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Commonwealth of Massachusetts -
u r City/Town of North Andover
w° System Pumping Record s �. 07 2014
Form 4 rn,.,,, , �„ c ✓�tz
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
filling out forms 1. System Location
on the computer, q16
use only the tab
key to move your Address
cursor - do not North Andover Ma 01886
use the return City/Town State Zip Code
key.
r�
2. System Owner:
Name
ream
Address (if different from location)
CityfTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
q�-O-
6. stem Pumped By:
G��6
n2C�
Name
Stewart's Septic Service
Company
Vehicle License Number
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of H er �
v
Date
Date
System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
W City/Town of No Andover 1AY 4 2913
lo System Pumping Record
Form 4
G„M �
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
tab
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
1. System Location:
Address
No andover
City/Town
2. System Owner:
Dybols
Name
Address (if different from location)
City/Town
B. Pumping Record
Ma
State
State
Telephone Number
Zip Code
Zip Code
1. Date of Pumping Date y 3 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes [�No
5. Condition of System: �
If yes, was it cleaned? ❑ Yes ❑ No
6. System Pumpe By:
Nam --- Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Receiving Facility
T �d~47
Date
Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts x NIAY 14 2013
Cityjown of No Andover
TOWN of NORTH ANDOVER,'
System Pumping Record .---HFALTN DEPAe�r;;�;,r
•` 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.
VQ
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
1. System Location:
975
Address
No andover Ma
City/Town State Zip Code
2. System Owner;
Address (if different from location)
City/Town
B. Pumping Record
State
Telephone Number
1. Date of Pumping Date IZ-- 2. Quantity Pumped:
3. Type of system: ❑ Cesspool(s) ( Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name
Stewart's Septic Service
Company
7. Locgtion,where contents were disposed:
Signature
Signature of Receiving Facility
20 So. Mill
Zip Code
Gallons 11
❑ Grease Trap
If yes, was it cleaned? ❑ Yes ❑ No
Vehicle License Number
Aa 01835
Date
Date
t5form4.doc• 03106 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
W City/Town of North Andover
a System Pumping Record
Form 4
M
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 f� --- d t in ll
accordance with 310 CMR 15.351. MillEN.r.. i t! - a
City/Town
B. Pumping Record
1. Date of Pumping 5/13/11
Date
State
Telephone Number
2. Quantity Pumped:
3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No
5. Condition of System:
x soilds
6. System Pumped By:
Mike Snow
Name
Stewart's Septic Service
Company
7. Locatio here contents were
Ste 's.f*e-treatment Plant,
/ ,gj�n re of Hauler V
Signature of Recei ' g Facility
t5form4.doc• 03/06
Zip Code
1000
Gallons
❑ Grease Trap
If yes, was it cleaned? ❑ Yes ❑ No
Vehicle License Number
Mill Bradford. Ma 01835
Date
Date
System Pumping Record • Page 1 of 1
A. Facility Information
JUN -7 '1011
Important:
When filling out
1. System Location:
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
forms on the
computer, use
975 forest St
only the tab key
Address
to move your
North Andover
Ma 01845
cursor - do not
use the return
City/Town
State Zip Code
key.
2. System Owner:
QDubois
Name
'e"tl7
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping 5/13/11
Date
State
Telephone Number
2. Quantity Pumped:
3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No
5. Condition of System:
x soilds
6. System Pumped By:
Mike Snow
Name
Stewart's Septic Service
Company
7. Locatio here contents were
Ste 's.f*e-treatment Plant,
/ ,gj�n re of Hauler V
Signature of Recei ' g Facility
t5form4.doc• 03/06
Zip Code
1000
Gallons
❑ Grease Trap
If yes, was it cleaned? ❑ Yes ❑ No
Vehicle License Number
Mill Bradford. Ma 01835
Date
Date
System Pumping Record • Page 1 of 1
.eonard A. Dana Dubois
Idress: 975 Forest Street
Andover
32.17
Clo��Bath
se�
b
n
Bedroom
32.0'
r .s
D Bath
FLOORPLAN
Bedroom
Bedroom
Scr. Porch
44.0'
Kitchen
0.: 1
No.:
MA
b b
Family
Family
Dining Room
Foyer r
O
32.17 12.17 L,;,:5
a,,tLa- r�1
� �, : til
Sketch by Apex IV WindoWSTM 4-0V" ,per Z a"c4 .
AREA CALCULATIONS SUMMARY LIVING AREA BREA DOWN
Coda Description size Totals Breakdown Subtotals
GLA1 First Floor 1144.00 1144.00 First floor
GMM Second Floor 864.00 864.00 26.0 z 44.0 1144.00
Secoad Floor
27.0 z 32.0 864.00
� 1p —, n) --," ",-1, 4 1,-
ej .5r -p4 -(c-
FORM U - LOT RELEASE FORM
0 '�r 3: This form is used to verify that all necessary approvals/permits from
artments having jurisdiction have been obtained. This does not relieve
J I/or landowner from compliance with any applicable or requirements.
**********APPLICANT FILLS OUT THIS SECTION*** --*********k******
APPLICANT f7ee,,e D r, ti o J SPHONE !� Z3-f
LOCATION: Assessor's Map Number PARCEL
SUBDIVISION LOT (S) '}
STREETS i'�-�.�� S� ST. NUMBER �l ' �_
*************OFFICIAL USE ONLY***********************************
r
RECOMMENDATIONS OF TOWN AGENTS:
CONSERVATION ADMINI§TRATO`R DATE APPROVED
DATE REJECTED
COMMENTS 144 1 ,yi r /lo-, 0 .1.. r_� ,� C% .' 1
'1
TOWN PLANNER DATE /APPROVED
DATE REJECTED
COMMENTS
i
FOOD INSPEC OR -HEALTH DATE APPROVED
, �;r . DATE REJECTED
-H
COMMENTS
DATE APPROVED
DATE REJECTED
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
E� L
-rem
INV asib, 5-' PI peri.Jqa" i
rR MR
Lit=
A. L M i 4--o
t.LI. I �'j AS A -b 5
F-
A
FORM..0 - 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.
*****************************APPL'ICANT FILLS OUT THIS SECTION*******************""
APPLICANT J. McKeown for L&D Dubois
LOCATION: Assessor's Map Number 105-D
SUBDIVISION
STREET Forest Street
PHONE 617. 242. 7300 — 0
PARCEL 74 %tl'97,3, 1 SCO "C-
LOT (S)
ST.NUMBER 975
************************************OFFICIAL USE ONLY***" "******************************
RECOMMENDATIONS OF7J0,WN AGENTS:
J CONSERVATION ADM
TOR
DATE APPROVED
DATE REJECTED
COMMENTS��c?d------------
TOWN PLANNER
COMMENTS—
FOOD INSPECTOR -HEALTH
COMMENTS—
DATE APPROVED -- _— --_
DATE REJECTED___—__—__________
DATE APPROVED
DATE REJECTED_
TH DATE APPROVED s 5 /2. 4. /by _
DATE REJECTED _er _ —
PUBLIC WORKS - SEWER/WATER CONNECTIONS--___—__—__—____
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR_ —__ _ ___DATE_ -__—
Revised 9197 jm
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
1).A'I'1:: 7
o STEM OWNER & ADDRESS
976-
e, anclox
SYSTEM LOCATION
(example: left front of house)
t
U:\Tc OF PUMP[NC: QUANTITY PUMPED0ALL0'v
(A 1) 00L: NO YES SEPTIC TANK: NO YES
'VATURE OF SERVICE: ROUTINEy EMERGENCY
uli.>FRV:\TIONS:
GOOD CONDITION
HEAVY CREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
s1'�"1'LM PUMPED BY:
C'UNI'YIENTS:
�.UNT1:'..NTS I'lZANSI E I Z R E D TO:
L -
NULL TO CUVCIZ
1,AFFLLS 1N PLACE
LEACHFIELD RUNBACK
FLOODED
�j�HFR (EXPLAIN)
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TO:
FROM:
DATE:
BUILDING INSPECTOR
E-911 COORDINATOR
FIRE CHIEF
HEALTH AGENT
POLICE DEPARTMENT
ASSESSORS OFFICE
ROBERT NICETTA
RICHARD BOETTCHER
WILLIAM DOLAN
SANDY STARR
FRED SOUCY
JEAN FOGARTY
TIM WILLETT, TOWN ENGINEER, D.P.W.
JUNE 26, 1997
PLEASE BE ADVISED THAT STREET NUMBER FOR
875 FOREST STREET HAS BEEN CHANGED TO
975 FOREST STREET AT THE REQUEST OF THE
HOME OWNER. PLEASE UPDATE YOUR FILES.
Y! P' PP (7;1T OP HSE
'•� : - PAF 1�1T0 lAL�ItiL � -_� -�-, � j � � - -
i&LV-PLPF-,2u T OF TANW-
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-- E5 U 1 L- _
F RnN1� G��E�.�►.1L1♦S L A`-�=��I�TES
�kI-T CTS
V... ... h
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
i
.1` 4 -:/13
William F. Weld
Trudy Caxe y�
Secretary, EOEA 1 7/
David B. Struh
Commisvaner `
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART A
L CERTIFICATION
/
Property Address; � /_ .`/ Address of Owner:
Date of Inspection: %6//1/1�S (If different)
Name of Inspector: 6jr?;>,,•o.r/;� (" 2
Company Name, Address and Telephone Number:%G'u�
CERTIFICATION STATEMENT
I-eri^:, 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 mspeciion. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system.
✓� PassF�s
Conditionally Passes
Needs Fur,her Evaluation By the Local Approving .Authority
Fa is
inspector's Signature: Date: ,,-� ,�
,,6,0,E e '
i he S', stem Inspecto, $ha!I cf�mit a cop of this inspection repon to the .Approving Authority within thirty (30) days of completing this
!nspect,on. If the shared system or has a des gn f!ow of "10,000 gpd or greater, the !n;pector drtd the system civ ner shall submit
,i)e re'or to the appropriate rational office of the Department of Environmental Protection.
Tne ongtnal should be sen' iC tr'P s%stem owner ane: cople> Sent 10 the JU\'er, d apG: i.dt)ie and the drli •'G'•ink dilthor„',
INSPECTION SUMMARY:
Check ;B, C, or D
Al SYSTEM PASSES:
I have not found an,, information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
b] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND) Describe basis of determination in all instances. If "not determined", explain why not)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
1
rrev-sect
One Winter Street • Boston, Massachusetts 02108 a FAX (617) 556-1049 • Telephone (617) 292-5500
�� Printed on Recycied Paper
oy,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
l CERTIFICATION (continued)
Property Address: ��c9,f�i�`?� `fie,
Owner;
Date of Inspection:
B; SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed In the distribution box is due to broken or obstructed
pipe(s, or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the
Board of Healthy
broken pipe(s) are replaced
obstruction is removed
dlstnbution box is levelled or replaced
The spsiem required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection ;f ,with aporoval of the Board of Health):
broken plpe(sr are replaced
obstruction is removed
C1, 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 the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC. HEALTH AND SAFETY AND THE ENVIRONMENT:
_ CesSpocl or pn. i5 ',vithiin 50 lee! of a 5uriace water
C.essp^:" Cr 51, feet of a bordering vegetated wetland or a salt n ar5n
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The (','qom 4d a Seotic tanK ono Soil absorption s1'stem and 15 wiiii n lou feet to a :uilr ur v io t:i iujrFi r Gi i(ibutal) i , a
surface water 5upply
T e , •ve, 5el>i ti ,r, ,k and soil absorption system andis within a Zone I of public water supply well.
The system ha > a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The a 5ep:,C tank and soil absorption system and is less than 100 feet but 50 feet or more from a private :iter
suppi,,' well, ur,ess a well water analysis 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
pprr.
D) SYSTEM FAILS;
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
DiScharFe or ponding of effluent to the surface of the ground or surface waters due to.an overloaded or clogged SAS or
Cesspool
(-ev1SE•,_4 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
y� CERTIFICATION (continued)
Property Address:
m
Owner;��>04
Date of Inspection:
Dj SYSTEM FAILS (continued):
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool,
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
_ Required pumping more than 4 tin -es in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped __
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Anv Portion of a cesspool or privy is within a Zone I of a public well.
Any pr
tt!on of a cesspool or privy is within 50 feet of a private water supply well.
Anv pomon 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform harena, volatile organic compounds, ammonia nitrogen and nitrate nitrogen
El LARGE SYSTEM FAILS:
'The folio,,,ing Criteria appy to large systems in addition to the criteria abo%e
'he des;,-- fiov, of system is 10,000 gpd or greater (Large Svstem' and the systen-i i5 a significant threat to public health and safety
and the en•: ronment uecause one or more of the following conditions exist,
the system is -,,ithtn 400 feet of a surface drinking water supply
the_,•; stem 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 ((NEPA) or a mapped Zone II of a
Dubh( �%�iter 5.rpp!% "ell'.
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information,
t;evXSed 8/:5/55' 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
ae
Property Address: /
Owner:.. 0-1114
Date of Inspection:
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of Health.
None of the system components ha%e been pumped for at least t"•o weeks and the system has been receiving normal flow rates
during that period Large volumes of water have not been introduced into the system recently or as part of this inspection.
As built plans have been obtained and examined. !vote if they are not available with N/A.
Y� The facility or dwelling was inspected for signs of sewage back-up
y' The system does not receive non-sanitar,., or industrial waste flov.,
The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, d mens ont, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on existing information or
/�apprrx r}ated 'r_ no^ nuuswP met ,00"
c%,. re k,ere prnvido r
N%its. ,nfnrmatipn on the U(Opef maintenance of Sub
Surface Drsnosal Svstem.
rev'sed 5/95; 4
�rr4 ;rtfc ir�y��•.
xr$K
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
t i 7
Property Address:
Owner: q 0 ons
Date of Inspection: !4 jay rye
FLOW CONDITIONS
RESIDENTIAL:
Design flow: Qallons
Number of bedrooms. - F_
Number of current residents: /
Garbage grinder (yes or no): fj!
Laundry connected to system (yes or no):
Seasonal use (yes or no): 4,0
Water meter readings, if available:" Gc��LG
Last date of cccupancy:���/?`
COM,MFRCIAUINDUSTRIAL:
Type of establishment -
Design flow,_gallons/da
Grease trap present: (yes or noj^
Industrial Waste Holding Tank present: (yes or no)—
Non-sanitary waste discharged to the Tale 5 systern. (yes or no)_,-,
Water. meter readings, if available:
Last dale of occupancv:
OTHER: !Describe' _
Lai( date of Occuperu.� ,
GENERAL INFORMATION
PUMPING RECORDS and so rce of information:
�
System pumped as part ofinspection: (yes or no) 41—
If yes, volume pumped /14*t) gallons
Reason for pumping. _� cv" zit-,W__—
TYPE OF SYSTEM
A-` Septic tankMistnbution box/'soil absorption systern
Single cesspool
Overflow cesspool
Privy
Shared system (yes or not (if yes, attach previous inspection records, if any)
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: ;"y L4 Gk4 /9 IF/
Sewage odors detet_ted when arriving at the site: (yes or no) 42
t:evised 6/15/95'
C
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 9 :eeis e, � W4
Owrre:r: �%�1p/� �GOd�C�i
Date of Inspection:
r � .
SEPTIC TANK:
(locate on site plan)
i
Dewh below grade: ;
Wl,e�ial of construct on: ✓oncrete ____metal ,_,_ERP ^otheriexplain)
Dimensions: I'M 6=*Z
Sii,rlge depth.=�
D*!,,nc;e from top of sludge to bouom of outlet tee or barfle.3-
i
Stun: !h.t.i ness.�,______
C,stance from top of scum to top of outlet tee or baffle: i
Di :ance from bottom of scum to bottom of outlet tee or baffle:__
`n,.-irnents:
(recomrnendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
ntcr,rit}•, evidence of ieakage, etc.i %c'e J 14 roo4 C'16'04/'0vr �l 'S Ply v�ey�rt 6e, .galalrt_ Ind �A��ea1T
GREASE TRAP:_
an site plan•
D��pti,. belo�ti� grade:�.�
t5t+ r,a� of constructgc _concrete metal _FRP _other(explain)
��n,Crtiipny �_
Scum tivCi.ne.>. .^
Distance frorn top of scum to top of Outlet tee or baffle;
i,rl Fp[tn n i n^ ci' C'1';!r ir'n or ha!!Y
(recnmmendation for purm)-g. iq :p t ;>r'' of Inlet and outlet tees or baffles, depth of liquid lovell In relation (o outlet Invert, struciural
evidence o' i(d(,u e'.
(revised 8,'15!951 6
7� -;�-S'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 97S
Owner: / r•,7 D 04 e!,
Date of Inspection: /'0/dor/y5i
IIGHT OR HOLDING TANK;
;':)rate on site plan) __
'Death below grade.
,•°,aterta! of construction: —concrete —metal _FRP —other(explain)
Dimensions
rapacity. gallons
Design flow;Qallons%day
r.'a�rl level'.
C ornmenic.
:cond:l.on of inlet tee, condition of alarm and float Switches, etc.)
DISTRIBUTION BOX:_
(locate on site plan;
[-�epth of liquid level above outlet nvert: 69
cc. ,r er cvidenre of leakaC'F.' in(c) or Out Of I)(\ P_IC.
,o �oc*:4e D -sox - "o��,h t�ry ePd__,00�►v /Lo w��
PIMP CHAMBER:
"; 'rate on site plan"
Pumps in working order.(yes or no)—
C, omments:
o)
Comments:
'ro'e condition of pump chamber, condition of pumps and appurtenances, etc.) _
:sed ai.5!55, 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address;
O,hner: ,�.4 0A 6 G, a GG
Date of Inspection: is
SOIL. ABSORPTION SYSTEM (SAS):____
;Jcncate on site plan, if possible; excavation not required, but may be approximated by non intrusive methods)
ii ;;ot determined to be present, explain:
T,,,,e
leaching pits, number:
leaching char,hr.,rs•
number
ir_ach!ng ga!Ic°ries
number!.
r:aching trenches,
njmbe.,Je.^.gth.
leaching fields, number.
dimensions:
overflow cesspool;
number.
t'_-.:,nments: (note condition of sail, signs of hydraulic failure, leve, of ponding, condition of vegeta1tion,etc.!
CE:�SPOOLS: _
uo.:ate on site plan)
and coniig.;ra!ir..n
C, tap or liquid to .ale. n er _ —
De:)th of solids layer --
nrr;;rh of scum laver.
f'! ....�inj�i�nt ii( ce5spoc,'__.
,.•I,.:r?r!a;s o. construe;nor' .—.._._._ _.
n, grounrjwate,
inflow (Cesspool must be pumped as pan of inspection)
Ccr+men,,s. (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc )
PRIVY: _
nc ite on site plan)
Mate!ials c- construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of.vegetation, etc.)
-ev'.sed 8"15r'°5! 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 775 �O ee,S7z si'-, l'vc, 0-1-4 ,04xdayeel ot"'
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within. 100'
i
i
t
1
....... . .....
a�✓�rlo
Ay r��a1z�,
DEPTH TO GROUNDWATER
Depth to groundwater: 2-8 feet
me!hod of determination or approximation: T'reooda /o 4o p eo'eiV/ '9,10
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
. Y DATE: r
a
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
,. fns (example: left front ouse)
k 1 t
1. 1 t3
DATE OF PUMPING: (� -� -,� -,
QUANTITY PUMPED=GALLONS
tw 1 .h
CESSPOOL: NO _ YES
SEPTIC TANK: NO YES
1�4+ �!, 1u�; 1rly� ii•. '11. ir ! i 4 �.I : Yi :, �
_
. .
NATURE OF SERVICE: ROUTINE E. rEMERGENCY
l;Q$SERVATIONS:
k{,1ir"Yi:�> I !'t '
/
�t�'rrr
A GOOD CONDITION'
FULL TO COVER
HEAVY GREASE
BAFFLES IN PLACE
ROOTS
LEA CHFIELD RUNBACK
EXCESSIVE SOLIDS
FLOODED
SOLIDS CARRYOVER
OTHER (EXPLAIN)
_-
r; .... •' -,'-
-
V"}i4 t�^� i, Q;1 ,441 A 1
,
S W STEM PUMPED By:
1
(t
�.
Ai
tr
y P
,1 r . �r•. r
-
�
+ I
J L •�
��'�� _ � �•I�
M,MMirNTV:...
w
fir.. 47 , S:Jri•.. �•(: I r'•;� ..
--...
,QNENTS TRANSFERRED TO:
rM,
,)y t o Ful: l; c „ores
SUBSURFACE DISPOSAL SYSTEM CHECK LIST
APPROVED
Title 5
Reg. 2.5
deg. 6
DATE PROVIDED
7-?,7�
NORTH ANDOVER BOARD OF HEALTH
DISAPPROVED DATE TIME REASON
FailJOKI The submitted plan must show as a minumum:
ta-j- the lot to be served (area,dimensions,l.ot 4/,abutters)
(Planning Board files)
.4-}- location and log of deep observation holes -distance
to ties
fc-j location and results of percolation tests -distance
to ties
{d� design calculations & calculations showing required
leaching area
{-e- location and dimensions of system (including reserve
area)
existing and proposed contours
location of any wet areas within 100' of the sewage
disposal system or disclaimer (check wetlands mapping)
41i�- surface and subsurface drains within 100' of sewage
disposal system or' disclaimer
k -i-)--- location of any drainage easements within 100' of
sewage disposal system or disclaimer (planning board
files)
44-)- known sources of water supply within 200' of sewage
disposal system or disclaimer
{-k) location of any proposed well to serve the lot (100'
from leaching facility)
.%L): location of water lines on property (10' from leaching
facilities)
ktr- location of benchmark
Ln) driveways
garbage disposers
{-� no PVC is to be used in construction
a profile of the system (elevations of basement, plumber.
pipe septic tank, distribution box inlets and outlets,
distribution field piping and any other elevations)
{-�-) maximum ground water elevation in area of sewage disposa'
system
4-s-)-�n must be prepared by a Professional Engineer or
other professional authorized by law to prepare such
plans
Septic Tanks
(a) pacities - 150% of flow, water table, tees, depth
of tees, access, pumping,
) Cleanout
(c) 10' from cellar wall or inground swimming pool
(d) 25' from subsurface drains
North Andover Subsurface disposal system check list' -.Page 2
pail
OK
Distribution Boxes
Reg.10.2Slope
greater than 0.08
Reg.10.4
(b Sump
Leaching Pits
Leaching pits are preferred where the installation is
possible
Reg.11.2
(a) Calculations of leaching area (minimum 500 S.F.)
Reg.11.4
(b) Spacing
Reg. -11.10
( c ) Surface drainage 2%
Reg.11.11
Cgver material
L�d)
eaching Fiel�ds
Reg.15.1
-ater than 20 minutes/inch
(a) NSVreea(minimum
Reg.15.1
(b) 900 S.F.)
Reg.15.4
( Construction of field
Reg.15.8
Surface drainage 2%
Reg. 3.7
Ye?, 20' from -cellar wall or inground swimming pool
Leaching Trenches
Reg.14.1
(a) Calculations of leaching area (min. 500 S.F.)
Reg.14.3
(b Spacing (4 ft. min. 6 ft. with reserve between)
Reg.14.4
(c Dimensions
14.5
Reg.14.6
(d) Construction
Reg.14.7
(e) Stone
Reg.14.1
(f) Surface drainage 2%
Dota .ill Slope
a) Slope y/x = (to be shown)
(b) y/x X 150 = (to be shown)
Pump
Reg. 9.1
(a) Approval
Reg. 9.6
(b) Stand-by power
SOIL PROFT'r.-,, P -c 7o,R(,PT,ATTON 'TEIST :BATA
�T
Board of Ileal.'11-h_Aorth Andover, Mass.
Street— Lot No.
Subdivision' Owner
Sea -
Investigator Observer
Date 5-3
Elev.
Inches
0
SOIL PROFILES
2. Date 3. Date
Elev. Elev.
4. Dat e
Elev.
Ties to Test Pits
1. — ----
2.
3.
4.
Tote: Top & subsoil depth; depths of other soil types; depth of water' table
depth of refusal. P ER C 0 L A T 10 N T E5'iP S
nrlfpTzS-U P,�-,tp nnfiP -Dq f-, P -nq -F. P
P-1
SI
T
I;,
T-71
t Number
1
2
3
4
;art Saturation
)7k --Mi i n s
,art Test -Time
on of 3" -Time
3:3
o -o of 6" -Time
ns. I st -0roD
e 1 r . /Tr
k
C)
§
/
f
$
�
$
§
t
�
�
�
■ &
E
2
2
2
§
co
k
a
0
2
�
k col-
2
®
q
k
2
)
a m
■§
0 2
a
a o
k
�
k
§
2
7
�
�
■ &
E
2
co
J£
a
0
2
�
k col-
2
■§
a o
�
0
�
W
■
0
3
%
� �
$
\
k
g ui
�
&
cf)
�
3
$
2 �
�
�
<
�
7
\
0
3
2 2 k
°
/
§
�E
■
■ ,
a I
—
w
§
§
i /
■ k
c
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2
)
2 2
&
A
= «ui
'
W
_-
CN
k
e
2
§
\
/
o
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CDE
'
'b &
■
°
$
° / 2
k
/
/
\ \
/
g
°
\
k
b
\
/
(
\
�
/
co
�
0
Type
of Permit or License: (Check box)
NORTH
:
F 9
Town of North Andover
s'•�,,,,,..�
CHU
HEALTH DEPARTMENT
CHECK #:
> '�
LOCATION:
$
H/0 NAME:
Dumpster
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)
$
❑
Title 5 Inspector
$�
L Title 5 Report
$
❑ Other: (Indicate) $
' U ?' 4 Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
I of 11
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
DECEIVED
Property Address: 975 Forest Street North Andover, MA 01845
Owner's Name: Dana DuBois OCT 17 2006
Owner's Address: 975 Forest Street North Andover, MA 01845
Date of Inspection: September 25, 2006 TOWN D RARTMEN
HEALTH
Name of Inspector: (please print) Benjamin C. Osgood, Jr. Certified Title 5 Inspector
Company Name: New England Engineering Services Inc.
Mailing Address: 1600 Osgood Street Building 20 Suite 2-64, North Andover, MA 01845
Telephone Number: 978-686-1768
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 the on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section
15340 of Title 5 (310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: 6
ate:
The system inspection shall submit a copy of this inspVction 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.
2 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 975 Forest Street North Andover, MA 01845
Owner's Name: Dana DuBois
Date of Inspection: September 25, 2006
Inspection Summary: Check A, B, C, D or E/ALWAYS complete all of Section D
A. System Passes:
,L� 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:
N .� One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system,
upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits
substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a
complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the
tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health):
Broken pipe(s) are replaced
Obstruction is removed
Distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if
(with approval of the Board of Health):
Broken pipe(s) are replaced
Obstruction is removed
ND explain:
3of11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 975 Forest Street North Andover, MA 01845
Owner's Name: Dana DuBois
Date of Inspection: September 25, 2006
C. Further Evaluation is Required by the Board of Health:
;6Ld 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 (SAS) Soil Absorption System and the (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 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 organize 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 5ppm, provided that no other failure criteria are
triggered. A copy of the analysis must be attached to this form.
3. Other:
4 ofl l
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 975 Forest Street North Andover, MA 01845
Owner's Name: Dana DuBois
Date of Inspection: September 25, 2006
D. System Criteria applicable to all systems:
You must indicate "yes or No" to each of the following for all inspections:
Yes No
✓' Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overload or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overload or clogged SAS or cesspool
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times
pumped
+r Any Portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply
Ll Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. ( this system passes if the well water analysis, performed at a DEP certified laboratory for
coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the
presence of ammonia nitrogen and nitrogen is equal to or less than 5ppm, provided that no other failure criteria are
triggered. A copy of fhe analysis must be attached to this form.)
Arr) (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 inwit indicate either "yes" or "no" to each of the following:
(The follo criteria apply to large systems in addition to the criteria above)
Yes No �
The system is wi iu400 feet of a surface drinking water supply "
The system is within 200 fee t3fa tributary to a surface drinking water supply
The system is located in a
of a public water supply v
(Interim Wellhead Protection Area — IWPA) or a mapped Zone II
If you answered "yes" to any quesfion in Section E the system is considered a sig cant threat, or answered "yes" in Section D above
the large system has failee'The owner or operator of any large system considered a sigtiificant 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.
5 of •11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 975 Forest Street North Andover, MA 01845
Owner's Name: Dana DuBois
Date of Inspection: September 25, 2006
Check if the following have been done. You must indicate "Yes" or "no" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health
✓r Were any of the system components pumped out in the previous two weeks_?
V Has the system received normal flows in the previous two week period ?
Have large volumes of water been introduced to the system recently or as part of an inspection ?
Were as built plans of the system obtained and examined? (If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up ?
Was the site inspected for sign of break out?
ZWere all system components, excluding the SAS, located on site?
V Were all the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner ( and occupants if difference from owner) provided with information on the proper
maintenance of the subsurface sewage disposal systems?
Yes No
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Existing information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable) [3 10 CMR 15.302(3)(b)]
6 of'11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 975 Forest Street North Andover, MA 01845
Owner's Name: Dana DuBois
Date of Inspection: September 25, 2006
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design) c� Number of bedrooms (actual):
DESIGN flow based in 310 CMR 15.203 ( for example: 110 gpd x # of bedrooms)
Number of current residents: 4
Does residence have a garbage grinder (yes or no): A10
Is laundry on a separate sewage system (yes or no): /✓J [if yes separate inspection required]
Laundry system inspected ( yes or no):
Seasonal use: (yes or no): /V, )
Water meter readings, if available (last 2 years usage (gpd):
Sump Pump (yes or no): N
Last date of occupancy C e
COMMERCIAL/INDUS TRIAL
Type of establishment:
Design flow (based on 310 CMR 15.203): gpd
Basis of design flow (seats/persons/sqft, 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: ' j ,� :n JE Z 1> • -. PC— &
Was system pumped as part of the inspection (yes or no): IVJ
If yes, volume pumped: gallons — How was quantity pumped determined?
Reason for i)umpine:
TYPE OF SYSTEM
_ Septic tank, distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from
system owner)
Tight tank Attached a copy of the DEP approval
Other (describe):
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected wen arriving at the site (yes or no): '✓=j
7ofll
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 975 Forest Street North Andover, MA 01845
Owner's Name: Dana DuBois
Date of Inspection: September 25, 2006
BUILDING SEWER (locate on site plan)
Depth below grade:.
Materials of construction: lf/ cast iron 40 PVC_other (explain)
Distance from private water supply well or suction line: 31�i;' ti -
Comments (on condition of joints, venting, evidence of leakage, etc.):
C, K- i o viiri--'-C"i,1&/V'4
SEPTIC TANK: (locate on site plan)
Depth below grade:
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:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: 3
Scum thickness: z "
Distance from top of scum to top of outlet tee or baffle: L-• t
Distance from bottom of scum to bottom of outlet tee or baffle /4 "
How were dimensions determined: 'VI Giis,=;1 L 4. ")C /r -
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet
invert, evidence of leakage, etc.):
7-4 Al i- iN C-' JA, C0 -J -> lie 2. - 7G: /I't/ii"3c ',/� C.-�rac
GREASE TRAP: -A/, (locate on site plan)
Depth below grade:
Materials 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 sludge 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.
8 orl 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 975 Forest Street North Andover, MA 01845
Owner's Name: Dana DuBois
Date of Inspection: September 25, 2006
TIGHT OR HOLDING TANK: n,, (,4 (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Materials 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: (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 evidnence of solids carryover, any evidence of leakage into or
out of box, etc.):
y -r 5 �, r3�'D�- i � c.11� .�L_ I� �� � i �F}r'i� �✓
t2tsrfl s C;
PUMP CHAMBER: V I I+(locate on sire plan)
Pumps in working order (yes or no)
Alarms in working order (yes or no)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
9of11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 975 Forest Street North Andover, MA 01845
Owner's Name: Dana DuBois
Date of Inspection: September 25, 2006
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required
If SAS not located explain why
TYPE
leaching pits number
leaching chambers, number
leaching galleries number
leaching trenches, number in length
X leaching fields, number, dimensions:1 r=! r�
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)
i D E F 16 0 i-(_>Nt e,,(,.' L` / X71;.,
.
!a NZ Gi 1. L iy' N i .� L V i' G—l:-`' •-7 �� f✓
CESSPOOLS: AV 1 dt (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::i! i (locate on site plan)
Material of construction:
Dimensions:
Depth of solids:
Comments (note condition of soil signs of hydraulic failure, level of ponding, condition of vegetation, etc.
10 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 975 Forest Street North Andover, MA 01845
Owner's Name: Dana DuBois
Date of Inspection: September 25, 2006
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.
+J
J
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 975 Forest Street North Andover, MA 01845
Owner's Name: Dana DuBois
Date of Inspection: September 25, 2006
SITE EXAM
Slope % ✓lam
Surface water
Check cellar N
Shallow wells
Estimated depth to ground water 6r,' feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record — If checked, date of design plan reviewed:
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health — explain:
Checked with local excavator, installers — (attach documentation)
•t Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
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Commonwealth of Massachusetts
City/Town of NORTH ANDOVER,
System Pumping Record
Form 4
MASSAC
DEP has provided this form for use by local Boards of Health. The
be submitted to the local Board of Health or other approving autho
A. Facility Information
1. System Location:
U
9 2010
A Q-75- EL -3 ' 0 � ee 4,-
City/Town State Zip Code
2. System Owner.
Address (if different from location)
City/Town
State
Telephone Number
Zip Code
B. Pumping Record , �j
1. Date of Pumping Dai %5 l Ci 2. Quantity Pumped: canons
3.: Type of system: ❑ Cesspool(s) Er'S"eptic Tank ❑ Tight Tank
y�] Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If ye5`Was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
M11(le 3, 14 W
'Natne Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler
http:/twww.mass.gov/deptwater/approvalstt5forms.htm#inspect
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Date
t5form4.docc 06/03 System Pumping Record • Page 1 of 1
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North Andover Board cif Assessors Public Access
C`
Page 1 of 1
North Andover Board of Assessorz
roperty Record Card
Parcel ID :210/105.D-0074-0000.0 FY:2012 Community: North Andover
Click on Sketch to Enlarge
Click on Photo to Enlarge
975 FOREST STREET
Location: 975 FOREST STREET �I
_ DUBOIS REALTY TRUST
Owner Name: L. DUBOIS & D. GALIN DUBOIS, TRUSTEES
Owner Address: 975 FOREST STREET
City: NORTH ANDOVER State: MA Zip: 01845
Neighborhood: 6 - 6 Land Area: 2.16 acres
'Use Code: 101-SNGL-FAM-RES Total Finished Area: 1932 sqft
Total Value: 386,300 386,300
Building Value: 170,600 170,600
Land Value: 215,700 215,700
(Market Land Value: T 215,700
Chapter Land Value:
Sale Price: 240,000 Sale Date: 09/26/1997
Arms Length Sale Code: Y -YES -VALID Grantor: STEPHEN GATCELL
I
4Cert Doc: Book: 04851 Page: 0268
http://csc-ma.us/PROPAPP/display.do?linkld=1895228&town=NandoverPubAcc 3/1
North Andover Board of Assessors Public Access Page 1 of 2
MNorth Andover Board of Assessor
MATCHING PARCELS
Click on a column title to sort data by that column
148 items found, displaying 101 to 148. [First/Prev] 1 1 2 1 3 [Nexaast]
Fiscal Year I Parcel ID I St.No. I Street Owner Name
2012 1210/105.D-0119-0000.0 Ij 728 [LFOREST STREET
2012 210/105.D-0034-0000.0 740 FOREST STREET
2012 1210/105.D-0175-0000.0 I 743 FOREST STREET
THOMAS P. LAURIE P
THOMPSON, STUART, JANE ANNE
THOMPSON
iIANNARONE_, JOHN_ R, ANNETTE_ I-
2012
210/105.D-0172-0000.0
747
FOREST STREET
'BUCK, ARNOLD L, ADELHEID DRESSEL
2012
210/105.D-0042-0000.0
754
FOREST STREET
NEW ESTATE REALTY TRUST, CHARLES
�F
-
-- -
& SUSAN E FOSTER, TRS
2012
210/105.D-0176-0000.0
757
FOREST STREET
JILLSON, DENNIS S, LINDA J JILLSON
2012
210/lOS.D 0072-0000.0
769 FOREST STREET
ITWILSON, MICHAEL & MICHELLE,
2012
210/105,D-0043-0000.0
770
'FOREST STREET
'UPSON JR, PAUL K, CYNTHIA ABATE
UPSON
_
2012
210/105.D-0071-0000.0 1
775
FOREST STREET
ISILVKA, ERIK, J., SILVKA, DEBORAH, A
2012
210/105.D-0035-0000.0
780
(FOREST STREET
BLANEY, SCOTT L, BARBARA L BLANEY
2012
210/105.D-0040-0000.0
781
FOREST STREET
JEMRO, RONALD F, LINDA M EMRO
2012
210/105.D-0044-0000.0
790
(FOREST STREET
GUERRIEO, PAUL, E., GUERRIEO,
PAMELA, J.
2012
1210/105.D-0039-0000.0 I
793
(FOREST STREET
�LE KEVIN & LIM ALYSSA,
2012
210/105.D-0045-0000.0
804
'.FOREST STREET
'CARNOVALE, FRANK L., CARNOVALE,
PAMELA R.
2012
210/105.D-0018-0000`0
805
FOREST STREET- jABBASI, IMAN, BENAYOUD, FARID
2012
210/105.D-0162-0000.0
851
'FOREST STREET
WYSOCKI, LISA M, TIMOTHY SHEEHY
2012
210/105.D-0077-0000.0
871
FOREST STREET
.RYAN, DANIEL B, CATHERINE S RYAN
2012
210/105.D-0036-0000.0
876
'FOREST STREET
IJDD TRUST, WATSON,JANE
TRUSTEES
2012
210/105.D-0010-0000.0
885
FOREST STREET
_S.&TIMPE,DAVE
MOINES, PER-ARNE, JANE L RUNNING -
L
2012
210/105.D-0131-0000.0
895
'FOREST STREETSIMONSON,
STREET:
PETER A, JENNIFER I
2012
210/105.D-0075-0000.0 (
925
FOREST STREET
.DOLFE, SIMONNE R,
'BEVERLY MAE LONGUEIL REVOCABLE
2012
210/105.D-0016-0000.0
926
'FOREST STREET
TRUST, JOHN & BEVERLY MAE
LONGUEIL, TRU
2012
I210/105.D-0006-0000.0
1210/105.D-0012-0000.0
940
FOREST STREET
CALLAHAN, COLIN, -
2012
951
'FOREST STREET
SWEENEY, KEVIN P, MARIA SWEENEY
2012
1210/105.D-0007-0000.0 I
970
.FOREST STREET iGUNN, THOMAS P, C/O 970 FOREST
STREET REALTY TRUST
2012
210/105.D-0074-0000.0
975
FOREST STREET
DUBOIS REALTY TRUST, L. DUBOIS & D.
GALIN DUBOIS, TRUSTEES
2012
210/105.D-0008-0000.0 j
976
(FOREST STREET
COUGHLIN, TAMI D.,
2012 210/105.D-0079-0000.0 980 FOREST STREET THIBAUD, DIDIER, THIBAUD, SABINE
2012 210/105.D-0058-0000.0 j 981 (FOREST STREET IFLEISHMAN, DARLENE M, DAVID B
.,FLEISHMAN - - - - - --
2012 210/105.D-0054-0000.0 987 FOREST STREET SOUTHWICK, RICHARD P, MARYLOU
http://csc-ma.us/PROPAPP/newSearch.do?noOwner=027%3BO84%3BO59%3BO04%3B 1... 3/20/2012
North Andover Board of Assessors Public Access
Page 2 of 2
http://csc-ma.us/PROPAPP/newSearch.do?noOwner=027%3BO84%3BO59%3BO04%3B 1... 3/20/2012
SOUTHWICK
FORASTE, MICHAEL C., FORASTE,-
2012
1 990 1 OREST STREET
-1210/105.D-0002-0000.0
KERRY E. T _
2012
210/105.D-0041-0000.0 995 FOREST STREET
.AGOSTI, MICHAEL A, JENIFER R AGOSTI
2012
210/105.D-0059-0000.0
1000 FOREST STREET(MIING,
FRANK T, LISA A MING
2012
1005 STREET
',STEWART, TODD A,
(210/105.D-0055-0000.0
jjFOREST
2012
1210/105.D-0056-0000.0
( -- -
FOREST STREET
iCUNHA, HERBERT J,
2012
210/105.D-0057-0000.0 1025 FOREST STREET
DONATO, DAVID L, SUSAN M DONATO
2012
210/105.D-0177-0000.0
1030(FOREST
STREET
INANGELO JR, JOHN J, JODI B INANGELO
2012
210/105.D-0180-0000.0 1041 FOREST STREET
;PEASE, DAVID A, PEASE, LYNNE, D
2012
T
210/lOS.D-0178-0000.0F1050 (FOREST STREEKROVITZ
KROVITZ 111, EDWARD J, NANCY J
2012
210/105.D-0181-0000.0 1055 FOREST STREET
SMART, DAVID W,
j 2012
2101105.B-0007-0000.0
1465
[FOREST STREET
SHINNERS, JOHN W,
2012
210/105.B-0003-0000.0 1470 FOREST STREET
-
'PICARIELLO, PHILIP A, PICARIELLO,
EXT.
;MARY
2012
1210/105.13-0006-0000.0 11493
[EXIST STREET
iRUSHFORD, SCOTT & LISA,
2012
210/105.13-0004-0000.0 1500 FOREST STREET
JACKSON, MARK, MATHEWS, MAUREEN
I 2012--�210/105.13-0005-0000.0
STREET
1520 EXT.
R R CIS PHILIP W, C/O JOSEPH &AMY
JF
2012
210/105.13-0002-0000.0 1525 FOREST STREET
'BEEKLEY FRANCES,
EXT.
__r
2012
1210/105.A-0025-0000.0
1530
FOREST STREET
_
�BIGGIO,
11210/105.13-0001-0000.0
JOHN J, EILEEN M BIGGIO
2012
1535;FOREST STREET
'MAHALATI, SIAVASH,
148
items found, displaying 101 to 148. [First/Prev] 1 1 2 1 3 [Next/Last]
http://csc-ma.us/PROPAPP/newSearch.do?noOwner=027%3BO84%3BO59%3BO04%3B 1... 3/20/2012
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Grant, Michele
From: DelleChiaie, Pamela
Sent: Tuesday, March 20, 2012 2:07 PM
To: Grant, Michele; Sawyer, Susan
Subject: Complaint - Odor - 975 Forest Street (caller)
Attachments: GeoTMS Complaint Tracking.rtf
Hello,
The caller on this complaint wishes to keep her name as anonymous. According to Mrs. Dubois,
the odor source is coming from one of the properties between 885-925 Forest Street. There
has been a very strong odor of fertilizer since 9:00 a.m. this morning. Thank you.
Pamela DelleChiaie
Health Department
Town of North Andover
1600 Osgood Street I Bldg. 20 1 Suite 2-36 North Andover, MA 01845
Phone 978.688.9540
Fax 978.688.8476
Email odellechiaie@townofnorthandover.com
Web www.TownofNorthAndover.com
Please note the Massachusetts Secretary of State's office has determined that most emails to
and from municipal offices and officials are public records. For more information please
refer to: http://www.sec.state.ma.us/pre/oreidx.htm.
Please consider the environment before printing this email.
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j -----------------------------------------------------------
FIRE & EXPLOSION DATA
See data pages for additional information.
AUTO -IGNITION TEMPERATURE: N/A.
EXTINGUISHER MEDIA: Water, foam, or dry chemical.
SPECIAL FIRE FIGHTING PROCEDURES: Use self-contained
breathing apparatus and protective clothing. Do not allow
contamination of any water supply.
UNUSUAL FIRE AND EXPLOSION HAZARDS: Toxic fumes may be
emitted.
PHYSICAL HAZARDS
(REACTIVITY DATA).
STABILITY: Stable.
CONDITIONS TO AVOID: Not determined.
INCOMPATIBILITY (MATERIALS TO AVOID): None determined.
HAZARDOUS DECOMPOSITION PRODUCTS: Fire conditions may emit
toxic fumes.
HAZARDOUS POLYMERIZATION: Will not occur.
CONDITIONS TO AVOID: Not determined.
HEALTH HAZARDS
ACUTE: Not determined.
CHRONIC: Not determined.
SIGNS AND SYMPTOMS OF EXPOSURE: Not determined.
MEDICAL CONDITIONS GENERALLY AGGRAVATED BY EXPOSURE:
Possible skin irritation for sensitive individuals.
CHEMICALS LISTED AS CARCINOGEN OR POTENTIAL CARCINOGEN:
NATIONAL TOXICOLOGY PROGRAM: No.
IARC MONOGRAPHS: No.
OSHA: No.
EMERGENCY AND FIRST AID PROCEDURES:
INHALATION: Remove to fresh air.
EYES: Flush with running water.
SKIN: Wash with soap and water.
INGESTION: Seek medical assistance.
ROUTES OF ENTRY:
INHALATION: Not likely.
EYES: Not likely.
SKIN: Possible for sensitive persons.
INGESTION: Not likely.
NFPA:
HEALTH: 1
FIRE: 0
REACTIVITY: 0
SPECIAL:
HEALTH 1
FLAMMABILITY 0
REACTIVITY 0
PERS. PROTECTION B
SPECIAL PRECAUTIONS AND SPILL/LEAK PROCEDURES
PRECAUTIONS TO BE TAKEN IN HANDLING AND STORAGE: Store in
dry, cool area, away from foodstuffs or other chemicals
and heat sources. Wash hands with soap and water after
handling.
OTHER PRECAUTIONS: None.
STEPS TO BE TAKEN IN CASE MATERIAL IS RELEASED OR SPILLED:
Clean up and use per label directions. If contaminated,
place in proper pesticide waste disposal.
WASTE DISPOSAL METHODS (CONSULT FEDERAL, STATE, AND LOCAL
REGULATIONS): Wrap carefully, and place in proper
pesticide waste disposal. Avoid contamination of any body
of water.
SPECIAL PROTECTION INFORMATION/CONTROL MEASURES
RESPIRATORY PROTECTION (SPECIFY TYPE): Nuisance dust
respirator.
VENTILATION: Normal.
LOCAL EXHAUST: Not required.
MECHANICAL (GENERAL): Not required.
SPECIAL: None.
OTHER: None.
PROTECTIVE GLOVES: Ma use rubber gloves.
EYE PROTECTION: May use goggles or glasses.
OTHER PROTECTIVE CLOTHING OR EQUIPMENT: Not normally
required.
WORK/HYGIENIC PRACTICES: Wash with soap and water after
using.
ADDITIONAL/IMPORTANT INFORMATION
DISCLAIMER OF EXPRESSED AND IMPLIED WARRANTIES: although
preparer and owner have taken reasonable care in the
preparation of this document, we extend no warranties and
make no representation as to the accuracy or completeness
•of the information contained herein, and assume no
responsibility regarding the suitability of this
information for the user's intended purposes or for the
consequences of its use. Each user should make a
determination as to the suitability of the information for
their particular purpose(s). A request has been made to the
manufacturer to approve the contents of this material
safety data sheet. Upon receipt of any changes a new MSDS
will be made available.
-----------------------------------------------------------
,(2463795 - PREEN GARDEN WEED PREVENTER
MSDS
MANUFACTURER/SUPPLIER: LEBANON SEABOARD CORP.
1600 EAST CUMBERLAND ST
LEBANON, PA USA 17042
PHONE: 800-532-0090 INFORMATION
HEALTH EMERGENCY: 888-208-1368 PROSAR
ENVIRONMENTAL: 800-424-9300 CHEMTREC
PHYSICAL/CHEMICAL CHARACTERISTICS:
BOILING POINT: NA
MELTING POINT: NA
FREEZING POINT: NG
POUR POINT: NG
SOFTENING POINT: NG
SPECIFIC GRAVITY: NA
VAPOR PRESSURE: NA
VAPOR DENSITY: NA
PERCENT VOLATILES: NG
EVAPORATION RATE: NG
pH: EQ 7
MOLECULAR WEIGHT: NG
VISCOSITY: NG
SOLUBILITY IN WATER: Slight
REACTIVITY IN H2O: N/A
ODOR/APPEARANCE/OTHER CHARACTERISTICS: Yellowish granules
slight odor
DENSITY: 30#/FT3.
FIRE AND EXPLOSION DATA:
CLOSED CUP FLASH PT.: NA
OPEN CUP FLASH POINT: NA
FIRE POINT: NG
AUTO IGNITION: NA
LOWER EXPLOSION LIMIT: NA
UPPER EXPLOSION LIMIT: NA
SHIPPING REGULATIONS:
UN/NA NUMBER: NG
DOT HAZARD CLASS: NG
SHIPPING LABEL: Not given
SHIPPING NAME: Not given
PREPARED:
PREPARER'S NAME & TITLE: Not given
PREPARATION DATE: 3/22/2010 rev.
COMPONENT(S):
A,A,A-TRIFLUORO-2,6-DINITRO-N N-DIPROPYL-P-TOLUIDINE:
OSHA PEL: N* ppm
it ACGIH TLV: N* ppm
STEL: NG ppm
PERCENT OF PRODUCT: EQ 1.47%
CAS NO.: 1582098
NOTE: * Trifluralin / PEL and TLV: N/L.
CORN COB BASE
OSHA PEL: 15 mg/m3
ACGIH TLV: 10 mg/m3
STEL: NG ppm
PERCENT OF PRODUCT: EQ 98.53%
CAS NO.: Not given
NOTE: * Non Hazardous Component / Nuisance Dust.
-----------------------------------------------------------
Text Section(s)
-----------------------------------------------------------
IDENTIFICATION
-----------------------------------------------------------
See data pages for additional information.
PRODUCT NAME: Greenview Preen the Weed Preventer 1.47%.
EPA #: 961-280
EMERGENCY TELEPHONE NO.: 888-208-1368 PROSAR +
OTHER INFORMATION CALLS: 800-532-0090
ENVIRONMENTAL: 800-424-9300 CHEMTREC
MANUFACTURER'S NAME AND ADDRESS:
LEBANON SEABOARD CORPORATION
1600 EAST CUMBERLAND ST
LEBANON, PA 17042
-----------------------------------------------------------
HAZARDOUS INGREDIENTS/IDENTITY
-----------------------------------------------------------
See component page(s) for additional information.
HAZARDOUS COMPONENT(S)
(CHEMICAL & COMMON NAME(S)) OTHER EXPOSURE LIMITS
-----------------------------------------------------------
a,a,a-trifluoro-2,6-dinitro-N N/L
N-dipropyl-p-toluidine
(Trifluralin)
NON -HAZARDOUS COMPONENTS:
-----------------------------------------------------------
(Corn Cob Base) Nuisance dust N/A
-----------------------------------------------------------
PHYSICAL & CHEMICAL CHARACTERISTICS
-----------------------------------------------------------
See data pages for additional information.