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Home My WebLink AboutMiscellaneous - 864 WINTER STREET 4/30/2018 (2)N p-0 ol mA c`E i Z g� m 00 ;u CO m m m o -' R z 4 1 I L LOA) E5ulL-T DI q Q, t d ^.t Calms^.. F 9;;i - , V C'.1 o A6604 ChC V64Z LawImesawT QF t1►1 )[ eM j a $ - 1-AZPAW M FS.A2UT &M 4 1 I L LOA) E5ulL-T DI q Q, t d ^.t Calms^.. F 9;;i - , V C'.1 o A6604 ChC V64Z .. Y �� .. Y Town of North Andover HEALTH DF.PARTMF,NT '4,'00 0 �A•`h SS�CNU CHECK LOCA1 H/O N CONTI 68'1 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) $ ❑ Title 5 Inspector $ Title 5 Report y �J $_ ❑ Other. (Indicate) L� Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer •i4s,L DRM1TiD �SSACHUS�� PUBLIC HEALTH DEPARTMENT Community Development Division To: All North Andover Residents with Septic Systems and Garbage Grinders 1 Please note that due to recent reviews of Title 5 Reports, your property has been identified as maintaining a working garbage grinder that is being used in conjunction with a septic system. The Health Department is concerned for the longevity of your septic system. Garbage grinders are never recommended where septic systems are used, but if they are installed, the system must be specifically designed to handle the waste from them; your system can not handle the waste as designed. Please note that continued use of this grinder could quickly cause a pre -mature failure of your septic system, resulting in a large expenditure to replace it. The North Andover Health Department recommends that you remove it from your home as soon as possible. Some information regarding regular maintenance of your septic system is attached. Please call the Health Department -at 978.688.9540 if you have any questions, or e-mail your questions to: healthdept(Ltownofnorthandover.com. Thank you for taking the time to consider the impact that your current setup has on your septic system and°the environment. Sincerely, Susan Y. Sawyer, REHS Z� Public Health Director /pfd Enc: Septic System Information: http://www.mass.fzov/der)/water/wastewater/dodont.htm 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web http://www.townofnorthandover.com 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. te6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 864 Winter Street Property Address Teckla Moulton Owner's Name North Andover MA 01845 City/Town State Zip Code 6/18/2014 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Neil J. Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover MA City/Town State 978-475-4786 S115 Telephone Number B. Certification License Number 01810 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant toectionl d�:1�° Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fairs JUN 2 3 2014 ❑ Ne5ds Further Evaluation by the Local Approving Authority AIA 6/18/2014 16spe,ctoN Signat Date TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 864 Winter Street Property Address Teckla Moulton Owner Owner's Name information is required for North Andover MA 01845 6/18/2014 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if itis 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 • 3/13 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 864 Winter Street Property Address Teckla Moulton Owner's Name North Andover Cityrrown B. Certification (cont.) MA 01845 State Zip Code 6/18/2014 Date of Inspection ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 3113 Title 5 Official Inspection 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 864 Winter Street Property Address Teckla Moulton Owner's Name North Andover MA 01845 6/18/2014 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins • 3/13 Title 5 ficial 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .. " 864 Winter Street Property Address Teckla Moulton Owner information is Owner's Name required for North Andover MA 01845 6/18/2014 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r� 864 Winter Street Property Address Teckla Moulton Owner Owner's Name information is required for North Andover MA 01845 6/18/2014 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 ® ❑ 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): 5 Number of bedrooms (actual): 6 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 550 t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments "< 864 Winter Street Property Address Teckla Moulton Owner information is required for every page. Owner's Name North Andover Cityrrown D. System Information Description: Number of current residents: 01845 Zip Code 6/18/2014 Date of Inspection Does residence have a garbage grinder? Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): 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 ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ® No Yes ❑ Yes ® No Current Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 3113 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 864 Winter Street Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Date 6/18/2014 Date of Inspection Pumped this year, owner 1200 gallons Measured tank Inspect tank & tees. ® Yes ❑ No Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Property Address Teckla Moulton Owner Owner's Name information is required for North Andover MA 01845 every page. Citylrown State Zip Code D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Date 6/18/2014 Date of Inspection Pumped this year, owner 1200 gallons Measured tank Inspect tank & tees. ® Yes ❑ No Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins - 3113 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 °r 864 Winter Street Property Address Teckla Moulton Owner information is required for every page. Owner's Name North Andover MA 01845 6/18/2014 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 21 years old, 8/6/1993, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 1.7 feet Material of construction: ® cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" Cast Iron through wall, 3" PVC in house, no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 7 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: 8'x 5'x 4' Sludge depth: 4" ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 9 of 17 Commonwealth of Massachusetts Ln Title 5 Official Inspection Form "s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 864 Winter Street Property Address Teckla Moulton Owner Owner's Name information is required for North Andover every page. Cityrrown State D. System Information (cont.) t5ins • 3/13 01845 Zip Code 6/18/2014 Date of Inspection Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts u°` Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 864 Winter Street Property Address Teckla Moulton Owner Owner's Name information is required for North Andover MA 01845 6/18/2014 every page. 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.): 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: Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ❑ Yes ❑ No "Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection form: Subsurface Sewage Disposal System • Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 864 Winter Street Property Address Teckla Moulton Owner's Name North Andover MA 01845 6/18/2014 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D -box level & distribution equal, has flow levelers in some pipes. No evidence of leakage. Evidence of carryover, pumped d -box to clean. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .•�r 864 Winter Street Property Address Teckla Moulton Owner information is required for every page. t5ins • 3113 Owner's Name North Andover MA 01845 6/18/2014 Citylrown State Zip Code Date of Inspection D. System Information (cont.) ' Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 6 trenches 25' 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 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 864 Winter Street Property Address Teckla Moulton Owners Name North Andover MA 01845 6/18/2014 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 • 3113 Title 5 Official Inspection Forrn: 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 864 Winter Street Property Address Teckla Moulton Owners Name North Andover MA 01845 6/18/2014 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 864 Winter Street Property Address Teckla Moulton Vwner's Name North Andover MA 01845 6/18/2014 City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >4feet 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: 6/4/1993 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Design plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Test pit data on design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 864 Winter Street Property Address Teckla Moulton Owner Owner's Name information is required for North Andover MA 01845 6/18/2014 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Summary Record Card generated on 6/2/2014 2:51:17 PM by Maureen McAuley Town of North Andover Tax Map # 210-104.B-0081-0000.0 Parcel Id 16404 864 WINTER STREET MOULTON, R. DOUGLAS 864 WINTER STREET N. ANDOVER, MA 01845 Page 1 Class 104 Two-family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.02 Acres FY 2014 UB Mailina Index Name/Address MOULTON, R. DOUGLAS 864 WINTER STREET N. ANDOVER, MA 01845 UB Account Maint. Account No Cycle Bldg Id. 18089.0 - 864 WINTER STREET 3180117 03 Cycle 03 UB Services Maint. Account No. 3180117 Service Code MISCFEE ADMIN FEE WTR WATER UB Meter Maintenance Account No. 3180117 Serial No Status 29955855 a Active Date 3/13/2014 12/13/2013 9/13/2013 6/14/2013 3/20/2013 12/13/2012 9/19/2012 6/18/2012 3/20/2012 12/19/2011 9/16/2011 6/13/2011 3/15/2011 12/15/2010 9/16/2010. 6/14/2010 3/18/2010 12/14/2009 9/16/2009 6/10/2009 Trouble Code:03 3/18/2009 12/15/2008 9/16/2008 6/10/2008 3/14/2008 12/17/2007 9/14/2007 6/21/2007 Type Loan Number Payor Active/Inact. From Occupant Name Active/Inactive Last Billing Date 4/2/2014 Active Rate Charge Multiplier/Users 0.635/8 7.82 1/ 01 ALL METER SIZE 768.05 /2 Until Location Brand Type Size YTD Cons 00 b Badger w Water 0.63 0.63 2275 Reading Code Consumption Posted Date Variance 3846 aActual 151 4/11/2014 282% 3695 aActual 40 1/17/2014 -69% 3655 a Actual 128 10/15/2013 157% 3527 a Actual 47 7/24/2013 489% 3480 a Actual 9 4/22/2013 -56% 3471 aActual 18 1/9/2013 -90% 3453 a Actual 190 10/15/2012 127% 3263 a Actual 81 7/16/2012 452% 3182 a Actual 15 4/14/2012 -45% 3167 aActual 28 1/17/2012 -85% 3139 a Actual 195 10/13/2011 168% 2944 a Actual 69 7/20/2011 109% 2875 a Actual 33 4/13/2011 -27% 2842 a Actual 45 1/12/2011 -81% 2797 a Actual 252 10/15/2010 93% 2545 a Actual 122 7/15/2010 125% 2423 a Actual 58 4/14/2010 -4% 2365 aActual 57 1/12/2010 -69% 2308 a Actual 202 10/15/2009 80% 2106 a Actual 96 7/20/2009 59% 2010 a Actual 67 4/29/2009 8% 1943 aActual 60 1/20/2009 -68% 1883 a Actual 202 10/10/2008 65% 1681 a Actual 110 7/16/2008 134% 1571 aActual 47 4/11/2008 -47% 1524 aActual 95 1/22/2008 -73% 1429 a Actual 313 10/12/2007 213% 1116 a Actual 114 7/20/2007 143% Commonwealth of Massachusetts City/Town of . System Pimping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using -this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: 07 Rlght45jo u Left ! Right rear of house, Left /right side of house, Left / Right side of building, Left ! Right front of building, Left / Right rear of building, Under deck Address Cityrrown state Trp Code 2. System Owner. ll -- Hou_ V'1 Name* Address (if different from location) city/Town Stat < Telephone Number' i B. Pumping Record `I LK Cha' 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) �eptcnk ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yep No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System _ n 44- 6. System Pumped By. Neil. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc- Company ncCompany 7. Location ere contents -were disposed: Lowell Waste Wi 01 t5fomu4.doc- 06/03 Data System Pumping Record • Page 1 of 1 STEWART'S SEPTIC TANK SERVICE 47 RAILROAD STREET - BRADFORD, MA 01835 J E L.: ( 508) 372-7471 15 � 0 /�� 5��' rd - 8 64 ��N �,� FL•1sR � u A!:IVdJpI vii Commonwealth of Massachusetts City/Town of �a Fh CEIVE® System Pumping Record 19 2014 Tol HEALTH DEPAR TND Facility Information: System Location: Address City/Town System Owner: f�6v�}yr Name: Adress (if different from location of pump) City/Town Pumping Record State 01 C5 q -S- Zip Code State Zip Code qD 6 - (093 - Telephone Number Date of Pumping 5hd hy Quantity Pumped, / . gallons Type of System—X—Septic Tank Grease Trap Other (what) System Pumped by: Company: ROOTER -MAN 46 Portland Street Lawrence, MA 01843 Location where contents were disposed: 0 S Signature of Hauler late ��1 Commonwealth of Massachusetts City/Town of 00 jq7 %&Veit) System Pumping ecord RECENED DEC 15 2009 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Facility Information: System Location: Address City/Town State Zip Code System Owner: Name: Adress (if different from location of pump) City/Town State Zip Code L-_bpo-lop� Telephone Number Pumping Record Date of Pumping 3 l U Quantity Pumped 15 J gallons Type of System Sep—Y--. Itic Tank Grease Trap Other (what) System Pumped by: UeV Company: ROOTER -MAN 12 East Dracut Rd., Methuen, MA 01844 Location where contents were disposed: Signature of Hauler Date ) % v I If I f TEL. 372-7471 JN. 3.16 STEWART'S SEPTIC TANK SERVICE, INC. CLEAN - SERVICE - REPAIR I 47 RAILROAD STREET BRADFORD, MASS. 01830 i' TO D�T TIME/ t FROM \ _ _ _ �O),( AR CODE NUMBER 113t- OF rg EXTENSION y A -L E lu 01- �0 s- a cn 3 00 w p €� SIGNED 1 ' � ,.tt 2CC tttt�' YAGFNIi: RETR ALL El N7L6 CltE AGAIN PHONED � S SSE YOU WAS IN AMPAD NO. 23-176-400 SETS NO. 23-376-200 SETS Board of Health North ArMcmertMass. P�tOV'E�''� DATE 7 L FAIL OK r SEPTIC STSTEli INSPALLATICN CHHCK LIST eu LOT 1. Distance Tot I AUG Ag6uur�J a. Wetlands Y(9y 4)jp M b. Drains ` c. Well l ✓r�N%S TO AQ) 2. Water Line Location M 3. No PPC Pipe !t. Septic Tank a. Tess - Length & To Clean __Ont Covers =- - b.' Cement Pipe to Tank - On Both Sides of Tank 5. Distribution Bqx a. Covers & Box - No Cracks b. All Lines Flowing Equal Amounts c. No Back Flow 6. Leach Field or Trench a. Dimensions 'V jw 491 b. Stone Depth c. Capped Ends d. Clean Double Washed Stone 7. Leach- is a* sions b. e Depth c.sh Pads Pee d.. e. ement Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. No Garbage Disposal 9 • FYnal Grading Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System c. Location with,Aegard_to Perc Test d• Elevations e. Water Table &ORTH p BOARD OF HEALTH 120 MAIN STREET NORTH ANDOVER, MASS. 01845 TEL. 682-6400 SSACHUSE Mardh 29,1985 Mr. Charles Foster. Re: Proposed addition Building Inspector 864 Jekneen St. -North Andover, Mass Dear Mr. Foster: I visited 864 Winter St. to discuss the proposed addition with Douglas Moulton. The existing septic system seems to be functioning adequately and there appears to be room for a new leaci area if one is necessary. Therefore, I have nc objection to his proposed addition provided it is lirLted to one story with one bedroom and kitchen as originally described to me. Very tru.1 yours, Michael Graf, R.S. Inspector mg;mj cc: D.Moulton I' •purr 44JON `s94ez00SSV I seut190 •0 xuV I Nope uo sagogaxS V sagoN Z oializ puZ * SUTN O.ZQu qsj ° suTw v; awTy-„g go doid auris-,►£ jo doic S/• auris-4sGI 4ae4S S •suT�-xpos 007: uoTgpjn4es qjp;S Z T jagwnN 416 Jti. f ` C.� 94ea-s4sas UOT4PTODJad wn4pQ UOT4P naTa u014po0a xzpwuauag OT . i -1 OI OI OI 6 8 L 9 9 Z 6 8 L 9 Sk 5 � 4 p N M L 4v N S T t I I p I 0 0 0 0 21va-Sa' iaoud 'IIOS O t JaAJasgp �C�/��fj�q zO4P6T4sanuZ zauMO upTa ll--VCJ i • nTPgnS/ • 00q /! -• ON 407 ~'' as z� S�• ON �A4t0/uM6s viva IS31 NOIIYIoou3a V 3ZI3oud 'Iios Ik C,A,. _ ,a i AA 1 'RBS. 4 X r'k }, s + iA Vy'�>`�+r ,. �}„ rd. C r ' `Y.a.•Y^„ r pY..''.,:,4`._ „t. ' .. J .. «-._ :. ,,.;= t K' „ ..4 •� lr'S' 4Wk ''s � ;�• aia �� ; yet � ». !4 � , t s (�'' y l ��sr.t • ' # h s � !� tE w 'M w�gMsqdty. Fir ♦ w: �;"i ,, �'r!;"�;... ��'{ �� _ tt ' - F` .. ya � ft �pi '� +f A • � �7„�?'. •a- t d c Wb�- Jk� � � {�� roYr � � Mr •, V ou R� • i �� 1 S may • +,._5511 4 pct s v t 4A 1i.�' °i r 1..��•'j„s'� { ,�,a •^ I t � s`rl R 4 , 1 C r. fi ri 'Y' e Giir r �'t 'x. �a3f ��r �"*�%� R� `.2 .'� t� R. •i f r, - +i ++YY •>t +"; '�P ywS 3� �r'si } t • , c �`r +1 ,Xx ri�x ,.Fs� i �-�5� 1,, \. - ; ni ' 1��4`��.. •; 4,.ijf�7R'd. tiR kk :+- tx. � [1tk'{Ct/i"'�«s. •. �'��..2Ft a kF�" � t �✓ �f. Y A< SOIL•PROFILE & PERCOLATION 'TEST DATA Torn/City ,-No.&Street LotNo.� . Loc. /Subdiv. .,_.Plan Owner r �l Investigator / Observer' SOIL PROFILES -DATE 112-7/11 1' Elev. _ 3' Elev. 3-Elev. 4. —...` Elev. 1 .� 2 3 0 � 4 5 6 3 7 8 0 1 2 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 10 10 10 I0 101 I Benchmark Location Elevation Datum Percolation Tests -Date 27� P.i t Number 1 2 3 4 S Start Saturation 3:00 Soak -Mins o ��- start Test -Time 3; Dro2 of 3" -Time Dro of 6" -Time. Mins.lst 3"Dro p Mins . 2nd 3 "Drop Z � Notes & Sketches on Back- Frank C. Gelinas & Associates, North And. r- NORTH 3? el T,-.. •� OL F P ♦ off+ " :. _'-: �� I ,SSACHUSES Applicant Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 3 DISPOSAL WORKS CONSTRUCTION PERMIT "ME- ADDRESS � TELEPHONE Site Location _ N, (lJ -IV ;-A ./Lc Permission is hereby granted to Construct ( ) or Repair (�dan Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. Fee CHAIRMAN, BOARD OF HEALTH D.W.C. No. b�( F� Date . l_ . �... �. ?. TOWN OF NORTH ANDOVER .o p PERMIT FOR PLUMBING This certifies that ..... �......�.`.? :'�'.: �...�. 0........... . has permission to perform ...... r �-^-. ...................... . plumbing in the buildings of ..//1!c-.(..( .{ I ..................... at. ... LA . (�. �. f �° .. j .�........... , North Andover, Mass. Fee. 4P. Lic. No.5 e. ? .. ....... `.0?.)...... . PiUMBING INSPECTOR Check # % S 5098 "1ASBACHUSET�S UNIFUhm APPLITION FOR PERMIT TGA- DO PLUMBING � 4P int or 1AQ � V, Mass. Date 2cr�_ Permit # S�4 Building Location Owner's Nam -l- -All �,T/ype"of Occupancy New ❑ Renovation ❑ Replacement [� Plans Submitted: Y-es'E]FIXTURES IV Installing Company Name__ 01 eT 10- ",a,(rM,4-rAe-Q Check one: Certificate1. Address r' 0 R ( N mt4t) s, r ❑ Corporation iY) E L4 l ' Fn) fyl A U r �(/L/ ❑ Partnership Business Telephone jcj 7 1 p-A'rm /Co -` Name of Licensed Plumber fhb INSURANCE COVERAGE: I have ayes current jabildy insoua ce policy or its substantial equivalent which meets the requirements of MGL Ch. 142. p� If you have checked Yes, please /indicate the type coverage by checking the appropriate box. A liability insurance policy 1d" Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Sianaturp of Ckvnar nr Cluinn.'e e...,•.• Owner ❑ Agent ❑ i nereoy certity that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations ormed under the permit issu for this application will be in compliance with all pertinent provisions of the Massachusetts State Plum ' gDde and?!apter7 of the eral taws. Title re of Licensed -Plumber City/Town Type of License: Master jam/ Journeymah ❑ APPROVED OF IC U ONL License Number �j3 3-5 Y • :■ ■. ■..■■■■�■■■■ ■ ■.■ ■ ■ NMI ■■■■.■�■�.■■�■ ■�.■■.0 ■■■I SEEN SEEMS SEEN WICK Installing Company Name__ 01 eT 10- ",a,(rM,4-rAe-Q Check one: Certificate1. Address r' 0 R ( N mt4t) s, r ❑ Corporation iY) E L4 l ' Fn) fyl A U r �(/L/ ❑ Partnership Business Telephone jcj 7 1 p-A'rm /Co -` Name of Licensed Plumber fhb INSURANCE COVERAGE: I have ayes current jabildy insoua ce policy or its substantial equivalent which meets the requirements of MGL Ch. 142. p� If you have checked Yes, please /indicate the type coverage by checking the appropriate box. A liability insurance policy 1d" Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Sianaturp of Ckvnar nr Cluinn.'e e...,•.• Owner ❑ Agent ❑ i nereoy certity that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations ormed under the permit issu for this application will be in compliance with all pertinent provisions of the Massachusetts State Plum ' gDde and?!apter7 of the eral taws. Title re of Licensed -Plumber City/Town Type of License: Master jam/ Journeymah ❑ APPROVED OF IC U ONL License Number �j3 3-5 101 V r c M W m x In m m n r d. S F V' _ 1 0 2 � t e&TY if 0 ell 1 �f1CVto W t QQ W , S Q t� `4 Q � .a• f w w �. Tr BF 'o" WN5+ r YSrf r • ' l • 5 - i S F V' _ 1 0 2 � t e&TY if 0 ell BF 'o" WN5+ r YSrf r • ' l • 5 - i Q -*A :moi S F _ 1 m t e&TY if r► ell 1 �f1CVto W t QQ W , S Q t� `4 Q � .a• f a a t �. Tr Q -*A :moi S F _ 1 t Q -*A :moi O �j S F -wo; IS Ab e&TY if r► 1s�r E 1 �f1CVto W QQ t� `4 l f a a t O �j Q W QQ a W a