed trench (eg; pipes/cable lines etc..) Please use reverse side If additional space is needed. Insurance Certificate #: HIP Officejet Pro L7500 All -in -One series Fax Log for Town Of North Andover Cle 9786889557 Nov 10 2009 2:35PM Last ' Transaction Date Time Type Station ID Duration Pages Result Nov 10 2:33PM Fax Sent 19784755451 1:24 5 OK s Name and Confect Information of Insurer: / C9 ae Policy Expiration Date: Dig Safe #: Name of Competent Person (as defined by520 CMR 7.02): Massachusetts Hoisting License # /� p 1'1;� a c7 License Grade: Expiration Date: -5 — BY SIGNING THIS FORM, THE APPLICANT; OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY THAT THEY ARE FAMILIAR WITH, OR, BEFORE COMMENCEMENT OF THE WORK, WILL BECOME FAMILIAR WITH, ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED, INCLUDING OSHA REGULATIONS, G.L. c. $2A, 520 CMR 7.00 et seq., AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR SUCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS AND WITH THE CONDITIONS SET FORTH BELOW, THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND THE EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER, AND ALSO, FOR THE DURATION OF CONSTRUCTION, AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WITH THE CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS GOVERING SUCH WORK. THE UNDERSIGNED APPLICANT, OWNER AND EXCAVATOR AGREE JOINTLY AND. SEVERALLY TO REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER, INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF THIS PERMIT, INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH, AND MEASURES TAKEN BY THE MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED NECESSARY BY THE MUNICIPALITY. THE UNDERSIGNED APPLICANT, OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY IAGENTS TO DEFEND, INDEMNIFY, AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF TS AND EMPLOYEES FROM ANY AND ALL LIABILITY, CAUSES OR ACTION, COSTS, AND EXPENSES RESULTING FROM OR ARISING OUT OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON .OR PROPERTY DURING THE WORK CONDUCTED UNDER THIS PERMIT. ;CAVATOR LIC SIGNATURE_ c ''® DATE �� 9 �— -NATURE (IF DIFFERENT) l DATE O NR'S Sit DIFFERENT) DATE:_ 21Page 0y, CONDITIONS AND REQUIREMENTS PURSUANT TO G.L.C.82A AND 520 CMR 7.00 et seq. (as amended) By signing the. application, the applicant understands and agrees to comply with the following: No trench may be excavated unless the requirements of sections 40 through 40D of chapter 82, and any accompanying regulations, have been met and this permit is invalid unless and until said requirements have been complied with by the excavator applying for the permit including, but not limited to, the establishment of a valid excavation number with the underground plant damage prevention system as ii, said system is defined in section 76D of chapter 164 (DIG SAFE); Trenches may pose a significant health and safety hazard. Pursuant to Section 1 of Chapter 82 of the General Laws, an excavator shall not leave any open trench unattended without first making every reasonable effort to eliminate any recognized safety hazard that may exist as a result of leaving said open trench unattended. Excavators should consult regulations promulgated by the Department of Public Safety in order to familiarize themselves with the recognized safety hazards associated with excavations and open trenches and the procedures required or recommended by said department in order to make every reasonable effort to. eliminate said safetyhazards which may include covering, iii. barricading or otherwise protecting open trenches from accidental entry, Persons engaging in any in any trenching operation shall familiarize themselves with the federal safety standards promulgated by the Occupational Safety and.Health Administration on excavations: 29 CFR iv. 1926.650 et.seq., entitled Subpart P "Excavations". Excavators engaging in any trenching operation who. utilize hoisting or other mechanical equipment subject to chapter 146 shall. only employ individuals licensed to operate said equipment by the Department of Public Safey pursuant to said chapter and this permit must be presented to said licensed operator before any excavation is commenced; V. By applying for, accepting and signing thispennit, the applicant hereby attests to the following: (1) that they have read and understands the regulations promulgated by the Department of Public Safety with regard to construction related excavations and trench safety.; (2) that he has .read and understands the federal safety standards promulgated by the Occupational Safety and Health Administration on excavations: 29 CMR 1926.650 et.seq., entitled Subpart P "Excavations" as well asany other municipality and {3) that he is aware of and has, with excavation requirements established by this muni regard to the proposed trench excavation on private property or proposed excavation of a city or town public way that forms the basis of the.permit application, complied with the requirements of sections 40- 40D of chapter 82A. vi. This permit shall be posted in plain view on the site of the trench. For additional information please visit the Department of Public Safety's website at www.maas. Q��dp 31Page Summary of Excavation and Trench Safety Regulation (520 CMR 14.00 et seq.) This summary was prepared by the Massachusetts Department of Public Safety pursuant to G.L.c.82A and does not include all requirements of the 520 CMR 14.00. To drew the full regulation and G.L.c.82A, go to www/mws.gov/dps Pursuant to M.G.L. c. 82, § 1, the Department of Public Safety, jointly with the Division of Occupational Safety, drafted regulations relative to trench safety. The regulation is codified in section 14.00 of title 520 of the Code of Massachusetts Regulations. The regulation requires all excavators to obtain a permit prior to the excavation of a trench made for a construction -related purpose on public or private land or rights-of-way. All municipalities must establish a local permitting authority for the purpose of issuing permits for trenches within their municipality. Trenches on land owned or controlled by a public (state) agency requires a permit to be issued by that public agency unless otherwise designated. In addition to the permitting requirements mandated by statute, the trench safety regulations require that all excavators, whether public or private, take specific precautions to protect the general public and prevent unauthorized access to unattended trenches. Accordingly, unattended trenches must be covered, barricaded or backfilled. Covers must be road plates at least W thick or equivalent; barricades must be fences at least 6' high with no openings greater than 4" between vertical supports; backfilling must be sufficient to eliminate the trench. Alternatively, excavators may choose to attend trenches at all times, for instance by hiring a police detail, security guard or other attendant who will be present during times when the trench will be unattended by the excavator. The regulations further provide that local permitting authorities, the Department of Public Safety, or the Division of Occupational Safety may order an immediate shutdown of a trench in the event of a death or serious injury; the failure to obtain a permit; or the failure to implement or effectively use adequate protections for the general public. The trench shall remain shutdown until re -inspected and authorized to re -open provided, however, the excavators shall have the right to appeal an immediate shutdown. Permitting authorities are further authorized to suspend or revoke a permit following a hearing. Excavators may also be subject to administrative fines issued by the Department of Public Safety for identified violations. Summary of 1926 CFR Subpart P -OSHA Excavation Standard This is a worker protection standard, and is designed to protect employees who are working inside a trench. This summary was prepared by the Massachusetts Division of Occupational Safety and not OSHA for informational purposes only and does not constitute an official interpretation by OSHA of their regulations, and may not include all aspects of the standard. For further information or a full copy of the standard go to MnE .osha. aov. Trench Definition per the OSHA standard: o An excavation made below the surface of the ground, narrow in relation to its length. o In general, the depth is greater than the width, but the width of the trench is not greater than fifteen feet. Protective Systems to prevent soil wall collapse are always required in trenches deeper than 5', and are also required in trenches less than 5' deep when the competent person determines that a hazard exists. Protection options include: o Shoring. Shoring must be used in accordance with the OSHA Excavation standard appendices, the equipment manufacturer's tabulated data, or designed by a registered professional engineer. o Shielding (Trench Boxes). Trench boxes must be used in accordance with the equipment manufacturer's tabulated data, or a registered professional engineer. o Sloping or Benching. In Type C soils (what is most typically encountered) the excavation must extend horizontally 1 %2 feet for every foot of trench depth on both sides, 1 foot for Type B soils, and % foot for Type A soils. o A registered professional engineer must design protective systems for all excavations greater than 20' in depth. continued 4 1 P a g e • Ladders must be used in trenches deeper than 41. o Ladders must be inside the trench with workers at all times, and located within 25' of unobstructed lateral travel for every worker in the trench. o Ladders must extend 3' above the top of the trench so workers can safely get onto and off of the ladder. • Inspections of every trench worksite are required: o Prior to the start of each shift, and again when there is a change in conditions such as a rainstorm. o Inspections must be conducted by the competent person (see below). • Competent Person(s) is: o CIpable (i&e trained and knowledgeable) in identifying existing and predictable hazards in the trench, and other working conditions which may pose a hazard to workers, and o Aufto-lized by management to take necessary corrective action to eliminate the hazards. Employees must be removedfrom hazardous areas until the hazard has been corrected. • Underground Utilities must be: o Identified prior to opening the excavation (e.g., contact Dig Safe). o Located by safe and acceptable means while excavating. o Protected, supported, or removed once exposed. • Spoils must be kept back a minimum of 2' from the edge of the trench. • Surface Encumbrances creating a hazard must be removed or supported to safeguard employees. Keep heavy equipment and heavy material as far back from the edge of the trench as possible, • Stability of Adjacent Structures: o Where the stability of adjacent structures is endangered by creation of the trench, they must be underpinned, braced; or otherwise supported. o Sidewalks, pavements, etc. shall not be undermined unless a support system or other method of protection_ is provided. • Protection from water accumulation hazards: o It is. not allowabWfor employees to work in trenches with accumulated water. If water control such as pumping is used to prevent water accumulation, this must be monitored by the competent person. o If the trench interrupts natural drainage of surface water, ditches, dikes or other -means must be used to prevent this Water from entering the excavation. . • Additional Requirements: o For mobile equipment operated near the edge of the trench, a warning system such as barricades or stop logs must be used. o Employees are not permitted to work underneath loads. Operators may not remain in vehicles being loaded unless vehicles are equipped with adequate protection as per 1926.601(b)(6). o Employees must wear high -visibility clothing in traffic work zones. o Air monitoring must be conducted in trenches deeper than 4' if the potential for a hazardous atmosphere exists. If a hazardous atmosphere is found to exist (e;g,, Oz <19.5% or >23.5%, 20% LEL; specific chemical hazard), adequate protections shall be taken such as ventilation of the space. o Walkways are required where employees must cross over.the trench. Walkways with guardrails must be provided for crossing over trenches > 6' deep. o Employees must be protected from loose rock or soil through protections such as scaling or protective barricades. 5 1 P a g e 412 5 Town of North Andover HEALTH DEPARTMENT CHECK DATE: LOCATION: /Tx-r� H/O NAME: CONTRACTOR NA , MEs_�aZ 1YRe of Permit or License: (Check box) 0 Animal $ 0 Body Art Establishment $ 0 Body Art Practitioner $ 0 Dumpster $ 0 Food Service - Type. $ 0 Funeral Directors $ 0 Massage Establishment $ 0 Massage Practice $ 0 Offal (Septic) Hauler $ 0 Recreational Camp $ 0 Sun tanning $ • Swimming Pool $ • Tobacco $ • TrashlSolid Waste Hauler • Well Construction SEPTIC Systems 0 Septic - Soil Testing $ 0 Septic -Design Approval 11 Septic Disposal Works Construction (DWQ 0 Septic Disposal Works Installers (DWI) 0 Ti le'5 Inspector $ Title 5 Report 11 Other (Indicate) 1 $ Hea Ith 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 v l� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage DisposaiZOtem Form - Not for Voluntary Asses; 83 Penni Lane Property Address Linda Trimble Owner's Name North Andover City/Town MA 01845 State Zip Code RECEIVED ants JUN 3 0 2009 FOWN OFNORTH ANDOVER HEALTH DEPARTMENT 6/18/2009 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 01810 State Zip Code SI15 License Number I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority P)ct- G 6/18/2009 Ins ct rs tignature 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 • 09/08 Title 5 ficial Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 e, 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 Penni Lane Property Address Linda Trimble Owner's Name North Andover Cityrrown B. Certification (cont.) MA 01845 6/18/2009 State Zip Code 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): Septic tank leaking t5ins • 09/08 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Penni Lane Property Address Linda Trimble Owner's Name North Andover Cityrrown B. Certification (cont.) B) System Conditionally Passes (cont.): MA 01845 6/18/2009 State Zip Code Date of Inspection ❑ 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 16.303(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 • 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 83 Penni Lane Property Address Linda Trimble Owner Owner's Name information is required for North Andover MA 01845 6/18/2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for 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: tank & d -box needs to be D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/Z day flow t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 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 Penni Lane Property Address Linda Trimble Owner's Name North Andover MA 01845 6/18/2009 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 the system is within 200 feet of a tributary to a surface drinking water supply 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 Area — IWPA) or a mapped Zone II of a public water supply well 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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 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 Penni Lane Property Address Linda Trimble Owner's Name North Andover MA 01845 6/18/2009 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): N/A Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): N/A t5ins - 09/08 Title 5 Official Inspection form: Subsurface Sewage Disposal System - Page 6 of 17 1 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Penni Lane D. System Information Description: Number of current residents: 6/18/2009 Date of Inspection Does residence have a garbage grinder? Property Address Yes Linda Trimble Owner Owner's Name information is required for North Andover MA 01845 every page. City/Town State Zip Code D. System Information Description: Number of current residents: 6/18/2009 Date of Inspection 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 ears usage d 9 ( y 9 (gP ))� Yes Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commerciallindustrial 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 - 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Date pumped 10 years ago 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Penni Lane Property Address Linda Trimble Owner Owner's Name information is required for North Andover MA 01845 6/18/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Date pumped 10 years ago 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M SVB,W 83 Penni Lane Property Address Linda Trimble Owner Owner's Name information is required for North Andover every page. Cityrrown D. System Information (cont.) State Zip Code 6/18/2009 Date of Inspection Approximate age of all components, date installed (if known) and source of information: Original Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 1 feet Material of construction: ® cast iron ® 40 PVC ❑ other (explain): — Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" Cast iron thru wall, 3" PVC in house, no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal ❑ Yes ® No inlet cover exposed, outlet cover 4" ❑ 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: Tx 5'x 4' Sludge depth: 2 ❑ Yes ❑ No t5ins - 09/08 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 83 Penni Lane Property Address Linda Trimble Owner Owner's Name information is required for North Andover MA 01845 every page. Cityrrown State Zip Code D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 28" 2„ 8e 15' 6/18/2009 Date of Inspection 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 baffle ok.Outlet baffle ok. Depth of liquid below outlet invert 4",evidence of leakage. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: t5ins - 09108 Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Penni Lane Property Address Linda Trimble Owner Owner's Name information is required for North Andover MA 01845 6/18/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: 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 • 09/08 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 83 Penni Lane Property Address Linda Trimble Owner Owner's Name information is required for North Andover MA 01845 6/18/2009 every page. Citylrown 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 -2" 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 & distibution equal. Evidence of leakage, liquid below inverts 2". Evidence of carryover. 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 M 83 Penni Lane Property Address Linda Trimble Owner Owner's Name information is required for North Andover every page. Cityrrown D. System Information (cont.) Type MA 01845 State Zip Code 6/18/2009 Date of Inspection ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 4 trenches 40' 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 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 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 Penni Lane Property Address Linda Trimble Owner information is required for every page. Owner's Name North Andover MA 01845 6/18/2009 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 - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17 s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Penni Lane Property Address Linda Trimble Owner Owner's Name information is required for North Andover MA 01845 6/18/2009 every page. Cityrrown State Zip Code Date of Inspection D. Sys�em 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 S�ep�,u Tawk � Iv 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 83 Penni Lane Property Address Linda Trimble Owner Owner's Name information is required for North Andover MA 01845 6/18/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground waters >6 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record b If checked, date of design plan reviewed: Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database - explain: Essex County Soil Map You must describe how you established the high ground water elevation: Essex County Soil Map, Sheet #36, Canton Soil, Water >6 'Deep 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 R i i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Penni Lane Owner information is required for every page. t5ins • 09108 Property Address Linda Trimble Owner's Name North Andover MA 01845 6/18/2009 Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 17 of 17 I ax map ;; ziu-7ui.u-uuiu-uuuu.0 Parcel Id 18606 83 PENNI LANE TRIMBLE, WALTER 83 PENN[ LANE N. ANDOVER, MA 01846 lass 101 Single Family Property Type 1 Residential ize Total 1.1 Acres Y 2009 IB Mailina Index ame/Address RIMBLE, WALTER 3 PENNI LANE .ANDOVER„MA. 1845 IB Account Maint. .ccount No Cycle Jdg Id. 13725.0 - 83 PENNI LANE 090403 01 Cycle 01 IB Services Maint. .ccount No. 1090403 ;ervice Code 11SCFEE ADMIN FEE VTR WATER 1B Meter Maintenance kccount No. 1090403 Type Loan Number Active/lnact. From Payor Occupant Name Active/lnactive Last Billing Date 5/1/2009 Active Rate Charge Multiplier/Users 0.635/8 7.82 1/ 01 ALL METER SIZE 13.56 11 teriat No Status Type Location ;2772741 a Active Consumption 00 Date. Reading Code 4/24/2009 71 a Actual' 1/23/2009 67 a Actual 10/22/2008 63 a Actual 7/22/2008 59 a Actual 4/23/2008 54 a Actual 1/28/2008 50 a Actual 10/24/2007 44 a Actual 7/20/2007 34 a Actual 4/19/2007 30 a Actual 1/29/2007 27 a Actual 10/25/2006 22 a Actual 7/282006 8 a Actual 5/2/2006 5 a Actual 1/24/2006 0 n New Meter 1/24/2006 2094 r Replacement 10/27/2005 2097 m Manual estimate MSG - ACTUAL SAYS 2089 7/262005 2097 a Actual Trouble Code:09 4222005 2074 a Actual 211/2005 2066 m Manual estimate MSG 10/272004 2061 a Actual 8/32004 2056 a Actual Trouble-Code:09 5/10/2004 2052 m Manual estimate Brand Type b.Badger w Water Consumption Posted Date 4 5/13/2009 4 2/10/2009 4 11/1212008 5 8/15/2008 4 5/19/2008 6 2/19/2008 10 11/16/2007 4 8/15/2007 3 5/21/2007 5 2/20/2007 14 11/16/2006 3 8/18/2006 5 5/162006 0 2/13/2006 -3 2/1312006 11/9/2005 23 8/10/2005 8 5/132005 5 2/15/2005 5 11/15/2004 4 8/252004 6 &/8/2004 Size 0.63 0.63 until YTD Cons 17 Variance 2% --1 % -22°/n 19% -26% -40% 140% 16% -28% -67% 356% -32% 0% 0% -1.00°/x. -100% 142% 94% -12% 25% -23% 20% BOARD OF HEALTH Julius Kay, M.D., Chairman Yr" `Ty NORTH ANDOVER ti a. R. George Caron Edward J. Scanlon MASSACHUSETTS 01845 { F 18557 1855 COMPLAINT REPORT Date Y-Wf 7 fi TEL. 682-6400 Made by / GT�,rt TtZtN t.e' - Address3 P&-NN7 1"-f. Tel W -S 7u Nature of comp lain j � Z 1�ayDurG, /N Pty p � - tdTiy f (2� vv ti b LAI oN rr- o � ,(%� z4�3cfL � J�JS F - 4 js Location to•� (Atilt, OccupanIyr Owner or Agent I/�CT' dw,a�D day Se.� P�uYF,�r°sAddress -_ DO NOT 14RITE BELOW THIS LINE Referred to Date Investigated 4f A6j 7Z Result of investigation e Action taken 1\ \ 1 I \� I \ J