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HomeMy WebLinkAboutMiscellaneous - 86 BROOKVIEW DRIVE 4/30/20181 e r A d, or MAP # LOT # ) L{ PARCEL # STREET����— " CONSTRUCTION PPRO HAS PLAN REVIEW FEE BEEN PAID? YESo*) NO PLAN APPROVAL: DATE -7&kAPP. BY DESIGNER: PLAN DATE CONDITIONS WATER SUPPLY: TOWN WELL WELL PERMIT DRILLER WELL TES CHEMICAL DATE APPROVED ACTERIA I DATE APPROVED BACTERIA I\ DATE APPROVED PLUMBING SIGNOFF WIRING \SII`GNOFF COMMENTS: FORM U APPROVAL: APPROVAL TO ISSUE YES NO DATE ISSUED By 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: NEW- REPAIR NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YE CONDITIONS OF APPROVAL YES NOS (FROM FORM U) ISSUANCE OF DWC PERMIT Y� NO DWC PERMIT PAID? Y S) NO DWC PERMIT N0. 11) 7,-7 INSTALLER: BEGIN INSPECTION YES 0: ZAC:AVA IUN INSPECTION: NEEDED: PASSED/7BY CONSTRUCTION INSPECTION: NEEDED: AS BUILT PLAN SATISFACTORY: YES: APPROVAL TO BACKFILL: DATE: /Owbel BY FINAL GRADING APPROVAL: DATE //(,� BY FINAL CONSTRUCTION APPROVAL: DATE: BY D RECEIVED Commonwealth of Massachusetts City/Town of JUN 2 4 2013 System Pumping Record TOWN OF NORTH ANDOVER Form 4 1 HEALTH DEPARTMENT DEP has provided this form for usea 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 LocationPinag.,NLeft Right front of house, Left / Rig rea of hous eft / right side of house, Left / Right side of buil / Right front of building, Left / Right rear of building, der ec (15� \bec�V v�'QZ City/Town State 2. System Owner. cc r1 Name Address (if different from location) Zip Code City/Town State Telephone Number (O B. Pumping Record 1. Date of Pumping Date 2• Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Conditio, n pf System:�� v 6. System Pumped By: Neil Bateson Name Bateson EnterDrises Inc Company 7. Lo ere contents were disposed: a. S. Lowell Waste Water 01 M. - F5821 Vehicle License Number Date MEl-ice <Q� I � A -!:,R t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 '1 4216 iSA���� l��,ALI�i��E�ARTME %� NT CI�ECk �: DATE: a LOCATION: �S% _ i H/O NAME: CONTRACTOrNAME: eve of Permit or License: (Check be ❑ Animal ❑ Body Art Establishment ❑ Body Art Practitioner S S ❑ Dumpster S ❑ Food Service - Type:__ S 1 S ❑ Funeral Directors ❑ Massage Establishment ❑ Massage Practice I ❑ Offal (Septic) Hauler ❑ Recreational Camp ❑ Sun tanning ❑ Swimming Pool ❑ Tobacco ❑ TrashlSolid Waste Hauler ❑ Well Construction SEPTICS stems: ❑ Septic - Soil Testing ❑ Septic - Design Approval ❑ Septic Disposal Works Construction (DWC) ❑ Septic Disposal Works Installers (DWI) ❑ Tittle 5 Inspector 8 --Title 5 Report .. c Fire & W ERVPRO of Billerica/Tewksba, AterC1, ERVPRO of Lawrence p & Restoration"" ERVPRO of Lowell 918.663.9833 ERVPRO of Salem/Plaistow 978-688-2242 ERVPRO of The Andovers 978.454-7577 Toll Free 800 603.893.9700 978-475.1199 r 2- ----------- 13 ❑ Other. (Indicate) I Health Agent Initials � White -Applicant Yellow - Health Pink - Treasurer 4216 �10RTN 0 • + Lik b i Town of North Andover .,,,.-.:tom' HEALTH DEPARTMENT SACHUSt CHECK #: 7 DATE: G� LOCATION: H/0 NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) • Animal $ ❑ Body Art F,stablishment $ 1 ❑ Body Ar ❑ Dumpst ' ' o Fire & Water - Cleanup & ResforationTm 11 Food Se SERVPRO of Billerica/Tewksbury j SERVPRO 978.663-9833 j of Lawrence ❑ Funeral SERVPRO of Lowell 978-688-2242 ❑ Massag SERVPRO of Salem/Plaistow 978-454-7577 603.893-9700 SERVPRO of The Andovers j ❑ Massag Toll Free 800-535-6322 978-475-1199 ❑ Offal (' j ❑ Recreaf ❑ Sun tai v I Q� ❑ Swim" $ - _ r - i ❑ Tobaci _--~�+ $ ❑ TrasWSolid Waste Hauler $ ❑ Well Construction $ i SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ k ❑ Septic Disposal Works Installers (DW() $ ❑ Title 5, nspector $ $ Title 5 Report I ❑ Other. (Indicate) $ i Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer x Ot NO oTM '+y of Permit or License: (Check box) Town of N `�;•:�' SS�CMUSE HEALTH ❑ Body Art Establishment CHECK #: ❑ LOCATION: a� H/O NAME: CONTRA 4216 orth Andover DEPARTMENT �{ nATR• Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title nspector $ _l fl Title 5 Report $ `�y ❑ Other. (Indicate) $ C�/1 11, Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. ISI 1, C'-L� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessm 86 Brookview Street Property Address Joel Myerson Owner's Name North Andover CitylTown MA 01845 State Zip Code fECEIVED nts JUL 2 2 2009 TOWN OF HEALTH DEPARTMENT 7/10/2009 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Neil J. Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Ar ills 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 Al"I" , 7/10/2009 In pector Signat Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 09/08 Title 5 official Inspection Form: Subsurface Sewage Disposal System . Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Brookview Street Property Address Joel Myerson Owner's Name North Andover MA 01845 7/10/2009 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Brookview Street Property Address Joel Myerson Owner's Name North Andover Cityrrown B. Certification (cont.) B) System Conditionally Passes (cont.): MA OLCILU 01845 7/10/2009 Zip Code Date of Inspection ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ 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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Brookview Street Property Address Joel Myerson Owner's Name North Andover MA 01845 7/10/2009 City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 Y2 day flow t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 09/08 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 86 Brookview Street Property Address Joel Myerson Owner Owner's Name information is required for North Andover MA 01845 7/10/2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 09/08 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Brookview Street Property Address Joel Myerson Owner's Name North Andover MA 01845 7/10/2009 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): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): A Ann t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 86 Brookview Street Property Address Joel Myerson Owner Owner's Name information is required for North Andover MA 01845 7/10/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 5 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 ears usage d 9 ( y 9 (gP ))� Yes Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: ❑ Yes ❑ No Current Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Brookview Street Property Address Joel Myerson Owner's Name North Andover Citylrown D. System Information (cont.) Last date of occupancy/use: Other (describe below): MA 01845 State Zip Code 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: Type of System: Date Pumped 2008,owner 1500 gallons Measured tank tank & tees ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy 7/10/2009 Date of Inspection ® 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): t5ins • 09108 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 86 Brookview Street Property Address Joel Myerson Owner Owner's Name information is required for North Andover MA 01845 7/10/2009 every page. Cityrrown D. System Information (cont.) State Zip Code Date of Inspection Approximate age of all components, date installed (if known) and source of information: 10 years old, 4/23/1999, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 1.6 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. 3" PVC in house. no leaks visible. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal .5 feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 10'x 5'x 4' Sludge depth: U ❑ Yes ❑ No t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 86 Brookview Street Owner information is required for every page. t5ins • 09/08 Property Address Joel Myerson Owner's Name North Andover Cityrrown D. System Information (cont.) State Zip Code 7/10/2009 Date of Inspection Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 25" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 19 How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumped septic tank. Inlet tee found clogged, cleaned same now ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness ❑ fiberglass Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: feet ❑ polyethylene ❑ other (explain): Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 86 Brookview Street Property Address Joel Myerson Owner Owner's Name information is required for North Andover MA 01845 7/10/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Brookview Street Property Address Joel Myerson Owner Owner's Name information is required for North Andover MA 01845 every page. Cityf town State Zip Code D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 7/10/2009 Date of Inspection Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D- box level & distibution equal. No evidence of leakage. Evidence of carryover, pumped d -box to clean. D -box cover broken, replaced it. 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 - 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 86 Brookview Street Owner information is required for every page. t5ins • 09/08 Property Address Joel Myerson Owner's Name North Andover City/Town D. System Information (cont.) Type: ❑ leaching pits ❑ leaching chambers ❑ leaching galleries ® leaching trenches MA 01845 7/10/2009 State Zip Code number: number: number: Date of Inspection number, length: 3 trenches 74' long ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 86 Brookview Street Property Address Joel Myerson Owner Owner's Name information is required for North Andover MA 01845 7/10/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Brookview Street Property Address Joel Myerson Owner's Name North Andover MA 01845 7/10/2009 CityfTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below. ® hand -sketch in the area below ❑ drawing attached separately �1 { 5`5" 24 1 , vQY14- t5ins • 09108 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 86 Brookview Street Owner information is required for every page. Property Address Joel Myerson Owner's Name North Andover Cityrrown D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells MA State 01845 7/10/2009 Zip Code Date of Inspection Estimated depth to high ground water: 4 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked date of Ansi n Ian review d' 9/30/1996 ' g p e 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: Asper design plan test pit data Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 86 Brookview Street Owner information is required for every page. t5ins • 09108 Property Address Joel Myerson Owner's Name North Andover MA 01845 7/10/2009 Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed E System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Summary Record Card generated on 7/8/2009 2:40:39 PM by Karen Hanlon Town of North Andover Tax Map # 210-105.A-0031-0000.0 Page 1 Parcel Id 16908 86 BROOKVIEW DRIVE JOEL MYERSON 86 BROOKVIEW DRIVE NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 0.98 Acres FY 2009 UB Mailina Index Name/Address JOEL MYERSON 86 BROOKVIEW DRIVE NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Bldg Id. 17857.0 - 86 BROOKVIEW DRIVE 3170522 03 Cycle 03 UB Services Maint. Account No. 3170522 Service Code MISCFEE ADMIN FEE WTR WATER . UB Meter Maintenance Account No. 3170522 Type Loan Number Active/Inact. From Payor Occupant Name Active/Inactive Last Billing Date 7/8/2009 Active Rate Charge Multiplier/Users 0.635/8 7.82 1/ 01 ALL METER SIZE 72.76 /1 Serial No Status Type Location 33605561 a Active Consumption ERT HH FR.RT. Date Reading Code 6/8/2009 212 a Actual 3/16/2009 191 a Actual 12/9/2008 170 a Actual 9/10/2008 153 a Actual 6/6/2008 136 a Actual 3!7/2008 117 a Actual 12111/2007 100 a Actual 9/5/2007 70 a Actual 6/19/2007 25 a Actual 3/14/2007 5 a Actual 2/16/2007 0 n New Meter 2/16/2007 938 r Replacement 12/12/2006 943 in Manual estimate 9/18/2006 918 in Manual estimate MSG 6/19/2006 878 a Actual Trouble Code:09 3/8/2006 856 a Actual 12/22/2005 841 a Actual 9/21/2005 822 a Actual Trouble Code:09 6/27/2005 784 a Actual 3/30/2005 765 a Actual 12/16/2004 735 a Actual Trouble Code: 13 9/24/2004 713 a Actual Brand Type b Badger w Water Consumption Posted Date 21 7/20/2009 21 4/29/2009 17 1/20/2009 17 10/10/2008 19 7/16/2008 17 4/11/2008 30 1/22/2008 45 10/12/2007 20 7/20/2007 5 4/16/2007 0 4/16/2007 -5 4/16/2007 25 1/19/2007 40 10/20/2006 22 7/10/2006 15 4/17/2006 19 1/17/2006 38 10/14/2005 19 7/15/2005 30 4/5/2005 22 1/14/2005 28 10/8/2004 Size 0.63 0.63 Until YTD Cons 95 Variance 15% 15% 7% -15% 7% -37% -46% 180% 7% 0% 0% -126% -33% 106% 8% -4% -53% 107% Commonwealth of Massachusetts RECEIV City/Town of I OCT 2 4 2006 System Pumping Record Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health.. The System Pumping Record must be submitted to the local Board of Health or other approving authority. . A. Facility Information Important: When filling out 1. System ation: fomes the computer, use only the tab key Address CK\` � ���C } to move your '-�i--/'_ ,fes v cursor - do not use the�retum Citylr°wn state Zip Code key. 2. System Owner:( / Name Address (it different from location) I Cityfrown state Zip Code &I Telephone Telephone Number B. Pumping Record 1. Date.of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: El cesspool(s) peptic Tank El Tight Tank ❑ Other (describe)` 4. Effluent Tee Filter present? ❑ Yes Lia If yes, was it cleaned? ❑ Yes ❑ No 5. condition of System: hftp://WWW.mass.gov/dep/­Water/approvaig/t5forms.htm#inspect t5form4.doc• 06103 Date System Pumping Record • Page 1 of 1 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: L (example: left front of house) C) hc� DATE OF PUMPING: QUANTITY PUMPED GALLONS CESSPOOL: NO ! YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: NOV 3 0 2001 FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) CONTENTS TRANSFERRED TO: 6, U- 4 0. (% Form No. 3 Town of North Andover, Massachusetts BOARD OF HEALTH of NORT a,ti0 a� 3? a .,,•. ... _ OL . o F 9 # r DISPOSAL WORKS CONSTRUCTION PERMIT SSACMUSE Applicant- � ��'`� NAME ADDRESS TELEPHONE Site Location r 1 `� /� ✓� D`'"' `� `� - Permission is hereby granted to Construct ( or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. ea' s CHAIRMAN, BOARD OF HEALTH / Fee D.W.C. No. eJZ-7 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: 9 CURRENT INSTALLER'S LICENSE# LOCATION: �� ! v�e LICENSED INSTALLER: i SIGNATURE: clteL TELEPHONE# CHECK ONE: REPAIR: NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. Administrative Use Only $75.00 Fee Attached? Yeses/ No Foundation As -Built? Yes No Floor Plans? 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CD TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE: 05/18/99 This is to certify that the individual subsurface disposal system constructed ( X ) or repaired ( ) by Peter Breen at Lot 14 Brookview Drive has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations as described in the Design Approval Site System Permit # 941 dated 7/08/97. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. . Es,'� f"") Wil°. f--1, Z. , Board of Health Inspector I 1 AS -BUILT CHECKLIST LOTE T NUMB R, STREET NAME � ASSESSORS MAP & PARCEL NUMBER v LOT LINES & LOCATION OF DWELLINGS LOCATION & DEMENSIONS OF SYSTENI, INCLUDING RESERVE ? TIES TO LOT LINES & DWELLING, WELLS a. FROM SEPTIC TANK b. FROM LEACH AREA LOCATIONS OF DEEP HOLES & PERC TESTS ELEVATIONS OF DISPOSAL SYSTEM ? TOP OF FDN ELEVATION LOCATIONS OF WELLS, DRAINS, WATERCOURSES W/N 1 50' OF SYSTEM LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK & D -BOX y STAMP & SIGNATURE IMPERVIOUS AREAS - DRIVEWAYS, ETC. NORTH ARROW LOCATION & ELEVATION OF BENCHMARK USED LOCUS PLAN MdiY-14-99 FRI 16:21 02 TQVtrN OF NORTHI ANDOVER SCIARD OF HEALTH 1 MAY 17 Ng i ZD_�� 14 42,592 S.F, 6. 9$ Ac. B.M.1pe l E V18�, NAILIN " PINE 00 �r aa W OD G -( '> X 74' TRENCHES VEN T CONC. _,�h 12' f as*� 0_.80X - F 1500 GAL. SEPTIC TANK v 26.8' A �v D >� TOP FND 1, 25.5' EL= 133.90 1 I ID sl I c co S \ EXIST. I DRIVEWAYy� II?< 1 Re; 1 qss tE� SUBGRAD£ I A �� M 4 ELEC. SERVICE 1�3� Sh APPROX. 011.. BROOKVIEW DRIVE ELEVATIONS TAKEN AT TOP Of PIPE _SWING TOP OF FOUNDATION: COMPONENT TIES _ • SEE PLAN COR A COR 8 COR C PIPE ® DWELLING: 128.98 SEPTIC TANK 61.2' ZJ.B' O' (CENTER) TANK IN: 128.48 D -BOX 69.9. .3' 0; (CENTER) • TANK OUT: 128.18 NO PIPE: 0 0' 0 -BOX IN: 128.02 NO PIPE: 88.8' 52_8' O' a ' IJQQ D -BOX OUT: 127.85 (ALL) _ _ N.T,S. • END PIPE - D: 127.39 ASSESSORS MAP 105A 1.01 003I END PIPE - E: 127.35 ? END PIPE - F: 127.30 ` AS -BUILT SEWAGE DISPOSAL SYSTEM PLAN LOT 14 BROOKVIEW DRIVE MARCHIONDA & ASSOC., L.P. NORTH ANDOVER, MASS. PREPARED FOR ENGINEERING AND PLANNING CONSULTANTS SROOKVIEW COUNTRY HOMES 62 MONTVALE AVE. SUITE I P.O. BOX 531 STONEHAM, MA. 02160 NORTH ANDOVER, MASSACHUSETTS (617) 438•-6121 r SCALE.: 1'"=' ' DATE: 4/23/99 02 TQVtrN OF NORTHI ANDOVER SCIARD OF HEALTH 1 MAY 17 Ng i MAY -17-99 MON 06;36 TRUS JOIST MACMILLAN FAX NO. 6099859806 P.01 r d A LI'M ITE0 PAITIEIS91t Manchester, NH Seminar Registration "An Introduction to EngEneered Lumber Products" i This is an excellent starting place for Code Officials to learn abort "how to choose acrd how to us¢ " Trus Joist NWMilian's engineered lumber products, P is expected that our guests will have an understanding oaf wood frame residential construction technigales, and will brim a cakalana r and sln ingest in learning the proper methods for bui'Iding with Trus Joi i MaeffXan's &Vipe red wood products Make reservations to attend the Trus Joist MacMillan Seminar! Scheduling now will allow your people to plan ahead and will also macre preparing accommodations for you easier. Fax this "Seminar Kegistrafion" to: Josh Bartlett, Trus Joist MacMillan, (603) 476-5068 Vowe line: (603) 476-5676. Please register early, space is limited. Name (Please Print Clearly): Dates of Seminar: Tuesday_ +fay 25,1999 Municipality Mailing Address: City, Telephone: State: Zip: Fax Number. Plan to arrive at the hotel by 7:30 AM and to leave after 4:00 p.m. The seminar and accommodations are at B.ohday IM Center of Nle 700131m St. Manchester, Nfi. 603-625-1000. Breakfast and lunch will be provided Parking is available at the Center of NH parkin gorse ajacent to the HoteL Fulfilling this commitment to product dviowledge will give you morie eonfidencs and haves � greatersuccess merehffg yOWre^rpvnr&ilitdes We ary iooki>'tg forward to yow participation. I MAY- 1 3 -`•FIS THU 1 4 : ee TOWN OF NORTH ANDOVER SEWAGE AISI'i7S U SYSTEM LNSTALLATION CERTIFICATIOi~ The undersig ed hereby certify rrat the Sewagc Disposal 5y5tcrrs ;Xconstractod; by — I r'z�e� located at r4 ) repaired; was installed it. conformance with the North Andover Board of Health approved plan, System Design Permit 0 9 �6, dated.0 9 , with an approved design, flow of ��D gallons per day. The trlat+:riats use were in conformance with those specified on the approved plaza; the systems was installed in accordance with d -=e provisions of 310 CMR I5.000, Title 5 and local regulations, and 6e mai grading agrees substantially with the approved plan. All work is accurately ,epresented on the As -built which has been submitted to the B ird of Health, Bed inspection, date: qr Wr_ nspeL or Final inspection elate; '5 1Z A 7 nsprZor Installer: Lic. s: bate: Design Engineer. .. Date: ' /?•� S �� P . 0 3 'AORTh o dL � w ;,ssACHUSEt� Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 2 DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM ApplicantTest No. Site Location w -r j4 Reference Plans and Specs.1�11�.�—�.Q ENGINEER DESIGN Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. Fee CHAIRMA , BOARD OF HEALTH Site System Permit No. S£ 16-068 (£09) :xoJ 66/0£/Z :01'0(1 VOW -969 (£09) :sn8 5t78 t O VWa�noatvd 'ON L80£0 HN 'Wo4PulfYl t £5 xo9 'O 'd cold aooH Is :a6od 399 x08 'O 'd S3 W OH AUIN (100 M3 AM 0021 S 0x£10 ;jagwnN 9ulmeJa DIAUDS ON11JU JC! hdm01IN .0'.43 &.a ol &.01 .5-.S .01-.3 .0.@ ►1, x Rib O 0 0 in in s� W� gj 4 P R zo .0-.bt r 1 1 .0-.ai 2 O 0 Z_ Z D c M M Cr M VI in O bj 10 ss 1 11 o+ r .s -.a 4 °0 '- 11 }� r +yh rl Q e r ti .0-.9 b a N Q------------- �1 rr r i r 1 ----r"-- _ r'----------.----_~ Q __r_______________ N � 0 0 rl 0 Z L/ij LLI D ca LLj E0 Lu c~i oo Q vi crw oW xWU Zf/ WO < Y J N� U Q o U 'v in of N 9 ;o cn M 0 �. o } o ; ; ,c,nn V Z rr In 9 1 Ir H c M M Cr M VI in O bj 10 ss o+ .s -.a 4 °0 '- iv. +yh Q e o+ .s -.a Q b a Q------------- r i r 1 ----r"-- _ r'----------.----_~ __r_______________ N � 0 0 0 Z L/ij Z D ca LLj E0 Lu c~i oo Q vi crw oW xWU Zf/ WO < Y J N� U Q o U 'v N 9 ;o S£ 16-069 (£09) =xt)J66/OE/Z :ales W20-969 (£09) :sng Sb8 � O VW a�noa►vy �oN L90£0 HN 'woypu'M t ES XO8 'O 'd ueld aoo�d puZ :abed 399 xog '0 'd S3 W O H AUJLN f1 O0 M31AN OOU S pt,£ -10 :1aquanN U!MeAl 331AU3S ONIJJUU(l AUM01131H z d J x 0 0 1 c N 0 LA ,s$CNUSt� , CHECK #: ��%� DATE: /� O LOCATION: 'll ��G'�/'✓/GYi�C� H/O NAME: 111,Mle, CONTRACTOR NAME: Type n Of "ORT" 'y 3469 Animal $ Town of North Andover ", HEALTH DEPARTMENT ,s$CNUSt� , CHECK #: ��%� DATE: /� O LOCATION: 'll ��G'�/'✓/GYi�C� H/O NAME: 111,Mle, CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ''Title 5 Report ❑ Other: (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer ct Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Beaver Brook Road Property Address Shawn Mahilati Owner Owner's Name information is MA 01845 d A No. Andover X014 jO required for N��L every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your Benjamin C. Osgood, Jr. cursor - do not Name of Inspector use the return key. New England Engineering Services, Inc. Company Name 1600 Osgood Street Suite 2-64 Company Address No. Andover MA 01845 City/Town State Zip Code 978-686-1768 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: asses ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority I i;' L Q,9 - -I/z1Z)8 l ' pector' Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. TITLE 5 FORM MASTER.DOC • 08/06 Tide 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form A o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Beaver Brook Road Property Address Shawn Mahilati Owner Owner's Name information is No. Andover MA 01845 7) 2./0 q required for every page. Cityrrown . State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: `lhave not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If "not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed TITLE 5 FORM MASTER.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 15 Commonwealth of Massachusetts w - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 36 Beaver Brook Road Property Address Shawn Mahilati Owner Owner's Name information is No. Andover MA 01845 �6AQ*-7/2-16 j2 6 8 required for 7/ 1 every page. Cityrrown State Zip Code Date of Inspectio B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. TITLE 5 FORM MASTER.DOC • 08106 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 36 Beaver Brook Road Property Address Shawn Mahilati Owner Owner's Name information is required for No. Andover MA 01845 -. -71? every page. City/Town State Zip Code Date of B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ D,.,- Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ g� Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ET- Liquid depth in cesspool is less than 6" below invert or available volume is less than'/ day flow ❑ 1', 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. TITLE 5 FORM MASTER.DOC • 08/06 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 4 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Beaver Brook Road Property Address Shawn Mahilati Owner's Name No. Andover MA 01845 -712,101-9' City/Town State Zip Code Date of Inspecti B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ [F"- 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. ❑ QK 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.] ❑ E- The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ [Y- 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 ❑ Ell the system is within 200 feet of a tributary to a surface drinking water supply ❑ ED/,' the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone I I 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. TITLE 5 FORM MASTER.DOC • 08/06 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 5 of 15 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Beaver Brook Road Property Address Shawn Mahilati Owner Owner's Name r information is required for No. Andover MA 01845 vis' e 7 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ v"'- 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? LEJ ❑ 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 El approximation of distance is unacceptable) [310 CMR 15.302(5)] TITLE 5 FORM MASTER.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Beaver Brook Road Property Address Shawn Mahilati Owner Owner's Name information is required for No. Andover MA 01845 W4-ww -z/ 2 %� $ every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Al YO Number of current residents: _9 Does residence have a garbage grinder? ❑ Yes [A No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes [g No Laundry system inspected? ❑ Yes 5 No Seasonal use? ❑ Yes 2 j No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: v rc G -Ai' 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? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Last date of occupancy/use: Other (describe): Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No TITLE 5 FORM MASTER.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 36 Beaver Brook Road Property Address Shawn Mahilati Owner Owner's Name information is No. Andover MA 01845 X98 -7 v required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: Type of System: sk u ecn -- 5�9 o f!67L— L e - gallons ❑ 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): Approximate age of all components, date installed (if known) and source of information: 19�1:Z lielL- cDw,jodL Were sewage odors detected when arriving at the site? ❑ Yes X, No TITLE 5 FORM MASTER.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 15 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): Approximate age of all components, date installed (if known) and source of information: 19�1:Z lielL- cDw,jodL Were sewage odors detected when arriving at the site? ❑ Yes X, No TITLE 5 FORM MASTER.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Beaver Brook Road Property Address Shawn Mahilati Owner Owner's Name information is re wired for No. Andover MA 01845 6/12/08 4 every page. Cityrrown D. System Information (cont.) Building Sewer (locate on site plan): Depth below grade: Material of construction: ❑ cast iron fZ 40 PVC State Zip Code ❑ other (explain): feet Date of Inspection Distance from private water supply well or suction line: feetA Comments (on condition of joints, venting, evidence of leakage, etc.): P. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal r feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: Sludge depth: 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? 41 AA CA= --1 4 S-7?C rL TITLE 5 FORM MASTER.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Beaver Brook Road Property Address Shawn Mahilati Owner's Name No. Andover MA 01845 CitylTown State Zip Code D. System Information (cont.) 6/12/08 Date of Inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TA+,3K (ti Crd6;> cz'f- -0l'%-7p^ cK LL 0'�C i�%I. ti Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass 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 feet ❑ polyethylene ❑ other (explain): Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): TITLE 5 FORM MASTER.DOC • 08/06 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 10 of 15 Commonwealth of Massachusetts v . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Beaver Brook Road Property Address Shawn Mahilati Owner Owner's Name information is required for No. Andover MA 01845 6/12/08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: Design Flow: Alarm present: gallons gallons per day ❑ 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 Distribution Box (if present must be opened) (locate on site plan): i z Depth of liquid level above outlet invert ®e, 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.): $c>)C r--% &r' z) I--). cr7.ao e -7u.4_ N'� 67L DDC LCC- C5 i L,c`' i9,� % c. 7, c-)/2- a "7ry /2 —C -a C. l lQS 6 aleP' Pump Chamber (locate on site plan): Pumps in working order: . Alarms in working order: ❑ Yes ❑ No ❑ Yes ❑ No TITLE 5 FORM MASTER.DOC • 08/06 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 11 of 15 Commonwealth of Massachusetts 4 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Beaver Brook Road Property Address Shawn Mahilati Owner information is required for every page. Owner's Name No. Andover MA 01845 Cityrrown State Zip Code D. System Information (cont.) 6/12/08 Date of Inspection 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: Type: M leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): C rbAJ 4F 15 CG. P_ Cer^ Gino z>& ILC TITLE 5 FORM MASTER.DOC - 08/06 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 12 of 15 • Commonwealth of Massachusetts a - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Beaver Brook Road Property Address Shawn Mahilati Owner Owner's Name information is required for No. Andover MA 01845 6/12/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 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 FORM MASTER.DOC • 08/06 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M ..' 36 Beaver Brook Road Property Address Shawn Mahilati Owner Owner's Name information is required for No. Andover MA 01845 6/12/08 every page. Cityrrown State Zip Code Date of Inspection f._ D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. V 17-1-0-11c65 1-7 f -z,( i #off �2•S, 2-D►3 KG9-� lot,cvt f RE R ki- 07 �y o G' aeltJCX F7�L�t-, -q.'0 TITLE 5 FORM MASTER.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Beaver Brook Road Property Address Shawn Mahilati Owner Owner's Name information is required for No. Andover MA 01845 6/12/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: []Check Slope [Surface water mo o [Check cellart��s�cc'-v a Shallow wells Estimated depth to ground water: (42 feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: 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: — S w -SA,% D e5« v► C,g If ` y#-$avc — ►4-rz;:'P- `r )44 tem 0 -0 -CA- 01-- C Atv i> w OT LA a.» S 19,t IWA-(Z moi- 1-��c TITLE 5 FORM MASTER.DOC • 08/06 . Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 15 of 15 Of MORT :,� O tir•` V` - • Op • Town of North Andover 77T ♦ i Tii 711r1r1 A "TXXV11►TT ,SSACHUst4 CHECK #: LOCATION: H/O NAME: CONTRACT( 3471 Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type. $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Tittle 55IInspector $ itle 5 Report ❑ Other. (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Boston Stret Property Address Richard Soloman Owner's Name No. Andover Cityrrown S4 STe/N l C7 i~ MA 01845 State Zip Code 5/8/08 Ga-jo (ct�� 1114�� Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector: Benjamin C. Osgood, Jr. Name of Inspector New England Engineering Services, Inc. Company Name 1600 Osgood Street Suite 2-64 Company Address No. Andover MA Cityrrown State 978-686-1768 Telephone Number License Number B. Certification 01845 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: BXp"asses El Conditionally Passes El Fails Needs Further Evaluation by the Local Approving Authority 9, 6�)'2 Inspector ignature ,5---z,d3— 08 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. Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Boston Stret Property Address Richard Soloman Owner's Name No. Andover MA 01845 City/Town State Zip Code B. Certification (cont.) 5/8/08 Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: 217have 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: �TEr�rn � c o�D Anf}> vvr v4., ✓tom? 8 r C1iPeti�/�ac r�vy __ ItdAVV19% 0-S 4,&e � 7Tf-, M/tiic� S) System Conditionally Passes: 0 One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If "not determined," please explain. 0 The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: [l 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): 10 0 broken pipe(s) are replaced obstruction is removed Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Boston Stret Property Address Richard Soloman Owner Owner's Name information is required for No. Andover MA 01845 5/8/08 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): 0 distribution box is leveled or replaced ND Explain: 0 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): 0 broken pipe(s) are replaced 0 obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: 0 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: 0 Cesspool or privy is within 50 feet of a surface water [l Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: 0 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. 0 The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. 0 The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Boston Stret Property Address Richard Soloman Owner's Name No. Andover MA Cityrrown State B. Certification (cont.) 01845 5/8/08 Zip Code Date of Inspection C) Further Evaluation is Required by the Board of Health (cont.): ® The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ Eg,.,,- Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool n E "- Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool n ®� Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow El 12-- Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: El E;J- 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. Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Boston Stret Property Address Richard Soloman Owner's Name No. Andover MA 01845 5/8/08 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No No D 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. ❑ &3-- Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet the system is within 200 feet of a tributary to a surface drinking water supply from a private water supply well with no acceptable water quality analysis. [This CT, system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence Area — IWPA) or a mapped Zone II of a public water supply well 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 [j 9**- the system is within 400 feet of a surface drinking water supply [a— the system is within 200 feet of a tributary to a surface drinking water supply 0 CT, 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. Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Boston Stret Property Address Richard Soloman Owner's Name No. Andover MA 01845 5/8/08 City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No C1 Pumping information was provided by the owner, occupant, or Board of Health El 8' 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? n 0 fjf A 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? El Was the site inspected for signs of break out? R [I 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? Q 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: C1 fi2-- 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)] Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Boston Stret Property Address Richard Soloman Owner Owner's Name information is required for No. Andover MA 01845 5/8/08 every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on .310 CMR 15.203 (for example: 110 gpd x # of bedrooms). Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Sump pump? Last date of occupancy: 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? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Last date. of occupancy/use: Date Other (describe): F1 Yes 0 No El Yes 19 No Yes No Yes No lab 6'en, t%otL �u+E�l.Wq Yes [R No/ Date El Yes [I No Q Yes [] No El Yes El No I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Boston Stret Property Address Richard Soloman Owner Owner's Name information is required for No. Andover every page. Cityliown D. System Information (cont.) Pumping Records: Source of information: MA State 01845 5/8/08 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: U P%4No.-.A/ gallons Type of System: Septic tank, distribution box, soil absorption system Single cesspool 11 Overflow cesspool Cl Privy 0 Yes W 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) E] Tight tank. Attach a copy of the DEP approval. E] Other (describe): Approximate age of all components, date installed (if known) and source of information: yNlr,No —ti – P 2oa hat.y amt 3a Sac,A-s Were sewage odors detected when arriving at the site? iiEMrM Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Boston Stret Property Address Richard Soloman Owner's Name No. Andover MA 01845 Cityfrown State Zip Code D. System Information (cont.) Building Sewer (locate on site plan): Depth below grade: feet Material of construction: P cast iron 0 40 PVC ,Q other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): r N &I-QA,&E Leo rt a t� Septic Tank (locate on site plan): 5/8/08 Date of Inspection Depth below grade: feet Material of construction: concrete ❑ metal F-1 fiberglass F-1 polyethylene other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) 0 Yes n No ------------------------------------------------------------------------------------------------------------------------ Dimensions: Sludge depth: 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? �ec�J C'rALLO^-1 02aJAJD < l 3B Ll C9 !a ME43-J4c SZ --f4. Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Boston Stret Property Address Richard Soloman Owner's Name No. Andover MA 01845 5/8/08 City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 11 TAN K L N o K c -Ci N io " i� 9 Aj. C d ✓%c e -C Pl?r Grease Trap (locate on site plan): Depth below grade: feet Material of construction: E] concrete El metal [I fiberglass 0 polyethylene other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 11111¢ Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: 0 concrete 0 metal El fiberglass polyethylene El other (explain): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Boston Stret Property Address Richard Soloman Owner Owner's Name information is required for No. Andover MA 01845 every page. City/Town State Zip Code D. System Information (cont.) N JA- Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day 5/8/08 Date of Inspection 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 Distribution Box (if present must be opened) (locate on site plan): b � Depth of liquid level above outlet invert 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.): F -J K t ti a K Cd rj A ,in,n. ph�)t Dt^cc o r= t..��1-1A►4� d(L GA-2/ly ou-� ,v),A Pump Chamber (locate on site plan): Pumps in working order: Alarms in working order: ❑ Yes ❑ No ❑ Yes ❑ No i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface'Sewage Disposal System Form - Not for Voluntary Assessments 208 Boston Stret Property Address Richard Soloman Owner Owner's Name information is required for No. Andover MA 01845 5/8/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: Type: El leaching pits number: E leaching chambers number: n leaching galleries number leaching trenches number, length: U0XArb —,y leaching fields number, dimensions: El overflow cesspool number: fl innovative/altemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): PrQ.Eb4 O Sys iH �0C3lr j n p._ s -.1-b err e—&4. --j 012 0 NUSJ A -L VG(T67)4+7766-/_ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Boston Stret Property Address Richard Soloman Owner Owner's Name information is uired for No. Andover MA 01845 5/8/08 req every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) N1r4 Cesspools (cesspool must be pumped as part of inspection) (locate on site pith): 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 El Yes El No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N 14 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.): Owner information is required for every page. Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Boston Stret Property Address Richard Soloman Owner's Name No. Andover MA 01845 5/8/08 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. SAWK M 2 eq . i • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Boston Stret Property Address Richard Soloman Owner Owner's Name information is required for No. Andover MA 01845 5/8/08 every page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Site Exam: 0 Check Slope F1 Surface water Cj Check cellar n Shallow wells Estimated depth to ground water: feet Please indicate all methods used to determine the high ground water elevation: 11 Obtained from system design plans on record If checked, date of design plan reviewed: Date 0 Observed site (abutting property/observation hole within 150 feet of SAS) n Checked with local Board of Health - explain: [l Checked with local excavators, installers - (attach documentation) 4 Accessed USGS database - explain: You must describe how you established the high ground water elevation: � t 05CrS� At -"5 1Nc joc-i-F ESK4w us � rr_C� ►� e la.� Q %yyD Srf S'^ C.w� .3 � e.lo..✓ 4 iby.weJ. tir2 V% s NA-%- a_—, V CAC ` ci t- P r9 -s i $ A -C V- 'j P D W S i O W A1129 "i* 8 C6- . 11 o w C- Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Boston Stret �J u 5_'M AA Z e Z Property Address Richard Soloman Owner Owner's Name information is required for No. Andover MA 01845 5/8/08 every page. Cityfrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your Benjamin C. Osgood, Jr. cursor - do not Name of Inspector use the return key. New England Engineering Services, Inc. Company Name 1600 Osgood Street Suite 2-64 Company Address No. Andover MA 01845 City/rown State Zip Code 978-686-1768 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: Q Passes A Conditionally Passes n Fails Needs Further Evaluation by the Local Approving Authority C-) b -2.9-y 8 - i� Inspect/s SignatureDate 17 The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or PEP) 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. ,'. Commonwealth of Massachusetts mmf Title 5 Official Inspection Form 64 WW --WW IR)W Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Boston Stret Property Address Richard Soloman Owner information is required for every page. Owner's Name No. Andover MA Cityfrown State B. Certification (cont.) 01845 5/8/08 Zip Code Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: 7-i9)l'` L. F+/4 ES One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If "not determined," please explain. 0 The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: <-C- r i L L,:— r4f4s 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): ii broken pipe(s) are replaced [) obstruction is removed t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Boston Stret Property Address Richard Soloman Owner Owner's Name information is required for No. Andover MA 01845 5/8/08 every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. Owner information is required for every page. Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Boston Stret Property Address Richard Soloman Owner's Name No. Andover MA 01845 5/8/08 City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool C] 2,-- Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow Q� Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: Q— 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. ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Boston Stret Property Address Richard Soloman Owner information is required for every page. Owner's Name No. Andover City/Town B. Certification (cont.) MA 01845 State Zip Code D) System Failure Criteria Applicable to All Systems (cont.): 5/8/08 Date of Inspection Yes No 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. ' Commonwealth of Massachusetts Title 5 Official Inspection Form VM Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Boston Stret Property Address Richard Soloman Owner Owner's Name information is required for No. Andover MA 01845 5/8/08 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No Q Pumping information was provided by the owner, occupant, or Board of Health F1 Er`,- Were any of the system components pumped out in the previous two weeks? 11 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) 2 n Was the facility or dwelling inspected for signs of sewage back up? P-' 0 Was the site inspected for signs of break out? ,,2' n 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)] Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Boston Stret Property Address Richard Soloman Owner Owner's Name information is required for No. Andover MA 01845 5/8/08 every page. City/rown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: -� 3 Number of bedrooms (design): Number of bedrooms (actual): DESIGN flaw based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: 2 - Does residence have a garbage grinder? Does 0 Yes 0 No Is laundry on a separate sewage system? [if yes separate inspection required] 0 Yes 5U No Laundry system inspected? 0 Yes 59 No Seasonaluse? F1 Yes 5Q No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? n Yes 9] No Last date of occupancy: c"r Date tet-•'' 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? El Yes El No Industrial waste holding tank present? El Yes Q No Non -sanitary waste discharged to the Title 5 system? El Yes [] No Water meter readings, if available: Last date of occupancy/use: Date Other (describe): Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Boston Stret Property Address Richard Soloman Owner's Name No. Andover MA 01845 Cityrrown State Zip Code D. System Information (cont.) General Information 5/8/08 Date of Inspection Pumping Records: VN K-0ja %- ' ?gam' Source of information: /yi9 ��MPC�D atter '/ Was system pumped as part of the inspection? [I Yes JQ No If yes, volume pumped: How was quantity pumped determined? Reason for pumping: gallons Type of System: Septic tank, distribution box, soil absorption system Single cesspool n Overflow cesspool n Privy 0 Shared system (yes or no) (if yes, attach previous inspection records, if any) 0 Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) 0 Tight tank. Attach a copy of the DEP approval. E] Other (describe): Approximate age of all components, date installed (if known) and source of information: PLC.aA-23.y Ir Were sewage odors detected when arriving at the site? Yes No ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Boston Stret Property Address Richard Soloman Owner Owner's Name information is required for No. Andover MA 01845 5/8/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer (locate on site plan): Depth below grade: Material of construction: 7 feet cast iron 0 40 PVC El other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): 3 Depth below grade: feet Material of construction: 9i concrete [] metal n fiberglass ® polyethylene El other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Yes [I No ----------------------------------------------------------------------------------------------------------------------- Dimensions: Sludge depth: 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? /Cos-- a'V4-L-(-6.A 4 ,O[A- -.,&) 16 'u)PA, luteg--sJU zi7rK Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Boston Stret Property Address Richard Soloman Owner Owner's Name information is required for No. Andover MA 01845 518/08 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.): 11/1� Grease Trap (locate on site plan): Depth below grade: Material of construction: 0 concrete 0 metal feet 0 fiberglass E] polyethylene n 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 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: 0 concrete [I metal] fiberglass polyethylene F1 other (explain): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Boston Stret Property Address Richard Soloman Owner Owner's Name information is required for No. Andover MA every page. cityrrown State D. System Information (cont.) AICA Tight or Holding Tank (cont.) Dimensions: Capacity: Design Flow: Alarm present: Alarm level: 01845 5/8/08 Zip Code Date of Inspection gallons gallons per day El Yes El No Alarm in working order; El Yes [I 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 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): �l �7c � /✓ OIJ. [ a7No . IZ�/t �7 a�?!': etiaitll✓l C4�'t�— ND ✓�flt�c�. c� �.taKa�� ..n aN oJryt2 gam•-•yS C A -!L 127 ovG� Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes El No Alarms in working order: n Yes C1 No &� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Boston Stret Property Address Richard Soloman Owner Owner's Name information is required for No. Andover MA 01845 5/8/08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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: Type: El leaching pits number: leaching chambers number: leaching galleries number: ® leaching trenches number, length: leaching fields number, dimensions: overflow cesspool number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): kajFA G, -F -r--ICI.a L4>016J /Ne%Rn,4-t ...o j'A^JDC! y -32 A -f-0, f d 6/3. WO -L. t)C►�t1c'ihJ� St�NC P Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y� 208 Boston Stret Property Address Richard Soloman Owner Owner's Name information is required for No. Andover MA 01845 5/8/08 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Al 1,+ 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 El Yes El No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ,, #, Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 208 Boston Stret Property Address Richard Soloman Owner's Name No. Andover Cityfrown D. System Information (cont.) MA 01845 5/8/08 state Zip Code Date of Inspection Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. % Commonwealth of Massachusetts U0297 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments IR 208 Boston Stret Property Address Richard Soloman Owner Owner's Name information is required for No. Andover MA 01845 5/8/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: 0 Check Slope Surface water Check cellar [1 Shallow wells Estimated depth to ground water: q feet Please indicate all methods used to determine the high ground water elevation: 0 0 Obtained from system design plans on record If checked, date of design plan reviewed: Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: Checked with local excavators, installers - (attach documentation) Accessed USGS database - explain: You must describe how you established the high ground water elevation: ,S�s4'C.•n g��� i FLN A Sc.9_�, f*��ae-0 C.re- C, los -GloS� '1b OG'� e� ,.�.i ti�0.ncy SJ Q..F-OCe• V > &-S rn A -PS t i D 44- .,.. ,A-?F!L TAf r- E 1 !n• (� �jCt s w Q lUw�e� ' Zy►�� e. -6 r e xp ea, to G4i 1 5 Q!'a� .�•.e� �y �s �- �c' ��—� ► �(z 53 252 N O W 249 247 %, 246' i 45 2/ 13 33,545 S.F. 0.77 Ac. ..-1141�1,li coI 24' �n Ln N N c IYICLCJI�IUI MZ "' ; 4 No. X90 26' IJ .a SES \0? q 00 REMISES AND THAT ALL APPARENT vv EASEMENTS AND ENCROACHMENTS ARE LOCATED THIS PLAN IS INTENDED FOR ZONING AS SHOWN. THE STRUCTURE SHOWN CONFORMS PURPOSES ONLY. IT WAS PREPARED TO THE ZONING LAWS OF THE MUNICIPALITY 'N3N0 WHEN CONSTRUCTED. ALSO, ACCORDING TO THE 904 F.E.M.A./H.U.D. FLOOD INSURANCE RATE MAP, BY AN INSTRUMENT SURVEY. THIS PLAN COMMUNITY PANEL NO. 250098 0009 C SHOULD NOT BE USED FOR PROPERTY DATED 6/2/93, THE STRUCTURE IS NOT LOCATED LINE DETERMINATION. 'O CERTIFIED PLOT PLAN LOT 14 BROOKVIEW DRIVE MARCHIONDA & ASSOC.,,-L.P. 0rn ENGINEERING AND PLANNING CONSULTANTS PREPARED FOR 62 MONTVALE AVE. SUITE I BROOKVIEW COUNTRY HOMES STONEHAM, MA. 02180 P.O. BOX 531 (617) 438-6121 NORTH ANDOVER, MASS. SCALE: 1 "=40' DATE: 1/27/99 coI 24' �n Ln N N IYICLCJI�IUI MZ "' ; 4 No. X90 ► 1 IJ .a SES \0? q WE ERE CERTIFY THAT WE HAVE EXAMINED REMISES AND THAT ALL APPARENT vv EASEMENTS AND ENCROACHMENTS ARE LOCATED THIS PLAN IS INTENDED FOR ZONING AS SHOWN. THE STRUCTURE SHOWN CONFORMS PURPOSES ONLY. IT WAS PREPARED TO THE ZONING LAWS OF THE MUNICIPALITY FROM EXISTING PLANS AND RECORDS WHEN CONSTRUCTED. ALSO, ACCORDING TO THE WITH THE STRUCTURES SHOWN LOCATED F.E.M.A./H.U.D. FLOOD INSURANCE RATE MAP, BY AN INSTRUMENT SURVEY. THIS PLAN COMMUNITY PANEL NO. 250098 0009 C SHOULD NOT BE USED FOR PROPERTY DATED 6/2/93, THE STRUCTURE IS NOT LOCATED LINE DETERMINATION. IN AN ESTABLISHED 100 YR. FLOOD HAZARD ZONE. CERTIFIED PLOT PLAN LOT 14 BROOKVIEW DRIVE MARCHIONDA & ASSOC.,,-L.P. NORTH ANDOVER, NIA ENGINEERING AND PLANNING CONSULTANTS PREPARED FOR 62 MONTVALE AVE. SUITE I BROOKVIEW COUNTRY HOMES STONEHAM, MA. 02180 P.O. BOX 531 (617) 438-6121 NORTH ANDOVER, MASS. SCALE: 1 "=40' DATE: 1/27/99 53 252 N O W 1 � 249 247 246 13 33,545 S.F. 0.77 Ac. THIS PLAN IS INTENDED FOR ZONING PURPOSES ONLY. IT WAS PREPARED FROM EXISTING PLANS AND RECORDS WITH THE STRUCTURES SHOWN LOCATED BY AN INSTRUMENT SURVEY. THIS PLAN SHOULD NOT BE USED FOR PROPERTY LINE DETERMINATION. CERTIFIED LOT 14 BROOKVIEW DRIVE NORTH ANDOVER, MA PREPARED FOR BROOKVIEW COUNTRY HOMES P.O. BOX 531 NORTH ANDOVER, MASS. v 26' v 0 2' Q L 2.5'N 3 � raj 2.5N f1 II 2.5' ~i O 0 f— w � rn 7' N 24' �n cD uj N N W Y 0 0 m pp WE 1JERE CERTIFY THAT WE HAVE EXAMINED PREMISES AND THAT ALL APPARENT EASEMENTS AND ENCROACHMENTS ARE LOCATED AS SHOWN. THE STRUCTURE SHOWN CONFORMS TO THE ZONING LAWS OF THE MUNICIPALITY WHEN CONSTRUCTED. ALSO, ACCORDING TO THE F.E.M.A./H.U.D. FLOOD INSURANCE RATE MAP, COMMUNITY PANEL NO. 250098 0009 C DATED 6/2/93, THE STRUCTURE IS NOT LOCATED IN AN ESTABLISHED 100 YR. FLOOD HAZARD ZONE. PLOT "PLAN } MARCHIONDA & ASSOC.�I.P. ENGINEERING AND PLANNING CONSULTANTS 62 MONTVALE AVE. SUITE I STONEHAM, MA. 02180 (617) 438-6121 SCALE: 1 "=40' DATE: 1/27/99 Or' i ,U pLp� �!J � m N o �o� QN IQ X �cAtlJ tD � L.I,1 u1 40 I r- [II ii Or' i I I I I I I i I I I I i I I I I I I I I I I I I I I I I I I I I I I I I i I I I I I I I I I I ' I I I I f I I I I I I I • I I I I 6 N J WI V } wQ� v J N � X to to c cn QWx (L Y Iu tL I I I I I I i I I I I i I I I I I I I I I I I I I I I I I I I I I I I I i I I I I I I I I I I ' I I I I f I I I I I I I • I I I I 6 N J WI o & X-� -u o -Z °§_° � -UNu I ° "'-o u7u a 6) x��0 u oTOO _0:;s to v 70 U L -M roNv E � Q)O u 3 O ROM SLO' O ° u a) O ��—vim U �u°uu °u 6 Q v V -u p V 4) -u �UJs LL u U1 usk)� 1074) a� PQ-9) R. -u 0 �-- v Q 15 -Q m en u ►- as N ai )E II II II it II II it II II II II II II II II it II II II II II II ----LI I Y'{ Q N X 9)O O o 514) Lf) x fu o & X-� -u o -Z °§_° � -UNu I ° "'-o u7u a 6) x��0 u oTOO _0:;s to v 70 U L -M roNv E � Q)O u 3 O ROM SLO' O ° u a) O ��—vim U �u°uu °u 6 Q v V -u p V 4) -u �UJs LL u U1 usk)� 1074) a� PQ-9) R. -u 0 �-- v Q 15 -Q m en u ►- as N ai )E II II II it II II it II II II II II II II II it II II II II II II ----LI tu z J z m u nnL� �tl r o mom o�NO x =cAao RD LL a' z w rq 9 V Q1 � r a w tr .o Q ONS x cA a0 � a' z w rq 9 CJS 4v uo Ilk' 14 42, 592 S. F. 0.98 Ac. .8' 41.90' 26 c6 37.10' N TOP FN-D�� N 25.5 ELS=132.59' 2 4' 6.6' 14 14' ' - v 4' N N N CP C1n CTI 3.2' 3.2' Lo 183.86' f BROOKVIEW DRIVE WE HEREBY CERTIFY THAT WE HAVE EXAMINED THE PREMISES AND THAT ALL APPARENT THIS PLAN IS INTENDED FOR ZONING EASEMENTS AND ENCROACHMENTS ARE LOCATED PURPOSES ONLY. IT WAS PREPARED AS SHOWN. THE STRUCTURE SHOWN CONFORMS FROM EXISTING PLANS AND RECORDS TO THE ZONING LAWS OF THE MUNICIPALITY WITH THE STRUCTURES SHOWN LOCATED WHEN CONSTRUCTED. ALSO, ACCORDING TO THE BY AN INSTRUMENT SURVEY. THIS PLAN F.E.M.A./H.U.D. FLOOD INSURANCE RATE MAP, SHOULD NOT BE USED FOR PROPERTY COMMUNITY PANNEL NO. 250098 0009 C LINE DETERMINATION. DATED 6/2/93 , THE STRUCTURE IS NOT LOCATED IN AN ESTABLISHED 100 YR.FLOOD HAZARD ZONE. CERTIFIED PLOT PLAN LOT 14 BROOKVIEW DRIVE NORTH ANDOVER, MASS. PREPARED FOR BROOKVIEW COUNTRY HOMES P.O. BOX 531 NORTH ANDOVER, MASSACHUSETTS MARCHIONDA & ASSOC., L.P. ENGINEERING AND PLANNING CONSULTANTS 62 MONTVALE AVE. SUITE I —•� STONEHAM, MA. 02180 (617) 438-6121 SCALE: I"=20' DATE: 1 /27/99 0 as z mO 00 Om m ,y INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant�lls out this section***************** APPLICANT: u/t h 44<S Phone ,�p ir LOCATION: Assessor's Map Number f0lf tjGy14 Parcel 3 t Subdivision zzeo'epl�"ekj ST <S. Lot (s; AY Street �00,�1//C� ��Q'yC St. Nu-=er Use Only************************ RE NDATIONS OF TOWN AGENTS: ✓1�� �� +� Date Aocroved q Conservation Ad=inis gyrator Date j ect�ed�� nRe / �W; Date Approved Z� Q Planner Date Rej ec med Conr„e:: -s .Fcod _:,spe�--cr- ealth Date Approved Date Reiec_ed Date Abcrcved Date Re j ec =ed put 1 ` c Wcr�:=_ - se.ier,'water connect ons _ - driveway per -tit Fire Decart.:1ent Recsived by Building Inspector Date Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 146 Main Street North Andover, Massachusetts 01845 WILLIAM J. SCOTT Director July 8, 1997 Mike Rosati Marchionda & Associates 62 Montvale Ave., Suite 1 , Stoneham, MA 02180 RE: Brookview Circle Dear Mike - This letter is to inform you that the proposed septic plans for Lots 14 and 15 Brookview 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, ~J1 i Sandra Starr, R.S. Health Administrator i cc: Wm. Scott, Dir. CD&S I File Dave Kindred 1 SEPTIC PLAN SUBMITTALS - LOCATION: . a j p NEW PLANS: YES $60.00/Plan REVISED PLANS: YES S25.00/Plan- DATE::„ DESIGN ENGINEER: f When the submission is all in place, route to the Health Secretary Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 146 Main Street North Andover, Massachusetts 01845 WILLIAM J. SCOTT Director July 8, 1997 Mike Rosati Marchionda & Associates 62 Montvale Ave., Suite 1 Stoneham, MA 02180 RE: Brookview Circle Dear Mike: This letter is to inform you that the proposed septic plans for Lots 14 and 15 Brookview 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, Sandra Starr, R.S. Health Administrator cc: Wm. Scott, Dir. CD&S File Dave Kindred BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 6&',033' I SEPTIC PLAN SUBMITTALS LOCATION: NEW PLANS: YES $60.00/Plan REVISED PLANS: YES $25.00/Plan DATE: - /.2, %9 `7 DESIGN ENGINEER: a. When the submission is all in place, route to the Health Secretary Marchionda �& Associates, L.P. Engineering and Planning Consultants TO: NORTH ANDOVER BOARD OF HEALTH LETTER OF TRANSMITTAL DATE: 2-11-99 JOB NO. 351-22 ATTENTION: SANDY/SUSAN RE: LOT 11 & 14 - BROOKVIEW ESTATES WE ARE SENDING YOU ® ATTACHED ❑ UNDER SEPARATE VIA ❑ SHOP DRAWINGS ❑ PRINTS ❑ PLANS ❑ COPY OF LETTER ❑ CHANGE ORDER ❑ COPIES DATE NO. 1 1/27/99 1 1 1/27199 1 1 2/3/99 1 1 2/3/99 1 FOUNDATION AS -BUILT (LOT 14) 1 "=20' FOUNDATION AS -BUILT (LOT 14) 1 "=40' FOUNDATION AS -BUILT (LOT 11) 1 "=30' FOUNDATION AS -BUILT (LOT 11) 1 "=40' THESE ARE TRASMITTED AS CHECKED BELOW: THE FOLLOWING ITEMS: ❑ SAMPLES ❑ SPECIFICATIONS DESCRIPTION ❑ FOR APPROVAL ❑ APPROVED AS SUBMITTED ❑ RESUBMIT COPIES FOR APPROVAL ® FOR YOUR USE ❑ APPROVED AS NOTED ❑ SUBMIT COPIES FOR DISTRIBUTION ❑ AS REQUESTED ❑ RETURNED FOR CORRECTIONS ❑ RETURN CORRECTED PRINTS ❑ FOR REVIEW AND COMMENT ❑ ❑ PRINTS RETURNED AFTER LOAN TO US ❑ FORBIDS DUE REMARKS: IF YOU HAVE ANY QUESTIONS PLEASE CALL. COPY TO: Flintlock Inc. SIGNED:Wj�wFC>rVG4w Marchionda and Associates, L.P. Tel: (781) 438-6121 62 Montvale Avenue, Suite Fax:(781)438-9654 WWW,marchionda.com Stoneham, Massachusetts 02180 email: engineers@marchionda.com TOWN OF NORTH ANDOVER BOARD OF EALTH =12""W9 Town. of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES WILLIAM J. SCOTT Director June 23, 1997 Mr. Mike Rosati Marchionda & Associates 62 Montvale Ave., Suite #1 Stoneham, MA 02180 30 School Street North Andover, Massachusetts 01845 Re: Lot 14 Brookview Estates This is to inform you that the proposed plans for the site referenced above have been disapproved for the following reasons: If new plans satisfactorily addressing all the following issues are submitted to the Health Department by July 7, 1997, then approval for the plans should be given by July 16, 1997. 1. Only two (2) copies submitted. (NA 6.01) 2. No signature. (3 10 CMR 15.220(2)) 3. Perc Elevations missing. (NA 6.02j) 4. Tank manhole to be within 6 inches of grade. (3 10 CMR 15.228(2)) 5. Reserve not 4 feet from primary. (NA 2.23) 6. Vent missing. (310 CMR 15.251) 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 C OMF.RVA770N 68P.9S30 HFAL TH 6&Q-9544 PLANNTNC 63R-9-5.15 'eo June 23, 1997 Mr. Mike Rosati Marchionda & Associates 62 Montvale Ave., Suite #1 Stoneham, MA 02180 Re: Lot 14 Brookview Estates This is to inform you that the proposed plans for the site referenced above have been disapproved for the following reasons: If new plans satisfactorily ddressing all the following issues are submitted to the Health Department by 777 , then approval for the plans should be given by --r Only two (2) copies submitted. (NA 6.01) y,,.2. No signature. (3 10 CMR 15.220(2)) t,-3`..- Perc Elevations missing. (NA 6.02j) --- Tank manhole to be within 6 inches of grade. (3 10 CMR 15.228(2)) L. 4- Reserve not 4 feet from primary. (NA 2.23) 1.,,-6. Vent missing. (3 10 CMR 15.251) 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 NORTH ANDOVER BOARD OF HEALTH DESIGN REVIEW REPORT DATE ,f'//,* FEE: PERMIT # �T� DATE RECEIVED �"IZZI'> APPLICANT MAP PARCEL ADDRESS LOT #_ STREET # ENG. / % �a6 1-7T/ STREET ENGINEER'S ADD. / PLAN DATE �l�/Q % REV. DATE CONDITIONS OF APPROV APPROVED DISAPPROVED REASONS FOR DISAPPROVAL: /, '59 e,opic5 6NIq � .Gl) 6/0 a2 Iq IJ(c-- /0 Z, VC -A)7- M1,561,06 3 /0 CNS SEPTIC PLAN SUBMITTALS LOCATION: NEW PLANS: (�E $60.00/Plan. REVISED PLANS: YES $25.00/Plan DATE: DESIGN ENGINEER: A41 401 When the submission is all in place, route to the Health Secretary PLAN REVIEW CHECKLIST kDDRESS l¢,�DKUIe ENGINEER 3ENERAL `'Q ado 3 COPIES STAMP LOCUS NORTH ARROW t---' SCALEt---_"' _ONTOURS_C,," PROFILE ✓ (Sc) SECTION [--' BENCHMARKy- SOIL & ?ERCS ✓ ELEVATION✓ WETS. DISCLAIMER l/^ WELLS & WETS ✓ 4ATERSHED?All) DRIVEWAY WATER LINE L---' FDN DRAIN L-- M&P 3CH40 ✓ TESTS CURRENT?SOIL EVAL M .�DS,q 7-1 'SEPTIC TANK / IIN 1500G V .17 INVERT DROP ✓ GARB. GRINDERV0 (2 comps +200) 10' TO FDN `l MANHOLEX ELEV �-' GW U/6_ # COMPS. GB C-' D -BOX SIZE # LINES FIRST 2' LEVEL STATEMENT INLET /27- 67 -OUTLET 1976D _ 7 ( 2" OR .17 FT) TEE REQ' D?/�/() LEACHING MIN 440 GPD?" RESERVE AREA 4FROM PRIMARY? 2° SLOPE`S 100' TO WETLANDS ✓'100' TO WELLSL-' 4' TO S.H.GW L-' (5'>2M/IN) 20' TO FND & INTRCPTR DRAINS6,� 400' TO SURFACE H2O SUPP `'' 4' PERM. SOIL BELOW FACILITY MIN 12" COVERL-_- FILL?�(15') BREAKOUT MET? ✓ TRENCHES I'MIN 440 gpd SLOPE (min .005 or 6"/1001)Ll__'SIDEWALL DIST. 3X EFF. W OR D (MIN 6RESERVE BETWEEN TRENCHES? L ---Ili FILL? MUST � BE 10' 4" PEA STONE? VENT? (>3' COVER; LINES >50') 'MIN. BOT 666 + SIDE �� = 1/�D X LDNGTOT (L x W x #) (DxLx2x#) (G/ft2) Copyright (D 1996 by S.L. Starr Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 5 TOWN OF NORTH ANDOVERI DEP has provided this form for use by local Boards of Health. �xhr�x�lut 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. ra:... '29VGD DEC 0 4 2008 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return kkey. A. Facility Information 1. System Location: Left fro t, left rear, efts a of hos Right front, right rear, right side of house. 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: 0 Other (describe): State Zip Code StateZip Code -� �g Telephone Number R ay--t- Date 2. Quantity Pumped: Gallons Cesspool(s) T Septic Tank Tight Tank 4. Effluent Tee Filter present? r] Yes EJ-1q—o— If yes, was it cleaned? Yes [j No 5. Condition of6fSystem: J'-OU� ��cD 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: O. L.S.D� Lowell Waste Water of F 5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. L Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 RECEIVED JUL 2 2 200g TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. Other f664& t ��frie 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 rear 1. System Location: Left fron le ft side of house. Right front, right rear, right side of house Address Cityrrown State Zip Code 2. System Owner: Name Address (if different from location) Cityrrown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Z. Quantity Pumped Date 3. Type of system: 0 Cesspool(s) Septic Tank 0 Other (describe): 4. Effluent Tee Filter present? Yes 0 /No 5. Condition of System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Locati�here contents were disposed: Lowell Waste Water A-�s 0 n Gallons 0 Tight Tank If yes, was it cleaned? 0 Yes El No F 5821 Vehicle License Number O-ZA A j �w --7- cc) - d re of Hq(utbr Date t5form4.doc• 06103 System Pumping Record • Page 1 of 1 ,C\ Commonwealth of Massachusetts City/Town of W� System Pumping Record RClE� E 41M SVey`w Form 4 HAY '18 Z Q 11 DEP has provided this form for use by local Boards of Health. Other form ma be used, but the information must be substantially the same as that provided here. Before:Jed your local Board of Health to determine the form they use. The System Pumpi u to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left front of house, right front of house, left side of house, right side of house(Gff� rear ofous Ight rear of house, left side of building, right rear of building, under deck. co�k�0-e X11, Cityrrown State Zip Code 2. System Owner: M Name Address (if different from location) City/Town B. Pumping Record State Zip Code ` alz-- o-31 Telephone Number 1. Date of Pumping S ` �. r t 2. Quantity Pumped: t Sa Z) Date Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes Cg/No 5. Condition of System: 6. System Pumped By: Neil J. Bateson If yes, was it cleaned? ❑ Yes ❑ No _ F5821 Name Bateson Enterprises Inc. Company 7. Location where contents were disposed: S. Lowell Waste Water Signature of Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1