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HomeMy WebLinkAboutMiscellaneous - 85 LACONIA CIRCLE 4/30/2018 (2)g r I LOT & STREET �`� �- �` MAP/PARCEL CONSTRUCTION APPROVAL HAS PLAN REVIEW FEE BEEN PAID? YES NO PLAN APPROVAL: DATE / 19r1c17 APP. BY DESIGNER: Mt-; Rfg66 -- 1GO, 1)/ X) PLAN DATE CONDITIONS WATER SUPPLY: WELL WELL TESTS: PLUMBING SIGNOFF COMMENTS: TOWN WELL DRILLER CAL DATE APPROVED DATE APPROVED BACTERIA II TE APPROVED __ WIRING SIGNOFF FORM U APPROVAL: ;BY PROVAL ISSUE YES NO DATE ISSUED CONDITIONS: ✓ FINAL APPROVAL: ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NO ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: BY: SEPTIC SYSTEM INSTALLATION IS THE INSTALLER LICENSED? YES, ---'NO TYPE OF CONSTRUCTION: REPAIR NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW (-YEP NO CONDITIONS OF APPROVAL YES (FROM FORM U) ISSUANCE OF DWC PERMIT, �� ED NO DWC PERMIT PAID? YE NO DWC PERMIT NO. / Sy INSTALLER: ,� BEGIN INSPECTION ES 0: EXCAVATION INSPECTION: NEEDED: PASSED f 14'4 g BY CONSTRUCTION INSPECTION: NEEDED. AS BUILT PLAN SATISFACTORY: YES�,-) : APPROVAL TO BACKFILL: DATE: BY _ FINAL GRADING APPROVAL: DATE r BY FINAL CONSTRUCTION APPROVAL: DATE: BY • I SEPTIC SYSTEM INSTALLATION IS THE INSTALLER LICENSED? YES, ---'NO TYPE OF CONSTRUCTION: REPAIR NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW (-YEP NO CONDITIONS OF APPROVAL YES (FROM FORM U) ISSUANCE OF DWC PERMIT, �� ED NO DWC PERMIT PAID? YE NO DWC PERMIT NO. / Sy INSTALLER: ,� BEGIN INSPECTION ES 0: EXCAVATION INSPECTION: NEEDED: PASSED f 14'4 g BY CONSTRUCTION INSPECTION: NEEDED. AS BUILT PLAN SATISFACTORY: YES�,-) : APPROVAL TO BACKFILL: DATE: BY _ FINAL GRADING APPROVAL: DATE r BY FINAL CONSTRUCTION APPROVAL: DATE: BY Commonwealth of Massachusetts . Title 5 Official Inspection Form - a 'Subsurface Sewage Disposal System Form - Not for Voluntary Assessments "LaconiaCircle rlzi Property Address Paula Keating Owner Owner's Name information is required for every North Andover MA 01845 6/13/2015 page. City/Town State Zip Code Date of Inspection B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: 0 Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6/13/2015 Ins ec or`4 Signature,_j 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 feature under the same or different conditions of use. t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 1 of 17 5 Inspection results must be submitted, on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: When A. General Information RECEIVED filling out forms on the computer, JUN 3 0 2015 use only the tab 1. Inspector: key to move your cursor - do not Neil J. Bateson TOWN OF NORTH ANDOVER use the return j{FALTH DEPARTMENT Name of Inspector icey Bateson Enterprises Inc. Company Name ISI 111 Argilla Road Company Address Andover MA 01810 City/Town State Zip Code 978-475-4786 S115 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: 0 Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6/13/2015 Ins ec or`4 Signature,_j 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 feature under the same or different conditions of use. t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 1 of 17 5 Owner information is required for every page. t5ins • 3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Notfor Voluntary Assessments 85 Laconia. Circle Property Address Paula Keating Owner's Name North Andover B. Certification (cont.) MA 01845 State Zip Code 6/13/2015 Date of 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 exfiitration or tank failure is imminent. System wifl pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. " A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 Laconia Circle Property Address Paula Keating Owner owners Name information is required for every North Andover MA 01845 6/13/2015 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins - 3113 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 Laconia Circle Property Address Paula Keating Owner Owner's Name information is required for every North Andover MA 01845 6/13/2015 page. C Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/Z day flow - -. t5ms - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 Laconia Circle Property Address Paula Keating Owner's Name North Andover Cityfrown B. Certification (cont.) MA 01845 State Zip Code 6/13/2015 Date of Inspection Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10, 000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t51ns • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal poral System •Page 5 of 17 Commonwealth of Massachusetts _ - Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Y Q 85 Laconia Circle Property Address Paula Keating Owner Owners Name information is required for every North Andover MA 01845 6/13/2015 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): 3 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 posel System •Page 6 of 17 Commonwealth of Massachusetts Lq Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 Laconia Circle Property Address Paula Keating Owner Owner's Name information is required for every North Andover page. City/Town D. System Information Description: MA 01845 State Zip Code 6/13/2015 Date of Inspection Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes Z No Is laundry on a separate sewage system? (Include laundry system inspection ❑Yes information in this report.) ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes Z 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 S 8 Po ystem •Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 Laconia Circle Property Address Paula Keating Owner owner's Name information is required for every North Andover MA 01845 page. City/Town State Zip Code t5ins • 3/13 D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Date 6/13/2015 Date of Inspection Pumped last year, owner 1500 gallons Measured tank Inspect tank & tees Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ® Yes ❑ No ❑ 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): 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 85 Laconia Circle Property Address Paula Keating Owner owner's Name information is North Andover required for every page. City/Town t5ins . 3113 State 01845 Zip Code 6/13/2015 Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 16 years old, 2/19/1999, certificate of compliance, d -box was replaced 3/20/2010, info at B.0. H Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" PVC through wall to septic tank, 3" PVC in house, no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: 0 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: 1" ❑ Yes ❑ No 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 85 Laconia Circle Property Address Paula Keating Owner Owner's Name information is required for every North Andover MA 01845 6/13/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? 31" 1° 8" 14" 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 cover under pool patio unable to excavate cover. Inlet tee ok, looked inside tank through outlet cover. Outlet tee ok. Depth of liquid level at 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 Tide 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 Laconia Circle Property Address Paula Keating Owner Owner's Name information is required for every North Andover MA 01845 6/13/2015 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: , Capacity: Design Flow: Alarm present: Alarm level: Date of last pumping: ❑ fiberglass ❑ polyethylene ❑ other (explain): gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 3113 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 lawall Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 Laconia Circle Property Address Paula Keating Owner's Name North Andover MA 01845 6/13/2015 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 N 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 light solid carryover, pumped d -box to clean Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No- .Alarms o* .Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 Laconia Circle D. System Information (cont.) leaching pits leaching chambers leaching galleries leaching trenches leaching fields overflow cesspool innovative/alternative system 01845 6/13/2015 Zip Code Date of Inspection number: — number: — number: — number, length: number, dimensions: number: 3 trenches 50' long 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Dis g poral System •Page 13 of 17 Property Address Paula Keating Owner Owner's Name information is required for every North Andover MA page. Cityfrown State D. System Information (cont.) leaching pits leaching chambers leaching galleries leaching trenches leaching fields overflow cesspool innovative/alternative system 01845 6/13/2015 Zip Code Date of Inspection number: — number: — number: — number, length: number, dimensions: number: 3 trenches 50' long 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Dis g poral System •Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 Laconia Circle Property Address Paula Keating Owner owner's Name information is required for every North Andover MA 01845 6/13/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc,): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5lns • 3/13 Title 5 official Inspection Form: Subsurface Sewage Disposal poral System •Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments " 85 Laconia Circle Property Address Paula Keating Owner owner's Name information is North Andover MA 01845 required for every page. CitylTown State Zip Code 6/13/2015 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 t3 �I t5ins • 3(13 Tide 5 Official Inspection Form: Subsurface Sewa a Disposal posel System •Page 15 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 Laconia Circle Property Address Paula Keating Owner's Name North Andover MA 01845 6/13/2015 City/Town State Zip Code D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 4 feet 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: 7/15/1998 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Design plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: As per test pit data on design plan. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal poral System •Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 85 Laconia Circle Property Address Paula Keating Owner Owner's Name information is required for every North Andover MA 01845 page. Citylrown State Zip Code E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked 6/13/2015 Date of Inspection ® 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 sews a Disposal poral System -Page 17 of 17 Lommonweann of massaonusetts 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 forrh 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: Left / Right front of house, Left / Right* near of house igh tde. of house eft / Right side of building, Left / Right front of building, Left / Right rear of Ing, Under Address City/Town State Zip Code 2. System Owner. Name Address (d different from location) cityrrown B. Pumping 1. Date of Pumping 3. Type -of system: 11 State � Zip de Telephone Number Date ❑ Cesspool(s) — Z. Qu ty Pumped Septic Tank Gallons } ❑ Tight Tank . ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yep �No If es was it cleanedY ? El Yes ❑ Na 5. Condition of System: 6.- System Pumped By.- Nell. y: Nell. Bateson Name Bateson Enterprises Inc Company 7. Location where contents- were disposed: F5821 Vehicle License Number Date ' t5formCdoca 06/03 System Pumping Record • Page 1 of 1 Town of North Andover Tax Map # 210-105.Q-0152-0000:0 Parcel Id 17111 85 LACONIA CIRCLE PAULA KEATING BARBARA KODYS 85 LACONIA CIRCLE NORTH ANDOVER, MA 01845 Class 101 Single Family Zoning2 i Residential BIzs Total 2.06Acres FY 2015 Property Type Zoning3 1 Residential 1 Residential US Mailing Index NamelAddress Type Loan Number Activellnact, From Until PAULA KEATING Payor BARBARA KODYS 4.5 LACONIA CIRCLE NORTH ANDOVER, MA 01846 ENGSTROM, WILLIAM & LINDA Previous Customer Inactive 9/152410 85 LACONIA CIRCLE NORTH ANDOVER, MA 01845 UB Account Maint, Account No Cycle Occupant Name AoUve/Inactive Bldg Id. 17526,0 - 85 LACONIA CIRCLE List Billing Date 4/16/2015 3170196 03 Cycle W Active UB Services Maint, Account No. 3170196 SlNioe Code Rat@ Charge multiplier/users MI6CFEE ADMIN FEE 0.63618 7.62 1/ WTR WATER 01 ALL METER SIZE 45.60 /1 UB Meter Maintenance Account No. 3170196 Serial No status Location Brand Type size YTD Cons 35487183 a Adive ERT HH b Badger w Water 0.63 0.83 849 Date Reading Coda Consumption Posted Dale Variance 6!912016 880 a Actual 24 98% 3110/2015 856 a Actual 12 4126!2015 -41%, 12110/2014 844 a Actual 20 1115/2015 .84% 911212014 824 a Actual 130 10/15/2014 263%- 611112014 694 a Actual 35 711612014 153% 311212014 659 a Actual 14 411112014 -24% 1711012013 645 aActual 18 111712014 -67% 9111/2013 627 2Actual 137 1011512013 135% 611112013 490 aActual 57 7/24/2013 288% 311312013 433 a Actual 15 4/2212013 =10% 12!112012 418 aActual 16 1/912013 -81% 911412012 402 a Actual 89 10/1512012 130% 611112012 313 a Actual 37 71162012 14195 3112/2012 276 a Actual 15 4/1412012 -22% 12/14/2011 261 a Actual 20 1/17/2012 -77% 9113/2011 241 aActual 92 10/1312011 10% 518/2011 149 a Actual 79 7/202011 118% 318/2011 70 a Actual 35 4/1312011 111 % 1218/2010 35 a Actual 16 111212011 163% 911412010 19 f Final Bill 7 9/1412010 -61% 611/2010 12 a Actual 12 7115/2010 -10D% 4/2/2010 0 n New Meter 0 7/16/2010 -100% 412/2010 1350 r Replacement 5 7/15/2010 9% 311012010 1345 9 Actual 18 4114/2010 14% 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. rmS redan t5ins • 09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Asses: 85 Laconia Circle Property Address William Engstrom Owner's Name North Andover City/Town W_—An QT111 ents APR -6 2010 OF NORTH ANDOVER LTH DEPARTMFKuT MA 01845 3/26/2010 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 Citylrown 978-475-4786 Telephone Number B. Certification Ma State SI15 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 3/26/2010 41nspeorsWignature 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. %05-1 Z) — /SI:pl Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 P Owner information is required for every page. t5ins • 09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 Laconia Circle Property Address William Engstr Owner's Name North Andover City/Town B. Certification (cont.) MA 01845 3/26/2010 State Zip Code Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: After permit from B.O.H., pumped septic tank & install new d -box, inspection from B.O.H. , septic system now passes Title 5 Inspection. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 i Commonwealth of Massachusetts a City/Town of System Pumping Record w 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 1. System Location: Left side of hous Right sid , Left front of house, Right front of house, Left rear of house, Right rear of house. Left rear of building. Right rear of building. Address , r ^ / o City/Town State Zip Code 2. System Owner: Name Address (if different from location) Cityrrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): otaie Zip Code Telephone Number 3 Date 2. Quantity Pumped Cesspool(s) Septic Tank 0 5av Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes 9-9-0 If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: L�S.D `? j n Lowell Waste Water of t5form4.doc• 06/03 Date 10 7—!0 System Pumping Record • Page 1 of 1 4726 RT" 04 Town of North Andover HEALTH DEPA .... . RTM T CHECK 37 DATE - LOCATION: H/O NAME:.&��a CONTRACTOR NAME: Type of Permit or License: (Check box) 1-3 Animal $ 0 Body Art Establishment $ 0 Body Art Practitioner $ 0 Dumpster 0 Food Service - Type. $ 13 Funeral Directors $ 0 Massage Establishment $ 0 Massage Practice $ 0 Offal (Septic) Hauler $ 0 Recreational Camp $ 0 Sun tanning $ 0 Swimming Pool $ 0 Tobacco $ 11 Trash/Solid Waste Hauler 11 Well Construction $ SEPTIC Systems 13 Septic - Soil Testing $ 13 Septic - Design Approval $ 0 Septic Disposal Works Construction (DWQ $ ❑ Septic Disposal Works Installers (DWI) ❑ Title,51inspector JO'- 'Title 5 Report V 0 Other (Indicate) Health Agent Initialgi, l White - Applicant Yellow - Health Pink - Treasurer � z.7 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. VkA renes t5ins • 09108 i Commonwealth of Massachusetts R1CIVE Title 5 Official Inspection For XOR 19 Z Subsurface Sewage Disposal System Form - Not for Voluntary Asse me09 85 Laconia Circle TOWN OF NORTH ANDOVER HIZA1 TU INCCADTNACAIT Property Address William Engstrom Owner's Name North Andover City/Town MA 01845 State Zip Code 3/12/2010 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 or inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover City/Town 978-475-4786 Telephone Number n. toertlrlcatlon Ma State SI15 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 16.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needkignature valuation by the Local Approving Authority 3/12/2010 Inspe o s 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. Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 ✓0 Owner information is required for every page. t5ins • 09/08 v t• i ~ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 Laconia Circle Property Address William Engstrom Owner's Name North Andover MA 01845 3/12/2010 City/Town 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): Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 4 0 Owner information is required for every page. t5ins - 09/08 A,.. y A"- f. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 Laconia Circle Property Address William Engstrom Owner's Name North Andover City/Town B. Certification (cont.) B) System Conditionally Passes (cont.): MA 01845 State Zip Code 3/12/2010 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 ® N ❑ ND (Explain below): ❑ Y ® N ❑ ND (Explain below): ❑ Y ® N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 o Owner information is required for every page. t5ins - 09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 Laconia Circle Property Address William Engstrom Owner's Name North Andover Cityrrown b. uertlticatlon (cont.) MA 01845 State Zip Code 3/12/2010 Date of Insoection 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 -Box needs to be D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y day flow Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17 E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone 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. t5ins . ogros Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M ' 85 Laconia Circle Property Address William Engstrom Owner is Owner's Name required for required for North Andover MA 01845 3/12/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone 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. t5ins . ogros Title 5 Official Inspection Forth: 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 85 Laconia Circle Property Address William Engstrom Owner Owners Name information is required for North Andover MA 01845 3/12/2010 every page. CitylTown 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): 3 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 y` 85 Laconia Circle Owner information is required for every page. t5ins • 09/08 r i UNci Ly P%UUM55 William Engstrom Owner's Name North Andover utyrrown D. System Information Description: MA 01845 3/12/2010 State Zip Code Date of Inspection 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: 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? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ 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: 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 y< 85 Laconia Circle Owner information is required for every page. rroperty Haaress William Engstr Owner's Name North Andover City/Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: MA 01845 3/12/2010 State Zip Code Date of Inspection General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Date Pumped 2007 owner gallons ❑ Yes ® No Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): f5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Fi Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 Laconia Circle Property Address William Engstrom Owner's Name North Andover MA 01845 3/12/2010 Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 11 years old, 2/19/1999, certificate of compliance Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" 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 If tank is metal, list age: ❑ metal ❑ fiberglass 1 feet ❑ polyethylene ❑ other (explain) years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x 5'x 4' Sludge depth: 1" t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 Laconia Circle Property Address William Engstrom Owner Owner's Name information is required for North Andover MA 01845 3/12/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) 31" Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 8 15" Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet cover under cement patio, unable to see tee. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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: Date t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 Laconia Circle Property Address William Engstrom Owner Owner's Name required for is North Andover required for MA 01845 3/12/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): " Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 Laconia Circle tiroperry AooresS William Engstr Owner's Name North Andover MA Cityfrown 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 u 3/12/2010 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 cover broken & d -box partiality filled with sand. Removed sand & installed new cover. D -box badlty corroded , needs to be replaced. D -box not level & distribution not equal. More flow going to one trench. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments SV•,y 85 Laconia Circle vroperty Aaaress William Engstrom Owner Owner's Name information is required for North Andover MA 01845 3/12/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits ❑ leaching chambers ❑ leaching galleries ® leaching trenches ❑ leaching fields ❑ overflow cesspool ❑ innovative/alternative system number: number: number: number, length: 3 trenches 50' long number, dimensions: number: 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 • 09108 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17 Owner information is required for every page. t5ins • 09108 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 Laconia Circle Property Address William Engstrom Owners Name North Andover Cityrrown D. System Information (cont.) MA _ 01845 State Zip Code 3/12/2010 Date of Inspection 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.): Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Owner information is required for every page. t5ins - 09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 Laconia Circle rroperry Haaress William Engstrom Owners Name North Andover City/Town D. System Information (cont.) MA 01845 State Zip Code 3/12/2010 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 -�o Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 0 E Owner information is required for every page. t5ins - 09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 Laconia Circle Property Address William Engstrom Owner's Name North Andover MA 01845 _ 3/12/2010 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 4 feet Please indicate all methods used to determine the high ground water elevation: ►4 W 0 0 C Obtained from system design plans on record If checked, date of design plan reviewed: 7/15/1998 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: As per test pit data on design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M Svey`'Y 85 Laconia Circle E. Report Completeness Checklist 3/12/2010 Date of Inspection ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins - 09108 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 17 of 17 Property Address William Engstrom Owner Owner's Name information is required for North Andover MA 01845 every page. City/Town State Zip Code E. Report Completeness Checklist 3/12/2010 Date of Inspection ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins - 09108 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 17 of 17 Summary Record Card generated on 3/1712010 11:35:11 AM by Lisa Evans ti Town of North Andover Tax Map # 210-105.D-0152-0000.0 Parcel Id 17111 85 LACONIA CIRCLE ENGSTROM, WILLIAM & LINDA 85 LACONIA CIRCLE NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type Size Total 2.06 Acres FY 2010 UB Mailina Index Name/Address ENGSTROM, WILLIAM & LINDA 85 LACONIA CIRCLE NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Bldg Id. 17526.0 - 85 LACON IA CIRCLE 3170196 03 Cycle 03 UB Services Maint. Account No. 3170196 Service Code MISCFEE ADMIN FEE WTR WATER UB Meter Maintenance Account No. 3170196 Type Loan Number Active/Inact. From Payor Occupant Name Activelinactive Last Billing Date 1/4/2010 Active Rate Charge Multiplier/Users 0.635/8 7.82 1/ 01 ALL METER SIZE 60.80 /1 Serial No Status Type Size Location 44820968 a Active Consumption R ENC RT Date Reading Code 3/10/2010 1345 a Actual 12/10/2009 1327 a Actual 9/10/2009 1311 a Actual 6/8/2009 1294 a Actual 3/12/2009 1268 a Actual 12/8/2008 1247 a Actual 9/9/2008 1225 a Actual 6/5/2008 1198 a Actual 3/11/2008 1168 a Actual 12/10/2007 1149 a Actual 9/5/2007 1120 a Actual 6/15/2007 1081 a Actual 3/15/2007 1052 m Manual estimate 12/12/2006 1033 a Actual 9/12/2006 1014 a Actual Trouble Code:03 6/13/2006 997 a Actual 3/6/2006 954 a Actual Trouble Code:03 12/21/2005 934 a Actual 9/20/2005 910 a Actual Trouble Code:03 6/13/2005 876 a Actual 3/22/2005 852 a Actual 12/13/2004 823 a Actual Trouble Code:03 Brand Type Size w Water 0.63 0.63 Consumption Posted Date 18 16 1/12/2010 17 10/15/2009 26 7/20/2009 21 4/29/2009 22 1/20/2009 27 10/10/2008 30 7/16/2008 19 4/11/2008 29 1/22/2008 39 10/12/2007 29 7/20/2007 19 4/16/2007 19 1/19/2007 17 10/20/2006 43 7/10/2006 20 4/17/2006 24 1/17/2006 34 10/14/2005 24 7/15/2005 29 4/5/2005 32 1/14/2005 Page 1 1 Residential Until YTD Cons 159 Variance 14% -3% -39% 32% -9% -13% -19% 69% -32% -36% 51% 54% -2% 12% -57% 63% 2% -24% 19% Commonwealth of Massachusetts City/Town of System Pumping Record �Form 4 DEP has provided this form for use, by local Boards of Health. Other information must be substantially the same as that provided here. BE local Board of Health to determine the form they use. The System Pi the local Board of Health or other approving authority. A. Facility Information APR a 2 Z-214 your ;d to 1. System Location: Left / Right front of house, Left / Right rear of house, Left side of hous , Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address Lot City/Town 2. System Owner: Name Address (if different from location) Cityrrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ H State Zip Code State Telephone Number Date 2. Quantity Pumped: Gallons Cesspool(s) Septic Tank F1 Tight Tank ❑ Other (describe): Effluent Tee Filter present? ❑ Yes No If, yes, was it cleaned? ❑ Yes ❑ No: 5. Condition of System: t n I (% 6. System Pumped By.- Nell y: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatie 6 L S. s Sign a Hau t5form4.doc- 06/03 contents were disposed: Lowell Waste Water Date System Pumping Record • Page 1 of 1 11 Commonwealth of Massachusetts w City/Town of a System Pumping Record ` Form 4 SV 9 y Rec ivE NOV 12 2012 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 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 1. System Location: Left side of hous �rea—ro , Left front of house, Right front of house, Left rear of house, Right rear of houng. Right rear of building. Address �� �^ ���\� City/Town 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ State Zip Code Stat 2P414c Telephone Number 10�-(-iZ Date 2• Quantity Pumped Cesspool(s) Ej Septic Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No 5. Condition o; Syst� k av 6. System Pumped By Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: Qa.LAS. D n ,� Lowell Waste Water Of Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 S PUBLIC HEALTH DEPARTMENT Community Development Division C'�E127I�F'ICA7E OAF CO�VL<1'LIANCE As of: May 175 2010 ,This is to cert that the individual su6surface disposal system received a SAVYTACTORTINSPEMOYof the: 47&cement of a Oistri6ution Bo.� for an On Site Sewage�DisposaCSystem Bv• ToddBateson At: 85 Laconia Circle Map --105.0; Farrel -152 North .Andover, WA 01845 The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. , '?ZS an 2'. Sawyer, REJfSM Tu6lic Yfealth Director 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 918.688.9540 Fax 918.688.8476 Web www.townofnorthandover.com Rfio# Commonwealth of Massachusetts Map -Block -Lot 105.D0152 ' Board of Health ----------------------- Permit No a BHP -2010-0522 North Andover _______________________ P.I. FEE ^CNg�F F.I. $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd -Bateson to (Repair--D-BOX ONLY) an Individual Sewage Disposal System. at No 85 LACONIA CIRCLE as shown on the application for Disposal Works Construction Permit No. BHP -2010-052 Dated March -15,_2010 ------ C!, ____ -------------------- Issued On: Mar-l5-2GV--, t"- " .t Board of�Health,_ Important: When filring out forms on the computer, use only the tab key to move your cursor - do not use the return key. Q rein Application for Septic Disposal System /S— /o (Construction Permit-- TOWN OF TODAY'S DATE ORTH ANDOVER, MA 01845 $ 250.00 - Full Repair $125.00 - Component Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system* ❑ Repair or replace an existing on-site sewage disposal system* 5?6-pair or replace an existing system component - What? ® , 1�10 Y_ A. Facility Information FS Address or Lot # City[Town d � d Vt rt- 2.- L 2.- *TYPE OF SFPTIC SYSTEM*: ❑ Pump Gravity (choose one) ***Ifpump system, attach copy of electrical permit to application*** Conventional System (pipe and stone system) ❑ infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system. El Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D -Box Present) S.A.S. 2. Owner Information Name �r`//� �r/a� 5 /re' -1 T x- 1-4- e-oN R- L r -A- Address Address (if different from above) Cityrrown State Zip Code ?�Fl Telephone Number 3. Installer Information Name Name of Com WON ENTER-PRISES, INC. 111 ARGIU-A ROAD Address Cityrrown 4. Designer Information Name Aaaress Cityrrown state Zip Code Telephone Number (Cell Phone # if le please) Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit - Page 1 of 2 °R Application for Septic Disposal Svstem 3-13--/10 ` �� o_:+ •.'� • o� ' pConstruction Permit - TOWN. OF TODAY'S DATE , MA 01845 $ 250.00 - Full Repair ORTH ANDOVER $125.00 -Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building:esidential Dwelling or ❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation until a Certificate of Compliance has been issue this Board of Health. Name Date Applicati Approved By oard of Health Representative) Zation Date Disapproved for the following reasons: For Office Use Only: I Fee Attached. Yes No 2. Project Manager Obligation Form Attached. Yes No 3. PumpS sv tem? If so. Attach copv of Electrical Permit Yes No 4. Foundation As -Built. (new construction ronly): Yes No (Same scale as approved plan) 5. Floor Plans? (new construction only): Yes No Application for Disposal System Construction Permit - Page 2 of 2 ,r SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: gs Are-"t'v r',9 cC'2 (Address of septic system) Relative to the application of -/." ZA40- 5,/_� (Installer's name) Dated o ay s ate For plans by (Engineer) And dated With revisions dated I understand the following obligations for management of this project: 1. 2. 3.` 11 5. ngnia date). (Last revised date) As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. As the installer, I must call for any and all inspections. If homeowner, contractor, project manager, or any other .person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion. of the items in accordance with Tide 5 and the Board of Health Regulations may result in a $50.00 fine beinglevied against me and/or my company , a. Bottom of Bed- Generally, this is the first (15) inspection unless there is a retaining wall, which should be done.. first The installer must request the inspection but does not have to be present. b. Final Construction Inspection — Engineer must first do their inspection for elevations, ties, etc. As -built of verbal OK (or e-mail to: healthidept(Itownofnorthandover.com) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system, all electrical work must be ready and able to cause pump to work and. alarm to function. c. Final Grade — Installer must request inspection when all grading is complete. Installer does not have to be on-site. As the installer, I understand that only I may perform the work (other than simple excavation) and I am required to complete the installation of the system identified in the attached application for installation..I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or:revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible As the installer, I understand that must be on-site during the performance of the following construction_ steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board ofHealth staff or consultant. d. Installation. of tank, D -Box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer. I understand that I am solely responsible for the installation of the system as per the apl2roved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersigned Ikensed Septic Installer: (Today's Date) e TOWN OF NORTH ANDOVER Noerp °�gt�eo°q'i Office of COMMUNITY DEVELOPMENT AND SERVICES o - HEALTH DEPARTMENT73 1600 OSGOOD STREET; Building 2-36 . 4. NORTH ANDOVER, MASSACHUSETTS 01845 Susan Y. Sawyer, REHS/RS Public Health Director NSITE 11 LOCATION INFOR ATIO ADDRESS: � LOT: INSTALLER: DESIGNER: 4�0�0 PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS D— /l©l TANK INSPECTION: /� DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: SEPTIC TANK 978.688.9540 — Phone 978.688.8476 — FAX []Existing septic tank properly abandoned ❑Internal plumbing all to one building sewer ❑Topography not appreciably altered ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading Monolithic construction ❑ Water tightness of tank has been achieved (Visual or Vacuum Test or Water held for 24hrs) ❑ Inlet tee installed, centered under access port ❑ Outlet tee (gas baffle or effluent filter) installed, centered under access port ❑ 24" inch cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present ❑ Hydraulic cement around inlet & outlet Wastewater System Documentation — Feb 2006 Page 1 of 6 TOWN OF NORTH ANDOVER o� aoRr„ q Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT p 1600 OSGOOD STREET; Building 2-36 NORTH ANDOVER, MASSACHUSETTS 01845"SSAC NUses`h Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ Combo Tank installed. Size: ❑ 1000 gallon Pump Chamber installed H-10 loading Monolithic construction) ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ 24" inch cover to within 6" of final grade installed over pump access port ❑ Water tightness of tank has been achieved Visual testing ❑ Hydraulic cement around inlet & outlet Comments: ADVANCED TREATMENT TECHNOLOGY ❑ Type of treatment device: Comments: ❑ Installed per manufacturers requirements ❑ All components working in accordance with manufacturer's requirements Wastewater System Documentation — Feb 2006 Page 2 of 6 TOWN OF NORTH ANDOVER F NORTH eO Office of COMMUNITY DEVELOPMENT AND SERVICES 3�°°`l °`'� °0 HEALTH DEPARTMENT 1600 OSGOOD STREET; Building 2-36 "+ �4 ," ► NORTH ANDOVER, MASSACHUSETTS 01845 "Ssp�H„5kt`h Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 97 688.8476 - FAX D -BOX Installed on stable stone base�'� ❑ Inlet tee (if pumped or >0.087foot) Hydraulic cement around inlet & outlets Observed even distribution Speed levelers provided (not required) Comments: SOIL ABSORPTION SYSTEM ❑_ Bott m of SAS excavated down to soil layer, as provi d on plan ❑ Size o SAS excavated as per plan ❑ Title 5 and installed, if specified on plan ❑ 3/4-11 , double washed stone installed ❑ 1/8-1/2" (peastone) double washed stone installed ❑ Laierals installed and ends connected to header ❑ Laterals vented if impervious material above ❑ Orifices @ 5 & 7 o'clock positions ❑ Gravel -less disposal systems: type, number and location as per plan ❑ Elevations of laterals installed as on approved plan ❑ 40 Mil HDPE barrier installed ❑ Retaining wall (boulder / concrete / timber/ block) ❑ Final cover as per plan Comments: Wastewater System Documentation — Feb 2006 Page 3 of 6 TOWN OF NORTH ANDOVER ,10 T Office of COMMUNITY DEVELOPMENT AND SERVICES0 HEALTH DEPARTMENT 0 A 1600 OSGOOD STREET; Building 2-36 NORTH ANDOVER, MASSACHUSETTS 01845 SACHUSE Susan Y. Sawyer, REHS/RS978.688.9540 — Phone Public Health Director 978.688.8476 — FAX PRESSURE DISTRIBUTION ❑ -- inch manifold ❑ laterals installed with end sweeps size: material: ❑ Squirt test ft in height ❑ Equal distribution to all laterals ❑ orifice size inch as per plan Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: ❑ Rated for exterior if placed outside Comments: Wastewater System Documentation — Feb 2006 Page 4 of 6 TOWN OF NORTH ANDOVER NORTH Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 1600 OSGOOD STREET; Building 2-36 P «' NORTH ANDOVER, MASSACHUSETTS,01845 �'"ssgrmuse�t� Susan Y. Sawyer, REHS/RS 978.688.9540 - Phone Public Health Director 978.688.8476 — FAX CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Wastewater System Documentation — Feb 2006 . Page 5 of 6 Tank SAS Sewer ❑ Property line 10 10 -- ❑ Cellar wall 10 20 -- ❑ Inground pool 10 20 -- ❑ Slab foundation 10 10 -- ❑ Deck, on footings, etc 5 10 -- ❑ Waterline 10 10 101 ❑ Private drinking well 75 1002 50 ❑ Irrigation well 75 100 ❑ Surface Water 25 50 ❑ Bordering Vegetated Wetland , Salt Marsh, Inland / Coastal Bank' 75 100 ❑ Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ❑ Trib. to surface water supply 325 325 ❑ Public well 400 400 ❑ Interim Wellhead Prot. Area ❑ Reservoirs 400 400 ❑ Drains (wat. supply/trio.) 50 100 ❑ Drains (intercept g.w.) 25 50 ❑ Drains (Other) Foundation 10 (5) 20 (10) ❑ Drywells 20 25 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Wastewater System Documentation — Feb 2006 . Page 5 of 6 TOWN OF NORTH ANDOVER o4 NORTH q Office of COMMUNITY DEVELOPMENT AND SERVICES 4' HEALTH DEPARTMENT 1600 OSGOOD STREET; Building 2-36 NORTH ANDOVER, MASSACHUSETTS 01845 �9SsgcNusE��y Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX SYSTEM ELEVATIONS Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 HIGH Lateral 1 LOW Lateral2 HIGH Lateral 2 LOW Lateral 3 HIGH Lateral 3 LOW Lateral 4 HIGH Lateral 4 LOW Lateral 5 HIGH Lateral 5 LOW INVERT ON DESIGN PLAN FIELD INVERT ELEV. Wastewater System Documentation — Feb 2006 Page 6 of 6 i Aj AS-13UIL'f CIILCKI..ISI' l/ LOT NUMBER, STREET NAME ASSESSORS MAP & PARCEL NUMBER LOT LINES & LOCATION OF DWELLINGS c% LOCATION & DEMENSIONS OF SYSTEM, INCLUDING RESERVE TIES TO LOT LINES & DWELLING, -a. FROM SEPTIC TANK f �. FROM LEACH AREA v LOCATIONS OF DEEP HOLES & PERC li TESTS ELEVATIONS OF DISPOSAL SYSTEM � TOP OF FDN ELEVATION LOCATIONS OF WELLS, RAINS, WATERCOURSES W/IN 150' OF SYSTEM V)E:06. Cv2 W15T—LAPZ. Loc (OCATION OF WATER, GAS, ELECTRIC LINES, CABLE COCA II -D 0)-1 OF HO(JSE�:- FIZ4t-1 DISTANCES FROM CORNERS OF HOUSE TO CENTER40F TANK & D -BOX v STAMP & SIGNATURE (D" (fI=z ) f l/ IMPERVIOUS AREAS - DRIVEWAYS, ETC. Stiowi-( App NORTH ARROW v FINAL CONTOURS LOCATION & ELEVATION OF BENCHMARK USED _ LOCUS PLAN (3EE PSD-�,w—S'S) 'T IN OF NOR' H ANDOVER/ BOARD OF HEALTH FEB 19 FA TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE: February 19, 1999 This is to certify that the individual subsurface disposal system constructed ( X ) or repaired ( ) by Peter Breen at 85 Laconia Drive (lot 32A), North Andover, MA 01845 has been installed mi accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations as described in the Design Approval Site System Permit # 988-4 dated 8/3/98. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. �•r Board of Health Inspector f NORTH -600 IAM A CMUSE� Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 3 /1�Le',.' / Z 19 '� F DISPOSAL WORKS CONSTRUCTION PERMIT Applicant Its. NAME e- e_i )DRESS EL Site Location___ � Z Z+ , L Permission is hereby granted to Construct (X or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System 0<) constructed; ( ) repaired;- by epaired;by RFTIER f3FE:QQ located at g5 Me-Ok l ft b,2 i vE T M, I -D -T:2.. was iustalled M conformance with the North Andover Board of Health approved plan, System Design Ferwit #' dated 3 with an approved design flow of LNO .gallons per day. The materials used were in eonfommce with those specified on the approved plan, the system wa& installed in accordance with tate provisions of 310 CMR 15,000, Title 5 and local regulations, and the final grading agrees substantially with the approved plan, All work is 'accurately represented on the As -built which has been submitted to the Board of Health. Installer Design Engineer: ljoTrr 51 Lie. #: Date: 1Tw- Date: 2-1 SE�D(�li T -Q -TA iZ, RAG� kllfEl-t CoLtD lTto�.( S n Fn r APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: CURRENT INSTALLER'S LICENSE# _ LOCATION: 4 3Z�t C d ,,7 /a LICENSED INSTALLER: SIGNATURE:— `�L% ' 1 TELEPHONE# 6 % 22 CHECK ONE: NEW CONSTRUCTION: v IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. Administrative Use Only $75.00 Fee Attached? Yes No Foundation As -Built? Yes No Floor Plans? Yes No J-. Approval Date: l� �� et s w)-Af lC� mo tjG 5y5rc' G , 7-0 D rf�GJr�-1 �UCC%b 7 w i r ri c FEB. -25' 98 (VIED) 12148 FEB -24-98 TUE 11:37 A 11 REMAX TOP ACHIEVERS TEL:617 944 1592 BROOKS INTERIORS FAX NO, 508988248 7c BOARD OF HEALTH P. 002 P. 02 MAR25 , 30 SCHOOL STREET TEL 588-954.0 NORTH ANDOVER, MASS. 01845 APPLICATION FOR SOIL TESTS DATE. LOCATION OF SOIL TESTS: Assessor's map & parcel number. C.�1.- OWNER: BK(r�ba �cal.t" TEL. NO. ('017 ` 70 `7 - ~% /,o✓?' ADDRESS: �o mail pa RV -G ShLivi, Rot. 62 O6 7 ENGINEER; TEL. NO.: CERTIFIED SOIL EVALUATOR: intended use of land: residential subdivision, single family home, commercial THE FOLLOWING MUST.BE INCLUDED WITH THIS FORM: — 1, Proof of land ownership (Tax bill, deed, or leiter from owner permitting tests) Plot plan [ / L/"3. Fee of $175.00 -per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area- Fee of $75.00 per lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections - 2. Only Mass, Registered Sanitarians and Professional Engineers can design septic plans. 3- At least two deep hales and *two percolation tests are required for each septic system disposal area, 4. Repairs require at least two deep holes and at least one pen=labon test, at the discretion of the 80H representative. 5. Full -payment *0. be required for all additional tests within ty co weeks of testing_ Wr 8_ thin 45 days of testing, a scaled plan (no smaller than 1'-"00') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 80 days of testing soil evaluation forms shall'be submitted. 60 'd 5LOL6PL 'ON XVd (NIdW)NVWdNNIIH CV 20 INH 86 -LZ -83.9 Town of North Andover F NORTH OFFICE OF �� ° ""`o ° • 0 L COMMUNITY DEVELOPMENT AND SERVICES p « , 30 School Street North Andover, Massachusetts 01845 � ,° WII-1 M J. SCOTT SAC HU Director August 31, 1998 Merrimack Engineering Services 66 Park Street Andover, MA 01810 RE: 32A Laconia Circle Dear Les: This letter is to inform you that the proposed septic plans for 32A Laconia Circle have been approved. If you have any questions, please do not hesitate to call the Board of Health office at the number below. Sincerely, --- r z'z" Sandra Starr, R.S. Health Administrator CC'. Bill Engstrom File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 n FORK? i I - SOIL EVALUATOR FORM Page 2 On-site Review 9 Deep Hole Number .'.q .. Date: �.� .`fig Time: 1D..:'..30..AM Weather 90......Su.,sti Location(identify on site pian)......KJ=...11--........................................................................................................................................r....... Land Use JC. -.D .0t`.1......M?........... Slope M ....Z........ Surface Stones ..'`(A..h1.y...........................................I........... Vegetation., WCb.®....................................................................................................................................................................:..................................... Landform....t'.:1#M1.kfl�...................'...........................................................................................................................................'........................................ Position on landscape (sketch -on the back) ... lk-l........ AFP.RS..LQ!........................................................................ ...................... Distances from: Open Water Body 400..t. feet Drainage way ... i'.C.Q..t feet Possible Wet Area 1.00.+ feet Property Line ...SD..... feet Drinking Water Well .NIA....... feet Other ..................................... EP, OBSERVATION HOLE LOG Depth from Surface (Inches) Soil Horizon Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other (Structure, Stones, Boullers, Consistency, % Gravel) a„ .511- 2W, R, F 5:./-. 10YfZIVY -014 wyeq& I��„ C V,��v ��s�rsl�{ SYyr/3 F ti iu P�+cr- b p S' L 30°,0 �e�&� Lu HAA] 7, SY)Z ,qk s0 a e�881:a: I jD�°ro Parent Material (geologic) ....��G4:G( ....,TfL..................................................... . Depth to Bedrock: ... ..--........... r, Qepth to Groundwater: Standing Water in the Hole: 16....... Weeping from Pit Face:. 7.�..... Estimated Seasonal High Ground Water:.l.. , 11 4� FORM 11 - SOEL EVALUATOR FORM Page 3 Determination for Seasonal High Water Table Method. Used: ❑ Depth observed standing in observation hole inches ❑ Depth weeping from side of observation hole ................... inches [0 Depth to soil mottles .... d... inches ❑ Ground water adjustment --.- 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 all areas observed throughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurring pervious material? Certification ' I certify that on 1.3aJP> (date) I have passed the 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 7-28-78 Al -,Co �o�C, �VALvAToQ : w�C�rA� Dsu� FORNI 12 - PERCOLATION TEST COMMONWEALTH OF MASSACHUSETTS j`1oM AksWuE5Z, , Massachusetts m Site Passed ® Site Failed ❑ ........................................................................................................................ Performed By: C,E� 60D16 Witnessed By: CA)�tbQA STAB-� Comments:...... ..........f�.C. ........I ST .....CO r.Dv "j ........ .-2.......-........ . ............................................... �/&-^ q DATE: 7 LCCA T ION: E—NGINEEP.: 50H' VVI I NIHS. rE: ,COL�TION TEST ;KT -70M DEPTHOF PLRC TEST: 3 /------ TIME OF SOAK: _ ! �p� (,Az legis 15ire -s Icnc; TIME :,T i TIMEAT9" TINILE- AT • l • t Tr7 W4, Nil 94. WT pi q, C� At iF, JO Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES viffiu" J. SCOTT Director December 18, 1996 Merrimack Engineering 66 Park Street Andover, MA 01845 146 Main Street North Andover, Massachusetts 01845 Re: Lot 32A Laconia Circle To Whom it May Concern: This is to inform you that the proposed plans for the site referenced above have been disapproved for the following reasons: 1. Wetlands disclaimer missing. (N.A. 6.020) 2. Benchmark within 75 feet of system missiong. (3 10 CMR 15.220q) 3. No foundation drain shown. (N.A. 6.02v) 4. Elevations of perc tests missing. (N.A. 6.02j) 5. Missing limit of A & B excavation on site plan. (N.A. 6.02x) 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 '6 BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 p .t No. * TOWN 0F 9Q_�RO IR ,► ,, 11 14 1996 11 - SOIL EVALUATOR FORNI Page 1 Date...�..�..""W Comn oon,wealth-ofT.Massach-usetts NveiN A wNvEfz , Massachusetts Soil Suitability Assessment for On-site Sewage Disposal Performed By:. .t 1.A.M...... A.u.Fi ZS.". E .... ............................. ...2,.--) _....................... Witnessed By: .... SA M DRAc...... S?"R 1Z.1Z ... ................................................................................................................................................................................................................................................................... Location Address or *0-5 LAC -0" iA c:. i IZGLE. o --'-N--. BOfzcR JooD $tJi w5P,S �� Telephone M 3.5-0 MASSR ROA4 AY a. HAV -6" , HA, 6Zo67 60-7941-7oi0 New Construction Pr Repair ❑ Office Review Published Soil Survey Available: No ❑ Yes Year Published ... Publication Scale V'J.50y0 Soil Map Unit Sh..F (. diTLATIE) Drains a Class Soil Limitations 51rV�C W... ..................................................................... Surficial Geologic Report Available: No Rr Yes ❑ Year Published Publication Scale GeologicMaterial (Map Unit)........................................................................................... Landform................................................................................................................................................ Flood Insurance Rate Map: Above 500 year flood boundary No ❑ Yes Within 500 year flood boundary No Yes ❑ d Within 100 year flood boundary No Yes ❑ Wetland Area: National Wetland Inventory Map (map unit) . ".....5.►-`F....DSL►. A.�'j.oti,l.................. Wetlands Conservanc Pro ram Ma (ma unit) Yg P p................................................................................................... Current Water Resource Conditions (USGS): Month 7..-14' Range : Above Normal ❑ Normal Z"' Below Normal ❑ Other References Reviewed: V, _".6.S j-7APS N oP•1*3 D.P, *Li FORM II - SOIL EVALUATOR FORM Page 2 On-site Review Deep Hole Number .3.t.14 ...... Date:7-4.9..-q(v Time: . f,!f1.! Weather 7V.....G �Y.... Location (identify on site plan) .... S -W..... kl-&W.......................................................................................................................... .................... Land Use 5t,U(A ...FA.-tl!.... H. QiAia Slope (%) ...... 57..... Surface Stones...N(.AJ,.i../Y ........................................................ Vegetation....(....).Ohl! p................................................................................... ................................... .................................................................... .......... Landform......1...wl.L.f.h.l............................................................................................................ Position on landscape (sketch on the back) ....5956 .... P"N............................................................................................. Distances from: Open Water Body ..... I Q.1' feet Drainage way.1.00.47 feet Possible Wet Area feet Property Line .2.S1' feet Drinking Water Well.�.Oi?..t.. feet Other ........ ............................. DEEP OBSERVATION HOLE ZO Depth from Surface Soil Horizon Soil Texture Soil Color Soil Mottling Other (Inches) (USDA) (Munsell) (Structure, Stones, Boulders, Consistency, % Gravel) ' t 3 I2" �w CtF-AU.LtS, Z. SySAl — FR�ss,Le,, FQrABL P1ASslty= F�2r1 [Woo Y, Sq, Bavt��lL$ 66'!- „ )b>j C2 V-69AL/. s�i Lt e- -713 P1ASSfvF, FreNA �•t..S� SSIRy2 Ot 611AV L.S. Z•SY Y-11 `- MASStt.F, Fant -t S �/u C,-+ 884 Es �, v, GRt�V. S-'/sl3 r-,Assr�, F+ar� I_.s. C-"/, COGaJES ?G''- 106' C.Z � RAV. Sysly et pox � ?y It V-1ASS1 �I<r, Flea) 1©% 6(ZAU. 1oylZylLo Parent Material (geologic) ...... 7Rw........................................................................................ Depth to Bedrock: l 't loo"--- Depth to Groundwater: Standing Water in the Hole: NgWEIPMA Neeping from Pit Face: NQ47 et 2" Estimated Seasonal High Ground Water: ]6`/,7y` FORM 11 - SOIL EVALUATOR FORM Page 3 Determination for Seasonal High Water Table Method Used: ❑ Depth observed standing in observation hole ............... inches ❑ Depth weeping from side of observation hole ................... inches Depth to soil mottles7.6 inches ❑ Ground water adjustment feet Index Well Number .......777.. Reading Date ......... Index well level ................... Adjustment factor ......'....... Adjusted ground water level...........7........................................ Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? Yffs If not, what is the depth of naturally occurring pervious material?. `— Certification I certify that on --7— q&(date) I have passed the examinatiorf 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 to ��W 0 FORA? 12 - PERCOLATION TEST COMMONWEALTH OF MASSACHUSETTS OF—T-H A kZow5z , Massachusetts Percolation Test Date:....... T-. �1.....g1,o Time:........ :.. .......,...... Observation Hole # Depth of Perc Sb „_ S7 „ Start Pre-soak 2'0Lf End Pre-soak 2:Z� Time at 12" 2�Z1 Time at 9" Time at 6" 3`v Time 19"-61 20 H I" Rate Min./Inch Site Passed 5 Site Failed ❑ Performed By: LF—S CQOA I N Witnessed By: SA �jbVA STFiR 2 Comments:..5:.......V..O.v.s.........1'.5.........`�g................................................ i of DATE DEC. / 71 /M BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW Sheet of FEE A-Ia6 PERMIT # DATE RECEIVED Al L), /t /9q� APPLICANT �E�C,S��p0j�JLJ��c��S ASSESSOR'S MAP /�///J GA���� �A PARCEL # ADDRESS 36-0/L%,¢�SA!'o/�l' VC po'{dlo 7 LOT # 3��4 STREET # ENGINEER ,%2,e%dl�4C,� /60D1A) ADDRESS/i/,) O (/&,�Z PLAN DATE 8�aZ7196 REVISION DATE CONDITIONS OF APPROVAL: APPROVED DISAPPROVED L(J�r�,s��p 5 /s c � ,¢ llz/ /%iss�•uG (/v /9 � c/0 -6a 0) C%dZ, �E.vG�u/lJi9 ek /Thi/dJ '7S D� 5YS7-,s/L/ M/55 /AJ G � . Na T-oc�,v D.�r%o •c� �,�-� ��v s�ou�v , � /11, /�- � , G� U� Q �� . �G� U/�T/D /1,�� p ` /�" �.�'c T�5T.5 /�J/S 5 /�C/C �✓l/, R Co • Gni `J VA Ti a,U p AJ s lTc PLAN REVIEW CHECKLIST ADDRESS �bT /� �,g�p�1,4 �'ENGINEER GENERAL 3 COPIES L� STAMP -e—_----, LOCUS L--� Nn, RTH ARROW �� SCALE L/ CONTOURS �� PROFILE L/ SECTION BENCHMARKS SOIL & PERCS .�<=ELEVATIONSk WE DISCLAIMERZ WELLS & WETS WATERSHED? ��//' / A /v0 DRIVEWAY ev)„ WATER LINEl- FDN DRAIN SCH40 L,"" TESTS CURRENT? L-' SOIL EVAL SEPTIC TANK / MIN 1500G �17 INVERT DROPy / / GARB. GRINDER�(2 comps +200) 10' TO FDN �/ MANHOLE L, ELEV GW'� )# COMPS. j GB D -BOX SIZE ## LINES FIRST 2' LEVEL STATEMENT INLET /0 9. /9 - OUTLET /04 97 _ ---,/7 ( 2" OR .17 FT)' TEE. REQ' D? _/ -I LEACHING MIN 440 GPD?`' RESERVE AREA 4' FROM PRIMARY?l/ 20 SLOPE 100' TO WETLANDS ✓ 100' TO WELLS 4' TO S.H.GW 6/ (5'>2M/IN) 20' TO FND & INTRCPTR DRAINS L--' 400' TO SURFACE H2O SUPP 4' PERM. SOIL BELOW FACILITY 00 MIN 12" COVER FILL?' (15') BREAKOUT MET? v TRENCHES MIN 440 gpd _ SLOPE (min .005 or 611/100')�� SIDEWALL DIST. 3X EFF. W OR D (MIN 61 RESERVE BETWEEN TRENCHES? C/ IN FILL? MUST 2/ BE 10' MIN. 4" PEA STONE?.V ENT?- &I----(>31 COVER; LINES >501) BOT 4q -J—+ SIDE_ L3� X LDNG = TOT 7 ( L x W x ## ) ( DxLx2x## ) ( G/ f t2 ) Copyright 0 1996 by S.L. Starr .. - B K 2197 U""CNU"M DY@CLAIN D® •HOW MON (INDWIDYAL) WI is + . We, Z. RICHARD WYSOCKI and BARBARA WYSOCKI, husband and wife, .J1L of North Andover, Essex �N County, ASassazfiusetts, xtaeingcxxwetuibat, for consideration paid, and in full consideration of ONE HUNDRED THOUSAND DOLLARS ' ($100,000.00) grant to Beachwood Builders, Inc., a corporation duly established ° under the laws of Massachusetts, having its usual place of business yt at 350 Massapaog Avenue, Sharon, Massachusetts with qutt&1M "Ecurmb [Description and enn mbnaas, if any) v 1 A certain parcel of vacant land situated on the northwesterly side of Laconia Circle so-called in North Andover and being shown as Lot 8 on Sheet 3 of Plan bntitled Definitive SubdivJsion Plan of "Equestrian Estates" located in North Andover,' Mass. Equestrian Estates Associates Realty dated January 3, 1985, revised April 18, 19859 Thomas E. Neve Associates, Inc., Engineers, said pian being recorded in Essex North District Registry of Deeds as Plan No. 9857. w Said Lot 8 is more particularly bounded and described as follows: y SOUTHWESTERLY a total distance of 150 feet by the northerly -�+ Az line of Laconia Circle so-called; WESTERLY a distance of 320.87 feet by Lot 7;- 6d 0 NORTHERLY a distance of 150 feet by a portion of Lot 9A; q and C d NORTHEASTERLY a distance of 289 feet by Lot 9; E: a All as shown on said plan. fLw Containing 43,857 square feet'more or less, or 1.01 acres, as shown on "iZo said plan. . is Together with the right to use said Laconia Circle for all purposes for which so streets are used in the Town of North Andover. M c Subject to the right reserved by Kenneth Hyde, Jr., Development Corporation -+ et al to approve any construction and site plans on said Lot 8 as more particularly set forth in deed of Kenneth Hyde, Jr. Construction et al to Z. Richard Wysocki I� et ux dated April 25, 1985, and recorded in said Registry, Book 1977, Page 79. Being a portion of the premises conveyed to us by said deed of Kenneth Hyde, Jr. Construction et al dated April 25, 1985, recorded in said Registry, Book 1977, 6.. Page 79. 10ttnres .... QUC.... hand 3 and seal s this ........ gA.§t............ day of....... k.......................19...P4 `.......................................................................... I Z�c tw� J ley o " .......................................................................... Z °ham d.:WYSOj .........:.....'............... arbara Wysocki ........................................................................... Essex ix4r G10ttttttatutita4 at 910MUIPULttie i ss. May 21 1986 V Then personally appeared the above named Z. Richard Wysocki and Ba ara Wysocki and acknowledged the foregoing instrument to be their FK bef i G { ::TTS :#j��NCM412 -�2 2 8.0 0� ,ecorded tray 22,1986 at 1:2Ptl #1396 �a o e I ................................................ ............................ David F. Bernardin - woof, 8t k*XyA 7Q6X*A*U1(X W comm"M epim November 10 19 89 z. I �a £0 'd 88,2235 I. Richard J. Kimall. Trusts& of Mainline Development Realty 'Cruet. under " Declaration of Trust dated October 1. ?585. recorded with Essex North District FROM of Deeds, of Lawrance, Essex County. MA In conalderetion of 1IQ0.000.00 grant to Beactmod Builders, Inc., a Massachusetts corporation. of 350 Massapoag Street, Sharon, MA With quttrIaim roornunts tholand in North Andover. Essex County, Nd9sdchutetta And being shown as Lot 32-A on a plan of land entitles "Plan of Land in North Andover, Mass. e!1owing lot line changes prepared for Equestrian Estates Associates Realty Trust, Kenneth Hyde 6 William lannaaai (Trustees) dated July 1, 1985• revised July 10, 1985" and recorde, with Essex North District Registry of Deeds as Plan No. 996I. Containing 89,821 square feet more or less according to said pian. With the right to use said Laconia Circle, in Common with others, for all purposes which streets are now used in the Town of North Andover. The within lot in hereby conveyed subject to easements, restrictions and condition Of record insofar as the acme are in force and applicable, but not intending to impose Che same anew. Subject to the reservation that Equestrian Estate Associates Realty Trust has the right to approve any and all construction and site plans on said lot 32-A. Further subject to Equestrian Estates Associatea,Realty Trust reservation to grant permanent conservation restrictions or covenants for all wat-land areas and etorag ponds as act forth in the Order of Conditions recorded at Essex North District Registry of Deeds400k 1960, Page 152. Subject to a power line easement to New England Power Company as shown On said PIs and subject to the further restriction of running parallel driveways, septic system Poole, sheds, fences or any other type of temporary or permanent structure within said easement linea. subject to a common driveway covenant affecting Lots 29-A. 30-A and 92-A as shown On said afore -mentioned pian. Subject to a drainage easement ea shown oa said &gore -mentioned plan. Being the same premises conveyed to Mainland Development Realty Trust by Deed of Richard J. Kimell, dated January 15, 19860 recorded with Essex North Registry of Deeds, BookAJJ1Pago.l.oy . r " [Ot1,fnOt�tiVEAIT�t Of MASSACHUSETTS r PB ltg06 till •� 67 9LOLUL 'ON M (N I M MINNAH ZP 20 IM 86 -LZ -83. 'ENUE MW_ IL i BK2235 3 I, Richard J. Kimell, Trustee of Mainline Development Realty Trust, under Declaration of Trust dated October 1, 1985, recorded with Essex North District y of Deeds, of Lawrence, Essex County, MA � w�ac�ca�y�Xuica�>SISYa�X In consideration of $100,000.00 grant to Beachwood Builders, Inc., a Massachusetts corporation, of 350 Massapoag Street, Sharon, MA with quttrlatm rournants the land in North Andover, Essex County, Massachusetts and being shown as Lot 32-A on a plan of land entitle) "Plan of Land in North Andover, Mass. s%owing lot line changes prepared for Equestrian Estates Associates Realty Trust, Kenneth Hyde b William Iannazzi (Trustees) dated July 1, 1985, revised July 10, 1985" and records with Essex North District Registry of Deeds as Plan No. 9961. Containing 89,821 square feet more or less according to said plan. With the right to use said Laconia Circle, in common with others, for all purposes which streets are now used in the Town of North Andover. The within lot is hereby conveyed subject to easements, restrictions and condition of record insofar as the same are in force and applicable, but not intending to impose the same anew. Subject to the reservation that Equestrian Estate Associates Realty Trust has the right to approve any and all construction and site plans on said lot 32-A. Further subject to Equestrian Estates Associates.Realty Trust reseryation to grant permanent conservation restrictions or covenants for all wet -land areae and storage ponds as set forth in the Order of Conditions recorded at Essex North District Registry of Deeds,Book 1960, Page 152. Subject to a power line easement to New England Power Company as shown on said Plan, and subject to the further restriction of running parallel driveways, septic system , pools, sheds, fences or any other type of temporary or permanent structure within said easement linea. Subject to a common driveway covenant affecting Lots 29-A, 30-A and 32-A as shown on said afore -mentioned plan. Subject to a drainage easement as shown on said agore-mentioned plan. Being the same premises conveyed to Mainland Development Realty Trust by Deed of Richard J. Kimell, dated January 15, 1986, recorded with Essex North Registry of Deeds, Book d/JYPage sof . r " �A� COMMONWEALTH OF MA"'AfCHUSET77TS 1�7`�I.J LfS (`� Z I`Jtl\II•. '`J N -�— N aur -res v. o PX UOOt l._�—J �A� Essex, ss. October 24, 1985 Then personally appeared the above named Kenneth Hyde, Jr., President and William J. Iannazzi, President and acknowledged the foregoing instrument to be the free act and deed of Kenneth Hyde, Jr. Development Corporation, Trustee and William J an azzi velopment Corporation, Trustee respectively as aforesaid, efore e Notary Pub is My commission expires: 2��0rrie1 Oct -<<,1935 at 4:28PM #25273 'r BK2O68 KENNETH HYDE, JR., Development Corporation and WILLIAM J. IANNAZZI, 9 1 +x. Development Corporation, Trustees of Equestrian Estates Associates Realty Trust, under a Declaration of Trust dated January 4, 1985 and recorded with Essex North District Registry of Deeds in Book 1914, Page 186. for consideration paid and in full consideration of $90,000.00 grants to Beachwood Builders, Inc., a Massachusetts corporation having .v. an usual place of business at 350 Massapoag Avenue, Sharon, Massachusetts WITH QUITCLAIM COVENANTS The land in North Andover, Essex County, Massachusetts and being shown as Lot 23-A on a plan of land entitled "Plan of Land .in North Andover, '= Mass. showing lot line changes prepared for Equestrian Estates Associates Realty Trust, Kenneth Hyde & William Iannazzi (Trustees) dated July 1, yc,c".... 1985, revised July 10, 19851 and recorded with Essex North District _•: > Registry of Deeds as Plan No. 9961. Containing 137,477 square feet more +x w or less according to said plan. Yrt a There is reserved from the above described land the fee inE uestrian Drive as it abuts said lot but grants to the grantees the right to use, a said Equestrian Drive for ail purposes for which streets are used in the N,+ Town of North Andover. du -Y.. Cr U)z The within lot is hereby conveyed subject to easements, restrictions: u and conditions of record in so far as in force and applicable. a �ro N y The Grantor herein, hereby reserves the right to approve any and all construction and site plans on.said.Lot 23-A on said plan. 0 a Grantor reserves the right to grant permanent conservation restrictions -v or covenants for all wetland areas and storage ponds as set forth in the co order of conditions recorded in Book 1960, Page 152. rob Q The within described premises are hereby conveyed subject to a 30 foot 4J c c wide common driveway covenant affecting Lots 23-A, 24-A and 31-A duly ti' u w recorded with said Registry of Deeds. ° roo z The within lot is hereby conveyed subject to an easement to New England Telephone and Telegraph Company recorded with said Registry of Deeds in Y 0 Book 2047, Page 313 and an easement to Massachusetts Electric Company v recorded with said Registry of Deeds in Book -2048, Page 254. z a Being part of the same premises conveyed to us by deed of V. Scott J i Follansbee et al Trustees, recorded with Essex North District Registry of 3r Deeds in Book 1914, Page 190. v 0 `4 a WITNESS our hands and seals this 24th day of October, 1985. EQUESTRIAN ESTATES ASSOCIATES REALTY TRUST ? KENNETH HYDE, JR., DEVELOPMENT CORPORATION, TRUSTEE enneth Hy e J ., Presi eat Aiaanac}iu!tefle Deed Excise Stamps EQUESTRIAN ESTATES ASSOCIATES REALTY TRUST f in sum of S •'0 WILLIAM J. IANNAllI, DEVELOPMENT CORPORATION, it(lred and cancelled on this TRUSTEE instrument. William J.\Jannazzi, Pre{Sadent Sa COMMONWEALTH OF MASSACHUSETTS Essex, ss. October 24, 1985 Then personally appeared the above named Kenneth Hyde, Jr., President and William J. Iannazzi, President and acknowledged the foregoing instrument to be the free act and deed of Kenneth Hyde, Jr. Development Corporation, Trustee and William J an azzi velopment Corporation, Trustee respectively as aforesaid, efore e Notary Pub is My commission expires: 2��0rrie1 Oct -<<,1935 at 4:28PM #25273 B H 20 6 8 92 KENNETH HYDE, JR., Development Corporation and WILLIAM J. IANNA: Development Corporation, Trustees of Equestrian Estates Associates Re! Trust, under a Declaration of Trust dated January 4, 1985 and reco with Essex North District Registry of Deeds in Book 1914, Page 186. for consideration paid and in full consideration of $90,000.00 - grants to Beachwood Builders,.Inc., a Massachusetts corporation ha -- an usual place of business at 350 Massapoag Avenue, Sharon, Massachuse WITH QUITCLAIM COVENAW The land in North Andover, Essex County, Massachusetts and being st as Lot 24-A on a plan of land entitled •Plan of Land in North Andov d Mass. showing lot line changes prepared for Equestrian Estates Associz a> Realty Trust, Kenneth Hyde 6 William Iannazzi (Trustees) dated July 1985, revised July 10, 1985• and recorded with Essex North Distr Registry of geeds as Plan No. 9961. Containing 237,702 square feet r c or less according to said plan. There is reserved from the above described land the fee in Equesti m m Drive as it abuts said lot but grants v4to the grantees the right to j 41 said Equestrian Drive for all purposes for which streets are used in W H Town of North Andover. 0 ¢ o The within lot is hereby conveyed subject to easements, restricts N and conditions of record in so far as in force and applicable. s y a � The Grantor herein, hereby reserves the right to approve any and a . construction and site plans on said Lot 24-A on said plan. oGrantor reserves the right to grant permanent conservation restricti or covenants for all wetland areas and storage ponds as set forth in a a order of conditions recorded in Book 1960, Page 152. 4J c t The within described premises are hereby conveyed subject to a pc UW line easement to New England Power.Company as shown on said plan and > y further restriction of running parallel driveways, septic systems, poc sheds, fences or any other type of temporary or permanent structure wit N said easement lines. in v The within described premises are hereby conveyed subject to a 30 f Q wide common driveway covenant affecting Lots 23-A, 24-A and 31-A d recorded with said Registry of Deeds. 4 O14 The within lot is hereby conveyed subject to an easement to New Eng! Telephone and Telegraph Company recorded with said Registry of Deeds u Book 2047, Page 313 and an easement to Massachusetts Electric Comp A. recorded with said Registry of Deeds in Book 2048, Page 254. Being part of the same premises conveyed to us by deed of V. Sc Follansbee et al Trustees, recorded with Essex North District Registry Deeds in Book 1914, Page 190. J ��' �FORMU LOTS RELEASE FO INSTRUCTIONS Tlilsformis Us verify that all necessary approvals/permits from Boards and Departments tiavng.�uisdlction have been obtained. This does not relieve the applicant and/ori ndowne�rfrom compilance with any applicable or requirements. Y A PLICANT_FILLS OUT THIS SECTION APPLICANT (11'a tt—'' L wA^— - - PHONE LOCATION: Assessors Map Number �.cu�w�v� Cwj-� PARCEL p SUBDIVISION LOT (S) STREET L ALov\ i 0. ST. NUMBER �S S OFFICIAL USE ONLY* R OMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE- REJECTED COMMENTS TOWN PLANNER DATE APPROVED r1� DATE REJECTED COMMENTS FOOD INSPECTOR -HEALTH C R -HEALTH DATE APPROVED DATE REJECTED DATE APPROVED d DATE REJECTED COMMENTS PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE FORM U - LOT V610 0 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 or requirements. *********************APPLICANT FILLS OUT THIS SECTION APPLICANT�(rJ4�£� Co�SyC� PHONE LOCATION: Assessor's MapNumber_ f p S loo /5-7- PARCEL SUBDIVISION LOT (S) STREET_ _Z,4e0ti14- �,2, ST. NUMBER 3 Z-- *�"'`'""'*�"'' OFFICIAL USE ONLY* RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TO N PLANNER p a4 COMMENTS (� O � —a2sue— DATE APPROVED DATE REJECTED_ ;FOOD/INSP CT6R-HEALTH DATEAPPROVED DATE REJECTED ECTO�THDATEAPPROVED 3 DATE REJECTED COMMENTS PUBLIC WORKS - SEWERIWATER CONNECTIONS DRIVEWAY PERMIT /FIRE! DEPARTMENT 1 r RECEIVED BY BUILDING INSPECTOR DATE Town of North Andover, Massachusetts BOARD OF HEALTH 199AY a 7 - tT APPLICATION FOR SITE TESTING/INSPECTION Form No. 1 19?.rl Applicant ZO/Ce!/q/Pq Z7;1J6J%/e0/-i NAME ADDRESS TELEPHONE Site Location 3,�?IQ rQ<�e 1 c� / r`/� ��,� ,. Engineer NAME / ADDRESS TELEPHONE Test/Inspection Date and Time 1r, lg98 9,,60 CHAIRMAN, BOARD OF HEALTHY �-- Fee �`- Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts Form No. 2 f N01VT1y BOARD OF HEALTH F DESIGN APPROVAL FOR C""5``� SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant ��-�! d�e� Test No. Site Location Reference Plans and Specs. I X �S2J ENGINEER TE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. � a Fee 0 CHAIRMAN, BOARD OF HEALTH Site System Permit No. FFSN3 SEPTIC PLAN SUBMITTALS LOCATION: NEW PLANS: YES $125.00/Plan REVISED PLANS: YES $ 45.00/Plan SITE EVALUATION FORMS INCLUDED: YES NO DATE: ? " 1� < 5 ? DESIGN ENGINEER: CeS (f.o l , DATE TO CONSULTANT: When the submission is all in place, route to the Health Secretary Town of North Andover, Massachusetts BOARD OF HEALTH v 19—_� DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Site Reference Plans and Specs. Le- S ENGINEER DESIGN, Test No. Permission is granted for an individual soil absoprtion sewage disposal system to be installed in accordance with regulations of the State and the Board of Health. BOARD OF HEALTH Fee Site System Permit No. Town of North Andover, Massachusetts Form No. 1 NORTH qA BOARD OF HEALTH 32o�sEo/646YO0 A1.44MLLI� �aJ 19 * i- ��RQOA° E.Pa e* APPLICATION FOR SITE TESTING/INSPECTION Applicant Lfx ,t. {.� r NAME f ADDRESS w TELEPHONE Site Location Lo -t-- ,,A -t�i.c .Klft_�t-G� 1 W -r Engineer 6.1 "\ NAME ADDRESS TELEPHONE Test/Inspection Date and Time Fee )�1 CHAIRMAN, BOARD OF HEALTH Test No. U 0 s S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. d z 0 CJ s m c COco � •Ea m o ►W. �: 'O.s a y 7 o m P ~ o� .A a = E d mm w *� C> m y as c 1: y A o E O CLC.) 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