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Ism Property
74 Record Card
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Location: 90 LOST POND LANE
Owner Name: IVAN, MIRCEA & CRISTINA
Owner Address: 90 LOST POND LANE
City: NORTH ANDOVER State: MA ZIP: 01845
Neighborhood: 7 - 7 Land Area: 0.87 acres
Use Code: 101 - SNGL-FAM-RES Total Finished Area: 2280 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 564,300 589,200
Building Value: 342,500 355,800
Land Value: 221,800 233,400
Market Land Value: 221,800
Chapter Land Value:
LATESTSALE
Sale Price: 620,000 Sale Date: 06/29/2005
Arms Length Sale Code: Y -YES -VALID Grantor: GOLD, ALAN
Cert Doc: Book: 9605 Page: 310
http://csc-ma.us/NandoverPubAcc/jsp/Home.jsp?Page=3&Linkld=1180399 4/30/2008
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MAP # �`.:t ^ LOT #t`''
--
PARCEL # STREET --pon A—
QONSTRUCTIO.N_APPROVAL
HAS PLAN REVIEW FEE .BEEN PAID? YES NO
PLAN APPROVAL: DATE dgjlq� APP. BY_
DESIGNER: Azuyg, PLAN DATE 1q /q'
CONDITIONS
WATER SUPPLY:
WELL P
WELL TESTS:
COMMENTS:
T WN
CHEMICAL
BACT
WELL
DRILLER
DATE APPROVED
BACTERIA II
DA f E (1PPRUVED
APPROVED
FORM U APPROVAL": APPROVAL TO ISSUE ,,_YES NO
DATE ISSUED 4�aa/ 8Y
CONDITIONS:
FINAL APPROVAL:
ALL PERMITS PAID YES NO
WELL CONSTRUCTION APPROVAL 5 NO
SEPTIC SYSTEM CONSTRUCTION APPROVAL NO
OTHER YES NU
ANY VARIANCE NEEDED YES NO
FINAL BOARD OF HEALTH APPROVAL: DATE:,%/._f�/.-.By: /`r>,,�J
= �Ep C SYS_TE.M__lNSSBL4fiT_l_QN
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iS 'THE' INSTALLER LICYES
NO
x
TYPE OF- CONSTRUCTION:
'PLAN
NO
NEW CONSTRUCTION CERTIFIED PLOT REVIEW-
CONDITIONS OF..APPROVAL. YES
!1
NO
,; (FROM FORM U)NO
J+ Vii. .�'f, - •' .: '. .. ,^
`.,ISSUANCE OF DWC PERMIT
' : y
DWC PERMIT N0. INSTALLER:
BEGIN INSPECTION
�J NO'
:NEEDED:ow
,EXCAVATION ;.INSPECTION:
%v
PASSED
- CONSTRUCTION INSPECTION: NEEDED: "
AS BUILT PLAN SATISFACTORY: :'YES:
DATE:_( BY /1�)
ROYAL TO BACKFILL:
.. APP •
�FINAL.GRADING APPROVAL: DATE BY
• DATE:,7
FINAL CONSTRUCTION APPROVAL:
Commonwealth of Massachusetts
_ City/Town of
System Pumping Record
Form 4
DEP has provided this form for use�by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using -this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Locatio : Vleft
Rig front of house eft / Right rear of house, Left/ right side of house, Left
' Right side of buil / Right front of building, Left / Right rear of building, Under deck
Address
�9--(l
Citylrown State Zip Code
2. System Owner.
Name
Address (if different from location)
Citylrown
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
Stato Zip Cot,/0'_7
o. de t `0
Telephone Number
�s- '7--(3
Date 2. Quantity Pumped
Cesspool(s) Septic Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No
5. Condition of System-
. po-�
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
Gallons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
t e��C ,lie
7. Location -where contents were disposed:
G,L SQ Lowell Waste Water
F5821
Vehicle License Number
a-a�._ �3
Date
t5form4.doc• 06/03
System Pumping Record •Page 1 of 1
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 90 Lost Pond Lane _
North Andover -
Owner's Owner's Name: _Mircea Ivan _
Owner's Address: _12950 University Crescent
_ Apt. 3C, Carmel, Indiana 46032
N0V 1 3
Date of Inspection: _11/1/2008
OF NORTH
TDHEALTH
Name of Inspector: _Neil J. Bateson_
DEPAWN
Company Name: _Bateson Enterprises Inc._
Mailing Address: _111 Argilla Road_
_Andover, MA 01810_
Telephone Number: _ (978) 475-4786_
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system:
Passes
_X_ Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
A4;�-riIA""&-'��Date:-111112008—
il
Inspector's Signature:
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or
DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments:
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 90 Lost Pond Lane _
North Andover
—
Owner: _ Ivan
Date of Inspection: _11/1/2008 _
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. Answer yes, no or not
determined (Y,N,ND) in the for the following statements. _Septic Tank & D -Box Leaking.
Y 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:
N Observation
of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of
Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
N 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:
Title 5 Inspection Form 6/15/2000
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 90 Lost Pond Lane _
_ North Andover—
Owner: _Ivan
Date of Inspection: _11/1/2008 _
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.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Title 5 Inspection Form 6/15/2000
Page 4 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 90 Lost Pond Lane_
_ North Andover—
Owner: _Ivan_
Date of Inspection: _11/1/2008 _
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following for all inspections:
_No_ Backup of sewage into facility or system component due to overloaded or clogeed SAS or cesspool
_No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
No_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_No_ Liquid depth in cesspool is less than 6" below invert or available volume is '/2 day flow.
_No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_No_ Any portion of the SAS, cesspool or privy is below high ground water elevation.
No— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_No_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
_No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described
in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to
determine what will be necessary to correct the failure
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either "yes" or "no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of 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.
Title 5 Inspection Form 6/15/2000
Page 5 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 90 Lost Pond Lane _
_ North Andover _
Owner: _Ivan_
Date of Inspection: _11/1/2008_
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
Yes Pumping information was provided by the owner, occupant, or Board of Health
_No_ Were any of the system components pumped out in the previous two weeks?
No_ Has the system received normal flows in the previous two week period?
No_ Have large volumes of water been introduced to the system recently or as part of this inspection?
Yes _ Were as built plans of the system obtained and examined?
_Yes_ _ Was the facility or dwelling inspected for signs of sewage back up ?
Yes_ _ Was the site inspected for signs of break out ?
_Yes_ _ Were all system components, excluding the SAS, located on site ?
_Yes_ _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the
condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of
scum?
_Yes_ — Was the facility owner (and occupants if different from owner) provided with information on the proper
maintenance of subsurface sewage disposal systems ?
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Yes No
_Yes_ —Existing information.
_Yes_ _ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable) [3 10 CMR 15.302(3)(b)]
Title 5 Inspection Form 6/15/2000
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 90 Lost Pond Lane_
_ North Andover—
Owner: _Ivan
Date of Inspection: _11/1/2008_
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): _4 _ Number of bedrooms (actual): _4_
DESIGN flow based on 310 CMR 15.203 _440 _
Number of current residents: _0
Does residence have a garbage grinder (yes or no): No _
Is laundry on a separate sewage system (yes or no): _No _
Laundry system inspected (yes or no):
Seasonal use: (yes or no): _No_
Water meter reading: _Yes _
Sump pump (yes or no): _No_
Last date of occupancy: _ Vacant since August 2008 _
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR 15.203): _gpd
Basis of design flow (seats/persons/sgft,etc.):
Grease trap present (yes or no): _
Industrial waste holding tank present (yes or no):
Non -sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available: _
Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: _Pumped last year, owner _
Was system pumped as part of the inspection (yes or no): _ No_
If yes, volume pumped: _ gallons -- How was quantity pumped determined?
Reason for pumping: _
TYPE OF SYSTEM
_X Septic tank, distribution box, soil absorption system
Single cesspool _ Overflow cesspool
Privy
_ Shared system (yes or no) (if yes, attach previous inspection records, 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 _12 years old, 7/26/1996,
as built plan, _
Were sewage odors detected when arriving at the site (yes or no): _No
Title 5 Inspection Form 6/15/2000
Page 7 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 90 Lost Pond lane
_ North Andover _
Owner: _Ivan
Date of Inspection: _11/1/2008_
BUILDING SEWER _ X _ (locate on site plan)
Depth below grade: _24"
Materials of construction: _ cast iron _X_40 PVC other
Distance from private water supply well or suction line:
Comments (on condition of joints, venting, evidence of leakage, etc.) _ 4" PVC thru wall, 3" PVC in house, no
leaks visible
tiy04-WIIsm 11VIX 1
Depth below grade: _12" _
Material of construction: _X concrete — metal _fiberglass _polyethylene
other(explain)
If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): ` (attach a copy of
certificate)
Dimensions: _IO' x 5 x 4'
Sludge depth: _ 0 _
Distance from top of sludge to bottom of outlet tee or baffle: N/A_
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:–N/A– N/A = Tank leaking
Distance from bottom of scum to bottom of outlet tee or baffle: N/A
How were dimensions determined: _
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc. _ Inlet tee ok. Outlet tee ok. Depth of liquid 2' below inlet
invert, evidence of leakage _
GREASE TRAP: (locate on site plan)
Depth below grade: _
Material of construction: _concrete _metal _fiberglass polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Title 5 Inspection Form 6/15/2000 7
Page 8 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 90 Lost Pond Lane
_ North Andover—
Owner: _Ivan_
Date of Inspection: _11/1/2008 _
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass _polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present (yes or no):
Alarm level: Alarm in working order (yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
DISTRIBUTION BOX X
Depth below grade _24" _
Depth of liquid level above outlet invert: _-2 _
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc. _D -box level & distribution equal. Evidence of leakage, liquid level 2" below
outlets. Evidence of carryover. _
PUMP CHAMBER: _ (locate on site plan)
Pump in working order (yes or no): _
Alarm in working order (yes or no): _
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Title 5 Inspection Form 6/15/2000
Page 9 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 90 Lost Pond Lane
_ North Andover—
Owner: _Ivan_
Date of Inspection: _11/1/2008_
SOIL ABSORPTION SYSTEM (SAS): X_ (locate on site plan, excavation not required)
If SAS not located explain why:
Type
_ Leaching pits, number: _
Leaching chambers, number:
Leaching galleries, number:
_X_ Leaching trench, number, length: _2 trenches 79' long_
Leaching field, number, dimensions:
Overflow cesspool, number:
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.): _ Soil ok. Vegetation ok. No sign of ponding to surface. _
CESSPOOLS:
Number and configuration: _
Depth — top of liquid to inlet invert: _
Depth of sludge layer: —
Depth of scum layer: _
Dimensions of cesspool: _
Materials of construction:
Indication of groundwater inflow (yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Title 5 Inspection Form 6/15/2000
Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: _90 Lost Pond Lane
_ North Andover—
Owner: _Ivan
Date of Inspection: _11/1/2008_
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
Title 5 Inspection Form 6/15/2000 10
A to Tank = 33'
A to D -Box = 39'6"
B to Tank = 41'8"
B to D -Box = 59'7"
Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 90 Lost Pond Lane _
_ North Andover—
Owner: _Ivan_
Date of Inspection: _11/1/2008 _
SITE EXAM
Slope _ No _
Surface water _ No _
Check cellar _ Yes _
Shallow wells No
Estimated depth to ground water _ 4'_
Please indicate (check) all methods used to determine the high ground water elevation:
_X_ Obtained from system design plans on record - If checked, date of design plan reviewed: _4/26/1995_
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain: _ _
Checked with local excavators, installers- (attach documentation)
Accessed USGS database -explain:
You must describe how you established the high ground water elevation: As per design plan_
Title 5 Inspection Form 6/15/2000 11
Tel: (978) 475-4786
Fax: (978) 475-5451
BATESON ENTERPRISES, INC.
Excavating -Water& Sewer Lines -Septic Systems & Pumping Service
111 Argilla Road Andover, Mass. 01810
Title 5 Inspection Report
Property Address: 90 Lost Pond Lane, North Andover
Owner: Ivan
Date of Inspection: 11/1/2008
My report contained herein does not constitute a guarantee of future usage and the functionality of the existing
septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further
operation of your current septic system.
N1, � , ")- �
Neil J. Bateson
Bateson Enterprises, Inc.
i
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• Town of North Andover
I HEALTH DEPARTMENT
,Ss4CHU
CHECK #: 7 DAT / p` `J4%
LOCATION: oaC�
H/O NAME:
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 Systems:
❑
Septic - Soil Testing
$
❑
Septic - Design Approval
$
❑
Septic Disposal Works Construction (DWC)
$
❑
Septic Disposal Works Installers (DWI)
$
nspector
$
��Ti�tle5
5
Report
$
❑ Other. (Indicate) $
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: _90 Lost Pond Lane_
—North Andover_
Owner's Name: _Alan Gold_
Owner's Address: _90 Lost Pond Lane_
_ North Andover, Ma 01845_
Date of Inspection: 8/12/2004
Name of Inspector: Neil J Bateson_
Company Name: _Bateson Enterprises Inc._
Mailing Address: _111 Argilla Road_
_Andover, Ma. 01810_
Telephone Number: _( 978 ) 475-4786_
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system:
Passes
X Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
ail
Inspector's Signature: r Date: _8/12/2004_
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 shard system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments:
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Page 2 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 90 Lost Pond Lane_
_ North Andover—
Owner: _Gold
Date of Inspection: 8/12/2004_
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:
X 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. Septic tank needs inlet cover. Inlet pipe pitched in wrong direction. Outlet pipe above inlet pipe
elevation.
N 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:
N_ Observation of sewage backup or break out or high static water level in the distribution box due to broken
or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
N The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system
w_ill pass inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 90 Lost Pond Lane_
_ North Andover_
Owner: _Gold
Date of Inspection: _8/12/2004
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.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 90 Lost Pond Lane _
—North Andover—
Owner: _Gold
Date of Inspection: _8/12/2004_
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following for all inspections:
Yes No
_ No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_No_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
No_ Liquid depth in cesspool is less than 6" below invert or available volume is''/z day flow.
No Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_ _No_ Any portion of the SAS, cesspool or privy is below high ground water elevation.
_No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_No_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ _No Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ _No Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered A copy of the analysis must be attached to this form.]
_No_ (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described
in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to
determine what will be necessary to correct the failure
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd-
You must indicate either "yes" or `no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
_ _ the system is within 400 feet of 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.
Page 5 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: _90 Lost Pond Lane_
_ North Andover—
Owner: _Gold
Date of Inspection: 8/12/2004_
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
Yes _ Pumping information was provided by the owner, occupant, or Board of Health
No Were any of the system components pumped out in the previous two weeks ?
Yes_ _ Has the system received normal flows in the previous two week period ?
No Have large volumes of water been introduced to the system recently or as part of this inspection ?
Yes _ Were as built plans of the system obtained and examined? (If they were not available note as N/A)
_Yes_ , Was the facility or dwelling inspected for signs of sewage back up ?
Yes Was the site inspected for signs of break out ?
Yes _ Were all system components, excluding the SAS, located on site ?
_Yes_ _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the
condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of
scum ?
_Yes_ _ Was the facility owner (and occupants if different from owner) provided with information on the
proper maintenance of subsurface sewage disposal systems ?
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Yes no
Yes` _ Existing information.
_
_ _NoDetermined in the field (if any of the failure criteria related to Part C is at issue approximation of
distance is—unacceptable) [3 10 CMR 15.302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: _90 Lost Pond Lane_
_ North Andover_
Owner: _Gold
Date of Inspection: 8/12/2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): _4_ Number of bedrooms (actual): _4_
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): _660_
Number of current residents: _3
Does residence have a garbage grinder (yes or no): —No _
Is laundry on a separate sewage system (yes or no): _ No_
Laundry system inspected (yes or no): —
Seasonal use: (yes or no): _No
Water meter readings: Yes, 004929ft3_
Sump pump (yes or no): _No_
Last date of occupancy: _Current
COMIyIERCIALANDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR 15.203): gpd
Basis of design flow (seats/persons/sgft,etc.):
Grease trap present (yes or no): _
Industrial waste holding tank present (yes or no): _
Non -sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: _Pumped two years ago, owner
Was system pumped as part of the inspection (yes or no): Yes_
If yes, volume pumped: _1500_gallons — How was quantity pumped determined? Measured tank _
Reason for pumping: Inspect tank & tees _
TYPE OF SYSTEM
X Septic tank, distribution box, soil absorption system
_ Single cesspool
_ Overflow cesspool
_ Privy
_ Shared system (yes or no) (if yes, attach previous inspection records, if any)
_ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be
obtained from system owner)
Tight tank _ Attach a copy of the DEP approval
— Other (describe): _
Approximate age of all components, date installed (if known) and source of information: _8 years old, 7/26/19%,
As built plan _
Were sewage odors detected when arriving at the site (yes or no): _No
Page 7 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _90 Lost Pond Lane_
_ North Andover—
Owner: _Gold
Date of Inspection: 8/12/2004
BUILDING SEWER _ X _ (locate on site plan)
Depth below grade: _2'_
Materials of construction: _ _ cast iron _X_40 PVC other
Distance from private water supply well or suction line:
Comments (on condition of joints, venting, evidence of leakage, etc.): _4" PVC to septic tank. 3" PVC in house,
no leaks visible.
SEPTIC TANK: X
Depth below grade: _12"_
Material of construction: X concrete — metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of
certificate)
Dimensions: 10' x 5' x 4'_
Sludge depth 6"_
Distance from top of sludge to bottom of outlet tee or baffle: 21"_
Scum thickness: _6"
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: _15"_
How were dimensions determined: _
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.)_ Pumped septic tank. Inlet cover broken. No inlet tee. Inlet
pipe pitched the wrong direction. Outlet tee ok. Liquid above inlet pipe. Outlet pipe enters tank on side &
extends into center of cover above inlet pipe elevation. No evidence of leakage. _
GREASE TRAP: (locate on site plan)
Depth below grade: _
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 90 Lost Pond Lane-
- North Andover
–
Owner: _Gold
Date of Inspection: _8/12/2004_
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass _polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present (yes or no):
Alarm level: Alarm in working order (yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
DISTRIBUTION BOX: _X_ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: _0_
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.) _D -box level. Distribution equal. No evidence of leakage. Light carryover,
pumped d -box to clean. _
PUMP CHAMBER: _ (locate on site plan)
Pump in working order (yes or no): —
Alarm in working order (yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): _
Page 9 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 90 Lost Pond Lane_
Owner: _Gold
Date of Inspection: _8/12/2004
SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan, excavation not required)
If SAS not located explain why:
Type
_ leaching pits, number: _
leaching chambers, number:
leaching galleries, number:
_X leaching trenches, number, length: 2 trenches 79' 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 or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 90 Lost Pond Lane _
_ North Andover
—
Owner: _Gold
Date of Inspection: _8/12/2004_
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.
A to Tank = 33'
A to D -Boz = 39'6"
B to Tank = 41'8"
B to D -Boz = 59'7"
Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _90 Lost Pond lane_
_ North Andover—
Owner: _Gold
Date of Inspection: _8/12/2004_
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water _ 49
_
Please indicate (check) all methods used to determine the high ground water elevation:
_X_ Obtained from system design plans on record - If checked, date of design plan reviewed: _4/26/1995_
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain: _
Checked with local excavators, installers- (attach documentation)
_ Accessed USGS database -explain:
You must describe how you established the high ground water elevation: 0e_S%5^ (La'
Tel: (978) 475-4786
Fax: (978) 475-5451
BATESON ENTERPRISES, INC.
Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service
111 Argilla Road Andover, Mass. 01810
Title 5 Inspection Report
Property Address: 90 Lost Pond Lane, North Andover
Owner: Gold
Date of Inspection: 8/12/2004
My report contained herein does not constitute a guarantee of future usage and the functionality of the existing
septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further
operation of your current septic system.
eJ. B eson
Bateson Enterprises, Inc.
DelleChiaie, Pamela
From: DelleChiaie, Pamela
Sent: Wednesday, April 30, 2008 10:06 AM
To: 'dzappala@andoverliving.com'
Subject: 90 Lost Pond Lane - Septic Information
88sf R, 00-11
Pa1w40ea 190AZOM1.1110
Health Department Assistant
Town of North Andover
1600 Osgood Street
Building 20, Suite 2-36
North Andover, MA o1845
9978.688.9540 - Phone
A 978.688.8476 - Fax
http://www.townofnorthandover.com
healthdept@townofnorthandover.com
Message from
Message from
KMBT_600
KMBT_600
88sf R, 00-11
Pa1w40ea 190AZOM1.1110
Health Department Assistant
Town of North Andover
1600 Osgood Street
Building 20, Suite 2-36
North Andover, MA o1845
9978.688.9540 - Phone
A 978.688.8476 - Fax
http://www.townofnorthandover.com
healthdept@townofnorthandover.com
DelleChiaie, Pamela
From: DelleChiaie, Pamela
Sent: Wednesday, April 30, 2008 10:06 AM
To: 'dzappala@andoverliving.com'
Subject: 90 Lost Pond Lane - Septic Information
M
El
Message from
Message from
KMBT_600
KMBT_600
g¢sf R¢gwAds,
PayyeBa D¢B�¢G�lfiwi¢
Health Department Assistant
Town of North Andover
1600 Osgood Street
Building 20, Suite 2-36
North Andover, MA o1845
V978.688.9540 - Phone
A 978.688.8476 - Fax
http://www.townofnorthandover.com
healthdept@townofnorthandover.com
Town of North Andover
Office of the Health Department
Community Development and Services Division
27 Charles Street
North Andover, Massachusetts 01845
Susan Y. Sawyer, RENS/ RS
Public Health Director
978.688.9540 - Phone
978.688.9542 - Fax
CT1271E1CA7E Off' COM�LIANCE
As of:
.August 18, 2004
This is to cert that
the individual subsurface disposal system
repaired(pipes ancCcover replacement onCy)
6y
den Osgoocfjr.
At
90 Lost Pond Gane
North Andover, WA 01845
has been installed in accordance with the provisions of Title V of the State Sanitary Code and
with the North Andover 0oard of 1ealth regulations.
The Issuance of this certificate shall not 6e construed as a guarantee that the system will
function satisfactorily.
Susan T Sawyer, REYfS19U
Tu6lic 9fealth Director
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
Commonwealth of Massachusetts
City/Town of
System Pumping Record
p` Form 4
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key
®ISI
ren
DEP has provided this form for use by local Boards of Health. Ott
RECEIVED
DEC 112007
TOVv,4 OF NORTH ANDOVER
HEALTH DEPARTMENT
er forms may be used. but
;he
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. Sy7 Location:
J� C Kouse-
Address
D V—��
`
City/Town
2. System Owner.
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
Vann
State
Zip Code
Stater f �Zi Cod
�
Telephone Number
H -3f)-0177
Date 2. Quantity Pumped:
Gallons
Cesspool(s) ErSeptic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes L3nro If yes, was it deaned? ❑ Yes ❑ No
5. Conditiono0_ t ' j tC42Ua_t_
6. Syst m umped
Name Vehicle License Number
Company
7. Location ere contentsn-
"-
disposed:
rlo- u S.
3<5j- -a7
Date
t5form4.doc• 06/03 System Pumping Record ^ Page 1 of 1
TOWN OF
SYSTEM PUMPING RECORI
DATE: S' � a
SYSTEM OWNER & ADDRESS
6e)l�
GA
DATE OF PUMPING:
SYSTEM LOCATION
(example: left front of shouse)
QUANTITY PUMPED:
CESSPOOL: NO L YES SEDC 'TANK: NO
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
AUG 17 2004
7u; .. OVER
HEP,L DEPARTMENT
/��� GALLONS
YES C ----
FULL L TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.O Lowell Waste
TOWN OF Jv• "tcc
SYSTEM PUMPING RECORD
DATE: T' LI' b o ,
SYSTEM OWNER & ADDRESS
6ol�
b ?osrvovA
SYSTEM LOCATION
(example: left front of house)
6us-c-
DATEOFPtJMPING: !J—q-0 v�— QUANTITY PUMPED : 156-6 GALLONS
CESSPOOL: NO YESEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED To:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
-t�QsA�?
q0 Los4
SYSTEM LOCATION
(example: left front of house)
kcv�
DATE OF PUMPING: '3 —'f0 "aIOUANTITY PUMPED / 5"GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO: �•
EMERGENCY
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
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Town of North Ando"ve`r 4,714 d
Health Department z7Date;
Location: ,! CJ's i CT' -i LL /L-�
(Indicate Address, if R;sidekial, or Name of Business)
Check
Tvve of Permit or License: (Circle)
➢ Animal
$
➢ Dumpster
$
➢ Food Service - Type:
$
➢ Funeral Directors
$
➢ Massage Establishment
$
➢ Massage Practice
$
➢ Offal (Septic) Hauler
$
➢ Recreational Camp
$
➢ SEPTIC PERMITS:
❑ Septic - Soil Testing $
❑ �eptzic
Design Approvalisposal Works Construction (DWC) $/
❑ Septic Disposal Works Installers (DWI) $
➢ Sun tanning $
➢ Swimming Pool $
Tobacco $
➢ Tras4lSolid Waste Hauler $
➢ Well Construction $
➢ OTHER: (Indicate)
r
187 Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
Town 6f North Andover O NORT1h
�? +' ``1<
Office of the Health Department O �.
Community Development and Services Division
27 Charles Street
North Andover, Massachusetts 01845 'SSwcHusEt
Susan Y. Sawyer, REHS/RS
Public Health Director
978.688.9540 - Phone
978.688.9542 - Fax
�1E27IFIC�`� OF C0911�'LIAVCE
As of:
August 18, 2004
,This is to cert that
the individual subsurface disposalsystem
repaired (pipes and cover repCacement onCy)
by
Ben Osgoocfyr.
At
90 Lost Pond .Gane
North Andover, W,4 01845
has been installed in accordance with the provisions of Title v of the State Sanitary Code and
with the North Andover Board ofWealth regulations.
The Issuance of this certcate shall not be construed as a guarantee that the system will
function satisfactorily..
Susan 7 Sawyer, 1REXS/1R5
Bu6fc ifealth Director
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9510 PLANNING 688-9535
. - - TOWN OF NORTH ANDOVER
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
27 CHARLES STREET
NORTH ANDOVER, MASSACHUSETTS 01.845
Susan Y. Sawyer, REHS/RS
Public Health Director
978.688.9540 — Phone
978.688.9542 — FAX
healthdept @ townofnorth,
www.townofn orthandove
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: e3 t 16 1 01-1
LOCATION: Cl 0 d o s+ ?t)'o fl izo pa_-_�
LICENSED INSTALLER NAME: e e VAi a wk 1\ c- 0� 6-0;z� 7 2_
PLEASE PRINT
SIGNATURE: TELEPHONE# 97P-6,96 -/ 76,5
� CHECK ONE:
FULL SYSTEM REPAIR:
COMPONENT REPAIR (indicate what parts): P E pis y r _r 4A1/L
* NEW CONSTRUCTION:
* If NEW CONSTRUCTION, please attach the Foundation As -Built Plan.
$250.00 Fee Attached? Yes No
Project Manager Obligation From Attached? Yes No
Foundation As -Built? Yes No
Floor Plans? Yes No
Approval of Health Agent Date: e l L o
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FORM U - VERIFICATION FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************F7,vTL
plicant fills out this section*****************
APPLICANT:
APPLICANT: 0 C4� Phone b S s
LOCATION: Assessor's Map Number �� ��� Parcel �`'�� �zl/� '2-3
Subdivision Lot(s)
Street S t� �' '4 N St. Number
************************Official Use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
Conservation Administrator
Comments
W 10 /I
Town Planner
Comments
Food Inspector -Health
Sep it c Inspector -Health
Comments
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approvedos23 c%6
Date Rejected
Public Works - sewer/water connections /��� �ZZ
- driveway permit zz -9�
Fire Department
C -0 -
Received by Building Inspector Date
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,SSACMusEt�
Town of North Andover, Massachusetts
BOARD OF HEALTH
Form No. 2
� 3 19
DESIGN APPROVAL FOR
SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant oL JQAJL� f..t�� Test No.
Site Location ac LA L&-a�
Reference Plans and Specs.
ENC-11TEER
k
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
Fee
CHAIRMAN, BOARD OF HEALTH
Site System Permit No. 19 1
Town of North AndoverNORTM
Qf t�ao 1ti
OFFICE OF 3� h•'
COMMUNITY DEVELOPMENT AND SERVICES ° .
146 Main Street
North Andover, Massachusetts 01845 9SSACHUSEt
(508) 688-9533
December 12, 1995
Thomas Neve
Neve Associates
447 Old Boston Road
Topsfield, MA 01983
Re: Lot 4 Lost Pond Lane
Dear Tom:
This is to inform you that the proposed plans for the site
referenced above have been disapproved for the following reasons:
1) Benchmark not within 75 feet of system.
2) Soil evaluator?
3) Groundwater elevation suspect.
4) What is soil log of pit (unnumbered) at east side of
system?
5) Map & Parcel missing.
6) Please update fill requirement.
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
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
Julie Parrino D. Robert Nicetta Michael Howard Sandra Starr Kathleen Bradley Colwell
THOMAS E. NEVE ASSOCIATES, INC.
Engineers • Land Surveyors • Land Use Planners
447 Boston Street US #1
TOPSFIELD, MASSACHUSETTS 01983
(508) 887-8586
FAX (508) 887-3480
TO �jAt,a r>►rA
'�Au . All" Pcsa sln 1•d IC -
[LI U LJ IE12 @1P o e UV�LJVLJ���Lti1L�
DATE
JOB NO.'�^� w
ATTENTION
DESCRIPTION
v1SED
1Zyllo-�'
TOWN OF NORTH ANDOVER/
BOARD Or= HEALTH
DEC 2 1 1995
WE ARE SENDING YOU §CAttached ❑ Under separate cover via I thjfQI1_ nting.i:o�1c��!
❑ Shop drawings Prints ❑ Plans ❑ Samples
❑ Copy of letter ❑ Change order ❑
COPIES
DATE
NO.
DESCRIPTION
v1SED
1Zyllo-�'
Pc"�. ►pw►�►42a A [SIS Pcspc._
t�j`t W►+1 S E . to tE�•J - 1>k SSbL. 1 C.,..
THESE ARE TRANSMITTED as checked below:
❑ 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 ❑
❑ FORBIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US
REMARKS C7-� - �lr � Fl ri C—I-I�SIJQ -_'r' 4r_ �� tSEr—>
- - - -
rjc_ a Vo� 'V6 11�r'
CAC rf' .- - VL. - 4--qA ,
COPY TO
- � RECYCLED PAPER:
r( Contents: 40% Pre -Consumer -10% Post -Consumer SIGNED: �t�•
if enclosures are not as noted, kindly n at once.
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Town of North Andover
OFFICE OF
COMMUNITY DEVELOPMENT AND SERVICES
146 Main Street
North Andover, Massachusetts 01845
June 18, 1996
Thomas Neve
Neve Associates
447 Old Boston Road
Topsfield, MA 01983
Dear Tom:
An as -built of the septic system installed at Lot 4 Lost Pond, signed and stamped by you
has been submitted to this office. A note on the as -built states, "invert elevations supplied
by installer One of the purposes of an as -built is to have an independent agency check
the installer's elevations, location, etc. In essence, this as -built has an installer certifying
his own work and is no check at all. For this reason I cannot accept this as -built.
In addition, ti -ie water line location is missing from this and for the one on Lot 1 C. Lost
Pond. It is necessan, to show this and any gas Lines when the system is located in the front
yard.
Sincerely,
Sandra Starr, R.S., -
Health Administrator
SS/cjp
cc: Bill Scott, Director, PCD
BOH
File
BOARD OF APPEALS 688-9541 BUMI)ING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANK NG 688-9535
Form No 3
Town of North Andover, Massachusetts
BOARD OF HEALTH 9 L
MORTM
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DISPOSAL WORKS CONSTRUCTION PERMIT
,SS/ICMUSEt
Applicant L TELEPHONE
AME p ADDRESS
Site Locations
Permission is hereby granted to Construct (,4 Repair ( ) an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No.
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NORTH ANDOVER BOARD OF HEALTH
DESIGN REVIEW REPORT
FEE: 0�0 PERMIT ## 7q1 DATE RECEIVED 111(31123—
APPLICANT MAP PARCEL
ADDRESS/I ''
ENG. NVQ
LOT #
li
STREET 4-667-� 1'76' Aid �C„9
ADDRESS
PLAN DATE '/�T /� i %`I� REV. DATE
CONDITIONS OF APPROVAL
APPROVED
REASONS FOR DISAPPROVAL:
7 -
DISAPPROVED
PLAN REVIEW CHECKLIST
ADDRESS 4057 f OA -ib ENGINEER
GENERAL
3 COPIESC/ STAMP L/ LOCUS(` NORTH ARROW �� SCALE
CONTOURS &,-- PROFILECI SECTION BENCHMARK, SOIL &
PERCS ELEVATIONS WETS. DISCLAIMER / WELLS & WETS
WATERSHED? 100 DRIVEWAY 1--'(Elev) WATER LINE[/ FDN DRAIN
SCH40 ,-/ TESTS CURRENT?G-*' SOIL EVAL
SEPTIC TANK //����
MIN 1500G_� .17 INVERT DROP GARB. GRINDER** (+200% EDF)
25' TO CELLAR ✓ MANHOLE ELEV GW ## COMPS.
D -BOX
SIZE # LINES FIRST 2' LEVEL STATEMENT
INLET OUTLET 13Z,7-7-= ( 2" OR .17 FT) TEE REQ' D?_z
LEACHING
MIN 660 GPD?,-' RESERVE AREA k-'-4' FROM PRIMARY?& --"'-2% SLOPE
ffEa. -3AS /"j
100' TO WETLANDS X 100' TO WELLS (--� 4' TO S.H.GW .(5'>2M/IN)
35' TO FND & INTRCPTR DRAINS C---325' TO SURFACE H2O SUPP ,—
4' PERM. SOIL BELOW FACILITY L.j MIN 12" COVER`S FILL? (�'l
if above natural elev; 10'if below) BREAKOUT MET? 1-1
TRENCHES l
MIN 660 gpd SLOPE (min .005 or 6"/100')(/ SIDEWALL DIST. 3X EFF.
W OR D (MIN 6') V**" RESERVE BETWEEN TRENCHES? L'IN FILL? -� MUST
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