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HomeMy WebLinkAboutMiscellaneous - 83 SHERWOOD DRIVE 4/30/2018 (2)I o 00 J W o (n n m o go � O C:) o LD o < o m Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Sherwood Drive Property Address Yin Shi Y: Owners Name North Andover Cityrrown MA 01845 8/28/2013 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. RECEIVED ---9 A. General Information �EP D 9 2013 1. Inspector: TOWN OF NORTH ANDOVER Nell J. Bateson I HEALTH DEPARTMEt4T" Name of Inspector Bateson Enterprises Inc. Company Name 111 Arailla Road Company Address Andover MA City/Town State 978-475-4786 SI15 Telephone Number B. Certification License Number 01810 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority i ), 8/28/2013 Inspector`s7SignatureV Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 3/13 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Sherwood Drive Property Address Yin Shi Owners Name North Andover Citylrown B. Certification (cont.) MA 01845 8/28/2013 State Zip Code Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old" or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old. is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 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 Sherwood Drive Property Address Yin Shi Owners Name North Andover City/town B. Certification (cont.) uA MAAF Jldlc c1N liuuc 8/28/2013 Date of Inspection ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ 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(l)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Sherwood Drive Property Address Yin Shi Owners Name North Andover Citylrown B. Certification (cont.) MA 01845 State Zip Code 8/28/2013 Date of Inspection 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Sherwood Drive Property Address Yin Shi Owner Owner's Name informationor every n is required fNorth Andover page. Cityrrown No MA 01845 8/28/2013 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 ❑ the system is located inanitrogen sensitive area (Interim Wellhead Protection obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a, facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located inanitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 3/13 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Sherwood Drive C. Checklist MA 01845 State Zip Code 8/28/2013 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes Property Address Yin Shi Owner Owner`s Name information is required for every North Andover page. Cityfrown C. Checklist MA 01845 State Zip Code 8/28/2013 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the'system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? . ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Sherwood Drive D. System Information Description: MA 01845 State Zip Code 8/28/2013 Date of Inspection Property Address Yin Shi Owner Owner's Name information is required for every North Andover page. Cityfrown D. System Information Description: MA 01845 State Zip Code 8/28/2013 Date of Inspection Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Number of current residents: 2 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes Z No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Yes Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Sherwood Drive Property Address Yin Shi Owner Owner's Name information is North Andover required for every page. Cityrrown D. System Information (cont.) Last date of occupancy/use: Other (describe below): MA 01845 8/28/2013 State Zip Code Date of Inspection Date General Information Pumping Records: Source of information- Pumped last year, owner Was system pumped as part of the inspection? If yes, volume pumped: 1500 gallons How was quantity pumped determined? Measured tank Rf Inspect tank & tees easo � - nom in r Flu F; g. Type of System: ® Septic tank, distribution box, soil absorption system El Single cesspool F-1Overflowcesspool ® Yes ❑ No ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Sherwood Drive Property Address Yin Shi Owner Owner's Name information is required for every North Andover MA 01845 8/28/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 16 years old, 10/19/1997, as built plan 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): 9 feet Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" PVC through wall, 3" PVC in house, no leaks visible. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 1 feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 10'x 5'x 4' Sludge depth: 4" ❑ Yes ❑ No t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Sherwood Drive Property Address Yin Shi Owner Owner's Name information is North Andover required for every page. CityrFown D. System Information (cont.) Septic Tank (cont.) MA 01845 State Zip Cod 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 23" 3" 8" 18" 8/28/2013 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.): Pumped septic tank. Inlet tee ok. 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 Dimensions: Scum thickness ❑ fiberglass Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: t5ins • 3113 feet ❑ polyethylene ❑ other (explain): Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Titre 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Sherwood Drive Property Address Yin Shi Owner Owner's Name information is required for every North Andover MA 01845 8/28/2013 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Sherwood Drive Property Address Yin Shi Owner's Name North Andover MA Citylrown State D. System Information (cont.) 01845 Zip Code Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert a 8/28/2013 Date of Inspection Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D -box level & distribution equal, has flow levelers. No evidence of leakage. Evidence of carryover, pumped d -box to clean. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 3113 1 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 ❑ 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Sherwood Drive Property Address Yin Shi Owner Owners Name information is required for every North Andover MA 01845 8/28/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2 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 inspection) (locate on site plan): Number and configuration Depth - top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Sherwood Drive Property Address Yin Shi Owner Owner's Name information ie required for every North Andover MA 01845 8/28/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins - 3/13 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System . Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Sherwood Drive Property Address Yin Shi Owner Owner's Name information is required for every North Andover MA 01845 8/28/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference, landmarks or benchmarks. Locate all wells within 100 feet. Locate where public -water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately � v t_ts►al• =aH`t� a =�� 9 D- - 33 a'` t5ins - 3113 1 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 Sherwood Drive Property Address Yin Shi Owner Owner's Name information is . North Andover required for every page. Cityrrown D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: MA 01845 State Zip Code 5 feet 8/28/2013 Date of Inspection 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: 4/21/1995Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Design plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: As per test pit data on design plan. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Sherwood Drive Property Address Yin Shi Owner Owner's Name information ie required for every North Andover MA page. Cityrrown State E Report Completeness Checklist 01845 Zip Code 8/28/2013 Date of Inspection ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Summary Record Gard generatea on dr1D12U13 9:29:4/ AM Dy Karen Hanlon Town of North Andover Tax Map # 210-105.0-0071-0000.0 Parcel Id 16987 83 SHERWOOD DRIVE YIN SHI 83 SHERWOOD DRIVE NORTH ANDOVER, MA 01845 Nage 1 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 0.96 Acres FY 2014 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until YIN SHI Owner 83 SHERWOOD DRIVE NORTH ANDOVER, MA 01845 EA, SENG AN & SILV PEK Previous Customer Inactive 2/12/2009 83 SHERWOOD DRIVE NORTH ANDOVER, MA 01845 UB.Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 17696.0 - 83 SHERWOOD DRIVE Last Billing Date 7/12/2013 3170367 03 Cycle 03 Active UB Services Maint. Account No. 3170367 .Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 1 1 9.18 1/ WTR WATER 01 ALL METER SIZE 109.30 /1 UB Meter Maintenance Account No. 3170367 Serial No Status Location Brand Type Size YTD Cons 35077357 a Active ERT HH b Badger w Water 0.63 0.63 581 Date Reading Code Consumption Posted Date Variance 6/12/2013 608 a Actual 26 7/24/2013 121% 3/14/2013 582 a Actual 12 4/22/2013 -44% 12/12/2012 570 a Actual 21 1/9/2013 -76% 9/13/2012. 549 a Actual 89 10/15/2012 231% 6/12/2012 460 a Actual 26 7/16/2012 208% 3/14/2012 434 a Actual 9 4/14/2012 -37% 12/9/2011 425 a Actual 13 1/17/2012 -87% 9/13/2011 412 a Actual 109 10/13/2011 439% 6/7/2011 303 a Actual 19 7/20/2011 31% 3/7/2011 284 a Actual 14 4/13/2011 -57% 12/8/2010 270 a Actual 33 1/12/2011 -78% 9/9/2010 237 a Actual 155 10/15/2010 792% 6/8/2010 82 a Actual 17 7/15/2010 21% 3/9/2010 65 a Actual 14 4/14/2010 -42% 12/8/2009 51 a Actual 24 1/12/2010 -53% 9/8/2009 27 a Actual 27 10/15/2009 -100% 7/22/2009 0 n New Meter 0 10/15/2009 -100% 7/22/2009 3261 r Replacement 0 10/15/2009 -100% 7/22/2009 3261 f Final Bill 10 7/22/2009 16% 6/8/2009 3251 a Actual 17 7/20/2009 -23% 3/13/2009 3234 a Actual 24 4/29/2009 4% 12/9/2008 3210 a Actual 22 1/20/2009 -73% 9/10/2008 3188 a Actual 88 10/10/2008 109% 6/6/2008 3100 a Actual 40 7/16/2008 32% 3/7/2008 3060 aActual 29 4/11/2008 1% 12/11/2007 3031 a Actual 32 1/22/2008 -77% Commonwealth of Massachusetts City/Town of ° System Pumping Record h Form 4 DEP has provided this form for use -by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the forrim they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location eft Right0jont of house Left / Right rear of house, Left / right side of house, Left / Right side of buil I g, Left / Right front of building, Left / Right rear of building, Under deck Address Cityrrown State Zip Code 2. System Owner. Name Address (if different from location) City/Town Zip ' State Code % Telephone Number B. Pumping Record 1. Date of Pumping P 9 Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s)tic Tank a P ❑Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? E] Yes to / If yes, was it cleaned? ❑Yes ❑ Na 5. Condition System: � .r 6. System Pumped By: Neil. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locati ere contents were disposed: S• Lowell Waste Water ISige Date t5form4.doc• 06103 System Pumping Record • Page 1 of 1 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. law ILEI Commonwealth of Massachusetts Title 5 Official Inspection For RECEIVED Subsurface Sewage Disposal System Form - Not for Voluntary Asse smenV NAR 2X 2009 0� 83 Sherwood Drive Property Address HEALTH DEPARTMENT Seng Ea Owner's Name North Andover MA 01845 3/18/2009 Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Neil J. Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover Ma 01810 CityTrown 978-475-4786 Telephone Number B. Certification State Zip Code S115 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 ❑e s Further Evaluation by the Local Approving Authority R; / 1&3/18/2009 Insp cto s Sign u 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 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 83 Sherwood Drive Property Address Seng Ea Owner Owner's Name information is required for North Andover MA 01845 3/18/2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ® N ❑ ND (Explain below): t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 _�_- 1 v== 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 Sherwood Drive Property Address Seng Ea Owner's Name North Andover Citylrown B. Certification (cont.) B) System Conditionally Passes (cont.): MA 01845 3/18/2009 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 distribution box is leveled or replaced ❑ Y ❑ Y ❑ Y ❑ N ❑ N ❑ N ❑ ❑ ❑ ND (Explain below): ND (Explain below): ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ❑ obstruction is removed ❑ Y ❑ N ❑ or obstructed pipe(s). The ND (Explain below): 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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Sherwood Drive Property Address Seng Ea Owner's Name North Andover City/Town B. Certification (cont.) MA 01845 State Zip Code 3/18/2009 Date of Inspection 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: 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 '/2 day flow t5ins . 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 83 Sherwood Drive Property Address Seng Ea Owner Owner's Name information is required for North Andover MA 01845 3/18/2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elev ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water suppl tributary to a surface water supply. EJ® Any portion of a cesspool or privy is within a Zone 1 of a public well. El® Any portion of a cesspool or privy is within 50 feet of a private water suppl well. El® Any portion of a cesspool or privy is less than 100 feet but greater than 50 from a private water supply well with no acceptable water quality analysis. system passes if the well water analysis, performed at a DEP certifie laboratory, for fecal coliform bacteria indicates absent and the prese of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 p provided that no other failure criteria are triggered. A copy of the ana and chain of custody must be attached to this form.] El® 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 failur criteria exist as described in 310 CMR 15.303, therefore the system fails. system owner should contact the Board of Health to determine what will b 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. or ation. y or y feet [This d nce pm, lysis e 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 The e 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Sherwood Drive Property Address Seng Ea Owner Owner's Name information is required for North Andover MA 01845 3/18/2009 every page. Cityrrown 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 t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 83 Sherwood Drive Property Address Seng Ea Owner Owner's Name information is required for North Andover MA 01845 3/18/2009 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No Number of current residents: 6 ❑ No 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 9 ( Y 9 (gpd))� Yes Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 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 Sherwood Drive Property Address Seng Ea Owner's Name North Andover Cityrrown D. System Information (cont.) Last date of occupancy/use: Other (describe below): State Zip Code General Information Date 3/18/2009 Date of Inspection Pumping Records: S f ' f t'iPumped last year, owner ource oIn orma on. Was system pumped as part of the inspection? E Yes El No If yes, volume pumped: 1500 gallons How was quantity pumped determined? measured tank Reason for pumping: Inspect tank & tees Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments "f 83 Sherwood Drive Property Address Seng Ea Owner Owner's Name information is required for North Andover MA 01845 3/18/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 12 years old, 10/19/1997, as built plan 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): 1111111111ym-_►1 • 2 feet Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" PVC thru wall to septic tank, 3" PVC in house no leaks visible. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal ❑ fiberglass 1 feet ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 10'x 5'x 4' Sludge depth: 2 ❑ Yes ❑ No t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 83 Sherwood Drive Property Address Seng Ea Owner Owner's Name information is required for North Andover MA 01845 every page. City/Town State Zip Code D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 25" Scum thickness 2" 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 20" t5ins • 09/08 3/18/2009 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.): Pumped septic tank, Inlet tee clogged , clean same.Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakaqe. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness ❑ fiberglass Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: feet ❑ polyethylene ❑ other (explain): Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 83 Sherwood Drive Property Address Seng Ea Owner Owner's Name information is required for North Andover MA 01845 3/18/2009 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ No Alarm in working order: Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ❑ Yes ❑ No * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins - 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 Sherwood Drive Property Address Seng Ea Owner Owner's Name information is required for North Andover MA 01845 3/18/2009 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D -box level & distribution equal. No evidence of leakage. Evidence of light carryover, pumped d -box to clean. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): 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 a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Sherwood Drive Owner information is required for every page. t5ins • 09108 Property Address Seng Ea Owner's Name North Andover City/Town State Zip Code D. System Information (cont.) Type 3/18/2009 Date of Inspection ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2 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 inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 83 Sherwood Drive Property Address Seng Ea Owner Owners Name information is required for North Andover MA 01845 3/18/2009 every page. 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 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 Sherwood Drive Property Address Seng Ea Owner's Name North Andover City/Tom D. System Information (cont.) MA 01845 3/18/2009 state Zip Code Date of Inspection 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 5-'CQ-�a 7�k WIE"11i A4c,;C* ;LV �aS I i I 11 ins . 09W Tft 5 Official hrspection 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 Sherwood Drive Property Address Seng Ea Owner Owner's Name information is required for North Andover MA 01845 3/18/2009 every page. Citylrown state Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated de th to hi h round water 5' below bottom of trenches p g g 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: 4/21/1995 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: You must describe how you established the high ground water elevation: Design plan test pit data. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 09/08 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 83 Sherwood Drive Property Address Seng Ea Owner Owner's Name information is required for North Andover MA 01845 3/18/2009 every page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Summary Record Card generated on 3/19/2009 9:26:56 AM by Lisa Evans Town of North Andover Tax Map # 210-105.0-0071-0000.0 Page 1 Parcel Id 16987 83 SHERWOOD DRIVE EA, SENG AN & SILV PEK 83 SHERWOOD DRIVE NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 0.96 Acres FY 2009 UB Mailina Index Name/Address EA, SENG AN & SILV PEK 83 SHERWOOD DRIVE NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Bldg Id. 17696.0 - 83 SHERWOOD DRIVE 3170367 03 Cycle 03 UB Services Maint. Account No. 3170367 Service Code MISCFEE ADMIN FEE WTR WATER UB Meter Maintenance Account No. 3170367 Brand Serial No Status YTD Cons 47509234 a Active NEPTUNE NEPTUNE Date Reading 3/13/2009 3234 12/9/2008 3210 9/10/2008 3188 6/6/2008 3100 3/7/2008 3060 12/1112007 3031 9/5/2007 2999 6/19/2007 2886 3/15/2007 2829 12/12/2006 2799 9/18/2006 2760 Trouble Code:03 4/11/2008 6/19/2006 2646 3/8/2006 2595 12/22/2005 2567 9/2112005 2518 Trouble Code:03 a Actual 6/27/2005 2399 3/30/2005 2354 12/16/2004 2315 9/24/2004 2285 6/11/2004 2184 4/16/2004 2149 12/19/2003 2080 Type Loan Number Active/Inact. From Payor Occupant Name Active/Inactive Last Billing Date 1/13/2009 Active Rate Charge Multiplier/Users 1 1 9.18 11 01 ALL METER SIZE 77.72 /1 Until Location Brand Type Size YTD Cons ENC F.RT. NEPTUNE NEPTUNE w Water 1 1 150 Code Consumption Posted Date Variance a Actual 24 4% a Actual 22 1/20/2009 -73% a Actual 88 10/10/2008 109% a Actual 40 7/16/2008 32% a Actual 29 4/11/2008 1% a Actual 32 1/22/2008 -77% a Actual 113 10/12/2007 144% a Actual 57 7/20/2007 84% m Manual estimate 30 4/16/2007 -30% a Actual 39 1/19/2007 -63% a Actual 114 10/20/2006 153% a Actual 51 7/10/2006 34% a Actual 28 4/17/2006 -31% a Actual 49 1/17/2006 -62% a Actual 119 10/14/2005 174% a Actual 45 7/15/2005 35% a Actual 39 4/5/2005 4% a Actual 30 1/14/2005 -62% a Actual 101 10/8/2004 54% a Actual 35 7/30/2004 8% a Actual 69 5/17/2004 0% n New Meter 0 12/19/2003 0% i Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important y �� 9 9 When fillip out 1. System Location: eft fron left rear, left sid of douse. Right front, right near, right side of house. forms on the computer, use only the tab key Address to move your � � � i U �, CC VN cursor - do not C. use the return 'ty Stafe Zip Code key- -- 2. System Owner. Name Y Address (if different from loca m) Cityfrown State Zip Code D 6 5-_ Telephone Number B. Pumping Record - 1 C9 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: 8 Cesspool(s) 0-teptic Tank L1 Tight Tank Q Other (describe): 4. Effluent Tee Filter present? 0 Yes M'No If yes, was it cleaned? [ Yes No t5fomr4.doc- 06/03 5. Condition of System: -T-V�, 4--e e n5. 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: Lowell Waste Water F 5821 Vehicle License Number Date System Pumping Record • Page 1 of 1 r COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION jECEIVED DEC 0 2 2005 TITLE 5 TOWN OF NORTH AN HEALTH DEPARTe_, OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: _83 Sherwood Drive _ _ North Andover_ Owner's Name: _Seng Ea_ Owner's Address: 83 Sherwood Drive_ _ North Andover, Ma 01845_ Date of Inspection: _11/17/2005_ Name of Inspectors Neil J. Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, Ma. 01810_ Telephone Number: _( 978 ) 4754786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: X_ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority F' 11/17/2005_ Inspector's Signature: Date: — The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a regional office ign flow of 10,t0h00 of gpd or greater, the inspector and the system owner shall submit the report to the appropriate 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 Sherwood Drive_ _ North Andover— Owner: _Ea Date of Inspection: _11/17/2005_ 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 Sherwood Drive_ —North Andover — Owner: _Ea Date of Inspection: _11/17/2005_ 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(l)(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 Sherwood Drive _ North Andover— Owner: _Ea_ Date of Inspection: _11/17/2005 D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no?' to each of the following for all inspections: _ 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 NoLiquid depth in cesspool is less than 6" below invert or available volume is 1/2 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 i 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 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 l l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 83 Sherwood Drive _ _ North Andover _ Owner: _Ea Date of Inspection: _11/17/2005 Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No Yes — Pumping information was provided by the owner, occupant, or Board of Health No Were any of the system components pumped out in the previous two weeks ? Yes _ Has the system received normal flows in the previous two week period ? No Have large volumes of water been introduced to the system recently or as part of this inspection ? Yes_ _ Were as built plans of the system obtained and examined? 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. _Yes_ _ 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 Sherwood Drive _ North Andover - Owner: _Ea Date of Inspection: _11/17/2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): _4 Number of bedrooms (actual): _5_ DESIGN flow based on 310 CMR 15.203 _440 Number of current residents: _6 Does residence have a garbage grinder (yes or no): Yes_ Is laundry on a separate sewage system (yes or no): No_ Laundry system inspected (yes or no): _ Seasonal use: (yes or no): No_ Water meter reading: Yes_ Sump pump (yes or no): -Nor- Last o_Last date of occupancy: _Current COMMERCIALJINDUSTRIAL Type of establishment: _ Design flow (based on 310 CMR 15.203): ygpd 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 this year, owner _ Was system pumped as part of the inspection (yes or no): Yes_ If yes, volume pumped: _1500 gallons -- How was quantity pumped determined? _Measured tank Reason for pumping: _Inspect tank & tees_ TYPE OF SYSTEM X Septic tank, distribution box, soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank _ Attach a copy of the DEP approval Other (describe): _ Approximate age of all components, date installed (if known) and source of information: _8 years old, 10/19/1997, 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 Sherwood Drive_ _ North Andover Owner: _Ea — Date of Inspection: _11/17/2005 BIJUMING SEWER _ X _ (locate on site plan) Depth below grade: _24" Materials of construction:cast iron _X _40 PVC "other Distance from private water supp_ly well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.) _4" PVC thru wall. 3" PVC in house, no leaks visible SEPTIC TANKS: X Depth below grade: _12" 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: 2"_ Distance from top of sludge to bottom of outlet tee or baffle: 25"_ Scum thickness: _I" 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: _20"_ How were dimensions determined: _Tape Measure _ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc. _ Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of 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 Sherwood Drive_ _ North Andover — Owner: _Ea _ Date of Inspection: _11/17/2005_ 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 BOXES: —X — 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 clan. D -Box cover broken, replace it._ PUMP CHAMBER: _ (locate on site plan) Pump in working order (yes or no): _ Alarm in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _83 Sherwood Drive_ _ North Andover _ Owner: _Ea_ Date of Inspection: _11/17/2005_ SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: _X leaching tranches, number, length: 2 trenches 50' long_ _ leaching field, 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 oL Vegetation oL No sign of ponding to surface _ CESSPOOLS: Number and configuration: _ _ Depth — top of liquid to inlet invert: T Depth of sludge layer: Depth of scum layer: _ Dimensions of cesspool: — Materials of construction: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): _ PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 10 of 11 OFFICIAL INSPECTION FORM _ NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _83 Sherwood Drive_ _ North Andover — Owner: _Ea Date of Inspection: _11/172005_ 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. Ato1=15'2" Ato2=18'5" A to D -Boz = 24'11" Bto1=22'2" Bto2=28'9" B to D -Boz = 33'2" 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 Sherwood Drive _ _ North Andover Owner: _Ea_ Date of Inspection: _11/17/2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water _ 5' _ 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: _4/21/1995_ 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 _ -Telnet 10.1.71.55 U/S ACCOUNT HISTORY 317036?-EA,,SENG AN & SILU PEHMETER 01:13170367 , BH:83 SHERWOOD DR I I i, 1, 1 1 1i 0 CYCLE SERUICE PRIOR CURRENT USE' WATER SERER , FEES ".TOTAL 1 2000-13 0913/1999 ?5 150 7S 204.75 - 0.00a 0.00 204.75 2 2000-23 01/18/2000 1002 1002 0 ", 0.00 0.00 0.00,. 0.00 3 2000-33' 03/31/2000 100'2 1019 "17 46.41 0.00!.0.00, 46.41 4 2000-43 06/20/2000 1019 1086 67 182.91 0.00' 0.00;, = 1.82.91 5 2000-31F 01/28/2000; -ISO 1002 852 2325.96 0.00=; 0.00• 2325:96 6:2001-13•.,09127/2000; 1086 1228 142 ,.:,387.66 0.001 14:30{: 0.00/.-14:30; 401:96 120:77 72001-23 , 01iO3/2001 1228 126? :'39 106.47 - 8 2001-33 04/04/2001 126? 1.286 19 ' 51.87 0.00F`14.30 66.17 9 200.1-43 '06/20/2001 ` 1286 1405 119 324.8? 0.00'`'14.30 339.1? 10 2002-13 09/21/2001" 1405 1630 22S 878.15 0.001 6.21 884.36 11 2002-•2.3 01./1.7/2002 1630 1.704 ?4 224.22 0.00' .6.21 230.43 12 2002-33 04/03/2002 1704 172.3 19 46.93 0.00' 6.21 53.14 13 2002-43 06/11/2002 1723 1.742 19 46.93 0.00, 6.2.1 53.14 14 2002 -CRD 09/22/2001 _:;1630 1630 0 -8.80 0.00; 0.00 -8.80 15 2003-13 09/13/2002 1742 185? 115 402.92 0.00', 6.68' 409.60 16 2003.2.3 1.2/19/2002. 1857 .1891 34 96.54 0.00: 6.68, 103.22 17 2003-33 03/13/2003 1891• 1912 21 51.40 0.00' 6.68, 58.08 1.8 2003-43 06/16/2003 1912 1938 26 67.56 0.001. 6 68 14.24 BEV IEW CHOICE .9 or.,<ENTER) MORE HISTORY ,' s Summary Record Card generated on 11/4/2005 9:36:07 AM by Lisa Warren Page 1 Town of North Andover Tax Map # 210-105.C-0071-0000.0 83 SHERWOOD DRIVE EA, SENG AN & SILV PEK 83 SHERWOOD DRIVE NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 0.96 Acres FY 2006 UB Mailing Index Name/Address Type Loan Number EA, SENG AN & SILV PEK Payor 83 SHERWOOD DRIVE NORTH ANDOVER, MA 01845 UB Account Maint. Active/Inact. From Account No Cycle Occupant Name Active/Inactive Bldg Id. 2977.0 - 83 SHERWOOD DR Last Billing Date 10/6/2005 3170367 03 Cycle 03 Active UB Services Maint. Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 1 1 9.18 1 / WTR WATER 01 ALL METER SIZE 592.50 /1 UB Meter Maintenance Serial No Status Location Brand Type Size 47509234 a Active ENC F.RT. NEPTUNE NEPTUNE w Water 1 1 Date Reading Code Consumption Posted Date 9/21/2005 2518 a Actual 119 10/14/2005 Trouble Code:03 6/27/2005 2399 a Actual 45 7/15/2005 3/30/2005 2354 a Actual 39 4/5/2005 12/16/2004 2315 a Actual 30 1/14/2005 9/24/2004 2285 a Actual 101 10/8/2004 6/11/2004 2184 a Actual 35 7/30/2004 4/1'6/2004 2149 a Actual 69 5/17/2004 12/19/2003 2080 n New Meter 0 12/19/2003 Until YTD Cons 0 Variance 174% 35% 4% -62% 54% 8% 0% 0% Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service 1 i 1 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 83 Sherwood Drive, North Andover Owner: Ea Date of Inspection: 11/17/2005 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. Bateson Bateson Enterprises, Inc. w COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION p D Property Address: Z,,`.\/e Owner's Name: Owner's Address: .. TOWN OF ,:,���i s�°F Date of Inspection: — �� b OF r Name of Inspector: (please print) 2003 Company Name: 1� e r�V C� AUG ' , Mailing Address: QX , Telephone NumbeFC1 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: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority, Fails Inspector's Signature:<i_,• Date: 7-.2q — 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. Title 5 Inspection Form 6/15/2000 page 1 I 'wsfge2ofII ` OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner(, Date of Inspection: "1' 2k Or- C z Inspection Summary: Check A,B,C,D or.E / ALWAYS complete all of Section D A. System Passes: yes 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:T 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. i 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) . r ' P brokea pipes) are replaced obstruction is removed distribution box is leveled or replaced "kl) 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 f ND explain: :F 2 r r ` Page 3 of 11 j OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Vin(1i- Owner: tc PteA W\ Date of Inspection: —7 - QI- C. Further Evaluation is Required by the Board of Health: 13 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. a 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)"that the :. „> r,t,�,Fw system -isnot functioning in manner which -*ill protect public hEaltb safety and the environment: i _ 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 t0 this form. 17 3. Other: 8 3 Page 4 of 11=• x OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:, Owner: Gi M Date of Inspection: ")-- ac%—Cy'_�j D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes No il-4ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ., oDischarge. or ponding of effluent to the surface of the ground or surface waters due to an overloaded or Clogged S1S or cesspool, : Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool --,Liquid depth in cesspool is less than 6" below invert or available volume is less than ''% day flow /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. 4 --'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 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.] _ (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: 8 To be considered_ a large system the, system' must -serve a facilitywith a des#gn. flow of. 10-000 gpd to 1'5,000 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 surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply 4 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. Y{ a Page 5 of l l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address -99 q k f wWd .ii (" -V e Owner: 6t M Date of Inspection: 1 aq —a �,. 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 ) ere any of the system components pumped out in the previous two weeks Has the system received normal. flows in the previous two week period? ave 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) f 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 ? J _ _ 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 t The size and location of the Soil Absorption System (SAS) on the site has been determined based on: k Yes no 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) [3 10 CMR 15.302(3)(b)] 5 . Page 6 of 11' A It, OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address 1ltX �(NNJP_ Al Owner:_CA[ N -N Date of Inspection: 77� =-11g=C)C� FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR5.203 (for example: 110 gpd x # of bedrooms): 4g o Number of current residents: Does residence have a garbage grinder (yes or no): �a (/Vu -r- T� F3 P i s c 0� Is. laundry on a separate sewage system (;yes or no): �/ , [if yes separate inspection required] L'tundry system,-inspected'(Yes or po): Seasonal use: (yes or no): J_16 Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or no): �d Last date of occupancy:c o. d / o d COMMERCIALANDUSTRIAL 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): at GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection (yes or no): p 5 If yes, volume pumped: LrO 0 eallons --How was quantity pumped determined? Reason for pumping: ( h e it 3:7A V C -' a6t E TYPE OF-SY9TEM ____.�,8 p is tank, distribution box, soil absorption system _ Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) _ Tight tank _ Attach a copy of the DEP approval Other (describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site (yes or no): 'kIa 6 x Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: `-_Z, { Dc 1 ire Owner:( M Date of Inspection: '7 CG TIGHT or HOLDING TANK: 1 4 (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: Cipa&�ity: 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: 165 (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 4_4u1/ 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.): r� CSCyc aaT c is Or -2&.2 T_e_ 1 PUMP CHAMBER:N.h, (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 ald appurtenances, etc.): 8 ' r .A Page 9 of I I t OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:R— csb&(L at�1. Amu� Owner: i Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Tye p' 1 leaching pits, number: leaching chambers, number: leaching galleries, number: i leaching trenches, number, length: 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.): !`iiu Sl ccs o4 H Y o,eAN i—i G P` 0) L t /Z r ea v B yu 0 CESSPOOLS: pA(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 or no): Comments (note condition of soil, signs of hydraulic failure, level` of ponding, condition of vegetation, etc.): PRIVY: a. if (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.): 9 Page 10 of 1 I f " OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: J1/ A i1r�o,/ef Owner: Nr\eal-1�^n Date of Inspection: —7 " Gk1%--Q3 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.' P-1 d P EDTA.ly6 e- 0' r A -e _ 1614 ' 0-r4 - - 3-3.r , :2s. s , b- 251-1 ' 5.7 2. 37 1 10 fage 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: F81 r_5)re( AI h3acb*r Owner: _��CCA Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells 41 ' Estimated depth to ground watertlfeet J Please indicate (check) all methods used to determine the high ground water elevation: 11✓o"'060btained from system design plans on record - If checked, date of design -#"viewed: 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: or c /Ja 4 gs r /Atp f C '4-rc 'T 2..4 • I 11 ip COMMONWEALTH OF MASSACHUSETTS — 71. EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUD -CORE ARGEO PAUL CELLUCCI DAVID B. STRURS Governor TICommisr over SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECON FORM - j PART A CERTIFICATION Property Address: 83 SfiEr2wivi") p(z1vE NameofOwner 0Af1Hy' Fr2fl9tr-1_t7 .t,'�, ,2T%4 AAA 3u Address of Owner: 0.3 S i+ e t2w<� � p (Live � ,00• RN OG JC rL Date of Inspection: /1/25l/ajy Name of Inspector: (Please Print) Benjamin_ C. Osgood, Jr. I am a DEP approved system inspector pursum7t to Section 15.340 of True 5 (310 CMR 15.000) Company Name: New England Engineering Services, Inc. Mang Address: 60 Beec w r, MA 01845 Telephone Number 686-1768 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true• accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _✓Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails n Inspector's Signature: ( Date: i i The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department ot•£nvironmermal Protection. The original should•be sent to-vxr system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Pace I or I I `� Vrroo<d on R<cyckd Pipe OF "F ice t�iAY 2 SUBSUOACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A CERTIRCATION (continued! Property Address: 83 SME 12 w w >> D lZr tJG, Nu rzT?_e r9.v v c u t: i2 Owner: 1/1 t4T)-IY r 12 A fl Et -A Date of Inspection: t r ► 2 44141 ( I INSPECTION SUMMARY: Check A, B, C, or D: ` h(. SYSTEM PASSES: r i V"— I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. I1 -not determined-. explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumpirtg-Trtore then fourtimes a yeardue to broken or obst, cted pipe(s). The system will pan inspection if (with approval of the Board of Health): - - broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOAM PART A CERTIFICATION (continued) Property Address: j 5 H E Rw u. O R I v c A,;-"-T7-r A'" O o Owner: K f4Tl-t Y r—x A O 6 LL A bate of Inspectim: 11 id Lety ( l 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 td protect the public health, safety and the environment. 1 J SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 (1)(b) THAT THE SYSTEMA IS NOT FUNCTIONING IN A MANNER WHICIi3K1LL.PRQTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVJBONMETLT_ _ Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF ANY) DETERMINES THAT THE SYSTEM tS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply of tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3of 11 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 193 0 t2 wF /V , tf v v I. 1Z Owner: Date of Inspection: 1 1 ` 2,1 1gi D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of xwage into 1ecifity-or-x"tem component, due ¢o an overloaded orctvgged SAS or•cesspod. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipets). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is -within a Zone 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for —coliform bacteria, volatile organic- compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system -ie -within 200 feet of a tributary to a surfeoa dririkiwg water st+pply —• - --- _ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area • IWPA) or a mapped Zone It of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4ortl - i SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM ; PART B �. CHECKLIST Property Address: g 2Q5 �w v�� :'7 f� at QF, iV'. f}N DO uc r2 Owner: K A:r}-t Y r -( Z& Q Ci -j- A Date of Iru'pe -tion: I trl2�+lgy Check if the following have been done: You must indicate either `Yes" or "No" as to each of the following: Yes No c: Pumping information was provided by the owner, occupant, or Board of Health. None of the system compmenu.kwua-baen pcxrnpad:(or--at least two awe&" and-ttre rystam ha -s P' =acaiuiog wmsaral flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with NIA. The facility or dwelling was inspected for signs of sewage back-up. y The system does not receive non -sanitary or industrial waste flow. _ The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank. was. inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System off the site has been determined based on: Existing information. For example, Plan at B.O.N. V Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) _ 115.302(3)(b)) _ The facility owner (and.occupauu,if different from -owner).w ere,prmridad.with intnr^+at�orsnn Ehe p.�nn^a�� ^'a^*'L^= ^f SubSurface Disposal Systems. revised 9/2/98 Pace 5ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 83 �11GRt,�tp;� �R1vC, .v. ff^r��vc 2 Owner: Date .of Inspection: 1/, ✓STH ` F 12R r� E Lt fi FLOW CONDmONS RESIDENTIAL: Design flow: //O g.p,d./bedroom. r Number of bedrooms (design):_ Number of bedrooms (actual):_ Total DESIGN flow yLJO Number of current residents:_ 6 Garbage grinder (yes or no): e. Laundry (separate system) yes or no):ArQ; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):_A10 Water meter_ readings, if available (last two year's usage (gpd): Sump Pump (yes or nol:_AV Lest date of occupancy: .-j .> COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: qpd ( Based on 15.203) Basis of design flow 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: A/Eve 9, PU AA PE O System pumped as part of inspection: (yes or no)_ If yes, volume pumped: gallons Reason for pumping: 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, ii any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date instaked{if known) -end source of•in(ormation: 2 �Pr:25 Sewage odors detected when -arriving at the site: (yes or not AZO revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: C.3 -; 5 H E t2 �. •,•, p 21 v r , '0-" Owner: Ih)4-114 Data of k%spectior,: t BUILDING SEINER: (Locate on site plan) Depth below grade: /L Material of construction: _ cast iron ✓ 40 PVC _ other (explain) Distance from private water supply well or suction line Diameter y„ Comments: (condition of joints, venting, evidence of Ioakage,-etc.l 15, J,v A,4 SF 44 E,I i SEPTIC TANK:— (locate on site plan) I Depth below grade: Material of construction: --concrete —metal _Fiberglass —Polyethylene—other(explain) If tank is (netal, list age _ Js -age .confirmed by Certificate of Compliance _ (Yes/No) Dimensions: 5 Sludge depth- L Distance from top of sludge to bottom of outlet tee orbaff(e:3-5— -' Scum thickness: *Z Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: /Vi G ASa k;-' IF $7:ci4 Comments: (recommendation for pumping, condition of inlet and outlet tees or -baffles, depth of liquid level in relation to outlet invert, structur&t4ntegrity, evidence of leakage, etc.) 7-0,v )A I N 6-o) 0 «ti 0 r T7 t) AJ- 5C H yJ 6-vo J / � N () 0--r N - GREASE TRAP:,dLh (locate on site plan) Depth below grade:_ Material of construction: _concrete —metal _Fiberglass —Polyethylene—otherlexplain) 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: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) revised 9/2/98 1 Page 7ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION. FOR0 PART C SYSTEM INFORMATION (continued) Property Address: g& 5 h tl'�wvc�0 D 121 v l= r nJ . R,v D 0 •) 07 R Owner: I/, wn-t K f= t2 A I> Ct.l. A Date of kupecti<m: 1. 13t2y�:Krj , TIGHT OR HOLDING TANK:J✓!a (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) r Depth below grade:_ Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order: Yes _ No_ Date of previous pumping: Comments: (condition of inlet tee. condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert:�� Comments: (note if level and distribution is equal. evidence of solids carryover, evidence of leakage into or out of box. etc.) — — a v�C I 'V LzK C o,v o I n r V C OUE/Z C 24 CA E D /-ice J I. IF A /I%.� CV'OiF A/C 7- Ar' "FA0 z_ T—v�2 PUMP CHAMBER:NA (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.) revised 9/2/98 Page 9of II 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (contimied) Property Address: B _S 5 h e�Lw` .� I> a 1 v' , owner: )A A-TH Y F 2A De "R Date of kupection: 111 241`cf SOIL ABSORPTION SYSTEM (SAS)—! (locate on site plan,. if possible: excavation not required, location may be approximated by non -intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number:_ _ leaching trenches, number, length:—z T(�P_y1t.y(t 5 �v� h.7 .v (r `t w� O C ac f leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.l G)s c )A Es 3-oo )L -s 6-00 :�. An ' v ,EJ 110 6A) (AF V G- p1QM 5 rL /� 12 UA�J`4�r4L �le-T-Ei 4 Tl®N. CESSPOOLS: IVA (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: Materiels of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of -vegetation, etc.) PRIVY:.&�- (locate on site plan) Materjals of construction: Dimensions. Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9of1l t , SUBSURFACE SEWAPE DISPOSAL SYSTEM INSPECTION FORM PART C, SYSTEM INFORMATION (continued) Property Addreu: 1-1F R vot, RI V e-, n:. ,qnl Q O UE 2 Owner: I��}n1Y F(LA hELLA Date of kmpection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 1 t revised 9/2/98 P2ge 10 of 11 SUBSURFACE SEWAGE Dt�POSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4;3 1�t,vA 9wout) DRIVE', ,v. An%;�CivG2 Owner: IA,0_FHY FpA qt 1 Date of knpection: NRCS Report name I t^ St) 2yI= y Ess tF X Ay TY Nv2Ti-[ G hti /1 r2 Soil Type_ }-r•f p Typical depth to groundwater 7 U USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater (p Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed.Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers _ Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) D [ Si G - A/ r' O y f} B C ✓C .., vI-1" ' 12 7W 14 4- 4-a !2 1!1*/31.L C)TA1'lel_> j7l)20 A^ -40it r-"0I-TLC�_y. revised 9/2/98 Page 11 or 11 I Form N0.4 Town of North Andover, Massachusetts BOARD OF HEALTH January 27 19 98 CERTIFICATE OF COMPLIANCE This is to certify that the Individual Soil Absorption Sewage Disposal System constructed (X) or repaired ( ) by Robert Innis INSTALLER at Lot #14 Sherwood Dr., N. Andover SITE LOCATION has been installed in accordance with Board of Health Regulations as described in the Design Approval Site System Permit No. 835 dated Sept. 10 1996 The issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. BOARD OF HEALTH � 3 z h a A v � A o a v E a W 'tw rrte,� moo C w ° Q v z C C C u x C w" p G C c� cY w G w°' w m cit cn c y- o �: me c :O= O N Cc C O ca m c :t p o R CD CE CD Z2 �C.D CD -- o a cm CD ' t; cm 0 3 m 9 "Ir c � ea N C � O N m .(Do N: m cc O Q N c O co : CD, 0 O m : N m C C :m�3 N o O h m ro.. m COD NJ O fl r C •_,, .� .y ct w c Z O-0 m •N CD ui •� v V V� O m� � S A � to O z co a co co v Z co C3. O CO) 0 C I CD cm CO3 0 CLI — f� 3 CQ 0 � � 0 a: C� C ca ca ca C Z co V y c • C _cc �. t NORTH 1 L FO. 9 • off; � - i�� 4 ass wCHus�t Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 3 I � /20 (! 5 - e,; 19 �'Z DISPOSAL WORKS CONSTRUCTION PERMIT Applicant ���—1-/VAl45 NAME ADDRESS TELEPHONE Site Location LlJT 14 /N' Permission is hereby granted to Construct ( or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. 513L--3— Fee 47-3� •d CHAHMAN, BOARD OF HEALTH D.W.C. No. 9'5e APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: S 9' . CURRENT INSTALLER'S LICENSE# LOCATION: L—o'/ / �f �h -e r c,�cs ®� ,D r _ LICENSED INSTALLER: 9 p A n ,4 c SIGNATURE: ��,��� TELEPHONE# &`oF CHECK ONE: REPAIR: NEW CONSTRUCTION: IF, NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS—BUILT. Administrative Use Only $75.00 Fee Attached? Yes No Foundation_ As -Built? Yes (/ No Approval Date: �� Q Town of North Andover 40RTol OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES ° . 30 School Street" r0 North Andover, Massachusetts 01845 �94oq�;,o',a`��� WILLIAM J. SCOTT SSA US Director April 13, 1998 Resident 83 Sherwood Drive North Andover, MA 01845 Dear Homeowner, This correspondence is in regards to the alteration in progress in the front yard at #83 Sherwood Drive. An inspection by authorized personnel of the health department was conducted on Friday, April 10, 1998. Please be advised that you are in violation of the State Environmental Code, Title V. 310 CMR 15.248 (2) - No permanent buildings or other structures shall be constructed on the reserve area. There are currently two stone structures over the area in question. This type of alteration is prohibited. The structures that have been constructed over this area must be removed within seven (7) days of receipt of this correspondence. In addition, the grading of the area is critical in the proper functioning of the septic system, therefore, you must have it restored to its original grade. You are hereby ORDERED to correct these violations within the time allotted. Failure to comply within the allotted time period may result in a criminal complaint against you in the Lawrence District Court and may result in an assessment of a fine. You have the right to request a hearing before the Board of Health if you feel this order should be modified or withdrawn. A request for said hearing must be made in writing and received by the Health Department within seven (7) days from the receipt of this order. At said hearing you will be given an opportunity to be heard and to present witness and documentary evidence as to why this order should be modified or withdrawn. All affected parties will be informed of the date, time and place of the hearing and of their right to inspect and copy all records concerning the matter to be heard. You may be represented by an BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 �y attorney. You also have the right to inspect and obtain copies of all relevant records concerning the matter to be heard. an Ford Ith Inspector M. Sandra Starr, Health Agent File April 30, 1998 Note To File: The owners of 83 Sherwood Drive appeared at a Board of Health meeting to discuss the planters on their front lawn, which lie on their septic system. They were made aware that in the event their septic system fails the planters will probably be destroyed, certainly removed.. They understand this and the fact that any change of grade that has been effected may negatively impact the longevity of their system. They agreed to accept the responsibility. { F k - — fr ir°2�F wi fl c�MV:1 ,f y ��J°'�'� x�,•. � �.�:��3^�'��`L. �� �}� f �v.!!�4+ ���ly'y3� y'•,, 'px+{� ..+1 �'� "'j �i �.,v� ,a�.:''� yr's 74 ;ria W � �� �T►' �."•r '� `>' t �o'J P � - .� •w � "4F � Vii► �"..�wYJ""° +a r+ I-�`+aL�' 3M � � . "� �` TF ... f -¢F it �. �`•db� 3'4+ b s• � '*g ��' 4i t '•! r`i-'- e1-199 / 1 _ Sbt't4 y� rkUM WHDH fv SALE6 bIi�atsy5b wHOH:rv,NFacsimile Cover Sheet 7 BULFINCH PLACE B O S T O H MASSACHUSETTS 021 14-2977 Company: Phone- Fax:- From': hone:Fax:-From: Terrie Brown Company: WHDH-TV Phone: (617) 725-0694 - Fax: (617) 248-9553 Date: Pages including this cover page:- - P. I ft IAN NBC AFFILIATE 11-10-1997 1:55PM FROM WHOH Tv SALES 6172489553 IAw OFFICES OE r ,JOHN CONNOMY, JR of%F. (.t7MMAN %-MET WAKEFIELD. MASSACiiL'n i 5 01 11Rp.257 JOHN COWOLLY JIe JoslR+A ItAlatcwtvN— �'�N.h xPMrTAD h �t�r KiN1'V AAt� November 5. 1997 Mr. Robert J. Janusz: President Timberland 8vildef8, Inc_ 40 Sunset Rode Road Andover, MA 01810 RE . LOT 14, SHERWOOD DRIVE, NORTH ANDOVE)k MASSACHUSETTS SUMS_ DR DONALD BROWN a 1MR& THERESA BROWN NOTICE- OF REP9RESENTA TION _ DEMAND FOR RELIEF UNDER M. ML-, CHAPTER 93A, SECTION I ET SEG Dear Mr. Janusz: P. 2 TL DW)NE lF17) ?0491) FAX tot 1)1 04174 By now I am sure you know (telt t nave been engaged by Dr. Donald Brawn and Mrs. Theresa. Brown to represent them in alt -matters relative -to a certain Purchase and Sale Agreement (the 'AgreemerW) which they executed with Timbertand Builders, Inc. ('Tnrbertand7 on or about June 4, 1897. Under the terms of the Agreement. Timberland agreed to construct a housr selected by the &owns upon a Jot of land owned by Timberland and identified as Lot 14 in the Sherwood Drive Subdivision in North Andover. The house selected is described as I*he Smithsonian 8-28° and had a particuWy attractive front elevatim. The Agreement contained various addends and exhibits, it ng a set of the standardized Shalt Design plans totaling 13 pages which were incorporated by reference into the Agreement. Certain modifications or alterstiorrs to Mie standardized design," agreed to as part of the Agreemem and confirmed in a number of desuiptive narrative specifications relative to the horns; sketched markings an the standardized plans themselves; and sketched reductions: of the plans attached to. the Agreement. After much discussion and negotiation, my clients entered into the Agreement with Timb dww in reasonable good faith reliance upon the express and implied assurances that the house they contracted to purchase would be constructed and presented to them consistent with the specifications and designs set (Orth in and/or lncorporetsd into the contract Based upon a review of the Agreement and the plans w4 specifications totorpomed into the Agreement upon a review of the records maintained by the Building Department of the Town of North Andover relative to the conStructton of the residence to be purchased by the Browns. upon a review of Orders of Conditions issued by the Conservation Commission of the Town of North Andover; upon discussions with represerhtatives of the Conservation Commission: upon ooservation of the structure 11-10-19.9i 1: 57PM FROM wHOH Tv SALES b 1 724139553 P.5 Page TW itself; and upon lengthy discussions wriM my clients, it is clear that Timberland is in default or breach of a number of provisions of the Agreement The provisions subject to default in the order in which those provisions appear in the Agmei n nt include the following: 1. The Agreement which was executed on or about ,lune 4, 1997. calls for a dosing date of October 1, 1997. or ".,.sooner by mutual agreement,". Due to extensive periods of irseavity on behalf of your staff. the proposed structure remains still far from ready for occupation and/or compliance with your obligations under tate Agreement. On or about June 30, 1997, your brokers -sought and received a written. extension on the dosing date from October 1st until October 1Sttt. A copy of that extension was secured from your broker. Although there have been unsubstaritiated damns of further agreed extensions. it is interesting to note that your broker also forwarded a proposed extension dated October 15, 1997. seeking to extend from October 15th to October 31st or November 21st, confirming no signature by any parry to the Agreement. cinder the terms of the Agreement Timbsrtartd does have a right to extend the closing date thirty days to bring the premises into compliance under conditions that written notice of the intent to extend is provided. No such notice has been provided at this time. 2. . Paragraph 3 of the Agreement states that the residents will be built "... per attached specif=tlons.. `. As referenced above, the attached spedfcations indude ten pages -of specifications and addenda and sxetch plans, as well as theattached standardized Scholz pians. Them.are numerous and dramatic inconsistencies between the sQudure as it presently exists and the proposed - residence under the terms of the Agreement Those inconsistencies, of which we are presently aware, include the fogowing; a. The proposed retocstion of the master suite from the first to the second ttoor raised some concern to the buyers as to the possible effect on the street appeal of the proposed structure. The buyers were assured by Mr. Steve Kerata. your agent, as can be eonf mare by markings made on the front elevation portion of Sheet 1 attached to the Agreement and filed with the Office of the Buiilding inspector. that this charge in the location of the master stave would require only the construction of a shed dormer a" the portion of the house above the living room study anti extended_ family roods. UnforturmWy. my Clients were also dissuaded from engaging tine services of an architect as they were assured that such services would tie unnecessary. Subsequently. when my cpent first viewed Mr. Kerala s apjustrnent. to the home they were shacked. as. I am sure. are others who visit the neighborhood by the mariner in which the entire street appeal of the structure was destroyed when the mofiine was extended far in excess of Me skamh (and incidentally tar in excess of the recently amended sketch plan submitted to the Building Inspector in octoDer). The building is now out of character with the quality and design of homes in the neighborhood and Is totally inconsistent with the design accepted and expected by my clients. b. The desOption of the proposed master suite set forth in the written spe"rcations and depicted in the sketch plans attached confirm that the proposed second floor master suite bathroom, was to have been Om relative equivalent to the suite as _depicted in the standardized plans. The master bath was to have been the same layout and size as the original design and was to include a three -partes frameless shower feature, which cannot now be arcomrrrodarted in this substandard -size bathroom. The sketch of the relocated master suit prepared by W Kerata and attached to the Apr+eemem shows a master suite comparative In size end layout to that which was originally on. the first floor. That plan, speCftglly referenced in the Agreeinent, constitutes an assurance of a similar layout 11-10-1997 1:57PH FROM WHDH Tv SALES 6172489553 P.4 Page Three for the second floor. These design irtconsistancies, coupled with Mr. KBrata's insistence on proceeding without input from an "tteCt. have been the undoing of my clients in this matter. C, As can be Confirmed both from the narrative description of the foyer and a review of the detail added to Sheet 2 of the standardized pians relating to the entry toyer, the staftase to Sere the second floor was to W curved. This was a critical design issue to the Browns and is one which Mr. Kerata has seen fit to ignore. The Browns have been advised plat such a staircase could certainly have been provided but that adjustments in the basic structure would have beers necessary -.--it fs apparent that Mr. Karate sought to save expense necesseuy to accommoUtc Timberland's . corn mitrnent regarding the curved staircase, as without agreement by My Client$. As it prest nay exists the entry foyer is in non -conformity and. is totally ur*cceptable. d. The written specifkcaftns e$Mlish that the realignmew of the rkst floor area was to have provided a study, which was to be equal In size to the 8xtended living room. It is dear from an inspection of the amended sketch pians filed with the Building Inspector that this commitment has also not been saftfled. e. The written specifications establish that the realignment of the first floor area was to live provided that ecce" to the study was to nave Dean byFrench doors orf study to adjacent hallway in front of family room.'. This requirement has also not been Satisfied in 0* structure as built and as described to the Budding Inspector in the amended pians. t The written specifications establish that the realignment. of the first door area was to hpve provided that there was to have been a hallway running from the study across the wall of the family room facing the front of the house througn the kitchen to the laundry room. The sketch plans submitted to the Building Inspector confirm that this halfway has been omitted by Mr. Karate: in violation of the terms or the Agreement. g. The written specifications and the attached sketch plans establish that a deck measuring 16 feet by 30t feet and spanning the entire near wall of the family room was to have been constructed. 'that deck does not presently exist, and, under the provisions of the Orders of -Conditions specifically relating to this Lot (discussed in further detail below), the deck cannot be built wiMout encroaching Into a so -gilled "no-consUuction tone". 3. Paragraph d reqs good dear record and marketable title, except for certain matters. a. It should be noted that there is no exception for the Orders of Conditions, conservation issues, requirement of clear record and marketable title. The only exception which reiattes to the present instance is one relative to easements and restrictions 'do not subsUrtialty attest the use of the property as a single-family"". As will be discussed below, your Agreemem contains affirmative statements obviously irtiended to be relied upon by the Browns to the effect that Lot 14 was not subject to any Orders of Conditions. Rather. as we learned last week to the surprise and disappointment of the Browns. Lot 14 is subject to a very significant easement for a drainage reality inck6mg a portion of a large retention basin. Further, restrictions have been placers on improvements to the lot by the Conservation Commission which significantly impedes the use and enjoyment of U* promises as a single-family home. Tile presence of the drainage easement and retention basin, along with intrusive 11-10-1997 1:56PM FROM WHDH Tv SALES 6172489SS3 P_3 Page Four tights of maintenance given to the municipality, exposes the Browns to significant risk of disruption in their family life. and anticipated landscaping to their residence. These provisions are clearly inconsistent with normal single -residence use. in addition, as the as -built drawing prepared on your behalf confirms. the foundation of the structure itself is within feet. if not inches, of the "no -construction" line, and only approximately twenly-five feet from the non -disturbance line. Effectively, this bars the ability of the Browns to enjoy the deck which was promised to them and furtner prohibits any future enjoyment of a significant potion of their becKyard. In fact, it would appear that their backyard.can only extend approximately 25 feet -frau the rear of this rattier large and imposing structure. Finally, the conservation reseicdats at= pmh bit the use of pesticides, thereby exposing the Browns, their family members and Quests to tate liKalirtood of being swarmed by mosquitoes and other insects certain to frequent and *e►ed in the retention pond whch they have now learned encroaches onto Lot 14. b. Both the subdivision plstrt and mairtgage plot plan- done for the Browns' prospective lender indicate the eidstence, of a so-caDW "gravel road'. The presence of fuch a road on a. subdivision plan raises ser aus title questions which I believe have been posed to your attomey by the Browns' title counsel. In response to direct a question relative to that road. Tenberlarid's attorney provided an unsubstantiated stater, in a letter dated October 17th claiming that "The old gravel road as shown on the plan was not a. right-of-way and was merely shown as existing on they ground. It has been extinguished and I do not believe it is a We issue.". This response is unsatisfactory and unacceptable in the absence of evidence as to the manner in Wrlicri rights in the gravel road were extinguished as Timbenani:Fs counsel alleges. 4. Paragraph 9 states that the proposed improvements will, rte built in accordance with all requirements of the State Code. It is dear from the records of the Building Inspector's Office that you have been in default of this provision in fiat you tiled inaccurate plans for the proposed structure at the time that tate original building permit was obtained. The plans as filed by you failed to include the significant changes that were made reivove to the location and layout of the master suite. Me size of the family morn. the prospective addition of a deck, the redesign of the first floor relative to a study, living mm and dining room, the curvedstairway in the front foyer and all necessary structural detail to cof firmm safety of the proposed relocation of the master suite to Me second floor. Even as now amended, the plans appmnfJy fail to satisfy the State Suilding Code in that they demonstrate no review and approval of fire pcafection fwAties by the local Fire Department. 5.. Paragraph 27.2 of the Agreement contains a provision acknowledging that, while V wre are outstanding Orders of Conditions relative to the subdivision. they do not affect Lot 14. The buyers are then "innocently' asked to accept such permanent provisions 'may" exist in tfie outstanding Orders of Conditions for the entire subdivision to the extent they impact on Lot 14 ww agree that the Buyers will take title Subject to such undisclosed provisions. This rather cleverly -worded provision was obviously intended to entice the Buyers into signing the Agreemerst without requiring furl disclosure of all existing Orders of Conditns. Those outstanding Orders of Conditions directly affecting Lot 14 were Issued by the North Andover Conservation Commission in October of 1995 and in June of 199e and were well known to Timbert8nd and its agents at the time the Agreement was negotiated and executed. Those Orders of Conditions require, among other things. a 25 -foot non -disturbance zone and a 50 -foot no- consmtction Zona across much of Lot 14: the granting of a sign;fiGartt drainage easement along the property fine between Lots 14 and 13; and an easement for a retention pond whisn encroaches extensively onto Lot 14. These provisions are inconsistent with the understanding of the parties at the 11-10-1997 1:59PM FROM WHDH TV SALES 6172489553 P_7 Page f=ive time that the Agreement was executed and with the statements made to the buyers both prior and subsequent to the exeCution of the Agreement. As an additional example or the callous manner in which Mr. Kereta has dealt with" my clients from the onset, i would also like to inform you of his dealings regaining a very specific and achievable request made by Mrs. SnNm relative to selection of 2' by 8' glass door paries to be installed in the family mom. Mrs. arowrt specifically 309Md.doors manufactured and soid by RivC0 and arranged for a site visit and measurements to be done.bY_Mr. Paul Collins. She informed Mr. Kerste of her choice and provided him vnt h the product of Mr. Collins' work. a Rivco catalog and the specifications on the doors requested. Notwithstarnding this eMt- and specific request by Mrs. Brown and the Browns' express witlirtgness to pay My increase in cost which the Rivao doors might have generated. Mr.. Kerata, after weeks of delay, ordered and ftwiled3' by 8' plass panels from a maturfatxufer or his choosing. Based upon the foregoing, it should be dear that Timberland is in significant default of its obligations under trtsAgreemeM executed between Timberiam and my clients. The scope and nature of the deficiencies involved are such that cure of the defaults is viRually impossible. in addition to trio express defaults, at bons of Tirnberlend. including. those undertaken by Mr. Kerata. Timber{and's appointed builder, throughout his dealings with the Browns, Oonstifaft a breach of the implied covenant of good faith and fair cleating recognized to existm trig Cornmonwea*t of Massecnusetts. These defaults by Timberland have exposed the Browns to Sigrhificent losses, Ongoing emotionaf distresS and unnecessary and unwarranted financial expense. The actions of Tirttbertand and its duty authorized agents also constitute violations of Massachusetts General laws. Chapter 93A, Section 1 et seq. That statute. commonly referred to as the Consurrner Pntedzon Act, makes it tnleWut for parties engaged in trade or commerce, such as Timberland, to engage in unfair andlor deceptive act or practices in their dealings with consurners, such as to Browns. Uniiateml and heavy-handed acsions taken by Mr. Karate in permitting wholesale changes to the residence promised to the grown$ without prior notification or agreement. at a lima when he knew of the BrownS' r+eilance upon hurt, is.ctearly a willfW and unfair act. Further, the failure of Timberland and its authorized agents to disclose to the Browns the existence of the two outstanding. Orders of Conditions *MCtty impacting Lot 14 constitutes an "oppressive or otherwise uneonscionabie" act as defined in 840 C.M.R. 318(2) of the regulations promulgated by the Office of the Attorney General under the provisions of Massachusetts General Laws. Chapter 93A. The provisions of the regulations cited state as follows: "Witthout limiting true scope of any other rule. regulation or statute an act or practice is in violation of M.G.L., Clhapter 93A, Section 2, if: (2) any person or Other legal entity subject to this Act fails to disclose to a buyer or Prospective buyer any fact, the disclosure bf which may have influenced the buyer or prospective buyer not to enter into the transaction:". Clearly, given the scope of the impact which the outstanding prders of Conditions have an Lot 14. the disclosure of the existence of thos6 Orders of Conditions and their particular terms, requirements and restrictions was of a nature whiCM "may influence' (rather Certainly would have influenced) the Buyers not to enter into the Agreement,for the purchase of tot 14 and such disclosure should have been made. 11-10-1997 1:58PM FROM wHDH TV SALES 6172489SS3 P.6 Page Six You should be advised that. under the provisions of Massachusetts General Liv$, Chapter 93A. the Browns are entitled, in the event of litigation, to pursue mimbursernBrIt for their attorney's fees Incurred as a result of your actions and to pursue double or triple the damages they incur as a resuft of those actions unless, within a period of thirty days from your receipt of this letter, you tender a offer of settlement of this matter, which is ubsequendy deemed by a trier of fact to be reasonable under the circumstances gf this matter. At the present time, the Browns are out-of-pocket for $56.800. repceser+ ng the deposit -------- tendered under me terms of the Agreement. approximately $6,000 paid W personalty and fixtum to. be installed in the subject residence; S2,000 for a relocation move which they were forced to undertake at the end of last week when the proposed struc.tura was not ready for their occupancy-. 5500 for storage charges (to be incurred on a mon*q basis until alternative living qu&rWs are located); and antICIPS d rental expense of $1,500 per month (the WWI rate they were paying on their previous residence) until a suitable aKama0ve residence is located. They have also lost the use and income which could have been generated by ft deppSit, which has been held by your broker. Finally. all of Me Browns have been subjected to significant emotional distress as a result of your adiorts and those of your duly-authofi$ed agents. I have discussed the various remedies and theories of recovery available to ft. Birowns with MGM and fain confident that their recovery will far exceed the expenses and sums. set forth above_ Notwithstanding my opinion and without in any way waiving their rights or your -obligations under MassachuSeits General Laws. Chapter 93A, or any other theory of recovery, the Browns have authodZed me to include within this 93A demand a statement of their conditional agreement to resolve this matter in the Mort -term based solely upon the refund of their entire deposit of 558.900, plus. f6imbur3ement of any portion of the $8,000 in deposits and payments made for fixtures and personalty which is not recoverable to the Browns. If this deposit is refunded to the Browns on or before 5' p.m. on Monday. November 17. 1997. and a written agreement to reimburse the Browns for non-recoverable deposits to the limit of $8.000 is tendered, the Browns will then execute mutual or recoveaf releases with Trmbw*M and Forego any efforts to recover any of the damaps which OW have incurred and. continue to incur as S result of wrongdoing by Timberland and its authorizedagents in this matter. I look forward to hearing from you or your legal representative at your earliest COnveitence. JC.Jr./spt cc, Dr. and Mrs_ Brown Fred Fls chief i @ ReMax Preferred George Rand. Esquire, by fax (975 - BY FAX TRAr15M03WN JM -337.3331) BY CERTIFIED MAIC, RETURN RECEIPT RMUESTED BY COURIER Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES WILLIAM J. SCOTT Director Memorandum 30 School Street North Andover, Massachusetts 01845 TO: BUILDING, PLANNII FROM: WILLIAM J. SCOTT RE: LOT 14 JARED , 83 DATE: NOVEMBER 10, 19f ION ,$a I received a phone call from a Mrs. Brown who has been involved with her husband in the purchase of a home at lot 14 Jared Place. The builders that Mrs. Brown has a concern with are; Steve Corretta, Robert Janos and Robert Innis. She indicated several problems with the difference between what was promised and what the contractor is intending on delivering. I would ask that each department prepare a file for the above lot and forward to me with a memorandum indicating the chronology for this lot. Please also inspect the premises and determine if there are any violations or deviations from the original plans. If there are violations or deviations from the plan take the appropriate remedies. Please return copies of plans and other documents to me by Monday November CONSERVATION - (978) 688 9530 • HEALTH - (978) 688-9540 • PLANNING - (978) 688-9535 *BUILDINGOFFICE - (978) 688-9545 • *ZONING BOARD OF APPEALS - (978) 688-9541 0 *146 MAIN STREET THS July 25, 1997 Ms. Susan Ford Board of Health 30 School Street North Andover, MA 01845 Re: Lot 14 Sherwood Drive Dear Susan: Find enclosed the floor plan for Lot 14 Sherwood Drive. Although the plans says its for Lot 15 this is the floor plan for Lot 14 pursuant to Timberland Builders. If you have any questions or require additional information please do not hesitate to contact me. Very truly yours, THOMAS E. NEVE ASSOCIATES, INC. Kathy Molina Personal Assistant Enclosure #1449 JANI4.WPS • ENGINEERS • • LAND SURVEYORS • • LAND USE PLANNERS • 447 Old Boston Road U.S. Route #1 Topsfield, MA 01983 (508) 887-8586 FAX (508) 887-3480 �y+9INW- . .' ��t4K- `Ix'�v 1 •` d '` , r , " y, NN' `9Y�`x°i 1 = poi pa _ A C N x � iiI Z O r cn Uq T tx Z � J 2 m v G C r: Ute^ d Po !I; • f�1 i i x � U a In ^X Uti CD R � l� n C • `� `C 1 = poi pa _ A C N x � iiI Z O LO 1 P T tx Z � uuuu c 2 m v A r D 2 m i _m o Wy Po !I; • i i x � U a In ^X L 33'-4' II �I � � I r AI _ A N O iiI Z LO 1 P T tx Z � uuuu c 2 L 33'-4' II �I � � I _ s' 3 A �L 'O N LO z o T .ol: 0an= p m v A r D 2 m i _m o Wy Po !I; Town of North Andover kORTH OFFICE OF o�.�o �? y°` "1, L COMMUNITY DEVELOPMENT AND SERVICES 0. F r: 9 146 Main Street z North Andover, Massachusetts 01845 9SSACHUSEt WMLIAM J. SCOTT f Director September 11, 1996 Neve Associates 447 Old Boston Road Topsfield, MA 01983 Re: Lot # 7,12, 14, 16 Sherwood Drive Dear Tom: This is to inform you that the proposed plans for the sites referenced above have been approved. If you have any questions, please do.not hesitate to call the Board of Health Office at the number below. Sincerely, Sandra Starr, R. S.) Health. Administrator. SS/cjp cc: Bob Janusz BOARD OF APPEALS 688-9541. BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 146 Main Street North Andover, Massachusetts 01845 June 11, 1996 Mr. Thomas Neve Neve Associates 447 Old Boston Road Topsfield, MA 01983 Re: Lot #14 Sherwood Drive Dear Tom: This is to inform you that the proposed plans for the site referenced above have been disapproved for the following reasons: , Liioo 11F0 •�P i��/ 1. No wetlands disclaimer. 2. Tank not 25 feet to cellar. No manhole to grade. 3. Design flow not based on 110 GPD w/660 GPD minimum. 4. Leach area not 35 feet to foundation, 5. Please show elevation of A & B soil removal plus 6 inches on profile. 6. Map & parcel missing.. 7. Please note for future reference that soil logs are incomplete: missing soil colors, structure. Soil mottling column should have mottle colors, abundance, & size. 8. Leach area less than 100 feet from drain (N.A. 4.18). 9. Perc elevations missing. 10. Note concerning excavation 6 inches into parent. If you have any questions, please do not hesitate to call the Health Office. Sincerely, Sandra Starr R.Sr Health Administrator SS/cjp cc: Bob Janusz BOARD OF APPEALS 688-9541 BUU DING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNLNG 688-9535 DATE lQ� Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEEPERMIT # DATE RECEIVED q� APPLICANT$ J ,4AJt),3Z ASSESSOR'S MAP ADDRESS PARCEL # LOT # STREET % 406 Ob D e ENGINEER ADDRESS PLAN DATE 0AW11,6 REVISION DATE CONDITIONS OF APPROVAL: APPROVED DISAPPROVED X �� , IUCD (.t�Er�A•U�js � 13C.cAi1�'►E/Z 7-,4A)/,/- h10 T TO C 5�6e X91- . NO M /) A) HO C6F TO /G •�'g� U . -Dg7 /� N EGD u> itJO T -- f9 5E d n x,) !! O IVO 7- 36 1--&C-t). s 01G b F40ie �G6�7f1Sg WOT'GA TN M15511V6 501E Coco,�S� ST/ZucTuf2� G A4077`4JR.J6 CaLu�,� 5/�ou�p 1-111�l/6 IL4071-1-E C066,eS ��U'U1�A'VG�y�L 51 Z� �0o ' z�s Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 146 Main Street North Andover, Massachusetts 01845 April 17, 1996 Mr. Thomas Neve Neve Associates 447 Old Boston Road Topsfield, MA 01983 Re: Lots 3,4,5,7,14,15,16,12,& 19 Sherwood Drive The above named lots at Sherwood Drive have been incompletely submitted. The submission of new designs after January 1, .1996 requires the inclusion of soil evaluation forms. Until these forms have been received, the above mentioned plans will not be considered submitted. Should you have any questions, please call me at the number below. Sincerely, i Sandra Starr, R.S. Health Administrator SS/cjp '1D 'e BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 PLAN REVIEW CHECKLIST ADDRESS ENGINEERSyE GENERAL / / 3 COPIES V STAMP L/ LOCUS Ci-- NORTH ARROW SCALE CONTOURS PROFILE L.,-- SECTION L,- BENCHMARK L-- SOIL & PERCS ELEVATIONS WETS. DISCLAIMER iC WELLS & WETS -" WATERSHED?k DRIVEWAY L--�(Elev) WATER LINE c/ FDN DRAIN SCH40 L% TESTS CURRENT? SOIL EVAL 5 -b lak-so SEPTIC TANK MIN 150OG �'� .17 INVERT DROP GARB. GRINDER Ab (+200% EDF) 25' TO CELLAR MANHOLE ELEV GW # COMPS._ D -BOX SIZE # LINES O` FIRST 2LEVEL STATEMENT INLET 143.69 - OUTLET 143,42 ( 2" OR .17 FT) TEE REQ' D?-,d/—O LEACHING / MIN 660 GPD?Z RESERVE AREAy 4' FROM PRIMARY? 6,`� 2% SLOPE - 100 1 LOPE100' TO WETLANDS 100' TO WELLS 1--' 4' TO S.H.GW L--�5'>2M/IN) 35' TO FND & INTRCPTR DRAINS 325' TO SURFACE H2O SUPP 4' PERM. SOIL BELOW FACILITY c, ' MIN 12" COVER t/.. FILL? --- (25' if above natural elev; 101if below) BREAKOUT MET? TRENCHES MIN 660 gpd-� SLOPE (min .005 or 6"/1001) Ll""SIDEWALL DIST. 3X EFF. W OR D (MIN 6') L" RESERVE BETWEEN TRENCHES? C/IN FILL? , MUST BE 10' MIN. L,,�4" PEA STONE?y VENT? (>3' COVER; LINES >501) BOT ©v + SIDE ,ZD L) X LDNG , 74- = TOT (L x W x #) (DxLx2x#) (G/ft2) Copyright O 1995 by S.L. Starr 0r'j!F'VU(JV April 16, 1998 7 190P Town of North Andover Office of Community Development and Services 30 School Street North Andover, MA .01845- - _ Attn: 011845- Attn: Susan Fork Health Inspector Dear Ms. Ford: We are in.receipt,,of your letter dated April 13, 1998, received in the mail April 15, 1998, explaining your violation stated in 310 CMR 15.248(2). This letter will serve as our notice requesting a hearing before the Board of Health requesting modification or withdraw of your -ordinance. We await yourreplyin working out a schedule for our meeting. We can be reached -at the following numbers: &-Mrs. lw---Frank-Fradefla's residence (978) 794-6899 . W. Frank Fradella's office (603) 890-3680, Extension 14 Thanks in. advance for your cooperation. Sincerely, CATHERINE A. FRADELLA 83 Sherwood Drive North Andover, MA 01845 x �tP aQz- �o�P 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***************** APPLICANT: R(_-( V 7-Y prw S 2 LOCATION: Assessor's Map Number Q _ Subdivision Street Phone %7 Parcel Lots) St. Number ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Conservation Administrator Comments Town Planner Comments Food Inspector -Health _,iep c Inspector=Health Comments Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Date Approved �. Date Rejected f s Public Works - sewer/water connectionsL� - driveway permit Fire Department Received by Building Inspector Date SEPTIC PLAN SUBMITTALS LOCATION: NEW PLANS: YES $60.00/Plan REVISED PLANS: YES $25.00/Plan DATE:' DESIGN ENGINEER:i When the submission is all in place, route to the Health Secretary gOR7q 1r• � � 9 • 4� �. ss�CHU Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 2 DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant- Test No (I Site Location Reference Pla Permission is granted for an individual soil absorption sewage disposal system to be .installed in accordance with regulations of Board of Health. CHA RMAN, BOARD OF HEALTH Fee �: Q Site System Permit No. OO5 No. 1449 _ 14 i FOR NI 11 - SOIL EVALUATOR FORM Page I of 3 Date: .--A \'Z(-- \9 (D Commonwealth of Massachusetts poPOvER— , Massachusetts Uitv Assessment a,.e Dim Date: -4\0�%�92S Performed By .......... ........ Witnessed BY: NZ(t- .... ......... I ........... . .............. . ...... ... .. ...... ...... Lamson Addrtss. iW L Tc!cphom I Ac� Vj 1: IU p.� ow e4- Pr o�s ko ew Construction 02/Repair L7 Off -ice Review Published Soil Survey Available: No ❑ Yes EVI/ k I Soil "Ylap Unit Year Published ...... Publication Scale ...... ........... Drainage Class oea ws ............. Soil Limitat ons ............................... .............. . ............ ............. Surfici'l Geoiogic Report vai Year Published Publication Scale Geologic. ,Material. .................................................... ........................... .................. .................. ............. ,(�Iap Unit) ........ .. ........... ... I ............ L�ndfbrn.I....................................................................... Flood Insurance Rate Map: Above 500 year flood boundary No 2"Yes 0 -:1, Xes Within 500"y6ar: flood boundary No Within 100 year flood boundary o es Wetland. Area: National Wetland Inventory Map (map unit) Wetlands Conservancy Program Map (map unit) Current Water Resource Conditions (USGS): Month Range :AboVeNoi'fnal ONormal E1BelcwNor'mal — Other References Reviewed: DFP APPROVED FORM - 12/07/95 ............................... ................................................ ...... ..... .............. I t- t . :.•,;Cocat-ion--Address or. Lot i4o. \4' SN��2w�c� venvMS On-site Review Y Deep Hole Number Date:'21 �9S Time: Weather FP-� Location (identify on site plan) S�rc .:SA�Tart--P fltSRtlsa�_ SS�bca �E�v Land Use Slope M Surface Stones Vegetation, w C>C>a> Yr> Landform Position.on landscape (sketch on the back) �,,r� �P«-��-�l�-f. 'L7�Sgp54q.__ 50-�(S'TfA.A Vv'-stC-J-� Distances from: (�-OusS P -P) Open Water Body {$5+/'feet Drainage way We, s feet Possible,Wet Area k'39*1— feet Property Line Z�'��-- feet mum 2T to'T %—%Vie) Drinking Water Well 91446. feet Other DEEP OBSERVATION HOLE BOG* Oepth from Surface (Inches) Soil Horizon Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other (Structure, Stones, Boulders, Consistency, % Gravel) O Co c�e.Av�L.--C r sa•�-�v�t - L.A G 5 I�t�1.c� s-rA-c��� Eb F►, �vo,c . -fo C�r�rrt-sE Ste-� c•�E i�toN IVIIIVIIvlulvl ur L ­:­.J..,...v - -. .' • -•-. ---- - -- --- --- ----- Parent Material (geologic) c�-'C W.A 151 DepthtoBedrock: �6�L Depth to Groundwater: Standing Water in the Hole:_Weeping Weeping from Pit Face: �f� Estimated Seasonal High Ground Water: s ► kiDEP APPROVED FORM - 12!07/95 Location Address or Lot No FORM 11 - SOIL LVALUATOR FORM Page 3 of 3 Determination for Seasonal High Water. Table Method Used: ❑ Depth observed standing in observation hole ................. inches r❑ epth weeping"'fron-i side of observation hole' ..,.. c ,_.; `inches 2 Depth to soil mottles inches �Mw ❑ Ground water adjustment .................. feet Index Well Number ................. Reading Date ......... ..... Index well level ....... _. Adjustment factor ................. Adjusted ground=water level. ................ Deoth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in II areas observed throughout the area proposed for the soil absorption system?.s If not, what is the depth of naturally occurring pervious material? Certification I certify that on "'. 11/94 (date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature Date 5/1/96 y y. . DEP APPROVED FORM - 12/07/95 03-21-1996 14:36 517 932 7615 DEP NORTHEAST REGIONAL P.02 FORM 12 - PERCOLATION TEST Location Address or Lot No. ��" SL�'`� 'LLiVE COMMONWEALTH OF MASSACHUSETTS I`,NPO�6- , Massachusetts Percolation Test" Date: 9 1 �19�j Time: 1 ZOFM Observation Hole # A3 4 Depth of Perc Start Pre-soak End Pre-soak Time at 12" W Wu0 � � I � G>pINA— Time at,9" Time at 6" Time (9"-6") Rate Min./Inch IJ Z • Minimum of 1 percolation test must be performed in both the primary area AND reserve ar . Site Passed Site Failed ❑ Performed By: Witnessed By: Comments: .. vv Xrrxorm roRm - u197ni