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Miscellaneous - 98 FOREST STREET 4/30/2018 (2)
North Andover Board of Assessors Public Access Click Seal To Retum Search for Parcels Search for Sales Summary Residence Detached Structure Condo Commercial Page 1 of 1 44 roperty Record Card Location: 98 FOREST STREET Owner Name: SALGUEIRO, JOYCE A Owner Address: 94 MIDDLE ROAD City: DEERFIELD State: NH Zip: 03037 Neighborhood: 6 - 6 Land Area: 1.01 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 1470 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 508,900 522,100 Building Value: 301,900 315,100 Land Value: 207,000 207,000 Market and Value: 207,000 Chapter Land Value: LATEST SALE Sale Price: 1 Sale Date: 01/05/1995 Arms Length Sale A -NO -FAMILY Grantor: SALGUEIRO, Code: HELDER Cert Doc: Book: 04194 Page: 0061 http://csc-ma.us/PROPAPP/display.do?linkld=1707794&town=NandoverPubAcc 9/13/2011 Tm O N LL W W H N H N W w LL co �W U v 0 mQ J W U aQ 2o - CL aa �o C O O O �0 O O 0 O d Q 6, MMI 'I I OO N OO OO OO' N N ; ► y N LO OO Nr' U N O (i OO NN Q:i �ooIU�U t i" c ..000 NCV) On O C C C N @ N fn O O� 00?cS UN�,tY JJ �Olc�'�' �w.y: C) O �, m C Coco � Nn C fO:wL,_�•C N N C O N N C. 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CLL L 0 O y m Z r) ti Z CLL a C C9 N ii 1z3 V OC.'0 O � N O U w 00 to av Z O to X O W r�Nr0HH M W toit N p y a Q CO U- 3 'O ` to P4,m e N_ e M M Q W w x V iri Co U m L w co (o 0 ELtr j CoV) d0)M� rNi CLO c 0 aism mCJd:_ C9 C7 co 61 v Ln LL Z a' n W M wa`m �mw cLiY am�coXto�-3'c yy U O HmLL2WmYW mmQ 01.1 O 0z OT -00 U XOT-Z OLU p J a 0LL rn H O °1 aQ a _HY �N� = F-JL' N 2 0. cNQrn00 M�cLLaO — aCL w2L V% n U) :r LLU W2 O a �LN Commonwealth of Massachusetts City/Town of FRECEIVECSystem Pumping RecordForm 4 CT 19 14011 DEP has provided this form for use by local Boards of Health but the 1 C{"'FRVIa information must be substantially the same as that provided ems. g'lfii§ orm, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left front of house, right front of house, left side of house, right side of house, Left rear of hous artre—oiou side of building, right rear of building, under deck. Cityrrown State Zip Code 2. System Owner: Name I Isv � Address (if different frpm. location_ ), City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe) State„C Zi de Telephone Number `�� f . Date 2. Quantity Pumped Cesspool(s) eptic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Conditio,yof,S(y�ste��� (aj-42'lc 6. System Pumped By: Neil J. Bateson Name Bateson Enterprises Inc. Company 7. Location where contents were disposed: L.S.D. Ao*ell Waste Water 611 F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 DelleChiaie, Pamela From: DelleChiaie, Pamela Sent: Tuesday, September 13, 20119:58 AM To: 'kevinmurphybuilding@gmail.com' Subject: I.R. - 98 Forest Street - Scanned Health Dept. File - Septic - continued - email #2 Attachments: 20110913093803359.pdf Importance: High Follow Up Flag: Follow up Flag Status: Flagged Hi Kevin......... this is the continued email from the one I just sent re: 98 Forest Street - last few pages. Pamela DelleChiaie Departmental Assistant I Community Development I Health Department Town of North Andover 1600 Osgood Street I Bldg 20 1 Suite 2-36 North Andover, MA o1845 1' Office - 978-688-9540 ( Fax - 978-688-8476 Email - pdellechiaie(@townofnorthandover.com ' 2l Website httD://www.townofnorthandover.com/Paees/index "We can never see the path of our life if we are too busy focusing on the pebbles under our feet. "--Anonymous If you are happy with the customer service you have received from town departments, please let us know ...feel free to complete the general Comment Form (link below): http://www.townofnorthandover.com/Paees/NAndoverMA WebDocs/contact DelleChiaie, Pamela From: DelleChiaie, Pamela Sent: Tuesday, September 13, 20119:57 AM To: 'kevinmurphybuilding@gmail.com' Subject: I. R. - 98 Forest Street - Scanned Health Dept. File - Septic Attachments: 20110913093747930.pdf Importance: High Follow up Flag: Follow up Flag Status;: Flagged To: Kevin Murphy 978-375-5798 Hi Kevin, Attached is the Septic As -Built information you requested as well as additional reference information on the last Title 5, COC, etc. A second email will follow to continue a copy of the file. Have a great day!;) Pamela DelleChiaie Departmental Assistant I Community Development I Health Department Town of North Andover 1600 Osgood Street I Bldg 201 Suite 2-36 North Andover; MA o1845 2 Office - 978-688-9540 Fax - 978-688-8476 Email - pdellechiaie@townofnorthandover.com 16 Website httD://www.townofnorthandover.com/Pages/index "We can never see the path of our life if we are too busy focusing on the pebbles under our feet. "--Anonymous If you are happy with the customer service you have received from town departments, please let us know ...feel free to complete the general Comment Form (link below): http://www.townofnorthandover.com/Pages/NAndoverMA WebDocs/contact Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. VQ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 98 Forrest St. Property Address Marcel Label Owner's Name North Andover City/Town MAj��� Y -z' /O / State Zip Code Date of Inspection 19 a Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Chad Jablonski Name of Inspector Jablonski & Sons Inc. Company Name Company Addr ss Haverhill MA 01830 City/Town State Zip Code 978-360-9358 4754 1-16--7`1 Telephone Number B. Certification 3.0 I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ ds F)rther Evaluation by the Local Approving Authority 8/ i3 Zo 7 Date The system i ector shall submit a copy of this inspection report to the Approving Authority (Board of Health EP Thin 30 days of completing this inspection. If the system is a shared system or has a sig w of 10,000 gpd or greater, the inspector and the system owner shall submit the rep a appropriate regional office of the DEP. The original should be sent to the system owner an copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the'conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 09/08 .Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 98 Forrest St Property Address Marcel Label Owner's Name North Andover MA Cityrrown B. Certification (cont.) State Zip Code Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR.15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System and all components are in good working order B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the structurally unsound, exhibits substantial infiltration or will pass inspection if the existing tank is replaced 7 Board of Health. / * A metal septic tank will pass inspection iv Compliance indicating that the tank is less th ❑ Y ❑ N ❑ ND (Explain tank (whether metal or not) is ip)n or tank failure is imminent. System ying septic tank as approved by the y sund, not leaking and if a Certificate of old is available. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 98 Forrest St. Property Address Marcel Label Owner's Name North Andover MA Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SASi within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the S is les 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, �erformed/at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ElN Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 98 Forrest St. Property Address Marcel Label Owner's Name North Andover CitylTown B. Certification (cont.) Yes No MA State Zip Code Date of Inspection ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is withi 00 re rface drinking water supply ❑ ❑ the system is wi in 0 butary to a surface drinking water supply ❑ ❑ the system is located i a ensitive area (Interim Wellhead Protection Area — IWPA) or a m peof a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments N 98 Forrest St. Owner information is required for every page. Property Address Marcel Label Owner's Name North Andover. City/Town C. Checklist h ilA State Zip Code Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health. ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® Were all system components, excluding the SAS, located on site? 9L ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 6 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 330 l5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 98 Forrest St. Property Address Marcel Label Owner information is required for every page. Owner's Name North Andover City/Town D. System Information Description: 2 family dwelling State Zip Code Date of Inspection Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: per day (gpd) ❑ Yes ® No 8/06 Date ❑ Yes ❑ No ❑ . Yes ❑ No ❑ Yes ❑ No t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gPd)) Unnoccupied <50 gpd Detail Dwelling has been unoccupied for more than two years Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: per day (gpd) ❑ Yes ® No 8/06 Date ❑ Yes ❑ No ❑ . Yes ❑ No ❑ Yes ❑ No t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 98 Forrest St. Owner information is required for every page. Property Address Marcel Label Owner's Name North Andover City/Town D. System Information (cont.) Last date of occupancy/user Other (describe below): Pumping Records: Source of information: MA State General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: Date of Inspection Date Home Owner ❑ Yes ® No gallons ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 I . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M ,•' 98 Forrest St. Property Address Marcel Label Owner Owner's Name information is required for North Andover MA every page. CitylTown D. System Information (cont.) State Zip Code Date of Inspection Approximate age of all components, date installed (if known) and source of information: 19yrs plans and perc test Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 14+11feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: na feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 2' risers were 6" below grade feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10' x 68" x 5' Sludge depth: >1" t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 i Owner information is required for every page. Commonwealth of Massachusetts zrz Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 98 Forrest St. Property Address Marcel Label Owner's Name North Andover Cityrrown D. System Information (cont.) MA State Zip Code Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of Inspection na no scum na na How were dimensions determined? tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank and tee's were replaced 12/06 Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal N 14ia ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date l5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17 Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 98 Forrest St. Owner information is required for every page. Property Address Marcel Label Owner's Name North Andover MA catyi I own State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not necessary at this time Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: allons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): I * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 09/08 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c� ,.•'°� 98 Forrest St. Property Address Marcel Label Owner Owner's Name information is required for North Andover MA every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Oil Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box level and distibuting equally. No solid carryover. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): / U// Soil Absorption System (SAS) (locate on slite plan, excavation not required): If SAS not located, explain why: t5ins • 09106 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,•' 98 Forrest St. Property Address Marcel Label Owner information is required for every page. t5ins • 09108 Owner's Name North Andover MA Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: >€--WVQ ydI ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions:—x q0 1 ❑ 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.): No sign of hydraulic failure or ponding Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 98 Forrest St. Property Address Marcel Label Owner Owner's Name information is required for North Andover MA every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): 4' Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 e , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 98 Forrest St. Property Address Marcel Label Owner information is required for every page. Owner's Name North Andover MA Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated de th to hi h round water' MWr 5-y ,. p g g feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date y/�T� ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: s� ! ,ego r..�� L/ ��P/79 %3 y Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 16 of 17 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 98 Forrest St. Property Address Marcel Label Owner Owner's Name information is required for North Andover MA every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 � NORTFf q O t`ap 16'b�OO PUBLIC HEALTH DEPARTMENT Community Development Division RTTFIC A TIF OECO�l4�LIA5VCrE As of February 6, 2007 This is to cert that the indiWuaCsu6surface d4osaCsystem received a SAW FACS ORT IMPECY OW of the: Septic System Component — 7ankOnCy 'By. ,john lDiVincenzo At: 98 Forest Street YorthAndover, JKA 01845 �,fie Issuance of this certificate shad not de construed as a guarantee that the system wid function satisfactoriCy. % an T Sawyer 1W filic Wealth Director 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com RTk a 10 `* O ww�t� � */ ►_ c0[M1tMlwl[11 _ 1' PUBLIC HEALTH DEPARTMENT Community Development Division February 1, 2007 Marcel Label 98 Forest Street North Andover, MA 01845 Re: 98 Forest Street Dear Homeowner, The Health Department has received all necessary documentation in regards to the recent septic component repair at Your property listed above. Enclosed you will find the Certificate of Compliance indicating that the septic tank repair has been completed, however, in accordance with the North Andover Subsurface Disposal Regulation I must notify you of the following requirement. Part F 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. A MA licensed septic inspector must conduct this inspection and a proper report must be submitted to the Health Department." The North Andover Board of Health is concerned that due to your septic tank's failure the leaching system has not recently received regular flows. Conducting an additional inspection will address some possible concern brought out due to this issue, however it does not guarantee the longevity of the septic system. This is a public document and a copy of this document will be placed in your building's permanent file and attached to the anticipated Title V inspection report to be submitted in no less than six months. Thank you for your cooperation in this important matter of public health. Thank you, usan Sawyer, REHSIRS Public Health Director 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com 1 J & S Development Corp, dba Stewart's Septic Service 58 South Kimball Street Bradford, MA 01835 978-372-7471 I 1 It) � JJb1riod�o �s :fir ��+M� A' IS 41' 06"7 TO Ile VO F �� .:, 61% 19 N. iz N. Cj N. I , 1 , I -ti L_ 1 r, ` •► Vit\' .; �yfy�IC ~, (` ,�., r -- '' C.t i ,� .tib ``, � -��\ , 41 r _ w.a �► { ti+ �; + F� �,. 1 } . 1CO°',�e+ •� , . �: ti ,. ply � � � tC ; .� �', a I n'�'�,� � ''�% � • f �, 1L71 IZV" •- E 11 ' 1 l Ln I -. ij M' i L--seoie N, J -u hoar '171-1/W r iwlom 41 he'a� /(;9,0 C5 LIN I T'- h, i. L--seoie N, J -u hoar '171-1/W r iwlom 41 he'a� /(;9,0 C5 LIN I T'- h, N4 jc h, N4 jc z 40 W 0 t O' v c C-4 i. C m CO) w o v a 3 o 0 d 0 o m a e 03 J 0 I O' c C-4 i. m CO) w o v a 3 o 0 d 0 0 I w 0 N rn m CL O' C-4 i. w z z o `m o o m Q = C ai a j m .O O a O y C Q Q H Q y 0 0 0 3 40. tq' C9 U � � I� v� C9 ►`4i d a y Sq, J' Z Z Z w 0 N rn m CL O' C-4 i. z z o z o o m N = C a j m .O O a H Q 0 3 tq' C9 U � � I� v� C9 ►`4i w 0 N rn m CL MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza Boston, Massachusetts 02108-1904 (617)723-3800 Ma Only (800)392-6108, FAX (800)851-8424 NORTH ANDOVER HEALTH DEPT. NORTH ANDOVER TOWN HALL NORTH ANDOVER MA 01845 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch.139, Sec.36 R EC. mit :: MAR 0 7 2007 T OWN OF NORT'1 ANDOVER HEALTH D—=,-ARTMENT Re: Insured: JOYCE A. SALGUEIRO Property Address: 98 FOREST STREET, NORTH ANDOVER, MA 01845 Policy Number: 0360300 Type Loss: Water Damage Date of Loss: 0212412007 Claim Number: 1 238514 Claim has been made involving loss, damage or destruction of the above captioned propert, which may either exceed $1000.00 or cause Massachusetts General Laws, Chapter 143, section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139 Section 36 is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. MPIUA Claims Division CMA00021 2127/2007 Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Commonwealth of Massachusetts Title 5 official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner's Name kc. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General information Inspector: Name of Inspector y r C 4 Company Name {i2 r'? Company Address City/Town Telephone number B. Certification C1 8 State Zip Code License Number I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes Q''Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority InspeS1gnatur Date The system ins or shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at f inspection and under the conditions of use at that time. This inspection does not addre")f a system will perform in the future under y b. the same or different conditions of use. (J? o . n � t5insp.doc • 08106 i.' .?, a Title 5 Offs �jispecfwn F : Subsurface Sewage Disposal System • Page 1 of 15 Owner i information is required for every page. Commonwealth of Massachusetts Title 5 official Inspection l=oan Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner's game Cityr town B. Certification (cont.) State Zip Code Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes; [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: 4A) 6 : a --10 ^�:'H-s 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 t5hsp.doc • 08M Title 5 Official Irtspertron Form: Subsurface Sewage Disposal System • Page 2 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner's Name City/Town State B. Certification (cont.) Zip Code Date of Inspection B) System Conditionally Passes (cont.): iP4 distribution box is leveled or replaced ND Explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Heap 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 land Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. t5insp.doc • oal06 TAW 5 Official Irtspection Form: Subsurface Sewage Disposal System . Page 3 of 15 Commonwealth of Massachusetts Title 5 official Inspection Forum Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y Owner information is required for every page. Property Address Owner's Name CitylTown State Zip Code Date of inspection S. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes i No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ / Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ©/ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ I [K Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ [g/ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5insp.doc • 08M Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 4 of 15 Owner ' information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner's Name City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ Y Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑R Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ IV* Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [this system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. ' Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (interim Wellhead Protection Area — IWPA) or a mapped Zone 11 of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5insp.doc - MOS Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspecti®n Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,r M Property Address Owner Owner's Name information is required for every page. Cityfrown State Zip Code C. Checklist of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ❑ E� Pumping information was provided by the owner, occupant, or Board of Health ❑ Er Were any of the system components pumped out in the previous two weeks? ❑ [B Has the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? Eq/ ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ["� ❑ Was the facility or dwelling inspected for signs of sewage back up? [" ❑ Was the site inspected for signs of break out? E3"'� ❑ Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc • 08!06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 15 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Foran - Not for Voluntary Assessments M Property Address 1 Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Wass stem pumped as part of the inspection? , � Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 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 El maintenance contract (to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): Approximate age of all components, date installed (if known) and source of information: I Were sewage odors detected when arriving at the site? ❑ Yes P No t5insp.doc • 08106 Title 5 Official Inspection Form: Subsu face Sewage Disposal System • Page 8 of 15 1 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Name City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): r 'c a6 i F- ft,),� C,�P- I Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: I Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grader Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): t5insp.doc • 08106 Trite 5 Official inspection Forth: Subsurface Sewage Disposal System • Page 10 d 15 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) ! Dimensions: Capacity: fi gallons Design Flow: �,A`� gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ❑ Yes ❑ No * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): ® yA Depth of liquid level above outlet invert j Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber (locate on site plan): Pumps in working order: Alarms in working order: ❑ Yes ❑ No ❑ Yes ❑ No t5inap.doa • 08106 i Idle 5 Official Inspection Fonn: Subsurface Sewage Disposal System • Page 11 of 15 Owner information is required for every page. Com Titl Subsu Property Address Owner's Name Citylrown monwealth of Massachusetts a 5 -Official Inspection Form rface Sewage Disposal System Form - Not for Voluntary Assessments State Zip Code Date of Inspection D. System Information (cont.) I Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number. ❑ leaching galleries number: ❑ leaching trenches number, length: Q� leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovativetaltemative system Type/name of technology: I T 4i1"' s Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): t5insp.doc - 08106 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 12 of 15 'Commonwealth of Massachusetts 'Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a` M Property Address Owner Owner's Name information is required for every page. CitylTown State Zip Code Date of inspection D. system Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): -Privy (locate on site pian): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t$insp.doc • 08M Title 5 Official Inspection Form: Subsurrace Sewage Disposal System - Page 13 of 15 ' Commonwealth of Massachusetts W 'T'itle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Sy Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. t5insp.doc • 0806 Title 5 Offmai inspection Form: Subsurface Sewage Disposai System - Page 14 of 15 r 11/29/06 To whom it may concern, The Soil Absorption System on 98 Forest St. conditionally passes and will pass upon replacement of a 1500 gallon septic tank. North Andover town by-laws require the system to be reinspected 6 months after completion. I�ard Ja Title V Inspector 'Commonwealth of Massachusetts v W Tide 5 Official Inspection Form 'Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M V' Property Address Owner information is required for every page. 'Owners Name City/Town D. System Information Residential Flow Conditions: state Zip Code Date of Inspection Number of bedrooms (design): r Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): , Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Sump pump? Last date of occupancy: Commerciallindustrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.1t., etc.): Grease trap present? Industrial waste holding tank present? -Non-sanitary waste discharged to the Title 5 system? Water meter readings, if available: Last date of occupancy/use: Other (describe): Gallons per day (gpd) Date I ❑ Yes 9,"No ❑ Yes E—No ❑ Yes a No ❑ Yes (" No CAInd ❑ Yes [ -14o e o&, Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5insp.doc - 08106 Title 5 Official Inspection Farm: Subsurface Sewage Disposal System • Page 7 of 15 Commonwealth of Massachusetts 'title 5 official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments N Property Address Owner information is required for every page. Owner's Name City/Town State D. System information (cont.) Zip Code Date of Inspection Building Sewer (locate on site plan): Depth below grade: feet Material of construction: ecast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: Material of construction: 19/concrete ❑ metal feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes [-No Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle 1�Ix X S: � IVi,wisal-z > � :Y Alied4/iS b tL !1d /PIT - Distance � Distance from bottom of scum to bottom of outlet tee or baffle — /M How were dimensions determined? �f� Cv ��� t5insp.doc - 08!06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 15 4 Commonwealth of Massachusetts a Title 5 Official Inspection Form ;Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M Vi` Owner information is required for every page. Property Atloress Owner's Name City/Town state Zip Code Date of inspection D. System Information (cont.) Site Exam: 2� Check Slope ° r [❑ Surface water /10 ❑ Check cellar ❑ Shallow wells r� Estimated depth to ground water: feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) i ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: t5insp.doc • 01106 We 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 15 10 9 8 Fo"sem s-IxswT ©, is noove' IMY4. iSCtj gw,.,o* oeoivzL v7Aax 4%jo'71r 74ok. rz' A6-1 'o .A ai:`. 02/01/2007 13:22 FAX 978 373 6611 J AND S DEVLOPUNT 1@001 Fox Cover Sheet 58 SOUTH KIMBALL STREET BRADFORD, MA 01835 978-372-7471 S'end to From: D. pI V% V, c fV10 Attention: S(j Date: Office Location: Office Location: Phone Number ❑', Urgent U Reply ASAP ❑ Please comment ❑ Please Review ❑ For your Information cover: Commonwealth of Massachusetts Title 5 official_ Inspection Form(,Nt4� Not for Voluntary Assessments Subsurface Sewage Disposal System Form Certification Statement: I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. l am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: Passes _ ❑ Conditionally Passes ❑ Fails ❑ Nee Fu rt i=va1 n by the Local Approving Authority 9 1 %G2 Insp a p The syst inspector all submit a copy of this inspection report to the Approving Authority (Board of Heart or DER ithin 30 days of completing this inspection. if the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of Inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 1 of.16 Inspection results must be submitted on this form or on the official Title 5Inspection Form dated 6/15/2000. Inspection forms may not be altered in any way. A. Certification Important: JAN 2 5 2007 When filling out 1. Property Information: forms on the computer, use 4 0' G -� TOWN OF ,,1Uk i ,-, ..,,NIF only the tab key Property Address .,� n ftiiGV to move your 18 e' cursor » do not use the return Owner's Name key. �tS i S 8 6 Owner's Address N. AIV''>av—L--0L �^ a Citylrown State inspection: zz- 6 _oIFjN"5- Zip Code Date of Date 2. Inspector: Gl-► 'I Name of Inspector �lt�C3n1�K Company Name 2QV KEW0-1-14 .5.T - Company Address Ww✓Fe44 Ll.. City/rown State Zip Code Telephone Number Certification Statement: I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. l am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: Passes _ ❑ Conditionally Passes ❑ Fails ❑ Nee Fu rt i=va1 n by the Local Approving Authority 9 1 %G2 Insp a p The syst inspector all submit a copy of this inspection report to the Approving Authority (Board of Heart or DER ithin 30 days of completing this inspection. if the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of Inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 1 of.16 lot 12, peke 4 DEC 2nlD S IZZS TOWN OF NORTH ANDOVER SYSTEM P'UMPI.NG RECORD �1 S'T'EM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) xe/� slw 6f U:\"I,E OF PUMPING: <'�f' QUANTITY PUMPCDf�5G'ALL0 � C.I:»I'UU.L: NO L/ YES SEPTIC TANK: NO YES .NATURE OF SERVICE: ROUTINE EMERGENCY FRV;\TIONS: GOOD CONDITION l/ FULL TO COVER }-HEAVY CREASE BAFFLES IN PLACE i, 7 ROOTS LEACHFIELD RUNBACK CXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER ��j�HER (EXPLAIN) i P U tin P r D B Y : C,U.1,I'YI FNTS: �:UN"I ENTS TRANSFCIZRLDTO: FORM - U - LO I KL' LLQ A, r Otuvl Op . INS TRUCTIONS- This form is used to verify that all-necessary approval/ permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. �.■rrr■■rrrr■■rrrrrrrrr■■rrrrrrrrrrrrrrr■■rr.■rmonism rrrrrrrrrrrrrrarnow ..rrrr APPLICANT e t j ` ;� �_ PHONE I ^I i ` % i (c k) ASSESSORS MAP NUMBER LOT NUMBER i SUBDIVISION LOT NUMBER STREET — r<` S +T STREET NUMBER i �rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr urrrrrr.rrrrrrrrrrrrrrrrrrrrrrrrrrrrrr OFFICIAL USE ONLY �rrrrrrrrr�rrrrr.■rrrrrrrrrrrrrrr rrrrrrrrrrrNunn rrrrrrrrrrrrrrrrrrrr■....rwas. RECONEVENDATIONS OF TOWN AGENTS �.... rrrrrrr■■rrrrrrrrrrrrrrrrrr■■rrrrrrrrrrrrrrrrrrrrrrrrrr was ......rrrr .� DATE APPROVED t� CONVAUONADMITZSTRATOR DATE REJECTED DATE APPROVED. TOWN PLANNER . DATE REJECTED COMMENTS FOOD INSPECTOR -'HEALTH DATE REJECTED DATE APPROVED SEPTIC INSPECTOR - HEALTH DATE REJECTED CO PUBLIC WORKS - SEWER / WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT COMMENTS DATE APPROVED DATE REJECTED RECEIVED BY BUILDING INSPECTOR DA I Loi 27 A I Zo 2 .0 Iz .rL./-\o of L/-\idr, . IK o LJ d F- P 13 VL%VJ/1JJ1 VV�JV JVVJI JV VII i1,6(4h AVLbver Q -n- 4, )-36 Aon St /1/e /*, A nr�over- W,=v/ L14- tSI pp }} lf)r4II Lie- #/-77-0 L L ti v L- V J I L'%'tl�l+, I / r11 �YV V Lit. I MVL Vl gnWARTIS SEPTIC TANK SMVICE 4 7 RAIJROAD S'T'REET BRADFORD, M 01835 978-372-7471 MONTH OF MOT rHLY REPORT FOR MniN OFr- •Y.,.. yam..-. _ - r ..w ''y :... ....-L1'.r'.r`.`^:r.:5lh+r - FORM II —.LOT RBLBASB FORM INSTRUCTIONS'' This fora 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 lav,. regulations or requirements. nt fills out this section***************** 1 � APPLICANT: JylF? �ii (�t��°�n'(� Prone 76YV LOCATION: Assessor's Map Number I Ot) parcel Subdivision AIC4 e RECCUIX- ,.YDATIONS OF TOWN AGFPiTS : i�/ C=,Mments T ti :, _ v111 Planner ll'.r Cc:t,;,erts SPS / zw/it/ Lots} I St. Number ( F on_Iic**�i�i�EX�Ex�E�t�ix�t�i=�rir�fr�ir�t�ir�Fic p, " 4 cc Wcr<s - sewer/Water ccnnections - drivewav permit Department I 44✓ P Received by Building Inspect== c Date Approved Date J ` Date Approved Date Rejected Date Approved Date Rejected Date Approved cS Data Rejected Date FORM U - IAT 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 local or state law, regulations or requirements. ** *************Applicant fills out this section***************** APPLICANT: _Af l.. L Phone v ACATION: Assessor's Map Number Parcel Sdivision Lot(s) Street St. Number ************************Official Use Only************************ G RFC OMiENDATIONS OF TOWN AGENTS: Date Approved Conservation Administrator Date Rejected Comments Date Approved .�' Town Planner Date Rejected Comments Foo Ins ector-HDate Approved ealth Date Rejected Date Approved .7 ` -3e is Inspector -Health Date Rejected Comments i Public Works - ewer/water connections - driveway permit Fire Department Received by Building Inspector Date i)WO � - Z� LA--, -I- -r_ A- e-D-lle-d - a aJ"D--.'I id x Z -o �f 7L-C,4i,-,p�.-� S i 00 IrJ z��•-�_ �/di� /� moo!. -�® .� , Lop `'`' of-`� Y�s �` Z ��y 6 U ;1-f 7CO .- 3 �3e� •-o -f- s L� s 7`_�- s �,,, ` •�- �74- ti s jK.cC1 ALUTI ON G1jrXK TJ ST APPROVED DATE DIUPPRUM OK I , - V TIOT —MAVATION OK FAI; I 1. Distance To: a. Wetlands b. Drains 0. Well 2. Water Line Location No PVC Pipe Septic Tank ----- a. Tees w. Length .&.To Clean Out covers b. Cement Pipe to Tank-- On Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Equal Amunts C. No Back Flow 6. Leach- Field or Trench - - - a. Dimensions b. Stone Depth c. Capped 'Ends - d. Clean Double Washed Stone 7. Leach Pits a. Dimansi0 b: Stoneaepth c psh Pads d. T's e /dewment Pipe to Pit Both Sides f.'Clean Double Washed Stone �j j 8. No Garbage Disposal 9. Anal Grading Inspection 10. Barricading Covered System 12. As Built Submitted a. Lot Location b. Dimensions of System c. Location with Regard_to Pere Test d. Elevations e: Water Table Board of ,96alth North�,Andover,Mass SUBSURFACE DISPOSAL DESIGN CHECK LIST LOT y �V APPRMED DATE `� 7 y DISAPPROVED DATE______ Providedt Reasons: Title V FAIL Reg 2.5 a submitted plan must show as a minimum: a) the lot to be served-area,dimensions lot #,abutters location and log deep observation holes to ties -distance / location and results percolation tests -distance to ties design calculations & calculations showing required leaching area ' e location and dimensions of system -including reserve area existing and proposed contours (g) location any Wet areas within 100' of sewage disposal system or disclaimer -check wetlands mapping (h) surface and subsurface drains within 1001 of sewage disposal p C%ls ' ✓ system or or disclaimer -� (i) location any drainage easements within 1001 of sewage disposal system or disclaimer -Planning Board files known sources of water supply witbin 2001 of sewage disposal system or disclaimer k) location of arq proposed well to serve lot -1001 from leaching facility 1) location of water lines on property -101 from leaching facility (m) location of benchmark (n) driveways o) garbage disposals no PVC to be used in construction (q) profile of system -elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and Other elevations Smaximum ground water elevation in area sewage disposal system ) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Reg 6 Septic Tanks (a) capcapac tieB-150% of flow, water table, tees, depth of tees, access, pumping fib) cleanout ( 10 I from cellar wall or inground swimming pool d) 25+ from subsurface drains Reg 10.2 Distribution Boxes Aa) slope greater than 0.08 Reg 10.4 b) sump � f✓ �1 SOIL PROFILE & PERCOLATION TEST DATA North Andevbr,I�j s. No.&Street No. �a Loc./Subdiv. Plan Owner Investigator Observer )�J SOIL PROFILES -DATE 1. Elev. ?' Elev. 3. 4' Elev. Elev. 0 0 0 0 1 1 1 1 Ties to Test Pits 2 3 4 5 6 7 8 9 10 2 2 3 4 5 6 7 8 9 10 4 2 3 4 5 6 7 8 9 10 Start Saturation .� 2 3 4 5 6 7 8 9 10 -' Soak -Mins. Start Test -Time Drop of 3" -Time .Drop of 611 -Time p -j - Mins. lst. 3"Dro Mins.2nd 3"Dro S — — Percolation Rate Benchmark Elevation 1 Location Datum //Pe,rcola_tion Tests -Date Pit Number 1 2 3 4 S Start Saturation .� Soak -Mins. Start Test -Time Drop of 3" -Time .Drop of 611 -Time p -j - Mins. lst. 3"Dro Mins.2nd 3"Dro S Percolation Rate Dotes & Sketches an Back Benchmark Elevation Location Datum Percolation Tests -Date Pit Number 1 2 SOIL PROFILE & PERCOLATION TEST DATA I S Start Saturation North Andover,I.Iss. No•&Street Soak -Mins. Lot No. Start Test -Time r Loc./Subdiv. 7 Plan " Drop of 31' -Time - " -Time - Owner Investigator Drop Dro of 6" --Time Observer _ Mins .1st . 3"Dro Mins.2nd 3"Dro PROFILES -DATE 1' Elev. �*c lation Rate _ 2. Elev. 3' Elev. 4'Elev. 0 0— 0 0-- 1 1 1 Ties to Test Pits 2 2 2 2 3 3 3 3 4l - 4 _ 4 -= 5 S 5 6 6 6 77 7 7 8*/1A� 8* 8 8 9 9 9 9 10 10 10 10 ' Benchmark Elevation Location Datum Percolation Tests -Date Pit Number 1 2 3 4 S Start Saturation Soak -Mins. Start Test -Time r Drop of 31' -Time - " -Time - r� Drop Dro of 6" --Time _ Mins .1st . 3"Dro Mins.2nd 3"Dro �*c lation Rate _ Pe o _ 'otos & Sketches on Back 1 fox -L\,, Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 98 Forrest St. Property Address Marcel Label Owner Owner's Name information is required for North Andover MA every page. CitylTown State Zip Code Date of Inspection D System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand -sketch in the area below ❑ drawing attached separately L_j t5ins - 09/08 I ;sssc- Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 f NORTN , J p Toron of North Andover «`'•;`� HEALTH DEPARTMENT �SS�cNus�� CHECK #: /4-15S LOCATION:5-�- H/O NAME: a�•-� L-�-�'e CONTRACTOR NAME::/ , 1�,•� �-.-�y Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) $ A r- 2204 46A;it nitials White - Applicant Yellow - Health Pink - Treasurer �1 ,AORTM 40 F _ 9 Town of North Andover HEALTH DEPARTMENT .'s CNUS�� CHECK #: LOCATION:' H/O NAME: CONTRACTOR NAME -94.-.d Z.t Ire ; 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 ❑ TrasIVSolid 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 mT tle 5 Report ❑ Other. (Indicate) $ 2019 4keafjflth 4 ent Initials White - Applicant Yellow - Health Pink - Treasurers 4201 NORTH a ' N } p 41 Town of North Andover ''•, HEALTH DEPARTMENT cNus CHECK #: //�'9 �J DATE: x . LOCATION: H/O NAME: CONTRACTOR NA 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 $ ❑ TrashlSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑0 Title 5, Inspector $ U,- itle 5 Report $3�X ❑ Other. (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer LnLri o O a O N �i f� Q 0 N c E o N o C .QCD ¢ E N �CDO�j 2 .0+ O Q a O , cc o W b a) ° � m Z +-� U a) Ec C c ° a) C: 0: N O C) w O; 0, =3 �--+ pn co Q; Ov�p t;t d L W76 a) >L +� z cc> ° ° cn h c ° ° Q O Ni a Uo CU cu o u 0Z U o 3 o 0. b cqs w A VJ r • a L ,yam "„� z H � U � ; O FY N jr Cd y i M O z YJ cn Mt 04 00 y , �i Q c E N o C .QCD ¢ E N �CDO�j 2 O 0 Q a O , cc o W b a) ° � m Z +-� U Ec C ° a) �L C) w O; 0, pn Q; Ov�p t;t h n M vl�eo ,�ti; /4i e. -10 - - h '6 OL` y �•� 16 Apo COCKKHR •.K@ */ MKw PUBLIC HEALTH DEPARTMENT (ommunity Development Division CYFRTI�'IC1`�`� OF'C091�1�1'GIA9VC�E As of: Ee6ruary 6, 2007 ,This is to cert that the indtWuaCsu6surface d4osaCsystem received a SAMEAC7oRTlYS(EC1TIOYof the: Septic System Component — 7ankOnCy 1By: John DiVincenzo At• 98 Forest Street North Andover, 3KA 01845 9fiie Issuance of this certificate shad not 6e construed as a guarantee that the system wid function sahz factoriCy. an T Sawyer 1t 6Cc iTeaCth Director 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com I No - 0 111NS � T/ '�_ COCwtMwK11 _ 7' PUBLIC HEALTH DEPARTMENT Community Development Division Februa i y 1, 2007 Marcel Label 98 Forest Street North Andover, MA 01845 Re: 98 Forest Street Dear Homeowner, The Health Department has received all necessary documentation in regards to the recent septic component repair at your property listed above. Enclosed you will find the Certificate of Compliance indicating that the septic tank repair has been completed, however, in accordance with the North Andover Subsurface Disposal Regulation I must notify you of the following requirement. Part F 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. A MA licensed septic inspector must conduct this inspection and a proper report must be submitted to the Health Department." The North Andover Board of Health is concerned that due to your septic tank's failure the leaching system has not recently received regular flows. Conducting an additional inspection will address some possible concern brought out due to this issue, however it does not guarantee the longevity of the septic system. This is a public document and a copy of this document will be placed in your building's permanent file and attached to the anticipated Title V inspection report to be submitted in no less than six months. Thank you for your cooperation in this important matter of public health. YOU, usan Sawyer, REHS/RS Public Health Director 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com AwAication for Seotic Dis tem �pCotstructi6n Permit -TOWN OF RECE Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. mrten )RTH ANDOVER, MA 01 Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal $ 250.00 — f ull Repair DEC j 5$186eO - lomponent TM,IN it NURYH ANDOVER HEALTH DEPARTMENT pair or replace an existing on-site sewage disposal system*1 --�_ Repair or replace an existing system component — What? 10A) A. Facility Infc L3 X Address or Lot # 1101 la�1-jC2 City/Town I- S4 2.- *TYPE OF SEPTIC SYSTEM*: ❑ Pump ❑ Gravity (choose one) ***If pump system, attach copy of electrical permit to application*** ❑ Conventional System (pipe and stone system) ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system: ❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D -Box Present) S.A.S. 2. Owner Information f M r b (., Name ^ (XJ fcf vis 'T Address (if different from above AY 0 !qA City/Town State Telephone Number 3. Installer Information Zip Code cel Namen� ` s � � +Name of Company City/Town 4. Desi -all Name Address City/Town ft o /" �K3 a State Zip Code b 7 L--7 H 71 -- Telephone Number (Cell Phone # if possible please) Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: ❑Residential Dwelling or ❑Commercial B. Agreement TODAY'S DATE $ 2W.00 - Full Repair $125.00 - Component The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Name Date Applicati Approved By:(B d of Health Representative) /Z // 5 Na Date Ap ication Disapproved for the foil wing reasons: For Office Use Only: 1. Fee Attached. Yes" No Z. Project Manager Obligation Form Attached Yes No 3. Pump Svstem? If so, Attach copv of Electrical Permit es No 4. Foundation As -Built. (new construction ronly): Yes No (Same scale as approved plan) 5. Floor Plans? (new construction only): Yes Application for Disposal System Construction Permit • Page 2 of 2 TRANSMISSION VERIFICATION REPORT TIME 01131/2007 09:50 NAME HEALTH FAX 9786888476 TEL 9786888476 SER.# 000B4J120960 DATE DIME 01131 09:50 FAX NO./NAME 89783736611 DURATION 00:00:18 PAGE(S) 02 RESULT OK MODE STANDARD ECM North Andover i ealt Partmlaen 1600 Osgood Street Building 20, Suite 2.36 North Andover, NIA 01845 978.688.9540 - Phone 978.688.8476 — Fax heakhoeptPiowo nerthandover.com - E-mail www.townofnorthandov_®j.com • Website Letter of Transmittal Page _/ , of V-���Ro •d .ry w~ 4L a Tp: DATE FROM: Pamela DelleChiaie, Health Department ,Assistant RE: Phone: _/ z 42 Fax. �, 4 r We are sending you: O Copy offeller ©Plans M�mvrffilllflhvlow) These are transmitted as checked below. ➢ L7ArA4vgff& ➢ 0,r COPY TO: � ,G7Far ➢ landmrs, MWWd > MAWR alaiNkr&t, North Andover Health Department 1600 Osgood Street Building 20, Suite 2-36 North Andover, MA 01845 978.688.9540 Phone 978.688.8476 — Fax healthdept(aD-townofnorthandover.com - E-mail www.townofnorthandover.com - Website Letter of Transmittal Page _'/ of I L F0-~ 1 OqA c«.iu-i�wrcw `y1 TO: U DATE: /� t3� / (OMPAN : FROM: Pamela DelleChiaie, Health Department Assistant c COPY TO: SIGNED: RE: L Phone:141 L� ;-GPJ Fax: We are sendingyou.- O Co of Letter O Plans ther fill in he%w Y AY ) These are transmitted as checked below: ➢ L7*povadffNafad ➢ Okr ➢ OasRhg6mY d ➢ IPeviiewar/aamn�ant );o OasRegr�d ➢ Okryowt* ➢ ORasabnrt Wofffor qpvld ➢ O.Subn* cgaiesfard#. REMARKS: i i COPY TO: COPY TO: SIGNED: L COPY TO: r 1- 0 } t W4 ti Y.. A p J 1 Izj- 0 O e 1 Z? IS a � J