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HomeMy WebLinkAbout- Miscellaneous - 220 DALE STREET 5/19/2022 *" Commonwealth lth f Massachusetts Map-wocx-IAA 064,00012 LT I BOARD OF HEALTH� Permit No " North Andover PMP-2011-0752 FEE DISPOSALWORKS CONSTRUCTION PERMIT Perrrussron is hereby granted Todd Bateson to(Repair-DISTRIBUTION BOX)an Individual Sewage Disposal Systern. at No 220 DALE STIR -, 'T.. as shown on the application for Disposal Works Construction Permit No. I3I.11'-2011-075 Dated July 20,2011. Issued On: Tut-20-2011 North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATIOU ADDRESS: � MAP: LOT: INSTALLED:. DESIGNER: �" PLAN DATE: BON APPROVAL DATE ON PLAN: ';..w . INSPECTIONS ,. TANK INSPECTION: " " DATE OF BED BOTTOM INSPECTION: DATE OF FINAL C `STRUCTION INSPECTION: DATE OF FINAL GRADEINSPECTION: SITE CONDITIONS Contractor reports any changes to design plan Existing septic tank properly abandoned Internal plumbing all to one building sewer Topography not appreciably altered Comments.- SEPTIC TANK [ Building sewer in continuous grade, on compacted firm base El Cleanouts per plan Bottom of tank hole has 6" stone base 'Weep hole plugged .w. gallon tank has been installed _ loading [l Monolithic to " .._ k' struction Cm� Water tightness of t has been achieved by testing Inlet tee installed, centered under access port. 01 FJ Outlet tee installed, centered under access port (gas baffle/effILient filter) El -___ww inch cover to within 6" of final grade installed over one access port Hydraulic cement around inlet & Outlet Comments: PUMP CHAMBER F Bottom of tank hole has 6" stone base Weep hole plugged El gallon Pump Chamber installed E] loading Ll Monolithic tank construction F Inlet tee installed, centered under access port Pump(s) installed on stable base Alarm float working E-1 Pump On/Off floats working E] Separate on/off floats Cl Drain hole in pressure line El cover at final grade installed over pump access port Watertightness of tank has been achieved by .---testing Hydraulic cement around inlet & outlet Comments: CONTROL PANEL Alarm & Pump are on separate circuits ww Alarm sounds when float is tripped Location of control panel: basement El Alarm signal located inside: basement Comments: DISTRIBUTION-BOX Installed on stable stone base H-20 D-Box Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & Outlets Observed even distribution Speed levelers provided (not required) Comments: 0 Application for Septic this oral S stem TODArS DATE #0 Construction Permit — TOWN OF $250.00—Full Repair X's ORTH ANDOVER, MA 01845 $125.00-component Important: Application,is hereby made fora p.2rmit to: When filling out F-1 Construct a now on-site sewage disposal system* forms on the computer,use 0 Re air or replace an existing on-site sewage disposal system* only the tab key to move your epair or replace an existing system component-What? cursor-do not use the return key� rn A. Facility Information Address or Lot 9 runes 14 Cfty[Town 7V�; Z�Z�`_ 2.-*TYPE OF SEPTIC SYSTEM*: El Pump ��ity(choose one) ***If pump system, attach copy of electrical permit to app iWAWORTH DOVER T'H DEPARTMEN Conventional System(pipe and stone system) El Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system, El Pressure Distribution S.A.S.(No D-Box)(Attach Draft Maintenance Agreement) n Pressure Dosed(D-Box Present)S.A.S. 2. Owner Information Name Address(if different from above) /Vo State Zip Code Telephone Number 3. Installer Information ,_ 7- Name --—-- Name of Co any Lj 'L I ARGI"pOAD -- A ANDO Address City/Town rep "P State Zip Code 1>l Y e fe p h o n e—Number Phone — --1fi—po-sis 1--b 1e please} 4. _—D_._e s ig n.er Inform Lion Name .... _Na—me of Company Address City/Town State Zip Code Telephone�Number(Best#fo�Reach)��� Application for D*-saj system construction permft.page 1 of 2 Application for Septic Disposal Svstem, o ro '�`�� '��° Monstruction Permit - TOWN OF Y'S DATE $250.00-Full Repair ORTH ANDOVER, MA 01845 $125.00-Component PAGE 2 OF 2 A. Facility Information continued.... s. Type of Building: 911'e"Sidential Dwelling or ElCommercial B. Agreement 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 b Is Board of Health. Date Application A roved By: (Bo of Health Representative) NameDike Application Disapproved for the following reasons: For Office Use Only: L Fee Attached? Yes No 2 Project Manager Obligation Form AttacliedP Yes No J. Pump S X,;t ef n? If so,Attach c*,b c-Qpy g,(EIecr_n_Lc_.WPera7_it e Y' S -A' NO 4. Foundation As-Built?(new construction ronly): yes.-- No (Sa-we scale as approved plan) 5. Floor Plans?(new construction only): YC.V-- No___ Application for Disposal System construction Permit-Page 2 of 2 d4,� Il "own of North Andover f1EALTH D FFPARTME TCHECK P 4. DATE: N, u LOCATION: _..H/O NAME: C�;N T°I AC I C A 'y cif Permit crr_i�iceI,, (Check box) — [ .Animal C) Body Art Establishment * Body Art Practitioner * Humpster lo Y'ood Service- 0 Funeral Directors o Massage i stabiishment o Massage Practice C3 Offal(Septic)Hauler 0 Recreational Cianap c3 Sun tanning l Swimming Tool � 0 Tobacco Yo Trasti✓solid Waste.Hauler [3 Well Construction SEpTT7c susteks. ❑ Septic-soil'T"esting © septr'c-,ah"es'ign Approval tic Disposal works ConstructionfDWC") =— m septic Disposal Works Installers(DWI) ----' Title 5 inspector C1 Title 5 Report 0 other:(indic,,ate)__�--------- P Health Agent Initials hi e-Applicant el ow-health Ian_Treasure SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: 6) Lf-, "51 For plans by (Address of septic system) (En Relative to the application of (Installer's name) And dated ,r sn ate Dated (I oday's date) With revisions dated 7 (Gast revised date) I understand the following obligations for management of this project: 1. As the installer, I am obligated to obtain all permits and Board of flealdi approved plans pn*,()r to performing any work on a site. I must have the approved 12fans and the l2erne t on site when anytivc>rk is being done. 2. As the installer, I must call for any and all inspections. If homeowner,contractor, project manager,or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 1 As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I Linder stand that recluestin -)Ietion of the .g an inspection.without coml z t the iterns in accordance with Title 5 and thg Board of Health RegglatioaLmay result L in a 59.00 fine beiag-l—ey my company. a. Bottom of Be -Generally, this is the first(1') inspection unless there is a retaining wall,which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction In,pection-Engineer must first do their inspection for elevations,ties, etc. As-built of verbal OK (or e-mail to: health dept@A�wi(fu®rhandover.com) from the engineer must be submitted to the Board of Health,after which instal!er calls for an inspection time. Installer must be present for this inspection. With a pump system, all electrical work must be:ready and able to cause pump to work and alarm to function. c. Final Grade-Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple exeavation)and I am required to complete the installation of the system identified in the attached application for installation. Lfirrtlier understand that wQtk done.,by others unlicensed to install,sewic systems in North ran lover can cottstittrte: reasons for deerasionlicense to operate in the Town of North Andover, are >ossle, 5. As the installer, lae;r£ormance of the following construction steps: a. Deteimination that dieprol)er elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. KJ7a1i"SPccd0j7 by Board of Healdi staff or consultant. d' 117stall'lt'on of tank,D-Bo-vl P'Pe"F, stone, vent,PUMP chamber, retaining wall and other components. 6. As .he installer :enders nd that I anx sea el res n ilple fc r film installation of the system as Lp�gr the al2l2roved p-lans. No instructions by thg h tracto)r- or 2iry ntliqir ppi-cr%ns shall absolve me of this!a�Iiio�r. Undersigned Licensed Septic Installer: (17 oday's Date) (Name— rmt :Mgned)�' FORM U - LOT RELEASE FORM 1INSTRUCTIONS: This form is used to verify th,-,L all necessary apprcva1sJpermi�.s frorn, Ecards and Departments having, jurisdiction have been cdtained. This dces not relieve the applicant and/or iandcwner from compliance with any applicable cr requirernents. APPLICANT LCCATICN: Assessor's Map Number PARCEL '/4911 L 11 S41 -190 STREET ST. NUMEER C-70T - Ze CFFICIAL USE CNLY** CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMEiNTS as TOWN PLANNER GATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED /�INSPEtTCR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUSLIC WCRK3 -SEIVER)WATER CkONNECTIGNS DRIVEWAY PERMIT FIRE7ECE-EIVED EY EUILEING eNSPEC DATE,___._ ;,evicec 9i97 .............. R,,,',IZZO BUILDINS(I MIODELINC-i r M ! _. _v r h x 4-1 � C 99 . _ . _.._. i W ,o 0119, e lq y r , uM r d ^Jsv v2;.,,P a....., Commonwealth, of Massachusetts Title 5 Official Inspection Form REC IVEI) .ww Subsurface Sewage Disposal System Farm Not for Voluntary Assess eats /$ 220 Dale Street Property Address tlG�.�)V,lP r-ri d'�dl if 6/i4iJG I r�t. Jarjj ajan .OwnerName---- - ............ .....-_.._.._- __.___-____. � • �� „�� �p Owner's Name information is required for North Andover MA 01845 4/16/2011 every page. City/Town State Zip Code Gate of Inspection- i r 1, Inspection results must be submitted on this form. Inspection forms may not be altered irt, y way. Please see completeness checklist at the end of the form. Important: A. General Information -When filling out forms on the computer,use 1. Inspector: only the tab key to move your Neil J. Bateson cursor-do±not _ __._..._..._.._--__.._ ...... ..____.____ _—...__ ..._._..... __. ..r _....._____ use the return Name of Inspector key. Bateson Enterprises Inc. ___— Company Name 111 Argilla Road IL Company Address Andover Ma 01810 -- _. _.... - _... ._ .._ -- -. ._ ......-- _- .._ . _.... mnr CityFt own State Zip Code 978-475-4786 SI 15 -...._._... ....._ _. . — Yelephone Number License Number B. Certification 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 ❑ Fails ❑dNeeFurther Evaluation by the Local Approving Authority 4/16/2011 Ingnature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. tl �17j:�] M, t5ins^09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page t of 17 _.. __ _... ......._-._ .... ..... ............_._......._....w_.................—._...-_...,...,. Commonwealth of Massachusetts M , _ Title 5 Official Inspection Form z .. t Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 220 Dale Street Property Address �.___.__.... Jan Bajan _ Owner Owner's Name information is North Andover MA 01845 4/16/2011 required far _ -._. - -- __. _.. every page. City/7own State Zip Code Date of Inspection B. Certification (cost.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes. One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes" "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 2.0 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. ❑ Y ® N ❑ ND(Explain below): t5ins 09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a` 220 Dale Street Property Address Jan Bajan ..,___ _,............... ..... ....... Owner Owner's Name information is required for North Andover MA 01645 4/16/2011 _ _.__.._.�__. ... .. .... every page. _it_........ State Zip Cade Date of Inspection B. Certification (cant.) B) System Conditionally Passes (cant.): FI Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y E N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): El distribution box is leveled or replaced n Y N ❑ ND(Explain below): ........ . _...._.. ._. __........ _ (� The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): E broken pipe(s)are replaced Y N ND (Explain below): ❑ obstruction is removed ❑ Y N ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 16.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: [� Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-09108 Firer 5 Official pnspe0on Form:Subsurface Sewage Disposal Sryyslem•Pago 3 of 17 'I Commonwealth of Massachusetts R Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 220 Dale Street Property Address Jan_Bajian Owner ---------- Owners Name information is required for North Andover MA 01845 4/16/2011 every page. -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 I of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria 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-Box needs-to.be.replaced ------------------- --------------------------- ..........----------------------- D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2day flow t5ins-09/08 Title 5 Official Inspection Form,Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 220 Dale Street Property Address Jan Bajan Owner Owners Name _ _ ... ........ .__.._....... information is required for North Andover MA 01845 4/16/2011 every page. City/Town State Zip Code Date of Inspection ............. ._........... _____.____ B. Certification (cant.) Yes No Z 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. 0 z Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El Z Any portion of a cesspool or privy is within a Zone 1 of a public well. El ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. El ® 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 CDEP 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.] ❑ z 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 ❑ M the system is within 200 feet of a tributary to a surface drinking water supply F ® 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. t5fns•W/08 Title 6 official Inspection Form Subsurface Sewage Disposal Systern•Page 5 of 17 c a, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Farm -Not for Voluntary Assessments 220 Dale Street Property Address Jan Bajan Owner's Name information is required for North Andover MA 01845 4/1612011 _....__._ _. every page. CityfT"own State Zip Code Date of Inspection _.._..,_..........__.,,___.......... ..._._................w._..._......._.m... C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No Z ❑ Pumping information was provided by the owner„ occupant, or Board of Health D ® 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? Z ❑ 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? Z ❑ Was the site inspected for signs of break out? Z 0 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? Z ❑ 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: ® Q Existing information. For example„ a plan at the Board of Health. Z 7 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)] _.._._�.._ _........ ......e _...______....____.e ...__ __ , ___ ......_w............_.._ W ___ _...._ ...._. D. System Information Residential Flow Conditions; Number of bedrooms(design): N/A Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms); N/A tins•09108 Tifie 5 Official hspection r'oarn:Stksbxrfasc o Seawage&7R"sal System-V>qam 6 of t"d Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Farm-Not for Voluntary Assessments 220 Dale Street __ ......_._ Property Address Jan Bajan Owner Owner's t arise information as North Andover MA 01845 4/16/2011 required for _...... .,_.... _..... _ every page. CitylTown State....._.. ^VWxY Zip Cove Coate of Inspection D. System Information Description: Two family,house only 1/2 of the house has been used Number of current residents: 2 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 [I No Seasonal use? ❑ Yes E No Water meter readings, if available last 2 ears usage d Yes 9 � y g �gp ))� ._ - Detail: Sump pump? .0 Yes E No Last date of occupancy: Current Co ate Commercial/industrial Flow Conditions: Type of Establishment: _ ..-_.-._ Design flow(based on 310 CMR 15.203): . . Gallo o ns per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): - Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes Cl No Non-sanitary waste discharged to the Title 5 system? ❑ Yes E] No Water meter readings„ if available: t5in-o„#ltbfl 'T 10 5 Official hspection rwrn "Subsu faatwe Sewage Disr*saP System.Page 7 of't 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .. t 220 l0ale Street _ Property Address Jan_Bafa.n Owner _ Owner's name information is required for North Andover MA 01645 4/16/2011 .....,. __.. . ......... ........__ ___....._ ..... every page. Cuiioown State Zip Cade Gate of Inspeatuan _.-._...... —.._..___--------._ _....... .........._--_.. __.- .......... ..-. _... �....__.._ D. System Information (cant.) Last date of occupancy/use: IJate Other(describe below): General Information Pumping Records: Source of information: Pumped two years ago, owner Was system pumped as part of the inspection's ® Yes P No If yes, volume pumped: 1200 gallons Now was quantity pumped determined? Measured tank Reason for pumping Inspect tank baffles &tee Type of System; E Septic tank, distribution box, soil absorption system D Single cesspool ] Overflow cesspool Privy [l 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 N/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe); t5ws w 09108 "title 5 Gffi aGaV Inspection rarrrr .Sutasaurtaca,"wage Disposal System-Page 8 of 17 Commonwealth of Massachusetts a. Tide 5 Official Inspection Form '= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 220 Dale Street _..._....... _.,,,,,..- ---- Property Address Jan Ba1a_n Owner C7wner's Naarne requiredfor is North Andover MA 01845 4/16/2011 required for _ . every page. Crfyrrown State Zip Code Date of Inspection. D. System Information (cant.) Approximate age of all components, date installed (if known)and source of information.- Original, owner Were sewage odors detected when arriving at the site? El Yes Z No Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ® cast iron .140 PVC ❑ other(explain): Distance from private water supply well or suction line: .feet Comments(on condition of joints, venting, evidence of leakage, etc.): 4°Cast iron thru wall. Septic Tank(locate on site plan): Depth below grade: _ feet Material of construction: Z concrete ❑ metal F1 fiberglass n polyethylene ❑ other(explain) _._—_._.. ... If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes El No Dimensions: g"x 5'x 4 6" Sludge depth: tsins 09108 rMe 6 Official Inspection Fcrr^dn:Sutrsur1lacv'Sewage Disr osW System-f arje 9 0'17 Commonwealth of Massachusetts µ Title 5 Official Inspection Farm r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 220 Dale Street Property Address Jan Bajan Owner Owner's Name informatbon is North Andover MA 01845 4/16/2011 required for _... _.. .. __.........._ __. _...... .... . ._-. _-- __._..._..------- every page. City/Town State Zip Code Date of Inspection D. System Information (cant.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 21 6„ Scum thickness 6.. Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 14" Now were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumped septic tank. Inlet baffle ok. Outlet baffle corroded off. Outlet tee ok. Depth of liquid at outlet invert No evidence of _. .. .... .................... Crease Trap(locate on site plan): Depth below grade: _......._.. ... feet Material of construction: [1 concrete Q metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness _- Distance from top of scum to top of outlet tee or baffle ----- --------- Distance from bottom of scum to bottom of outlet tee or baffle _ Date of last pumping: Date t5 ms•Woe TitW 5 Officiat Inspection Foam Subasurfac:a Sewage Dsposal System.Page't 81D ol 17 Commonwealth of Massachusetts - = Title 5 Official Inspection Form Subsurface Sewage Disposal System Farm -Not for Voluntary Assessments w., f 220 Dale Street Property Address Jan Bajan Owner _. )._ ............. �_. ... _.-- .�........, . Owner's Name infrequired is North Andover MA 01845 4/16/2011 required for every page. CrtyfTown State Zip Code Date of Inspection _......... „ ......._.. _..___. - -- — - ._. --........... D. System Information (cant.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage„ etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass polyethylene ❑ other(explain): Dimensions: _....... _ Capacity: _..._-___ ._............... gallons Design Flow: - . gallons per d 11 ay Alarm present: 0 Yes No Alarm level: Alarm in working artier: ❑ Yes [:1 No Date of last pumping: 11 ...._..-- Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes [ No h`,,In%-09M S'We 5 OfCGa;dal lnspecfion r-am S uk uilaucm Sewage Msposal System Page 1%of 17 Commonwealth of Massachusetts y Title 5 Official Inspection Form . � Subsurface Sewage Disposal System Form Not for Voluntary Assessments Ewa'' 220 Dale Street Property Address Jan Bajan Owner Owner's Name information is North Andover MA 01845 4/16/2011 required for __. _ _.. every page. City?rown State Zip Code Gate of Inspection _..._._.._ ...._..-._.._... _...,....w ......__. , .._a_.._...-_-___.__w......... . ........... .... ...._ . _....._. _...... D. System Information (cant.) 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 evidence of solids carryover„ any evidence of leakage into or out of box, etc.): D-box level&distribution not equal. Evidence of leakage, has corrosion holes. D-box needs to be replaced Evidence of carryover, pumped d-box to clean Pump Chamber(loc,3te on site plan): Pumps in working order: 0 Yes ❑ No Alarms in working order: El Yes ❑ No 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: t5ins 4 '6 TWe 5 Official Inspection Fwtr'Subsurface rfaace Sewage Dsposal Syslem-page 12 0 1'7 Commonwealth of Massachusetts Tide 5 Official Inspection Farm A Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 220 Dale Street Property Address Jan Baja, Owner Cwner's Name information is North Andover MA 01845 4/16/2011 required for _....... ......_.. ...____ ... ........�_...._... every page, Cityifown State Zip Code Gate of Inspection ......... ..........__.,_..___�__.w. ._,.._,,, ___.._..._...._..._ __ . ............. _.. _ _..... D. System Information (cant.) Type: [l leaching pits number: - [l leaching chambers number: [l leaching galleries number: — leaching trenches number, length: 4 trenches 50' Jong ❑ leaching fields number, dimensions: E] overflow cesspool number: © innovative/alternative system Type/name of technology: _.___._._...... _ _._._.... .............. ._ .... . ._...._..___.. . Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil Ok. Vegetation ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration _ Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer - Dimensions of cesspool Materials of construction Indication of groundwater inflow El Yes ❑ No rt5ms•09/08 "1 nle 5 4DpridW inspection Fonn Seukasufiace Sewage DispcsW Symein-Gage 13 d W Commonwealth of Massachusetts Tide 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 220 Dale Street Property Address Jan Bajan Owner Owner's Name information is North Andover MA 01545 4/16/2011 requiredfor ...,_.... ..,.. . �._.._..�. _�__..... _......__. .. .._... _._........ _..._.. _. every page. CitytTown State Zip Code hate of Inspection .,.,., .. __._..._..__.__...,..__ __ ...._ __.__,.w_.._._w.____..____ __., _. _ D. System Information (cant.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions .........._... __ ---- - Depth of solids _ __. . . . Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): _.....__._.. , _ -------- t uns-09/08 1"We Ga Of'rnrial rrnspecbtx�r�alrrrn Sn.bsul�aco Sqwage F3*os.a6 System.Page 14 0'0 N Commonwealth of Massachusetts m? Title 5 Official Inspection Form W Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0, ` 220 Dale Street Property Address Jan Bajan__.. Owner Owner's Name information Is required for North Andover MA 01645 4/16/2011 .._...._ ____............. every page. CptyfTown State Zip Code Date of Inspection __ .....—._ .......................... ...____......__.._... __._... _...........,.._,__.— _.. _.....__.. D. System Information (cant.) 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 r;UdL e)' f A-0 4 / J- _ Lf s ffA ns»09108 '1"itpo 5 Of6al Enspecton Form rti4.NSSsurfae, S+awage Msp anal System•Page 15 rA I Commonwealth of Massachusetts Tine 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 01` 220 0ale Street Property Address Jan Bajan Owner Owner's Name information is North Andover MIA 01845 4/16/2011 required for _- -- --- .. ._ — Nary page. CityfTown State Zip Cade Elate of Inspection D. System Information (cant.) Site Exam: 0 Cheek Slope Surface water Check cellar Shallow wells Estimated depth to high ground water: 3-.,. .... ........ _.......� ...... 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: _ Elate Observed site (abutting property/observation hole within 150 feet of SAS) EJ Checked with local Board of Health -explain: El Checked with local excavators, installers- (attach documentation) ❑ Accessed IJSGS database-explain: You must describe how you established the high ground water elevation: Transfer elevation of swamp_to trench bottom. _....... Before filing this Inspection Report, please see Deport Completeness Checklist on next page. t&ns•09,( 8 nufo 5 r,.ffloal hspedw Form,Swubsurf w:a Sewage LNsposs0 System-Pt go)16 taf 17 :,. Commonwealth of Massachusetts u: Title 5 Official Inspection Farm V. Subsurface Sewage Disposal System Farm Not for Voluntary Assessments 220 Dale Street...__. ._ _............ _.... _ _ ._ . ... Property Address Jan Bajan Owner Owner's Name information is North Andover MA 01845 4/16/2011 requiredfor .__.....___...._.. ....... ..._....... __..... . .... _........____. _.. ......_.... _ .�..._ .....__ ._.......,_ .. every page. City/Town State Lip Code Date of Inspection E.�l�f'pOCt �:Ctt"I"I�JlIt�'��'i"t._.........._______.._____.._.._....__�..._._.____.W_.._..__........__..._ .___.._.. ess Checklist Z Inspection Summary: A, B„ C, D, or E checked Z Inspection Summary D (System Failure Criteria Applicable to All Systems)completed Z System Information- Estimated depth to high groundwater Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-09/08 Title 5 Ofrird�¢al Inspocil 1 Form,`,Subsurface Sewn"Disposal Systom.Page 17 of 17 Summary Record Card genef ate d of)5612,011 2.22 18 PM by Karen I aftrr Page I Town of North Andover Tax Map # 210-064.0-0012-0000.0 Parcel ld 12014 220 DALE STREET BAJAN, JAN 220 DALE STREET NORTH ANDOVER, MA 01845 .......... Class 104 Two-farnily Property Type 1 Residential Size Total 1.5 Acres FY 2011 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until BAJAN,JAN Payor 220 DALE STREET NORTH ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 18360.0.220 DALE STREET Last Bilfing Date 41612011 3180441 03 Cycle 03 Active UB Services Maint. Account No.3180441 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0,635/8 7,82 1/ WTR WATER 01 ALL METER SIZE 60.80 /2 UB Meter Maintenance Account No.3180441 Serial No Status Location Brand Type Size YTD Cons 16335724 a Active 00 METE METE w Water 0.63 0.63 125 Date Reading Code Consumption Posted Date Variance 3116/2011 617 a Actual 16 4/13/2011 23% 12114/2010 601 a Actual 12 1/1212011 -29% 9/20/2010 589 a Actual 20 10/15/2010 70% 6/11/2010 569 a Actual 10 7/15/2010 53% 3/17/2010 559 a Actual 7 4/14/2010 15% 12/15/2009 552 a Actual 6 1/12/2010 -22% 911512009 546 a Actual 8 10/15/2009 19% 6/12/2009 538 a Actual 6 7/20/2009 -49% 3/19/2009 532 a Actual 13 4/29/2009 40% 12/15/2008 519 a Actual 9 1/20/2009 -5% 9/15/2008 510 a Actual 10 10/10/2008 16% 6/1112008 500 a Actual 8 7/16/2008 -2% 3/14/2008 492 a Actual 8 4111/2008 -55% 12/18/2007 484 a Actual 19 1/22J2008 12% 9/17/2007 465 a Actual 16 10/12/2007 3% 6/22/2007 449 a Actual 17 7/2012007 12% 3/1912007 432 a Actual 15 4/16/2007 6% 12/15/2006 417 a Adual 13 1/1 9�2007 -15% 912012006 404 a Actual 16 10/20/2006 1% 6/22/2006 388 a Actual 16 7/10/2006 16% 3/23/2006 372 a Actual 12 4/1712006 -6% 1/3/2006 360 a Actual 16 1/17/2006 -18% 9f26/2005 344 a Actual 20 10/14/2005 8% 611612005 324 a Actual 14 7/15/2005 6% 313112005 310 a Actual 17 4/5/2005 3% 12/22/2004 293 a Actual 14 1/14/2005 -13% ............."""Wem"Mem........... C' ry/� sd ., 6 *" °a Town o North Andover HEALTH DEPARTMENT [ IBC' #�; �r � r LOCATION: r " ype o T'errrrit cwr 1 - cis+ .(Check box) 0 Animal °�..M..... * Body Art Estalrlislonent �.__... © Body Art Practitioner ] Durnpster . 0 Food Service-'I`ype:—..._..._......_. _ _._._._._.._. _._ 0 funeral Directors .._.... © Massage Establishment ,__._.... ❑ AI'assage Practice ._........_..__.. © offal('Septic).Hauler © Recreational Camp .....w__ • Sun tanning S..-..._..w... _. • Swimming Pool 0 Tobacco S.w._ .. © Trash/Solid Waste Hauler _ p Well Constructiixra .- - SEPTIC Systems: 0 Septic-Soil Testing © Septic_Design Approval S 0 Septic Disposal Works Construction(DW0 © Septic Disposal Works Installers(DWI) 0 Ti(k'.�Inspector $ 771� f $ I Title 5 Report 0 Other:(Indicate)__........__._.,_ ._ .....-- Health,Agent initial; White-Applicant )LelLozv-Health l l - Treasurer FAX r IM 1! « • « « M « r" • w * w M « r r rr • r • r.i ` i i y r i.i ` 1 i • r *i r r • - r -r • ii. `r • r i • ` r i r • r r "" • •r s r � • r �. as TRANSMISSION VERIFICA'TION REPORT TIME 04/13/20I1 I0:33 NAME HEALTH DEPARTMENT FAX 9786888476, TEL z 9786888476 BER.# : 880LQM655497 ; 'i Y El STIN " y� co a,��y'r 4�R ,; ,, a / 1 %J r 9 r" i VMS , Y ✓r it 7 r , wr "nW I I,Map oars A MAMA MAC" NS iris�ll��°1��"���1kr`i�� '.�����F";.."�i 7„b",�'�r 1 �1'�!� 007 /��A �' ��";�(1;wP,� y �Je �' �tl rY pia �*� �� ""„ U "d F .'R T I ,."%�� r � .. �n -ea✓ p y� ary�''e � w �,D� ,w uw;, a,�rY`✓,,v✓wf. �f��. �Y' „�%,,, >��-w;o,�1� I c"a,ue'�"grv. o, e i77",," still.as, f wy nj t s ai. ,,,,.,✓�,,,¢ �,,,,.�G„ ,�,u�i. iui,.�.l�//di/%wi i/i,,,,,,,...ii �l�„4,�, ,f,/,,..,i..,o��;;,,.///,.,� ,.m.�Af.GI,,,,,,�� a//.ni, �1;, ,G,,,<„� ,,,���� .//,�/l/,�:�/i iJ�✓,,.;�,�.c,,,�,,,, �i��r"lL/li/�� �i,�,,.,.. ,'Y/�✓. <r u'v � r „e :err r..wv'm'"'�u�':.w nrvsu&NHVMAI¢I n..'. .. u � x � ,, l r i•RA nr. _ .. � � • MORTGAGE INSPECTION PLOT PLAN NORTHEFI14 A"SOCIATES, INC. 65 SALEM STREET,tAWRENCE,MA 0180•Tot.508-976-7117 I�yv TAIM «lam O"W V VMW Ali"`, 1i1M fAW 04rj ht' Sit — AW A4LF BIREEr PL"Mr. 10141 I'rAM N. ANWVEA . MA BIGALE! 1• 00' DAM OOr/11 f 00 uk71S► sit OOf 41m 11 pb� b 1' uk 1 1 ' 4� A 1.376 acmes �W G �n p♦ Ci x�y i» NAOY►TMAOM V MWTIRAW GO. r11*M tnspocoon was pnprrad 1 FURTHER STATE THAT IN W P i ",SWONAL " Prsp*sss and H OPINION npt to be OPINIONria prVrrctpN ssuc►ne s and srx assary Narfwrn Asswctnes, Inc, accopts no pl auriwildnp. CONFORM td M+�s nautdnq Mom.ssk Mssilon by ky1 $ MMr aIW mnrgapaa+r'Id Ma aaslpns In +* widr d»setback raquliram*rts of to Mxal WdrW M Rlpoasad marpsps fiftnrdrp b said g S ems,sit dut tw*am no aromas of s knpmvo"W—s Attar wiry Mann pop"*m M XOW*9 0.0112 AV,S0 r tp 411.Pmp*,IV is not In a Flood Hssard Arm *r** rxordanca 4 4'r 11 tq �p� ©2,Prop"is in a Flood Hazard Area. wrI».kortpapa twan k0 1 V Kati 0&InAonnoti n Is k1�10 dlWmkw FMwd Hazard. Aaswcisdon Rood Kozwd dam Mom Is*st FadwW Fl wd Muwrano Rtw wo PWNA /y�`y FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: l� �,J Phone ,"- ' a y LOCATION: Assessor' s Map Number � '� Parcel Subdivision Lot(s) Street .� �- ' � ' St. Number _ ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS Date Approved Conservation Administrator Date Rejected Comments Date Approved Town Planner Date Rejected Comments Date Approved :flood Inspector-Health Date Rejected A-) Date Approved -------- . Septic Inspector-Health Date Rejected Comments Public Works - sewer/water connections driveway permit Fire Department raot C � 4. �✓ � Received by Building Inspector Date ._ ..... Commonwealth of Massachus tts u city/Town of C` System Pumping Record Farm 4 DEP has provided this farm for use by to I oards of Health. Other farms may be used, but the information must be substantially the sam s that provided here. Before using this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information important: System Locat forms on the lo When filling out comp uter,use only the tab key Addre 9 to move your �" d _... _ 2i Code cursor-do not City/TownState P use the return key. 2. System Owner: Address(if different from location) Ci_._ty_._/T.__own.__. . ._ ._.___ .. ._...__._ State Zip Code Telephone Number' B. Pumping Record 1. Date of Pumping Da -- 2. Quantity Pumped: Gallons 3, Type of system: Cesspool(s) ET Septic Tank ❑ Tight Tank ❑ Other(describe): 4, Effluent Tee Filter present? ❑ Yes P.-Ne.• If yes,was it cleaned? ❑ Yes ❑ No 5, Condition o"ff System: 6. Sy stem Pumped By: Vehicle License m. Numbef ompany 7. Location where contents were disposed: / k n tu�o Mauler [late t5form4.doc*OG/03„ System Pumping Record•Page t of'I SEPTIC SYSTEM INSPECTION FORM ADDRESS I)ATE INSPECTED PROPERLY FUNCTIONING? Y N WEATHER CONDITIONS COMMENTS: A- K36 6 �6 0 Stl VA,CL S K NA'rF'IZ aVALITY TESTEb '? JZESOL-rS� DYE TEST PERFORMED? Y N DATE? SKETC11: ........ ... it ...... I P -"d ........... WATERSHED RESIDENTS QUESTIONNAIRE 1. Name 2. Street Address 3. flow many members are in your household? 4. What type of sewage disposal system do you have? cesspool septic tank and leaching area connection to municipal sewer [-J other (describe) .......... ------------- E-1 do not know 5. Are the plans (drawings) for your sewage disposal system on file with the Board of Ifealth? yes C1 no X do not know 6. How old is your sewage disposal system? [""] 0-5 years 6-10 years C^11-20years over 20 years do not know 7. Has your sewage disposal s stem been rebuilt or repaired? E I yes m do not know If yes, approximately how long ago? years. What was done? .......... 8. How frequently is your sewage disposal system pumped out? annually every 2-4 years DI every 5-10 years over 10 years I,vsl never 9. Have you had any problems with your sewage disposal system? LJ yes no If yes, what problems? repeated pump-outs needed system clogs, backs up, or drains slowly odors sewage surfaces through ground 10. How many of each appliance are connected to your sewage disposal system? washing machine dishwasher garbage disposal dehumidifier drain Sump pump toilet roof/pavement drains shower/bathtub 11. Please state the brand and type (liquid or powder) of detergent you use for: dishwasher clotheswasher T- 12. Does your property have a lawn? yes no If yes, approximately / what ze? I/ E'-] '/,, acre [--j' -14 acre acre less than 1,/4 acre 4 acre more than 'I acre (Specify) --.. -.... acres 13. How often do you fertilize your lawn? Y)e V of No. of applications per year Season(s) of the year 14, Please state the brand and type (liquid or granular) of lawn fertilizer you use: Check here if your lawn is maintained by a professional landscape contractor- "WON ...WOW STATEMENT Tel. (608)475-4786 Bateson Enterprises Inc. 111 Argilla Road * Andover, Mass. 01810 Jec . 2.9 19 _23_ 1,,r . Jan Bajan 220 Dale Street North Andover , !,!a. 01845 L To insure proper credit mease return this stub with your remittance. AMOUNT s.11ald- DATE DESCRIPTON AMOUNT 12/20/93 220 Dale Street North Andover , L.,a. 01845 At the time of pumping out the septic tank, the septic system was in proper working order , The septic tank is 1200 gallons . In no way is this certification guaranteeing the septic system from .1ailure. Beteson Enterprises, lnc. -Andover, MA 01810 "Y 0'A