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Miscellaneous - 96 LOST POND LANE 4/30/2018 (2)
N � ? rn r y, co fC/J o Z Or C) D o m 0 ` (D • MAP # ? PARCEL # STREET �ONS_T_RUCTIOlV APPROVAL, HAS PLAN REVIEW FEE .BEEN PAID? -CYES- NO PLAN APPROVAL: DATE ZZ / Z-QhKl APP. DESIGNER: Alav6- 4:5-soa PLAN DATE. /4? CONDITIONS Odo"Ov Or &46&MQ5Ar-;7- 0 A44k)140&67- WATER SUPPLY: TOWN WELL WELL PEJi-M—IT----,.. DRILLER WELL TESTS: CHEMICAL-,, DRIE APPROVED BACTERIA I f)PPRUVED BACTERIA II DA T'E nPPRuV COMMENTS: FORM U APPROVAL': APPROVAL TO ISSUE YES NO DATE ISSUED By CONDITIONS: FINAL APPROVAL:. ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NO,, SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER, YES NU ANY VARIANCE FINAL BOARD OF -HEALTH APPROVAL: YES 'NO DATE- DY: pl +x IS THE INSTALLER LICENSED? `+ ��t YE5 NO is r w1� `I .8• y.�^ . .< t� � . _ -rt. � •,. TYPE. OF CONSTRUCTION: ? NEW REPAIR NEW CONSTRUCTION:',.. CERTIFIED PLOT PLAN ,REVIEW -- NO CONDITIONS OF..APPR0 AL YES NO I s (FROM FORM —ISSUANCE•OF DWC PERMIT YES NO DWC PERMIT, N0. %� 1 INSTALLER. BEGIN INSPECTION YE b: EXCAVATION INSPECTION: ;NEEDED: rASSED , 'yn .:CONSTRUCTION INSPECTION: NEEDED: .:.:.As BUILT PLAN SATISFACTORY: YES APPROVAL TO BACKFILL: DATE:' BY:_ "FINAL .GRADING APPROVAL: DATE % /T� l �U BY FINAL CONSTRUCTION APPROVAL: DATE: Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. r Commonwealth of Massachusetts r City/Town of NORTH ANDOVER, MASS CHUSETTS System Pumping Record OCT 10 2006 Form 4 TO`NV OF NC'�-F1 k, ,:v�'�it HEAL TI I UF''ART "'�.'v DEP has provided this form for use by local Boards of Health. The System -Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: % Ios4 ,onnJ Pd Address n op -1 A,d oo-- &7 u City/Town State Zip Code To 2. System Owner: Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): State Telephone Number i Date®'� 2. Quantity Pumped Cesspool(s) ZSeptic Tank 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: Zip Code _1 1!570 CO Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No 6. System Pumped By: 9 Name'� Vehicle icense Number ` Company 7. Location where contents were disposed: S -- Signature of Hauler http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect 911"z/9 ro Date t5form4.doc- 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts �V City/Town of NORTH ANDOVER MASSACHUSETTS System Pumping Record E �4 Form 4 OCT 1 0 2006 � DEP has provided this form for use by local Boards of Health. Th System -Pumping Record must be submitted to the local Board of Health or other approving authority-. TOWN OF NOK -T! � rity. A. Facility Information Important: When filling out 1. System Location: forms on the/ computer, use only the tab key Addrreesp Ito our cursor edo not use the return City/Town State Zip Code key. 2. System caner: 'r'�'-------- Name Address (if different from location) City/Town Stat Zip Code _ 7')7'-- y62o 3 Co Telephone Number B. Pumping Record 1, Date of Pumping // 2. Quantity Pumped: < �/-- / /6 &�j� �� Date Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Cis _ T� Name1 pp Vehic License Number W " VG 0`. Company 7. Location where contents were disposed: Signature of Hauler– — `--, http://www.mass.gov/dep/water/approvaIs/t5forms.htm#inspect Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 iT i Lot 4 3,54 23, L ' N of 5 ` Vft. C -V 80,4 79 S.F. 1.85 A Cres Upland= 52,4 10 S.F. & y E riveK,o C o re% FOUND• `1 500 GAL. SEPTIC, 9s-7 D—BOX Lot 6 \ ' Shallow L each\ "0 -C♦ Cj7 ♦.po Chamber SOe" Ck ystem o„ s� the construction of this disposal system and that been in accordance with the designer's intent to the plan specificotions and 310 CMR 15.00. ourpose of showing the "As—Built" conditions 'led on the premises All work was done in gn plans as prepared. All work was done ected for a job of this typo. s/z¢�9� Dote: IC. vers 6-� /A cA ............ 5 � L ' N of 5 ` Vft. C -V 80,4 79 S.F. 1.85 A Cres Upland= 52,4 10 S.F. & y E riveK,o C o re% FOUND• `1 500 GAL. SEPTIC, 9s-7 D—BOX Lot 6 \ ' Shallow L each\ "0 -C♦ Cj7 ♦.po Chamber SOe" Ck ystem o„ s� the construction of this disposal system and that been in accordance with the designer's intent to the plan specificotions and 310 CMR 15.00. ourpose of showing the "As—Built" conditions 'led on the premises All work was done in gn plans as prepared. All work was done ected for a job of this typo. s/z¢�9� Dote: IC. vers 6-� /A cA ............ Rp PUBLIC HEALTH DEPARTMENT Community Development Division Date: September 19, 2006 Address: 96 Lost Pond Lane Re: Application for: family room addition Dear: Mr. And Mrs. Jacobs, Your application for a deck at has been reviewed by the Health Department. The application was denied on, September 19,2006 for the following reasons: 1. x Nfissing information 2, x Passing Title 5 inspection of septic system required 3. ❑ Location of structure not acceptable 4. ❑ Undersized septic system ** still remains undetermined. Review of floor plan needed prior to decision To address the problem(s): If #1 is checked, please supply: a. Floor plan of existing and proposed addition — all rooms b. Certified plot plan snowing house, septic system and proposed project in scale If #2 is checked: 3. I lave the septic system inspected by a certified Title 5 inspector to determine the size of the system and ,vhether it is operating properly: OR b. Tie-in to municipal sewer If #3 is checked: a. Relocate the project If #4 is checked: 1600 Osgood Street, North Andover, Mossachusetts 01845 Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.com te PART F Title V System Inspectors 17.00 Title V Svstem Inspector License: No person shall conduct a System Inspection in the Town of North Andover without first obtaining a license with the Board of Health. To be eligible to obtain the license the applicant must first be certified by the MA Department of Environmental Protection (MA DEP). Inspections performed by inspectors not licensed by the North Andover Board of Health will not be accepted. A nonrefundable fee for annual licensure shall be paid to the Town pursuant to the current fee schedule. 17.01 Application for licensing shall include a copy of the MA DEP's System Inspector certification or equivalent documentation. 17.02 There will be a fee for each Title 5 inspection submitted to the Health Department by a system inspector licensed by the town. The amount of the fee shall be pursuant to the current fee schedule. 17.03 All Title 5 inspection submittals must be completed and submitted in accordance with MA DEP 310 CNIR 15.301(10) 17.04 A Title 5 system inspection is required when an addition or renovation to an existing building, excluding decks and screened in porches, is proposed that increases the footprint of the building and requires a building permit from the building inspector. The inspection requirement shall be waived if a Certificate of Compliance was issued or a Title 5 System Inspection was completed within the previous 5 years or if the system is under an operation and maintenance contract. 17.05 Any Title V inspection that identifies the septic tank, pump tank or distribution box at an elevation of greater than 36 inches below grade, without an access riser, shall have a riser and cover installed within 9 inches to grade, by a N. Andover licensed installer. 17.06 Any septic system that conditionally passes a Title 5 inspection due to a component failure, which has resulted in the leaching area having not received usual effluent flow., is required to have a second inspection conducted 6 months later. AMA licensed septic inspector must conduct this inspection and a proper report must be submitted to the Health Department. 17.07 Inspector License Revocation: The Board of Health may suspend or revoke for cause any license as stated in 3.02 License Revocation of this regulation. !L�. Commonwealth of Massachusetts kvCity/Town of System Pumping Record NORTH ANDOVER 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 within 14 days from the pumping date in accordance with 310 CMR 15.351, A. Facility Information important; When fling out t . System Location: forms an the computer, use .-. _. only the tab key Address rr to move your 4, .... cursor - do not --- _ le Zip Cotle use the return Cityrrown key. 2. System owner: m Nam Address (if different from tocatio ) CityfTown Code stat+ r� _r ? ...., �-� ...... Telephone Number B. Pumping Record '_ -7 �_�.. 2, Quantity Pumped: 1. [)ate of Pumping Date p Gallon 3. Type of system: ❑ Cesspool(s) arc Tank Q Tight Tank ❑ Grease Trap ❑ Other (describe). .. _ ._. — _ . --- .. ..-_.... –.... - . 4. Effluent Tee Filter present? [I Yes D -Mo if yes, was it cleaned? ❑ Yes E] No 5. Condition of System: 8, System Pumped By: Ndme vehicle License NUMID9r Company 7. Location where contents were disposed: Sigrealur9 of Hauler Date ^.... --- •----�-�— _ , of Reoe-Wing Faci. _ .... _......---...,.., , . �,. - Date Signature fify l5forn*doc- 03106 System Pumping Record • Page 1 of t lz O 0 m rn m a w r — 0 d Z � � a a as d y C 0 a N y c co m � 2 J J D o C O a m e a Y Q w � � Q c co V J 0 C3 a- J 0 O d O a m m � c fd w w Q J bj to co O a► � > m c W a w a'� y w @ N J Z Z Z U y d H m � c co n Z Z Z CoaU) co � .WH WNrn o k o J F- N = LL cn E sn ' m o aa) co CL0 o m,O E co a o 0 3 c 0 U U d U O co (9 Fo_ co 0 m rn m a S77 MAIN STREET HUDSON, MA 01749 800-499-1682 WINDRNER ENVIRONMENTAL REQ IE VED OCT 2 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNER'S NAME: PROPERTY ADDRESS: ADDRESS OF OWNER: (IF DIFFERENT) DATE OF INSPECTION: PAUL WOLMERING 96 LOST POND LANE NORTH ANDOVER, MA 01848 SAME OCTOBER 5, 2006 NAME OF INSPECTOR: DANIEL DECOSTA Important: When filling out forms on the computer, use only the tab key to move your cursor- do not use the return key. fA t5insp.doc - 11/20( a 0 ••10/ t / Commonwealth of Massachusetts 14 `� Title 5 official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form r on the official Title 5 Inspe Ion Forff dated 611612000. Inspection forms may not be altered In ny way. A. Certification RECEIVED 1. Property Information: OCT 2 4 2006 U aV1� Prop rty Address wp TOWN OF NORTH ANDOV DEPARTMENT R A Vt^Ct � � HEALTH Owner's Name �e Owner's Address AA City7own State Zip dode Date of Inspection: Date 2. Inspe(cttor. (� Y JA S Dc -c<) Name of Inspector Wind River Environmental Company Name 561 Main St. Company Address HudsonMA 01749 Cityrrown State Zip Gode. 978-562-4500 Telephone Number Certification Statement: I certify that I have personally inspected the sewage di posal system at this address an J that the information reported below Is true, accurate and comp ete.as of the time of the inspectic in. The inspection was performed based on my training and experience i i the proper function and mainter ante of o i site sewage disposal systems. 1 am a DEP approved sys em inspector pursuant to Sec on 15. of Title 5 (310 CMR 15.000). The system: asses ❑ Conditiona ly Passes ❑ Fails eds Further valuation by. a Local Approv ng Authority lnspectoft,gignature Date The system inspector shall submit a copy of this in ection report to the Approving: Authority Board of Health or DEP) within 30 days of completing thisinspection. If the system _i ... sh red syst :m or has a design flow of 10,000 gpd or greater, the ins ector and the system owner sh II submit I he report to the appropriate regional office of the DE . The original should be sent tot a 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 ndition i of use at that.time. This inspection does not address hoW the system will perform in the futum under the same or different conditions of use. 4 Title 5 Official Inspection Form: Subsurface Sewa a Disposal System Page 1 of 16 . 0 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments �Subsurface Sewage Disposal System Form A. Certification (cont.) Property Address city/rown I State Zip Owner's Name Date of Inspection Inspection Summary: Check A,B,C,D or E I alwq4 complete all of Section D A) System Passes: VI have not found any information which indicatE s that any of the failure criteria d scrib in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: I� IC C'� D anJ►1t�� 70�= M Pj' &4 —IAA �'A r B) System Conditionally Passes: ❑ One or more system components as describec replaced or repaired. The system, upon compl the Board of Health, will pass. Answer yes,. no or not determined (Y, N, ND) in the determined," please explain. ❑ The septic tank is metal and over 20 years old' structurally unsound, exhibits substantial infiltr. System will pass inspection if the existing tank approved by the Board of Health. in the "Conditional Pass° section need to tion of the replacement or repair as appr ❑ for the following statements. If "not or the septic tank (whether metz il or not) tion or exfiltration or tank failure s immirn s replaced with a complying septic tank * A metal septic tank will pass inspection if it is Istructurally sound, not leaking a d if a of Compliance indicating that the tank is less t an 20 years old is available. ND Explain: by t5insp.doc • 11/2004 Title 5 O Taal Inspection Form: Subsurface Sewa a Disposal ystem Pa6 2 of 16 t5lnsp.doc • 11/2004 mmonwealth of Massachusetts itle 5 Official Inspec ion Form t for Voluntary Assessments. bsurface Sewage Disposal System Form Certification (cont.) Property Address City/rown State Zip C ide Owner's Name Date of Inspection B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or Agh static water level in the distri bution box due to broken or obstructed pipe(s) or due to a broh en, settled or uneven distribution box. Sysi em will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstru ted pipe( 3). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced 0 obstruction is removed ND Explain: C) Further Evaluation Is Required by the Boart of Health; ❑ Conditions exist which require further evaluatiorl by the Board of Health in order to detem ine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance Witt 310 CMI Z 15.303(1)(b) that the system is not functioning in a manner which will protf ct 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 mare h Title 5 Of ficial Inspection Foran: Subsurface SewaC a Disposal ystem Page 3 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) City/rown State Owner's Name I Date of I C) Further Evaluation is Required by the 2. System will fail unless the Board of Hea determines that the system is functioning I safety and environment: ❑ The system has a septic tank and soil 100 feet of a surface water supply or tributary ❑ The system has a septic tank and supply. ❑ The system has a septic tank and supply well. of Health (cont): i (and Public Water Supplier, if any) a manner that protects the public hi ).sorption system (SAS) and they SAS is a surface water supply. and the SAS is within a Zone 1 �f a and the SAS is within 50 feet of � private FM ❑ The system has a septic tank and SAO and the SAS is less than 100.feet but 50 et or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysi , performed at a DEP certified la Doratory, or f coliform bacteria and volatile organic compoun s indicates that the well is free om pollu on from that facility and the presence of ammonia nitro jen and nitrate nitrogen is equal I o or less than 5 ppm, provided that no other failure criteria are riggered. A copy of the analysis ust be a (ached to this form. 3. Other. t5insp.doc • 11/2004 Title 5 O ficial Inspection Form: Subsurface Sawaa Disposal pystem Paol 3 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspec Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) Address Cityfrown Owner's Name D) System Failure Criteria Applicable to All Sy You must indicate "Yes" or "No" to each c Yes No ion Form State Date of Inspection the following for all ❑ Backup of sewage into facility or system component due to c verloadecor clogged SAS or cesspool a 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 o :erloaded or clogged SAS or cesspool ❑ Er Liquid depth in cesspool is I Dss than 6" below invert or available volum e is less than'/ day flow ❑ Required pumping more the n 4 times in the last year NOT d e to clogged or obstructed pipe(s). Number of times pumped: ❑ [[ Any portion of the SAS, ces pool or privy is below high ground water levation. ❑ �/ Any portion of cesspool or p rivy is within 100 feet of a surfaci a. water su pply or tributary to a surface water upply. ❑ Any portion of a cesspool oi privy is within a Zone 1 of a pubic well. ❑ [� Any portion of a cesspool or privy is within 50 feet of a privat water s pply well. ❑ �/ Any portion of a cesspool oi privy is less than 100 feet: but g ater tha ' 50 feet :is. from a private water supply mell with no acceptable water qu lity analy [This system passes if the well Water analysis, performed ata EP cert fied laboratory, for coliform bg cteria and volatile organic con pounds indicates that the well is f ee from pollution from that fac ility and the presence of ammonia nitirogen and nitrate nitrogen is eq jaito or[ess than 5 ppm, provided that no other failure criteria are triggered. Xcopy of the analysis must be attached to this form.] Yes No ❑ LN' The system fails. I have de termined that one or more of the above fai lure criteria exist as described in 310 CMR 15.303, therefore the systern fails. The system owner should conta t the Board of Health to determi a what will be necessary to correct the fail i re. t5insp.doc • 1112004 Title 5 Mcial Inspection Form: Subsurface Sew go Disposal System Paine 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspec ion Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) Address Cityfrown Owner's Name E) Large Systems: To be considered a large design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" questions in Section D. YES NO ❑ ❑ the system is within 400 feet ❑ ❑ the system is within 200 feet ❑ ❑ the system is located in a nit Area — IWPA) or a mapped i State the system must serve # facility "no" to each of the following, in a surface drinking water a tributary to a surface drinkin water yen sensitive area (Interim Wel head F e II of a public water supply w 41 If you have answered "yes" to any question in Sec ion E the system is considered or answered "yes" in Section D above the large sy tem has failed. The owner or c system considered a significant threat under Section E or failed under Section D t system in accordance with 310 CMR 15.304. The ystem owner should contact th regional office of the Department. A Title V inspection is often misunderstood to suggest that we are conducting a complete inspection of your system. A Title V inspection is limited to determining if, at the time of the inspection, the existing septic system is functioning. The State of Massachusetts has outlined specific tests that are to be performed, which will be completed during your Title V inspection. However, a Title V inspection, and the inspection that Wind River Environmental is performing hereunder, does not evaluate if the system was installed correctly, has been engineered in accordance with state and local regulations, or whether the system will continue to function in the future. It also does not evaluate whether the system would meet the past, current, or future Board of Health or State DEP regulations. A system can pass Title V but still not meet state or local requirements or be suitable for continued use. If the customer would like a complete inspection of their system, including an evaluation as to the design and suitability of your system, Wind River Environmental can provide a quote as to the cost of such services. As well, Wind River Environmental strongly recommends persons interested in buying a home to have a full and complete system evaluation before purchasing a new home. A new home buyer should not rely on a Title V inspection in determining if the system will function in the future, and instead should commission a complete system inspection. t5insp.doc • 11/2004 Titie 5 O ficial Inspection Form: Subsurface Of a the threat, y large the Disposal System - Pa e6of16 Commonwealth of Massachusetts Title 5 Official Inspec Not for Voluntary Assessments �y Subsurface Sewage Disposal System Form B. Checklist Property Address Citylrown State Owner's Name Date c Check if the following have been done. You must YES NO ion Form Zip Code Inspection ndicate "yes" or "no" as to each f the Of > two we Rs7 period? mtly or as part of were of thf tank inspected for the condition of the baffles or tees, material of co strucuc dimensions, depth of liquid, depth of sludge and depth of scum r,/ ❑ Was the facility owner (and opants if different from owner) rovided It �� information on the proper mai tenance of subsurface sewage c isposal The site and location of the soil Absorption System (SAS) ion the situ has been determined based on: Existing information. For example, a plan at the Board of He Determined in the field (if any of the failure criteria related to approximation of distance is u acceptable) [310 CMR 15.30 Cis at S? t5insP.doc • 11/2004 Title 5 Oficial Inspection Form: Subsurface Sawa�a DisposallSystem . i Pa¢4e7of16 ❑ Pumping infotmation was provided by the owner, occupant, or ❑ 211, Were any of the system components pumped out in the previoi [� ❑ Has the system received norrr al flows in the previous two weel ❑ ❑/ Have large volumes of water been introduced to the system reg ❑ this inspection? Were as built plans of the system obtained and examined? (If t available note as N/A) [� ❑ Was the facility or dwelling in ected for signs of sewage back ❑ Was the site inspected for sigi is of break out? [ ❑ Were all system components, excluding the SAS, located on si [� ❑ Were the septic tank manholes uncovered, opened, and the ini Of > two we Rs7 period? mtly or as part of were of thf tank inspected for the condition of the baffles or tees, material of co strucuc dimensions, depth of liquid, depth of sludge and depth of scum r,/ ❑ Was the facility owner (and opants if different from owner) rovided It �� information on the proper mai tenance of subsurface sewage c isposal The site and location of the soil Absorption System (SAS) ion the situ has been determined based on: Existing information. For example, a plan at the Board of He Determined in the field (if any of the failure criteria related to approximation of distance is u acceptable) [310 CMR 15.30 Cis at S? t5insP.doc • 11/2004 Title 5 Oficial Inspection Form: Subsurface Sawa�a DisposallSystem . i Pa¢4e7of16 Commonwealth of Massachusetts Title 5 Official Inspec Not for Voluntary Assessments ry Subsurfage Sewage Disposal System Form C. System Information Property Address CitylTown ion Form State Zip Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual) DESIGN flow based on 310 CMR 15.203 (for exar iple: 110 gpd x # of bedrooms): Number of current residents: Does residence have a.garbage grinder? ❑ Yes ENo Is laundry on a separate sewage system? [if yes eparate inspection required] ❑ Yes: M' No Laundry system inspected? ❑ Yes. M"No Seasonal use? Water meter readings, if available (last 2 years us 3ge (gpd)): ❑ Yes, 03"No Sump pump? ❑ Yes. No i Last date of occupancy: Date Commercial/industrial Flow Conditions; Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes: ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other (describe): t5insp.doo • 11/2004 Title 5C�fricial Inspection Form: Subsurface Sew ge Disposal; System I Pabe8of16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) Address City/rown Owner's Name General State Zip Date of Inspection Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: gal ons How was quantity pumped determined? Reason for pumping: Type of System: Septic tank, distribution box, soil bsorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection r ❑ InnovativeWtemative technology. Attach a copy of the current maintenance contract (to be obtai ied 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 Were sewage odors detected when arriving. at the 2 I!] ❑ fires if t5insp.doc • 11/2004 Title 5fficial Inspection Form: Subsurface Sew ge Dispose System Pade9of16 Commonwealth of Massachusetts Title 5 Official Inspec Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) Property Address Cityrrown Owner's Name Building Sewer (locate on site plan): Depth below grade: Material of construction: ❑ cast iron NK40 PVC ❑ othi Distance from private water supply well or suctior Comments (on condition of joints, venting, evider AU v; <,,..� i' n.. 1 ./, LAY,eeA, 5 Septic Tank (locate on site plan): Depth below grade: Material of construction: .concrete ❑ metal ❑ fit If tank is metal, list age: Is age confirmed by a Certificate of Compliance? certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet to Scum thickness Distance from top of scum to top of outlet tee or t Distance from bottom of scum to bottom of outlet How were dimensions determined? ion Form State Date of I feet r (explain): line: feet :e of leakage, etc.): ck Ao P—V( Cts M A, Q polyethylene years a copy of 1 0`L iii or baffle or baffle +r ode L le LJ other ❑ Yes ❑ i J x ti "o 1 Ll a, v%Aea�v� t5insp.doc • 11/2004 Title 5 Mcial Inspection Form: Subsurface Sew ge Disposal System Pada 10 of 16 t5insp.doc 9 1112004 mmonwealth of Massachusetts itle 5 Official Inspection Form t for Voluntary Assessments bsurface Sewage Disposal System Form System Information (cont.) Property Address Citylrown State Zip Code Owner's Name. Comments (on pumping recommendations, inlet and liquid levels as related to outlet invert, evidence of p - . ,w. e.. � ` n L e Date of Inspection outlet tee or baffle condition, structural leakage, etc.): 1 cA �r S ✓ U integrity, 2V e� S Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene other xplain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or b e Distance from bottom of scum to bottom of outlet I ee or baffle Date of last pumping: Date Comments (on. pumping recommendations, inlet and liquid levels as related to outlet invert, evidence of outlet tee or baffle condition, structural leakage, etc.): integrity, Tight or Holding Tank (tank must be pumped at ime of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene other xplain): Title 5 C fficial Inspection Form: Subsurface Sewg ge Disposa Pag ;System 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspe tion Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) Property Address Citylrown State Owner's Name Date of Inspection Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Al 3rm in working order. Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Distribution Box (if present must be opened) (Ic Depth of liquid level above outlet invert Comments.(note if box is level and distribution to ev ence of leakage into RLiP or out of box, etc.): �-- �O nb / \,OX U,, —iC-A If -i, ', k I Srt Pump Chamber (locate on site plan): Pumps in working order. Alarms in working order: on site plan): xf eS ©" equal, any evidence of L1++1Q l rFct,v/5 ❑ Yes ❑ Yes Zip ❑ Yes ❑ No ❑ No ❑ No any t5insp.doc • 11/2004 Title 5�fricial Inspection Form: Subsurface Sew go Disposal System Paa 12 of 16 P. t5insp.doc • 11/2004 immonwealth of Massachusetts itle 5 Official Inspection it for Voluntary Assessments bsurface Sewage Disposal System Form Form System Information (cont.) Property Address City/town State Zip code Owner's Name Comments (note condition of pump chamber, condition Date of Inspection . of pumps and appurtenances, etc.): Sol[ Absorption System (SAS) (locate on site ph If SA$ not located, explain why: n, excavation not required): Type: ❑ leaching pits [� leaching chambers ❑ leaching galleries ❑ leaching trenches ❑ leaching fields ❑ overflow cesspool ❑ innovative/alternative system . Type/name of technology: Comments (note condition of soil, signs of hydrau vegeta6gn, etc.): number. number. number. number, length: number, dimensions: number. is failure, level of ponding, damp soil, conc ition of 06 G L— Title 5 Official Inspection Form: Subsurface Sew ge Disposal Page System 13 of 16 t5insp.doc • 1112004 ►mmonwealth of Massachusetts 'itle 5 Official Inspection ►t for Voluntary Assessments ibsurface Sewage Disposal System Form Form System Information (cont.) Property Address Cityrrown State Zip ode Owner's Name Cesspools (cesspool must be pumped as part of 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. Comments (note condition of soil, signs of hydraulic etc.): Date of Inspection nspection) (locate on site plan): ❑ Yes failure, level of ponding, condil ❑ No on of ve etation, Privy (locate on site plan): Materials. of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic etc.): failure, level of .ponding, condii ion of veg etation, Title 5 (ficial Inspection Form: Subsurface Sew ge Disposa Pag System 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) f Property Address cityrrown Owner's Name Sketch Of Sewage Disposal System: Provide a sN to at least two permanent reference landmarks or Locate where public water supply enters the build F Ob State Date of Inspection :h of the sewage disposal : nchmarks: Locate all wells 646 P- S31at� � 1t Clot- `���t,�►, 1t Ci01-- 100 ft: ties t5insp.doc • 11/2004 Title 5 fficiai inspection Form: Subsurface Sew pe Disposa)System tPap 15 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) Cityr town State Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water. Please indicate all methods used to determine the high ground water elevation: Zip ( Obtained from system design plans on record y1��Jgs If checked, date of design plan revie ed: pate ❑ Observed site (abutting property/obse rvation hole within 150 feet of S ❑ Checked with local Board of Health - plain: Cl Checked with local excavators, install Brs - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high]round /nwater elevation: I t5insp.doc - 11/2004 Title 5Official Inspection Form: Subsurface Sew ge Disposal System - I Pa9 16 of 16 Sep 2706 04:03p - 10.1 Summary Record Card generated on 9/27/2006 2:57:21 PM by Lisa Warren Town of North Andover Tax Map # 210-104.B-0213-0000.0 p 96 LOST POND LANE WOLMER(NG, PAUL T79— &sr7"O&4i/ AC BS JACQUELINE 95 LOST POND LANE NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type Size Total 1.85 Acres FY 2007 UB Mailing Index Name/Address WOLMERING, PAUL JACOBS, JACQUELINE 95 LOST POND LANE NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Bldg Id. 17996.0 - 96 LOST POND LANE 3180025 03 Cycle 03 UB Services Maint. Service Code MISCFEE ADMIN FEE WTR WATER UB Meter Maintenance Type Loan Number Active/Inact. From Payor Occupant Name Active/Inactive Last Billing Date 7/5/2006 Active Rate Charge Multiplier/Users 0.635/8 7.82 1/ 01 ALL METER SIZE 54.24 /1 Serial No Status Type Location 41849460 a Active Consumption ENC L Date Reading Code 9/19/2006 1795 m Manual estimate MSG 4/17/2006 29 6/20/2006 1675 a Actual 3/20/2006 1659 a Actual Trouble Code:03 13 1/14/2005 1/3/2006 1651 a Actual Trouble Code:03 26 5/17/2004 9/15/2005 1622 a Actual Trouble Code:03 6/14/2005 1501 a Actual 3/23/2005 1488 a Actual 12/15/2004 1478 a Actual 9/17/2004 1465 a Actual Trouble Code:03 6/16/2004 1438 a Actual 4/23/2004 1426 a Actual Brand Type METE METE w Water Consumption Posted Date 120 i 16 7/10/2006 8 4/17/2006 29 1117/2006 121 10/14/2005 13 7/15/2005 10 4/5/2005 13 1/14/2005 27 10/8/2004 12 7/30/2004 26 5/17/2004 Size 0.63 0.63 Page 1 1 Residential Until YTD Cons O Variance 658% 65% -60% -80% 731% 53% 30% 50% 31% 4% 0% t f� itbs�— �afn -t P—OC)Cr C1reCA+,90 ff-v- � o : I 4 '� c ° C ° lb 00 O 4f "� a�Qhn .cJ v o �2 O o(0 a� liE nnO ` h Q y o ° O N QO oacli O O vii "111 \` O O �+� .2 L O o U Co�a �°o N �4 mph OjZ O o Uw o~ c 3 ad ° °* c, :z ocy n m L U cz o rnrn w �° \ � I CZ�° 4r�Q oU. Liz �Z oN� �� 0 N "5 ° Z N N O am O Z�Q� �ZZ� �•� ON 90 5� ri Re 25 N,\ 50 ° free 1�g. k I r \�\oo to �� , qo i( �c op ri Sys oma, p ,v,, LQ Q Lr) Lr) II c i F \ C lb ,OM 1 Ll. L6 11 ,f �. Jo a6 os9 a / Qj o� ro ,� J O (b ,f 00 mE �• o � . v 6,60.00' pM)CI - aP141 ci u G7 'WSJ Puod Iso FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. ***********APPLICANT FILLS OUT THIS SECTION* APPLICANT N3 a,Inas n LOCATION: Assessor's Map Number SUBDIVISION I STREET PHONE W- 7YJ 307 PARCEL LOT (S) _ ST. NUMBER q4 ********'""OFFICIAL USE ONLY*** ENDATIONS OF TOWN AGENTS:IA& %a_l CONSERVATION ADMINISTRATOR COMMENTS DATEAPPROVED DATE. ATE REJECTED - 0 1n TOWN PLANNER DATE APPROVED DATE REJECTED / COMMENTS _V1--eS ©� Z2 ZS7"�G= ��� Gr:3✓�, j^� G�odc�,r� 8 r 9 - FOOD INSPECTOR -HEALTH DATE APPROVED __-� DATE REJECTED SPECTOR-HEALTH COMMENTS /orz� ea'4- ---- S DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT ft RECEIVED BY BUILDING INSPECTOR DATE FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION APPLICANT el arras �y n R LOCATION: Assessor's Map Number. SUBDIVISION j STREET `�o Los T Pd n� fl RECOMMENDATIO PHONE X78- M-30? ***OFFICIAL USE ONLY*** OF TOWN AGENTS: A�L�_ PARCEL LOT (S) _ ST. NUMBER q4 X' CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER DATE gPPROVED DATE REJECTED COMMENTS FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED S TI NSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS f06"ZJ . ez,Iu PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE NS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: APPLICANT: R 1 Ne Phone LOCATION: Assessor's Map Number Parcel / -/fZ3)% Subdivision -105T ionic Lot (s) Street L o s )PoALJ L 9exIC St. Number ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Conservation Administrator Comments 4 'a i /Qci VA Town Planner Comments Food ector-Health S c nspector-Health Comments Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Public Works - sewer/water connections L0 - driveway permit `7 C,J 7 Fire Department Received by Building Inspector Date o •7 O C� hhO.L orf U p J Z , ATION FORM NS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: APPLICANT: R 1 Ne Phone LOCATION: Assessor's Map Number Parcel / -/fZ3)% Subdivision -105T ionic Lot (s) Street L o s )PoALJ L 9exIC St. Number ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Conservation Administrator Comments 4 'a i /Qci VA Town Planner Comments Food ector-Health S c nspector-Health Comments Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Public Works - sewer/water connections L0 - driveway permit `7 C,J 7 Fire Department Received by Building Inspector Date to) c) o v� q or Q � 0 � � o 4b L O O S' -O 1 v o 5 p 11 1 ; , _ p Y �} C'� _V / II i' n 1 F � � 111111 Q .. O -- - -- ' welliDg �i 126' Exist D 87' ' c r \ 133• ' v � � 128 _, ra�lb �� �, ' /r.o.F• ' .. � o � � -41fA �{ 0o M �l� oo�� ' .;�—�., til ,, •�, , AA 0 �0 d v � fence or- Od dY ko Q 0i1w1"1 �{ - c . ko _ Q _ c c ito ti Y, AC\22 kr, to N C to 1 cc) Form No. 4 Town of North Andover, Massachusetts BOARD OF HEALTH October 15, 19 96 CERTIFICATE OF COMPLIANCE This is to certify that the Individual Soil Absorption Sewage Disposal System constructed (X ) or repaired ( ) by Peter RrPPn INSTALLER at STW'L&Aftr" Anrjauprf MA 01 R41; has been installed in accordance with Board of Health Regulations as described in the Design Approval Site System Permit No. 2g7 datedDec. 21 , 19 95 The issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. BOARD OF HEALTH ".. E CD _N .0 N a G i N C O _R as W cc C m O cm C .0 C P.t 0 0 Z O Q CD J m Q7 c c� C CD0 1 CO) CD CA CD = cm CO a w C.% rt� Co O L 7 CDe O tC Cl 0- 0- Q . co G: Citi V .� C CD QIP O CL C3 Cra GAJ V w fig: z Cl) C40VD C U O C C O E - U \ C c C ` 7 -'G P. C/) r b0m C L11 U Lz O Lzi > ro 6 1 i E CD _N .0 N a G i N C O _R as W cc C m O cm C .0 C P.t 0 0 Z O Q CD J m Q7 c c� C CD0 1 CO) CD CA CD = cm CO a w C.% rt� Co O L 7 CDe O tC Cl 0- 0- Q . co G: Citi V .� C CD QIP O CL C3 Cra GAJ V C U O C C O C c C toy U •Qa CL _ CC CQ s O cc jJ �� �+ L w.2 cn v E E L m w y O O - WE f �Q= WN CO = L co ' 'M Cc C m \X E in N Cd N E m L a m a CLU i y O G1 a CoQ N QCDC s •y O V � '� Z cc O o ao m N C CD 67 C W 0 w •y. - C +- LAI Ca a c, an o o w cap C cn CL CD :Ei � L = E CD _N .0 N a G i N C O _R as W cc C m O cm C .0 C P.t 0 0 Z O Q CD J m Q7 c c� C CD0 1 CO) CD CA CD = cm CO a w C.% rt� Co O L 7 CDe O tC Cl 0- 0- Q . co G: Citi V .� C CD QIP O CL C3 Cra GAJ Town of North Andover, Massachusetts Form No. 2 e MORTM BOARD OF HEALTH -- DESIGN APPROVAL FOR �SSACHUSEt SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant-'/4V� !�/ /U� ��1-�— Test No. Site Location Reference Plans and Specs. /Ve1/ ENGINEER DESIGN Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. Fee A 6 1. AIRMAN, BOARD OFITEALTH Site System Permit No. Rln7 } \ § E _ LL \ t @ L / Q t / � } . 2 ° . \ k Wuj2t'n CL z ® § ] � w U > a § 2 cu 2 ® 2 2 a § $ < V) § o c / 3 ' .\ < 2 U 6 -C O / O } z 14-m a o c o U o 0 \ F 2 f W 9 ƒ ) 4 m { ui ƒ l z � » ®' c \ _L 0 � & � CL m WN OARD OF HALDTHVER/ NO 2Q M COMMON DRIVEWAY, UTILITY AND CON Whereas, Flintlock, Inc. is the owner of two certain j parcels of land situated in No. Andover, County of Essex, Commonwealth of Massachusetts, shown as Lots 5 and 6 on a plan I W entitled "Plan of Land in North Andover,. Mass. Prepared for Flintlock, Incorporated, P.O. Box 531, North Andover, Mass. 01845, showing 25' Common Driveway & Utility Easement & Construction Easements" dated February 2, 1996, Thomas E. Neve Associates, Inc., Engineers -Surveyors -Land Use Planners, which said plan is recorded with the Essex North District Registry of Deeds, herewith, and T Whereas, the Planning Board of the Town of North Andover m ^. c has issued a Special Permit dated April 10, 1995 and recorded in� said Registry of Deeds, Book 4274, Page 39 permitting the construction of a Common Driveway to service Lots 5 and 6, and 1� 3 Whereas, the Planning Board of the Town of North Andover `T has issued a Special Permit dated April 10, 1995 and recorded with said Registry of Deeds, Book 4274, Page 64 permitting access 6, and i Whereas Flintlock, Inc. intends to install sub -surface sewer disposal systems on Lots 5 and 6 in or adjacent to the areas shown on the said plan as "Construction Easement for Lot #5" and "Construction Easement for Lot #611, and ' /.',l ,'+'fid-� �.%' ��--• �+ /i t%�' ►i Whereas, Flintlock, Inc. intends by these presents to' establish the rights of present and future owners of Lots 5 and 6 with respect to the Common Driveway and Utility Easement and the Construction Easements as shown on the aforesaid plan. Now, therefore, Flintlock, Inc. does hereby declare for , itself and its successors in title that said Lots 5 and 6 shall I! be subject to and have the benefit of the Covenants, hereinafter I set forth: 1. The owner of Lot 5 shall have the right to pass and repass by foot and motor vehicle over that portion of Lot 6 `j designated as 1125 foot wide Common Driveway and Utility Easement Area" shown on the aforesaid plan for ingress to and egress from I - Lot 5 to Lost Pond Lane as shown on said plan, and for any other jlpurpose for which driveways are commonly used in the Town of I' North Andover. I! 2. The owner of Lot 5 shall have the right to install, (� maintain and repair lines of utilities within said Easement Area to service the single family residence to be -constructed on said Lot 5. 3. Neither the owner of Lot 5 nor .the owner of Lot 6 shall allow any obstruction to be placed or parked within tae Easement Area which would inhibit or obstruct -the free passage of vehicles over said Easement Area or which would obstruct the installation, maintenance or repair of utilities within said Easement Area. I - 2 4. The owners of Lot 5 and 6 shall each be responsible for 50% of the cost to maintain, repair and remove snow from the Common Driveway to be constructed with the Easement Area and eacY shall be responsible for 50% of the cost to maintain and repair the utilities to be installed within said Easement Area. 5. The owner of Lot 6 shall have the right to maintain or Lot 5 in that area designated "Construction Easement for Lot 611, a grading, slope and construction easement as required by the owner of Lot 6 for the installation, maintenance and repair of a sub -surface sewage disposal system to be located on Lot 6 southwesterly of said Construction Easement. If the owner of Loth 6 is required to enter upon Lot 5 within said Construction Easement in order to maintain or repair the sub -surface sewer disposal system to be located on Lot 6 then the owner of Lot 6 shall re -loom and reseed any disturbed area on Lot 5 resulting from the entry. 6. The owner of Lot 5 shall have the right to maintain o Lot 6 in that area designated "Construction Easement for Lot 5", a grading, slope and construction easement as required by the owner of Lot 5 for the installation, maintenance and repair of a sub -surface sewage disposal system to be located on Lot 5 northeasterly of said Construction Easement. If the owner of Lot 5 is required to enter upon Lot 6 within said Construction Easement in order to maintain or repair the sub -surface sewer disposal system to be located on Lot 5 then the owner of Lot 5 shall re -loom and reseed any disturbed area on Lot 6 resulting from the entry. - 3 - 7. This Covenant shall run with the land and shall be binding on and be for the benefit of the Declarant, its successors and assigns. In Witness Whereof, Flintlock, Inc. has caused these presents to be signed and sealed by David A. Kindred, its duly authorized President and Treasurer this 14th day of February, 1996. ESSEX,SS FLINTLOCK, INC. i By: c D vi re , President and Treasurer COMMONWEALTH -OF MASSACHUSETTS February 14, 1996 Then personally appeared the above named David A. Kindred and acknowledged the foregoinge e free act and deed of Flintlock, Inc., before me, Notary Public My commission expires: 3v FLINT.COV/DMT - 4 - (� (� Re/sem of Deeds Northern District of Essex County ( Lawrence, m 3840 oJml6 . FLI#La INC PL # q +e:62 Rb Type COVEN 10.00 T 210 Posta-le 5 £ »GI m,& # » Payment a 10.7 !L THANK '± Thomas J. Burke Re,jister off Dews \ PLAN REVIEW CHECKLIST ,(� ADDRESS 1 J��ONJ ENGINEER /VC1lG GENERAL 3 COPIES --' STAMP (--' LOCUSy' NORTH ARROW c� SCALE CONTOURS t--' PROFILE SECTION Z/ BENCHMARK SOIL & PERCS ELEVATIONS WETS. DISCLAIMER WELLS & WETS WATERSHED?J/Q DRIVEWAY �(Elev) WATER LINE ✓ FDN DRAIN !/ SCH40i/ TESTS CURRENT? Com- SOIL EVAL SEPTIC TANK MIN 150OG ✓/ .17 INVERT DROP GARB. GRINDER /vO (+200% EDF) 25' TO CELLARi/� MANHOLE ELEV GW # COMPS. D -BOX SIZE # LINES FIRST 2' LEVEL STATEMENT INLET 1�7,7, - OUTLET A 7,- ( 2" OR .17 FT) TEE REQ' D? LEACHING MIN 660 GPD? `- RESERVE AREA LI/ 4' FROM PRIMARY? (--' 20 SLOPE 100' TO WETLANDS c/ 100' TO WELLS' 4' TO S.H.GW ----(5'>2M/IN) 35' TO FND & INTRCPTR DRAINS L'_ 325' TO SURFACE H2O SUPP 4' PERM. SOIL BELOW FACILITY MIN 12" COVER t/ FILL? (25' if above natural elev; 101if below) BREAKOUT MET TRENCHES MIN 660 gpd SLOPE (min .005 or 6"/100') SIDEWALL DIST. 3X EFF. W OR D (MIN 6') RESERVE BETWEEN TRENCHES? IN FILL? MUST BE 10' MIN. 4" PEA STONE? VENT? (>3' COVER; LINES >501) BOT + SIDE X LDNG = TOT (L x W x ##) (DxLx2x#) (G/ft2) Copyright © 1995 by S.L. Starr /V ,�SeD MAk)��UG� PITS MIN 660 LEACHING _ MIN 1 (13'x16') PIT MANHOLE/PIT GW MIN 4' BELOW BOTTOM EXC 2x EFF W OR D 12"-48" STONE_ BOT + SIDE x LOAD = TOTAL (L x W x #) (2x(L+W)xD x #) (G/ft2) CHAMBERS MIN 660 LEACHING GW MIN 4" BELOW L / COVER >3 FT - VENT 4!5�< MANHOLES ✓ 12"-48" STONE c--' SPLASH PADS L'' SLOPE .005 BED/TRENCH cc (Bed max. 60' X 601) MIN 13' X 16' PIT r� BOT 4ZI , 03 + SIDE I 0 f, 3 5 X LOAD = TOTAL f l� (L x W x #) (2 x (L+W)xD x #) (G/ft2) FIELDS MIN 660 GPD 900 ft2 BED GW MIN 4' BELOW BOTTOM OF FIELD_ PIPE ENDS JOINED? 4" PEA STONE? DIST LINE SLOPE .005? >31COVER-VENT SCH 40 MIN 12" COVER RATE LDG X 660 = X = TOTAL_ G/ft2 REQ'D (ft2) LXW DOSING TANKS AND PUMPS DIMENSIONS X X = PUMP CAPACITY 9Pm L W D Vol. DISCHARGE SIZE DISCHARGE RATE DISCHARGE TIME 9Pm MANHOLES TO GRADE ALARM SEP. CIRC. GW (Min. l' below inlet) HWL LWL CHECK VALVE BLEEDER HOLE MANUAL OP. SWITCH Copyright © 1995 by S.L. Starr 1 Of NORTAI • o o s • Town of North Andover HEALTH DEPARTMENT �ss�cNus°A CHECK #: LOCATION: i H/O NAME: ( r�uis 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) $ 0 5 Inspector $ ,Tit%le Title 5 Report $ ❑ Other. (Indicate) $ 8 Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer M OD `Z (D Ln E -i o `C� o (h o ZL_ o O o Ln o o H o � v o 0 o U) � >� OZ N o�E W a M �� UJ Q) 0 H H �4 M a 4-I 0 J � 3 J 0 a 0 J Q 0) to o Z W O � � r 0 H O O 4 W Z x a Lid H m O U k.D Ln LLI > ( M o H x U 577 MAIN STREET HUDSON, MA 01749 800-499-1682 ENVIRONMENTAL RECEIVED OCT 2 3 2006 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNER'S NAME: PROPERTY ADDRESS: ADDRESS OF OWNER: (IF DIFFERENT) DATE OF INSPECTION: PAUL WOLMERING 96 LOST POND LANE NORTH ANDOVER, MA 01848 SAME OCTOBER 5, 2006 NAME OF INSPECTOR: DANIEL DECOSTA Important: When filling out forms on the computer, use only the tab key to move your cursor- do not use the return key. t5insp.doc - 11/20C Commonwealth of Massachusetts Y Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form Dr on the official Title 5 Inspec Ion Forrr dated 611512000. Inspection forms may not be altered in any way. A. Certification 1. Property Information: V C ` o ,'A Prop rty Address Owner's Name Owner's Address �oy e2 �`� `� i City/Town State Zip G ode Date of Inspection: Date 2. Inspector: �F ✓AL3 �UJ ? �� . Name of Inspector Wind River Environmental Company Name 561 Main St. Company Address MA 01749 Hudson Cityl1 own State Zip Code. 978-5624500 Telephone Number Certification Statement: I certify that I have personally inspected the sewage di posal system at this address an that the information reported below is true, accurate and comp ete.as of the time of the inspection. The in pection was performed based on my training and experience i I the proper function and mainter ante of on site sewage disposal systems. I am a DEP approved sys em inspector pursuant to Sect on 15.34D of Title 5 (310 CMR 15.000). The system: asses ❑ Conditiona ly Passes ❑ Fails eds Further valuation by the Local Approv ng Authority `� E ` Inspector ignature Date The system inspector shall -submit a copy of this inspection report to the Approving kuthority :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 ShE II submit I he report to the appropriate regional office of the DER The original should be sent tot the syste owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the tirr e, 6f inspection and under the ndition' of use at that:time. This inspection does not address iow the system will perform in the futur under the same or different conditions of use. 4 Title 5 0 ficial Inspection Form: Subsurface Sewa le Disposal System - Pa 'e 1 of 16 . t5insp:doc • 11/20( Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) Property Address city/Town State Zip C de Owner's Name Date of Inspection Inspection Summary: Check A,B,C,D or E / aiwayi complete all of Section D A) System Passes: 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: 1 ,` B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" sectior need to e replaced or repaired. The system, upon compic tion 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. f "not determined,° please explain. ❑ The septic tank is metal and over 20 years old or the septic tank (whether met I or not) i structurally unsound, exhibits substantial infiltrc, tion or exfiltration or tank failure s immine t. System will pass inspection if the existing tanks replaced with a complying sep is tank a approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking ar d if a Cer tificate of Compliance indicating that the tank is less tt an 20 years old is available. ND Explain: 4 Title 5 0ificial Inspection Form: Subsurface Sewaj a Disposal .§Iystem Pag 2 of 16 t5insp.doc • 11/2004 mmonwealth of Massachusetts itle 5 Official Inspec ion Fora t for Voluntary Assessments bsurface Sewage Disposal System Form Certification (cont.) Property Address City/Town State Zip C de Date of Inspection Owner's Name B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or to broken or obstructed pipe(s) or due to a broken, high static water level in the distr settled or uneven distribution bution box box. Sysi due em will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstru ted pipe( s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Boarc of Health: ❑ Conditions exist which require further evaluatio 1 by the Board of Health in order to determine if the system is failing to protect public health, sa ety or the environment. 1. System will pass unless Board of Health determines In accordance Witt 310 CM IZ 15.303(1)(b) that the system is not function! ig in a manner which will prot ct public. health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a urface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt mar h Title 5 Of ricial Inspection Form: Subsurface Sewac 6 Disposal Systern Pag 3 of 16 IU t5insp.doc • 11/200.4 mmonwealth of Massachusetts itle 5 Official Inspection Form t for Voluntary Assessments bsurface Sewage Disposal System Form Certification (cont.) Property Address Citylrown State Zip C de Owner's Name Date of Inspection C) Further Evaluation Is Required by the Boarc of Health (cont.): 2. System will fail unless the Board of Health determines that the system is functioning In (and Public Water Supplier, if a manner that protects the public any) health, safety and environment: ❑ The system has a septic tank and soil 100 feet of a surface water supply or tributary t bsorption system (SAS) and the a surface water supply. SAS is w thin ❑ The system has a septic tank and SAS and the SAS is Within a Zone 1 ef a publi 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.fe t but 50 f et or more from a private water supply well''. Method used to determine distance: This system passes if the well water analysis, coliform bacteria and volatile organic compoun that facility and the presence of ammonia nitrogen ppm, provided that no other failure criteria are triggered. to this form. performed at a DEP certified la Js indicates that the well is free f and nitrate nitrogen is equal lo A copy of the analysis oratory, om pollut or less ust be a or on from Pan 5 'tached 3. Other: Title 5 01 ficial inspection Form: Subsurface Sewal a Disposal Pagi 3ystem 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspec Not for Voluntary Assessments Y` Subsurface Sewage Disposal System Form A. Certification (cont.) Property Address City/Town Owner's Name D) System Failure Criteria Applicable to All Sy You must indicate "Yes" or "No" to each c Yes No tion Form State Date the following for all ❑ 0 t Backup of sewage into facility clogged SAS or cesspool Discharge or ponding of effluent due to an overloaded or clogged or system component due to c to the surface of the ground SAS or cesspool ElStatic EV ❑ E3oe ❑ tj�r liquid level in the distribution or clogged SAS or cesspool Liquid depth in cesspool is I than % day flow Required pumping more thE obstructed pipe(s). Number box above outlet invert di ass than 6" below invert or availz n 4 times in the last year NOT dt of times pumped: ❑ [ Any portion of the SAS, ces 5pool or privy is below high grout ❑ ®/ Any portion of cesspool or p tributary to a surface. water rivy is within 100 feet of a surfac supply. ❑ 02"" Any portion of a cesspool or privy is within a Zone 1 of a pub Any portion of a cesspool or privy is within 50 feet of a privat ❑ �/ Any portion of a cesspool or I privy is less than 100 feet: but gr II 'th no inc—ca—catable water nu: from a pnvate waer supp y e wt p system passes if the well Water analysis, performed at a laboratory, for coliform bacteria and volatile organic cor indicates that the well is fee from pollution from that fai presence of ammonia nitrogen and nitrate nitrogen is eq than 5 ppm, provided that no other failure criteria are tri! the analysis must be atta hed to this form.] verioaaec or or surface waters ie to an o erioaded ble volume is less e to clogged or d water elevation. water SL pply or is well. water St. pply well. rater thar 150 feet ility analysis. [This DEP certified pounds ility and he jal to or ess gered. A `copy of Yes No ❑ The system fails. l have dE termined that one or more of the above failure criteria exist*as described in 310 CMR 15.303, therefore thesystem fails. The system owner should conta t the Board of Health to determi a what will be necessary to correct the fail re. t5insp.doc • 11/2004 Title 5�fricial Inspection Form: Subsurface Sew$ge Disposal System Paige 5 of 16 Commonwealth of Massachusetts Title 5 Official Inapec ion Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) Property Address City/Town Owner's Name E) Large Systems: To be considered a large f design now of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" c questions in Section D. YES NO ❑ ❑ the system is within 400 feet ❑ ❑ the system is within 200 feet ❑ ❑ the system is located in a nit Area — IWPA) or a mapped i State Date Zip the system must serve # facility "no" to each of the following, in a surface drinking water a tributary to a surface drinkin water len sensitive area (Interim Wei head F le II of a public water supply well If you have answered "yes" to any question in Sec ion E the system is considered or answered "yes" in Section D above the large sy tem has failed. The owner or c system considered a significant threat under Section E or failed under Section D system in accordance with 310 CMR 15.304. The ;ystern owner should contact tt regional office of the Department. A Title V inspection is often misunderstood to suggest that we are conducting a complete inspection of your system. A Title V inspection is limited to determining if, at the time of the inspection, the existing septic system is functioning. The State of Massachusetts has outlined specific tests that are to be performed, which will be completed during your Title V inspection. However, a Title V inspection, and the inspection that Wind River Environmental is performing hereunder, does not evaluate if the system was installed correctly, has been engineered in accordance with state and local regulations, or whether the system will continue to function in the future. It also does not evaluate whether the system would meet the past, current, or future Board of Health or State DEP regulations. A system can pass Title V but still not meet state or local requirements or be suitable for continued use. If the customer would like a complete inspection of their system, including an evaluation as to the design and suitability of your system, Wind River Environmental can provide a quote as to the cost of such services. As well, Wind River Environmental strongly recommends persons interested in buying a home to have a full and complete system evaluation before purchasing a new home. A new home buyer should not rely on a Title V inspection in determining if the system will function in the future, and instead should commission a complete system inspection. t5insp.doc • 11/2004 Title 5 0 1111cial Inspection Form: Subsurface significz :rator of III upgra a the threat, y large the e Disposal ystem Pa e6of16 Commonwealth of Massachusetts Title 5 Official Inspec o Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Checklist Property Address Cityrrown State ion Form Zip Code Owner's Name Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each cf the YES NO 53 ❑ Pumping information was prov ided by the owner, occupant, or oard of f lealth ❑ Q'� Were any of the system comp vents pumped out in the previous two we ks? [� ❑ Has the system received nonT al flows in the previous two week period? Have large volumes of water been introduced to the system re ently or as part of ❑ this inspection? / ❑ Were as built plans of the system obtained and examined? (If they were h.ot available note as NIA) ❑ Was the facility or dwelling in ected for signs of sewage back up? 03"" ❑ Was the site inspected for sigiis of break out? Cg'*" ❑ Were all system components, excluding the SAS, located on si e? ❑ Were the septic tank manholes uncovered, opened, and the interior of th tank inspected for the condition of I he baffles or tees, material of co struction ; dimensions, depth of liquid, depth of sludge and depth of scum -,/ ❑ Was the facility owner (and o9cupants, if different from owner) rovided ith information on the proper mai tenance of subsurface sewage isposal s ;stem; The size and location of the Soil Absorption System (SAS) �on the situ has been determined based on: Existing information. For exery ple, a plan at the Board of He Determined in the field (if any of the failure criteria related to approximation of distance is u acceptable) [310 CMR 15.30: rtCisat i(b)] t5insp.doe • 1112004 Title 5 0ficial Inspection Form: Subsurface Sawa a Disposal System Pa.'e 7 of 16 \ Commonwealth of Massachusetts Title 5 Official Inspeo ° Not for Voluntary Assessments r? Subsurfape Sewage Disposal System Form C. System Information Property Address CitylTown Owner's Name Residential Flow Conditions: Number of bedrooms (design): DESIGN flow based on 310 CMR 15.203 (for exa Number of current residents: Does residence have a.garbage grinder? Is laundry on a separate sewage system? [if yes Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years u; 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 Water meter readings, if available: Last date of occupancyluse: Other (describe): E on Form State Zip Inspection Number of bedrooms pie: 110 gpd x # of bedrooms): inspection required] (gpd)): ons per day (gpd) Date (0 V10 0 ❑ Yes : 0"' No ❑ Yes 9?r No 0 Yes M No ❑ Yes. [2"No ❑ Yes 2"' No Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5insp.doc • 11/2004 Title 5C�fricial Inspection Form: Subsurface Saw$ge Disposa System I I Pa e8of16 Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments r` Subsurface Sewage Disposal System Form C. System Information (cont.) Property Address City/town State Zip Gode Owner's Name Date of Inspection General lnfrmation Pumping Records: Source of information: i �� �� —'—" Was system pumped as part of the inspection? If yes, volume pumped: gal ons How was quantity pumped determined? Reason for pumping: Type of System: Septic tank, distribution box, soil.,, bsorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection r ❑ Innovative/Alternative technology. Attach a copy of the current maintenance contract (to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEEP approval. ❑ Other (describe): Approximate age of all components, date installed (if known) and source of Were sewage odors detected when arriving. at the ❑ Yes s, if X03011p, is t5insp.doc • 11/2004 Title 5 fficial Inspection Form: Subsurface Sew ge Disposa;System - Pa'e9of16 Commonwealth of Massachusetts Title 5 Official Inspe tion Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) Property Address Cityrrown State Zip Code Owner's Name Date of Inspection Building Sewer (locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron OR -'40 PVC ❑ oth r (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, eviden a of leakage, etc.): _A) l k i: ,• 1 0, D . )--pA /) _ e - l' i A v .9- V, UVA� ;E, 4LA lL Septic Tank (locate on site plan): Depth below grade: feet Material of construction: (concrete ❑ metal ❑ fiberglass ❑ polyethylene If tank is metal, list age: Is age confirmed by a Certificate of Compliance? certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet to Scum thickness Distance from top of scum to top of outlet tee or t Distance from bottom of scum to bottom of outlet How were dimensions determined? other years a copy of ❑Yes El or baffle WK or baffle I LI J, vvA e ti .s „ K t5insp.doc • 11/2004 Title 5 �fficial Inspection Form: Subsurface Sew ge Disposal) System Pada 10 of 16 t5insp.doc • 11/20( Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) Property Address Cityrrown State Zip ode Owner's Name. Comments (on pumping recommendations, inlet a liquid levels as related to outlet invert, evidence of j� ,� •� .� L Date of Inspection d outlet tee or baffle condition, structural leakage, etc.): 1 i tegrity, fL Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee orbaffle Distance from bottom of scum to bottom of outlet I ee or baffle Date of last pumping: Date Comments (on. pumping recommendations, inlet and liquid levels as related to outlet invert, evidence of outlet tee or baffle condition, structural leakage, etc.): i ntegrity, Tight or Holding Tank (tank must be pumped at lime of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fibe lass ❑ polyethylene other(explain): 4 Title 5 C fficial Inspection Form: Subsurface Sew, ge Disposa Pag ;System 11 of 16 t5insp.doc • 11/2004 immonwealth of Massachusetts itle 5 Official Inspe tion Form t for Voluntary Assessments bsurface Sewage Disposal System Form System Information (cont.) Property Address Cityrrown State Zip Code Owner's Name Date of Inspection Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Al 3rm in working order. ❑ Yes No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Distribution Box (if present must be opened) (locate on site plan): e5 O" Depth of liquid level above outlet invert Comments. (note if box is level and distribution to evnce of leakage into r out of box, etc.): utlets equal, any evidence of so L i� :fir ids carryover, t�lv any �Vi 11t,, Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Title 5 fficial Inspection Form: Subsurface Sew ge Dispose Pag System 12 of 16 cr C� t5insp.doc • 1112004 mmonwealth of Massachusetts itle 5 Official Inspection ,t for Voluntary Assessments bsurface Sewage Disposal System Form Form. System Information (cont.) Property Address cityfrown State Zip Code Owner's Name Comments (note condition of pump chamber, condition Date of Inspection . of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site ph If SAS not located, explain why: n, excavation not required): Type: ❑ leaching pits leaching chambers ❑ leaching galleries ❑ leaching trenches ❑ leaching fields ❑ overflow cesspool ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydrau vegetatiyn, etc.): number: number: number: number, length: number, dimensions: number: is failure, level of ponding, damp { I t L �{' � !J 1�� soil, conc Ui L ition of `. Ini `'t Title 5 Official Inspection Form: Subsurface Sew ge Disposal Page System 13 of 16 1. t5insp.doc • 11/2004 Immonwealth of Massachusetts itle 5 Official Inspection It for Voluntary Assessments bsurface Sewage Disposal System Form Form System Information (cont.) Property Address Cityrrown State zip ode Owner's Name Cesspools (cesspool must be pumped as part of 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. Comments (note condition of soil, signs of hydraulic etc.): Date of Inspection nspectlon) (locate on site plan): ❑ Yes failure, level of ponding, condition ❑ No of ve etation, Privy (locate on site plan): Materials. of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic etc.): failure, level of ponding, condi ion of veE etation, Title 5 fficial Inspection Form: Subsurface Sew ge Disposa Pag System 14 of 16 • ^ � Commonwealth of Massachusetts Title 5 Official Inspection dorm Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) Property Address City/Town I State owner's Name Date of Inspection Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal to at least two permanent reference landmarks orbenchmarks.- Locate all wells Locate where public water supply enters the building. 0 )-A Zip includng ties 100 fe t. t51nsp.doc • 11/2004 Title 5 M621 Inspection Form: Subsurface Sewge Disposa System Paab 15 of 16 o P 3 3 � 0 L/ Zip includng ties 100 fe t. t51nsp.doc • 11/2004 Title 5 M621 Inspection Form: Subsurface Sewge Disposa System Paab 15 of 16 t5insp.doc • 11/2004 immonwealth of Massachusetts itle 5 Official Inspe tion Form t for Voluntary Assessments bsurface Sewage Disposal System Form System Information (cont.) Property Address Cityrrown State Zip Code Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells ro Estimated depth to ground water: ,5 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: pate ❑ Observed site (abutting property/obse rvation hole within 150 feet of SiS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, install ars - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: ✓lv `4_�yz 5) Title 5 fficial Inspection Form: Subsurface Sew go Disposa Paga System - 16 of 16 Sep 27 06 04:03p Summary Record Card generated on 9127;2006 2:57:21 PM by Lisa Warren Town of North Andover Tax Map # 210-104.B-0213-0000.0 96 LOST POND LANE qi�_� J � �� t_, r� WOLMERING, PAUL 7 JACOBS, JACQUELINE 95 LOST POND LANE NORTH ANDOVER, MA 01845 Class 101 Single Farn Size Total 1 .85 Acres FY 2007 UB Mailing Index Property Type Name/Address Type Loan Number Active/Inact WOLMERING, PAUL Payor JACOBS, JACQUELINE 95 LOST POND LANE NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Bldg Id. 17996.0 - 96 LOST POND LANE Last Billing Date 7/5/2006 3180025 03 Cycle 03 UB Services Maint. 7.82 l/ Service Code /1 Rate MISCFEE ADMIN FEE METE METE 0.635/8 WTR WATER Posted Date 01 ALL METER SIZE UB Meter Maintenance 16 Serial No Status 8 Location 41849460 a Active 1/17/2006 ENC L Date Reading 13 Code 9/19/2006 1795 m Manual estimate MSG 27 10/8/2004 6/20/2006 1675 a Actual 3/20/2006 1659 a Actual Trouble Code:03 1/3/2006 1651 a Actual Trouble Code:03 9/15/2005 1622 a Actual Trouble Code:03 6/14/2005 1501 a Actual 3/23/2005 1488 a Actual 12/15/2004 1478 a Actual 9/17/2004 1465 a Actual Trouble Code:03 6/16/2004 1438 a Actual 4/23/2004 1426 a Actual From Active/Inactive Active Charge Multiplier/Users 7.82 l/ 54.24 /1 Brand Type METE METE w Water Consumption Posted Date 120 16 7/10/2006 8 4/17/2006 29 1/17/2006 121 10/14/2005 13 7/15/2005 10 4/5/2005 13 1/14/2005 27 10/8/2004 12 7/30/2004 26 5/17/2004 Size 0.63 0.63 p.1 Page 1 1 Residential Until YTD Cons 0 Variance 658% 65% -60% -80% 731% 53% -30% -50% 31% 4% 0%