Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Building Permit #743-15 - 150 LIBERTY STREET 8/31/2015
NORTh `BUILDING PERMIT ge tio TOWN OF NORTH ANDOVER ` o ; APPLICATION FOR PLAN EXAMINATION yf Permit No#: I Date Received �i 4.0R gSSACHU`��� Date Issued: �IPORTANT: Applicant must complete all items on this page LOCATION PROPERTY`OWNER Print 100 Year Structure fires ^ MAPO PARC - G S,ZONING'DISTRICT Historic District yes -rno- Machine Shop Village yes re- TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family 0 Addition ❑Two or more family ❑ Industrial 0 Alteration No. of units: ❑ Commercial D&Repair, replacement 0 Assessory Bldg 0 Others: ❑ Demolition ❑ Other Septic, ❑1Nell, ❑ Flgo-dplain p Wetlands 0 Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: rJe-w Qoor Layovr r Identification- Please Type or Print Clearly OWNER: Name: covr-ti o ;Phone: '(1T- 3`f as Address: l S.� ���-�� S� _ _ ____ . ------ Contractor Name: �_.. . _.Phoneh _ . _ _ . '��5��8 - �. a �_ Address: Supervisor s Construction °License . _C S o S y Exp +Date;_ / _ �, a I Horne Improvement License z_ _ ... Y-:� .Exp. Date: `!�_� _ ►_ .e ,. ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ d � Check No.: Receipt No.: II'I NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund I Signature of Agent/Owner_ .�p_ Siahatture of contractor__ r. f Building Department The.following is a list of the required forms to be filled out for the appropriate permit to be obtained. ,l. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) u Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit is Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:BuildingPermit emit Revised 2014 Plans Submitted ❑ Plans Waived Certified Plot Plan ❑ Stamped Plans ❑ F F SEWERAGE DISPOSAL ewer ❑ Tanning/MassageBody Art ❑ SwimmingPools❑ Tobacco Sales ❑ Food Packaging/Sales" ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS i 1 CONSERVATION Reviewed on Signature R COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes I Plhnning Board Decision: Comments � s Cofservation Decision: Comments n Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTiMENT - Tern p'Dumpster-on site yes no. w: - _ Located at 124..Main Sheet Fire Department ignature/daterA COMMENTS 8 I ' Dimension Number of Stories: Total square feet of floor area, based on Exterior, dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service;drop`requres-'`approval of Electrical Inspector Yes No Z;. DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 u li s. Location No. Date • - TOWN OF NORTH ANDOVER • � n7ry ' • • Certificate of Occupancy $ Building/Frame Permit Fee $ �� Foundation Permit Fee $ � Other Permit Fee $ TOTAL $ Check# v Building Inspector own o . ? EAndover No. h ver, Mass, S coc"Ic"IWICK y1 ASR^TED 1,100 S U BOARD OF HEALTH Food/Kitchen PERMIT LD I Septic System THIS CERTIFIES THAT D.avee...... . .. . . :. . ........... BUILDING INSPECTOR .......... ........................................... has permission to erect buildings on Foundation .......................... ....l.S�............ . . Rough to be occupied as ....... ....PQ. .... :.............. ...!f/ ':?....�!`!.1�4�:!. �. .�.................................. Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCT RTS Rough - Service ....... .. ............................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. YES TA Building and Remodeling Start date 4/1/15 5 APPLETON STREET Finish date 6/1/15 NORTH ANDOVER, MA 01845 HIC Lic. 120296 Expires 11/19/15 (978) 682 2023 CSL Lic. CS 54718 Expires 6/8/16 Proposal March 30, 2015 Proposal Submitted To: Dave lacoviello Cell Phone: (978)975-3402 150 Liberty Street North Andover MA 01845 Job: Roof and replacement windows Obtain building permit Complete removal of all demolition and construction materials generated By Testa Building and Remodeling and its subcontractors. J Roof: Reroof over single layer existing on the main part of the roof. Strip and rubber the whole roof over the family room. Shingles will be IKO Cambridge Charcoal Grey $5650 Replacement Windows: Remove the sash and balances from the existing windows. Install a Harvey or Paradigm replacement window. Caulk and foam around window the best I can. Add a new stop to hold the window in place. 24 double hung windows only(No Casement) $375 each $9000 A finance charge of 1±/2%per month(18%per year)will apply to all accounts over 30 days past due. In the event collection activity is required the customer shall be responsible for all costs associated with collection,including reasonable attorney's fees. I propose hereby to furnish material and labor complete in accordance with above specifications, for the sum of: $ 14,650 Fourteen Thousand Six Hundred Fifty Dollars One-third to start,one-third after roof is done,one-third upon completion. Authorized signature I reserve the right to cancel this contract if not accepted in 30_days Signatu e Signature i DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners.Seek legal advice if necessary.Any person planning home improvements should fust obtain a copy of"A Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of Date when contractor will begin contracted work. MGL chapter 142A.) Express Warranty-Is an express warranty being provided by the contractor? No Yes(all terms of the warranty must be attached to the contract) Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor.The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement. Contract Acceptance-Upon signing,this document becomes a binding contract under law.Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence.Review the following cautions and notices carefully before signing this contract. •Don't be pressured into signing the contract.Take time to read and fully understand it.Ask questions if something is unclear. •Make sure the contractor has a valid Home Improvement Contractor Registration.The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration.You may inquire about contractor registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. •Does the contractor have insurance?Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof of insurance"document. •Know your rights and responsibilities.Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement.See the attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! Two identic c—ouimoUhe contract must be cc I igned.One copy should go to the eowner.The other copy should be kept by the contractor. Hon er's S' � � tor's Signature 3 0 � Date Date Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an alternative to court action)if they have a dispute with a contractor.The same right is not automatically afforded to a contractor,however.The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner b the Improvement Contractor g Y Home Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor may submit the dispute to a private arbitration firm which has been approved by the Secreta-j3, of the Executive Office of Consumer Affairs and Business Regulation and the cons re ired t ubmit to such arbitration as provided In Massachusetts General Laws,chapter 2A. Homeowner's gnature Contractor's Signature NOTICE:The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor.The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e. MGL chapter 93A)may not be waived in any way,even by agreement.However, homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law.Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law.The contractor is responsible for completing the work as described,in a timely and workmanlike manner.Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts cavy an implied warranty of merchantability and fitness for a particular purpose.An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights, contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor.Any modification to the original contract must be in writing and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of the contract,and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure.However, in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work.Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights,or if you wish to obtain a free copy of"A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the OCABR website at http://www.mass.gov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law, contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170, Boston,MA 02116 617-973-8787, 888-283-3757 or visit the HIC website at http://www.mass.gov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: http://db.state.ma.us/homeimprovement/licenseelist.as 1 ,11 � 11 .s. 1 � .I � . - 1 . ., 1 , --. ... .. f . _ 1 ii t, 4, S �, � i 1 1 � i r 1 r 1 . �jj i.. ' � � � 1 �< . 1 ,'] �r i. '1 � I � � '1. � )r .� r. .. .:lit .. i� .. it :!'1• ' .. .. '/ _ i 1 . .. � d _ _ '1 _ i . . . ��%� S.5.... ,.. �,.a. � S . Ij'}'tt � er` ., it r� . 4. �.� ' :.<.. '' .. � _1 . 1 � � � � �<. . � ! it i 1 ` 1 r' '1 ' .. ' � _ �. - ' � it � % 1� � � ' - I � � f .i .. � '_ t .Lv '. . . 1{ . .i .1. r. .; For assistance with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-6524800,508-755-2548 or 413-734-3114 Version 2.1—11/22/201 NOTICE OF CANCELLATION YOU MAY CANCEL THIS TRANSACTION,WITHOUT PENALTY OR OBLIGATION,WITHIN THREE BUSINESS DAYS FROM THE ABOVE DATE. IF YOU CANCEL,ANY PROPERTY TRADED IN,ANY PAYMENTS MADE BY YOU UNDER THE CONTRACT OR SALE,AND ANY NEGOTIABLE INSTRUMENTS EXECUTED BY YOU WILL BE RETURNED WITHIN TEN BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOU CANCELLATION NOTICE,AND ANY SECURITY INTEREST ARISING OUT OF THE TRANSACTION WILL BE CANCELED. IF YOU CANCEL,YOU MUST MAKE AVAILABLE TO THE SELLER AT YOUR RESIDENCE, IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN RECEIVED,ANY GOODS DELIVERED TO YOU UNDER THIS CONTRACT OR SALE; OR YOU MAY, IF YOU WISH, COMPLY WITH THE INSTRUCTIONS OF THE SELLER REGARDING THE RETURN SHIPMENT OF THE GOODS AT THE SELLER'S EXPENSE AND RISK. IF YOU DO MAKE THE GOODS AVAILABLE TO THE SELLER AND THE SELLER DOES NOT PICK THEM UP WITHIN TWENTY DAYS OF THE DATE OF CANCELLATION,YOU MAY RETAIN OR DESPISE OF THE GOODS WITHOUT ANY FURTHER OBLIGATION. IF YOU FAIL TO MAKE THE GOODS AVAILABLE TO THE SELLER, OR IF YOU AGREE TO RETURN THE GOODS TO THE SELLER AND FAIL TO DO SO,THEN YOU REMAIN LIABLE FOR PERFORMANCE OF ALL OBLIGATIONS UNDER THE CONTRACT. TO CANCEL THIS TRANSACTION, MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS CANCELLATION NOTICE OR ANY OTHER WRITTEN NOTICE, OR SEND A TELEGRAM TO [Name of Seller],AT [Address of Seller's Place of Business]NOT LATER THAN MIDNIGHT OF (date). I HEREBY CANCEL THIS TRANSACTION. Date: Buyer's Signature: ell. rrxar;cae2�l�`e elation . � f{ice of Consumer Affairs&Business Rei ME IMPROVEMENT CONTRACTaR _- — / Type' _ gistration: - 120296 DBA I xpira1111912015! _ , , tion TESTA BUILDING&REMODELLING 1 JAMES TESTA • g—�=o {� 5 APPLETON STREET 01845 Undersecretary MA N.ANDOVER, y L�� Massachusetts -Department of Public Safety 9 Board of Building Reguiat ions and Standards Construction Supervisory License.-CS-0547`18 y JAMES M TESTA-` '"- 5'APPLETON ST, Q N ANDOVER MA'01845 jT' Expiration 06!0812016 Commissioner 150 LIBERTY STREET t �1 --- ---- 210/0900000.0 1 1 i �� �� ..r hio- _��� �� .n�� '� O� �, \rte 1�3n�-1 � �-�'� OF NORTH•ANDOV79.R-`R-`-. S'SCSTFM PUMPING RECORD D s'TFM OWNER & ADDRESS Alp SYSTEM LOCATION — (example: left front of house) . DATE OF PUMPINC: ' �S QUANTITY PUMPS-D j,' C ALLc», i a.' �I UUL: NO YES` SEPTIC TANK: NO YES/ _ aTURE OF SERYICE, ROUTINE EMERGENCY uIIsERVATION& GOOD CONDITION. FULL TO COYER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACH FIELD RUNBACK. EXCESSIVE SQLIDS � FLOODED SOLIDS CARRYOVER HRR (EXPLAIN) d//k7wl ep" (.'U:11Ivi FATS: , ONThN7'S I'RAKSPORRED TO: a^� `i . I �� 9 ..� � + .tiii '� + �1�. ` . � ..�, Gln. � ice•11�� _ .���....�.-�. �.. 4 'F�_1'�`- ....r.�.�Mc�tk.F"...—«..�_s.-•.^i:= ._.S.r �.. .r -..u.. � �� i�� W - . �. ii Fes.S �+; - r .�� �I N 1 . — ^n 9 Lor 5 AJRG�4 = Z,Ot.ac/z��s 1 � o M 1 i 311 �A --,351 26\\\ �SEPTIC T.ahlK Ex�Sr�NG I=NS, AkF-4 9XCAVgTC0 TD !2EML)Ve, Ui✓SVITAl5t4 ° 321. ;��`— p1A7�rLIAL /JNA l5�1CKF4ll�i� w i1Y/ c[traN 30 i 1 `D-WX ® LE/AC(W(;� 1 } L 16E1Z>,TY 57-9EE F - - - THIS 15 /D cziZT/Gy TN T T NAvE /NSRrLCrEt) TliF- corisiEVC7-701-1 OF 7YI f PISP0 S,4 C.. 5 ys7FM AT LOT S 1 LI r6ER ry 5%tZ"i, /N0v/-,)j,p/yob L/g 71�� GrZAb%s A .is 5IoGcIGIoo IN Tim P(�IYS ,vN0 5prcciG/C.41�U1�iS DAI�d Ap121C 16,090 ) GW7Y1 T)tZ. FXC.ejonoNS 45 1_151-yD CiFlow, o�y� N OF cy 9 �+ /� /�LU /� P41 G L ORGr I L OVII 4 E/Y T o aN ss X - /50 — = FSS�ONAL DESION EL EPW-10N 47.. ..... . .(TOP OF 570NE) _ EX/5T/NCS ELEI/ RON ,47 . . . .. . . . . 2EQU/r2E0 F/LL = ' DES/QN !JS 3U/LT IAIV RIPE OUT OF NOU5E 11VP/PE INTO TgNK 28135 IL 5, 0-7 ,5443 wJUpF.4d Cc ®1.S/ 0.,54L /NV f`.iPE OUT OF T,4NK t Z S.10 127, 8 4- INV INV PIPE INTO D. BOX 1 z-7,gz I z.-7.48 INV P/PE OUT OF D. BOX 1 z-7, s /27,3Z /N INV END OF PIPE 2-7,So C/ 1z6o7 NOR7 1-� AlhIl] UyER 1 MA 17--7, 04- FOR GV.4TE2 EL EIlLI TION MICHAEL ANL) MAu2F�t/ MERTA 12-010 .4VE?,46E STONE 5C.4LE / = 40' D4TE.- Nov, Is1/qqo DFP7-1/ 47- RleO,3E NOTE• 7-1//,5 PZ-.4N /.5 NOT ,4 w,4,e1e4NTY CgRl5TIA NSEN SER C71 , INC. OF Tk1 5Y57-67M BUT A VE1?/1c-1C,47-10N 16,0 SUMMER STREET HAVERN/LL ,MA5S." Of T11E LOC.4TION OF 7WE EX/STING S7-1eUC7L/2E5. I • i FORM - U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that allnecessary 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. APPLICANT ......... .............. ..................................... .............. ' t !� G �.��c a i�1 � PHONE 9 78 _ 175 ASSESSORS MAP NUMBER 6 /Zn LOT NUMBER D O 6>�5 SUBDIVISION LOT NUMBER - , l• STREET STREET NUMBER �5 ..................... ..........■■.■.■■r■r■■■..■r■■■■■r■.■■■■■■ ........... OFFICIAL USE ONLY �_ RECOMIV1ENDATIONOF TOWN AGENTSsummon nomemosm nowmanow muss mouo-go Sonoma 0 manom muss 0 mailman / ----� DATE APPROVED I ✓ r NI b® CONSERIVATION ADMINIS TOR )SATE REJECTED CoNmfENTS Q' '^� a f� / — t� s (d C ��d.nl �►,np 'gyp be al�s aQ TOWN PLANNER �- DATE APPROVEDmm O l�0 DATE REJECTED COMM ENT'S DATE APPROVED FOOD INSRECTOR TH DATE REJECTED 'A DATE APPROVED PECTOR-HEALTH DATE REJECTED coNmans PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTNIENr DATE REJECTED CONAAENTS RECEIVED BY BUILDING INSPECTOR DATE " Town of North Andover, Massachusetts Form No. 1 6` NORTH BOARD OF HEALTH Q` 11.ED �ti 0 19- 6 APPLICATION FOR SITE TESTING/INSPECTION �1 AOkA TED PPp �h �SSACHUS�� 4�c7iz Applicant NAME J ADDRESS TELEPHONE Site Location . y Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time tCHAIRMAN,BOARD OF HEALTH Fee o r" _f Test No. ()Le S.S. Permit D.W.C. No.� C.C. Date — Plbg. Permit No. 00-62 ~ � . , � � / | | � ` CHECKLISl FOR PLAN REQUIREMEN] S FOR SUBSURFACE SEWAGE DISPOSAL SYS;ENS TOWN OF NO. ANDOVER BOARD OF HEA1-111 MARCH, 1990 | ( _ 1. p_ (Su ggested Scale: 1" = 20001 ) � � A. Locus identified. . Streets and names within 1/2 mile. - C. North arrow and scale 2. (Suggested Scale: 1 " = 201 ) .........................I/*�A. Lot to be served, its dimensions and area. _ ,-� B. Fronting street. __ North arrow and scale. _.......... Assessor' s designation. / ................7-E. Abutters names and lot numbers. � | - F. Easements. ' ---��'-G. Property lines. � | __~ H. Footprint of proposed hoosn to be served showing � garage (attached or detached) . /~ D. Where applicable setbacks to house. . Number of proposed bedrooms, . Location and type of material ( if known) of driveway. _.............. Water service line from )/Jell. Location of existing or proposed well. N. Location of deep observation holms arid percolation � tests. � Existing and proposed contou,-s' ____e_p. Den�h marks (2) -arid ties to proposrd systr.., leaching facility from bench marks or other permanent physical features (stonewa1lsv �tc. ) .................... Location and d�men�im`s o� systrm <��pt �c� tan!�, pipes and leaching facility) including the reserve � area. Profile and' snction arrows. Location of any stre�ms water bodies � ----- " ' surface and | subsurface drains, known suurces of water supply / � � within 200-feetv and wetlands within � ( locate wetlandsv specify type of resource and show | / 100-foot buffer zone line if applicab�e> � ~ ' _T. Erosion control devices as required by Con. Comm. , Board of Health or Planning Doar-d with detail and description of device proposed. � ' ^ | | ~ � / . � 3. ~ A. Pei-colation rate used for design. _----- Bmi% log results - designate various strata depths and description, depth to ledge and/or groundwater ~/ if encountered. � `_C. Date of percolation arid deep hole tests. . Number of bedrooms. _E. Calculations for leaching area requirements. 4~ Profile of ���8� (Suggested Scale: 1 '' = 41 ) /A. Finished floor- of house. � ___ Invert elevations at house, septic tank ( inlet 8 ou± let) v and distribution box. If applicable for- pump orpump systems, inlet and outlet of pon/p chomber and pump bloat switch settings with supporting calculations. Lengthv type and grade of pipe and length of leaching facility. _L D. Elevation of ledge and/or, groundwater.�'E. Elevation of bottom of leaching facility. Existing and proposed grades. .........................B. Slope (breakout ) requirement and calculations. Scale. 5. Ol (Suggested Scale: 1" = 40 ) ' A. Elevations of various components. . Existing and proposed grades. /C. Types dimensions and stone and system components / specifications. . Elevation of ledge and/or groundwater. ___��E. Elevation of bottom leaching facility. /-.-.F. Dimensions. ! __....... Slope (breakout ) requirements and calculationn. � � _...........__.N. Scale. � 6^ Add itiq�)��--Ngt��si_anc|-Othe�_Detsxils / Owner» s namev address and phone number. / Applicant' s name, -Address and phone number. G. Engineer" sm 'mev address and phone number. ' . The designer should indicate any notes or special conditions peculiar to the site of interest to the / Boardv Installer or Owner. | � Plans should be dated. Any revised plans after the � initial submission should show a revision date and � abbreviated explanation of the revision. � F. If a pump system, type, make, modelv operation head | and pump 'rates should be provided. All required alarm, power and float switch dita should be � provided for review and apprnval | � / _ | � ! " |� / � � | System components (scptic t,-Ir);(, D-bon, etc. ) � details should be provided if other than standard as required from local suppliei`s. Component spec should be indicated somewhere on the plans for ' standard items. � - / . Reviewed and recommended by: � ! | | L / � ___.... _......-_.........._-............. --__ � Date � � i ! � � | � � ! ' � / � � . } |' REVIEW FORM FOR SUBSURFACE SEWAGE DisrusnL SYSTL- Pt-mis TOWN OF NORTH nNDUVER BOnRD OF HEM-111 OWNER — NAME: ............. ........... -------........................ ............ .......... ADDRESS: PHONE: ..................................................................... ............................................. ........... ..................... GRIRLLCANT NAME: ADDRESS: PHONE: ENGINEER. NAME: ADDRESS: PHONE: RRQREUYP0N.RRT.A. . ASSESSOR' S MAP.____._ .. .... LOT .... ... ...... ............... STREET LOCATION___---. --.. .. ............ ............. PLnlq DnIE CHECKLIST DEFICIENCIES ................. .......... ................ ............................. ................... ...................................... .................. .................. ........- .......... OTHER .......................................................... ............. ............. ............. .............................................. RECOMMENDED DENIAL REASONS---....--....-, i REASONS (CONT. ) i ' RECOMMENDED APPROVAL ----......_..................._............-................................_.._.....__....... CONDITIONS/COMMENTS .--........-..............................................__..._...........-.................... ......_............._.._ ..._................. ................__.........._....._...... -----......................................_......................--......._.._............................._.._.............................................................._.._._........_.. II I � i i � � i i I =. `�q u MAP #_ _ __. — LOT # ......_..... ............_.._._......._.._......_.....__....._........ PARCEL # STREET.__.._... — s..�...........__-.... __.. C_O.N.ST RQCT_I-0N_.,._APP.RO..VAL. YES NO HAS PLAN REVIEW FEE BEEN PAID? I' . PLAN APPROVAL: DATE_ !I�U____.____ APP. BY...,._.0 6 7 DESIGNER: G �sT4� ! - PLAN CONDITIONS WATER SUPPLY: TOWN WELL WELL PERMIT---I ------ DRILLER. ...........V 1 ...........� C.c� .. _.... ...._.............._................_.... WELL TESTS: CHEMICAL DA E A{=`(='f�UVED..._.lf...27. T _1`........_. BACTERIA I DOI E (K)PROVED ./J�21 ©... .,, BACTERIA II DATE APPROVED_............................_....._...... COMMENTS: FORM U APPROVAL: APPROVAL TO ISSUE YES NO DATE ISSUED I BY CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID r, WELL CONSTRUCTION APPROVAL SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NO ANY VARIANCE NEEDED YES FINAL BOARD OF HEALTH APPROVAL: DAI'E: �S � BY: • IS THE INSTALLER LICENSED? YES NO TYPE OF CONSTRUCTION: NE REPAIR NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW ES NO CONDITIONS OF APPROVAL YES NO� (FROM FORM U) ISSUANCE OF DWC PERMIT �ES. NO DWC PERMIT NO. (1 INSTALLER:_„A�_;�____ BEGIN INSPECTION YES 0: EXCAVATION INSPECTION: NEEDED: PASSED l/ 13 AV. BY CONSTRUCTION INSPECTION: NEEDED: ............................................... _ d1 � AS BUILT PLAN SATISFACTORY: APPROVAL TO BACKFILL: DATE: _ _BY ,_' . FINAL . GRADING APPROVAL: DATE ____BY_ FINAL CONSTRUCTION APPROVAL: DATE: BY _ C. 7 Z I ? �e12a2�ine�2� �� �'�t�i2annaen�a� �cca�i�� (%,t e2i�z baa l2elnce &XIM' ime"I 91Ca &n 37 9Aallac'c 99heel, Yaw""Ce, t-1ftaodac1iu6ell6 018113 CERTIFICATION FOR ENVIRONMENTAL ANALYSIS LABORATORY: MA126 DATE: 04/15/90 Tewksbury Water Treatment Plant 71 Merrimac Dr. EXPIRATION DATE: 12/31/90 Tewksbury. MA 01876 DIRECTOR: Lewis Zediana 508-858-0346 PRIMARY CATEGORIES (DRINKING WATERS) FULL CERTIFICATION: Trace Metals, Nitrate, Fluoride, Corrosivity Series, Sodium, Chlorine, Turbidity, Total Coliform (MI') 'PROVISIONAL CERTIFICATION: Cyanide SECONDARY CATEGORIES (OTHER MATRICES) FULL CERTIFICATION: Fecal Coliform (MF) , Standard Plate Count PPf)V!SI NIAI, ('F.RTTPTrA4!IONe None at. Present. 'Phis certificate supersedes all previous certificates issued to this laboratory. Reporting of analyses other than those authorized above shall be cause for revocation of certification. Original Certificate, not copies, must be displayed in a prominent place at all times. Certification subject to approval by OGC. Jose:p E. O'Brien, Ph.D. Director, Laboratory Certification . For the ,Commissioner i Lewis W. Zediana P1ant* Chemist ' Tewksbury Water Treatment Plant s 71 Merrimac Drive Tewksbury, MA. 01876 July 3, 1990 Wilmington Pump Supply 639 Woburn Street Box 517 Wilmington, MA. 01887 Dear Sirs, .. The results of the analysis of the water samples submitted on June 29, 1990 from Lot"'#5`150 LibertySt"reet North Andover, Ma. may be found below: Test & Result State Limit MCL Type Total Coliform: 0 colonies/ 100 mis. 1 Primary Color: 7.7 Hazen Units 15 Secondary Turbidity: 2.94 NTU 1 - 5 Primary pH: 7.70 6. 5 - 8.5 Secondary Alkalinity: 91 .2 mg/L as CaCO3 No Limit Hardness: 92.0 mg/L as CaCO3 No Limit Sodium: 9.7 mg/L 250 mg/L Secondary Iron: 0. 16 mg/L 0.3 mg/L Secondary Manganese: 0.04 mg/L 0.05 mg/L Secondary Conductivity: 230 u�i�il0 No Limit * Mass. Guideline 20.0 mg/L Laboratory Mass. CertificationYV# MA 126 Analyst:—Co Lewis W. Zediana Plant Chemist b. , _: Tewksbury WTP TEWKSBURY WATER TREATMENT PLANT LABORATORY ANALYSIS SHEET CERTIFICATION # MA 126 Sample From: fT— Address: / 5 2 41'6zrty 5�yte ' 1014�hone• City/Town: AYvdc've,K State: MA Collected: / d? Time: 00 By: Received : )Z�' ` o By: eo4,a1V4- Code: 19NAL030 c Analyzed : Analyst: BACTERIAL ANALYSIS T. Coliform: 100 ml . F. Coliform:- /100 ml . HPC: MI. i INORGANIC ANALYSIS Color: �O color units Turbidity: NTU q pH: - d Alkalinity: / l mg/L Conductivity: ;L3 0 umho/cm Hardness: ! - � mg/L- Chloride: mg/L Fluoride: mg/L Ammonia: mg/L Nitrate: mg/L Nitrite: mg/L Free Chlorine: mg/L Sulfate: mg/L Total Chlorine: mg/L Cyanide: mg/L METALS Iron: o ' _ PPM Manganese: a D PPM Calcium: PPM Magnesium: PPM Sodium: �� PPM Potassium: PPM Zinc: PPM Other: PPM II TRACE METALS Lead: PPB Arsenic: PPB Mercury: PPB Silver: PPB Selenium: PPB Barium: PPB Cadmium: PPB Chromium: PPB Thallium: PPB Beryllium: PPB I Nickel: PPB Antimony: PPB i Copper: — PPB I "0 Th , ttto 6gti0 = 0 BOARDO F HEALTH 120 MAIN STREET TEL: 682-6483 "SSACHUS NORTH ANDOVER, MASS. 01845 Ext. 32 or 33 June 14, 1990 Mr. & Mrs. Michael Merta 18 Wisconsin Ave. Somerville, MA 02143 Re: Lot 5 Liberty St. No. Andover, MA 01845 Dear Mr. & Mrs. Merta: I have recently been made aware that a building permit was issued some time ago for the construction of a single family dwelling on your lot.' Before this permit was issued, the well to service the dwelling was supposed to have been drilled and approved by the Board of Health. I realize that you may not have been informed of this. I would appreciate it if you would contact me at the Board of Health office so that this situation can be remedied. Thank you for your cooperation in this matter. � . ' Very truly y Y[Ys,; ' , S44i Michael Ro ti Acting Health Agent MR/re 1 641 DQ��= 4 t', Dat 1 leL� e � � 19No. uv✓ Received Of —�—e�— Address CA c For HOW PAID BALANCE DUE REDIFORM© 8L 190 carbon/eaa BY BOARD OF 1-11�AL1 H Town of North Andovcr ,Mass . Date 19_� Permit APPLICATION FOR WELL & PUMP PERMIT rill a well O . Application is permit to d PP Application is hereby made for pe _ made to install (_) a pump system'. ' I Location: Address 160 - f � .� E�-Lot f ' Owner MCeIA Address M4.Ci cam` Well Contractor VIZ'eA �a Address Pump Contractor&, Z4-.,A„y�ry ;DoAddress Tel .�5 WELL CONTRACTOR (To be completed at time of pump test ) Type of Well Well used for Diameter of Well Size of Casing Depth of Bed Rock Depth casing into Bed Rock Was Seal Tested? Yes ( ) No ( ) Date of Testing Depth Well Ended in Wha-t. Material Depth to Water_ Delivers Gals . Per Min . for 4 hours Drawdown feet after pumping —_hours- at GPM Date of Completion Signature Well Contractor I '..'':C:�'.C.a.....V✓.::::''.:C:::::'C::::::':C::'"%Gni.i' :'.. .. .. .. n .. n .. .. .. .. .. .. .. .. .. .. .. .. .. .:is:. n .. .. .. .. nnn .. ..'n;, .. n'.`':.::'..`"n::'.'t�iC.-i.�.:C*.'1' I • I PUMP INSTALLER (To be'• f-illcd i.n before i.nsn.illation ) Size & Name Pump _ __ —_ __;Pump Type Used i Water Pump Delivers GPM Size of Tank Pipe Material Used in Well : Cast Iron ( ) G.-11vanized (—) Plastic II Well Pit ( ) or Pitless •Adapte'r ( ) I Was sleeve used to protect pipe? Yes (—) NO(_) 'Type or Name Well Seal nate tiaIle l4ti'tl4I'rti4ti'rYr Yeti'ryrY; t,'; It :;,r:;,:,;::,:;::::; Date Water analysis repor-t submitted to Board of: Health Date release given tD owner of record & Bldg . Insp th Ins ector Heal p 2 � i 1 t 3�O,S7 t VO - w h>`tG�2 _.:?`• .. K I.F�J. 'r•..el:f.! nhtAO �N� :! .. �:�..V:! �. ��/�-! �.0 Ll•.• N: �0 •r,J_ N.. 30.8 _ _ .. � � � �� - � .-. :. _: _• � -may - . . M Mm Commonwealth of Massachusetts Executive Office of Environmental Affairs \\\j ®apartment of Environmental Protection W111lam F.Weld Trudy Coxe Govemor Secretary Argeo Paul Calluccl David B. Struhs U.Govemor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: (ksQ111�Qx � �•- ��V� Address of Owner. Date of Inspection: --^a =a (If different) Name of Inspector. � �;�, ��, r<>�Y� Company Name, Address and Telephone umber. BATESON ENTERPRISES, INC. TEL:15081 s%5-1.1704 l�i, ,, Excavating-Water&Sewer Lines-Septic Systems&Pumping Se vke FAX:(508) 175-5451 l CERTIFICATION STATEMENT 1 1 1 Argilla Road Andover,Mass.0 18 10 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority F . Inspector's Signature: qT��� Date: The System Inspector s bmit a cop- of this inspection report to the Approving Authority within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM SFS: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B1 SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved b theBoard by of Health. (revised 11/03/95) I One Winter Street • Boston,Massachusetts 02108 • FAX 617 556-1049 • Telephone 17 1 ) P Is )292-ssoo A est Pnnted on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A r CERTIFICATION (con 'nue !\ d) Property Address: o Owner. ".(- �, L Date of Inspection: B1 SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken; settled or uneven distribution box. The system will pass inspection if(with approval of tho Boar,of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 Cl FURTHER EVALUATION I9 REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require'further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM I9 NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or,less than 5 ppm. 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) �-- Property Address: l.5� � %. Owner. Date of Inspection: Dl SYSTEM FAIL: J. I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. 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 1/2 day flow, _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ Any portion of the Soil Absorption System, cesspool or privy is below the groundwater high elevation. g Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteriaabove: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 U of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 � I r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: l Owner. Date of Inspection: V UV 1 Check if tizg ' have been done: _�Zinformation was requested of the owner, occupant, and Board of Health. ne the system components have been pumped for at least two weeks and the system has been receiving normal flow rates p puri that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As t plans have been obtained and examined. Note if they are not available with N/A. The cility or dwelling was inspected for signs of sewage back-up. �Thegelkm does not receive non-sanitary or industrial waste flow he ite was inspected for signs of breakout. _ _All stem components, excluding the Soil Absorption System, have been located on the site. _The se 'c tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. _The size and location of the Soil Absorption System on the site has been determined based on existing information or appro ' ted by non-intrusive methods. he facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 4 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner. Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Number of bedrooms: Number of current residents: Garbage grinder(yes or no): Iluo Laundry connected to system (yea or no): ps Seasonal use(yea or no):-P—(6 VLAa1� Water meter readings, if available: Last date of occupancy: --�� 4- l( 1 I So 25i(�kI111PSt3l�IAL./INAUk7TRIAI Type of establishment: Design flow:-----_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no) \Ij �tJ If yes, volume pumped: gallons Reason for pumping: TYPE, 0 "TEM 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) Other(explain) APPROIqMATE AGE o all components,date installed(if known)and source of information: � � I A- Sewage �,�, Sewage odors detected when arrivingat the site: J( •�U (yes or no) 1_ (revised 11/03/95) 5 el SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner ` cv f� Date of Inspection: ,/ t SEPTIC TANK_V (locate on site plan) II l/ Depth below grade: l U _ Material of construction: t, n mW_metal_FRP—other(explain) Dimensions: (�►n� Sludge depth: y 1� Distance from top of sludge to bottom of outlet tee or baffle:10-� Scum thickness: .G 1 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumpin�con� tion o inlet and outlet tees r b es, de th of liquid lev relati to outlet invgr�, etruct into ' e 'den f�le' gie, etc.) t� l dLj V C N U i GR TRAP:X-Orp (locate on site plan) Depth below grade: Material of construction: _concrete_metal_FRP —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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) I (revised 11/03/95) g i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: L 1 j Dto of Inspection: TIGHT OR HOLDING TANK: j�^t(� (locate on site plan) Depth below grade: Material of construction: _concrete_metal_FRP_other(explain) - Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:L//"" (locate on site plan) Depth of liquid level above outlet invert: C/ Comments: (n if level d di,#trib i n i$ ual a 'dente of solids carryover, e ' en f leakage into or out of box,e (�� c J c , v c� S� . v 1 L C)v IQ PUMP CHAMBER:-Vt)r 2 — (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATI (continued) Property Address Owner. Date of Inspection: �\ SOIL ABSORPTION SYSTEM (SAS): L� (locate on site plan, if possible;excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number- leaching r C.,n P/'I„O leaching trenches, number,length: ..L,y�=--f_ .� 4� CJV� ' leaching fields, number, dimensions: overflow cesspool, number: J Co nents: (note pundit' n,of soil signs of h draulic fAil lev 1 f ponding, Condit' n of ve do ,etc.) CESSPOOLS: v P (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(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:Jv ICN ` (locate on site plan) Materials of construction: y' Dimensions: Depth of solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.) (revised 11/03/95) g I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ( 5O Owner. l 0 ci Date of Inspection: � Q ` � - �10 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' g 3 3a' y If A-Ao 3 DEPTH TO GROUNDWATER'( Depth to groundwater: I feet method of determination or approximation. (revised 11/03/95) 9 a Department of Environmental Management/Division of Water Resources WATER WELL COMPLETION REPORT WELL LOBATION GEOGRAPHIC DESCRIPTION AddressO /Oa Q S E W of �/ (feet) / (circle) City/Town ��I ' � AICIOCA _e Well owner /C/.�4 �✓ (road) Address /$ / 'CCS�'✓.SDl1� t�U? e`'M S N S Q W of (mi.in tenths) (circle) v /• t intersect.�v/ ���'���� Board of Health permit: yes no ❑ 1�oNcd AC (road) WELL USE WELL DATA Domestic Q Public❑ Industrial ❑ Total well depth ��S ft. Monitoring❑ Other Depth to bedrocks ft. i.�_f�✓ Method drilled Water-bearing rock/unconsolidated material: lf-� ! m1 8CUC Date driller] Description CASING Water-bearing zones: Type 1) From 26�_ To 2) From �6 To &. o Length yO ft. Dia(I.D.) 6 in.. 3) From To Length into bedrock <>Q ft. Gravel pack well: dia. Protective well seal: Screen: dia. Grout-0 Other✓�/�� r'��� Slot# length—from— PUMP ength from_PUMP TEST Static water level below land surface w ft. Date Drawdown 3F-5ft. after pumpinghr, min.at I Z gpm How measured�f�C�i Recovery ft. after—hr. min. o o � Z� ' o LOG of FORMATIONS COMMENTS Materials From To 0 I cerQvl3c�,ti`CJ ' /6 Zo Driller L'Q�i�LCA�SO� Ah CI �E Mass. R,eggistration# o Firm �E Y1,---e4 G2- rel_ r ? S�o.� Address City/Town .t Signature o/supervising registered well driller Please print firmly V BOARD OF HEALTH COPY � Town of ZY1 )&I a,C_-�t Masschusetts a 0 Board of Health Permit No. Date a APPLICATION FOR WELL AND PUMP PERMIT Application is hereby made for permit to drill or repair a well. Application is also made to install ( ) major renovation ( ) or major repair ( ) of pump system. Location: Address /,5-Q /l8 �j�/ 27- Lot Number Owner �C F /�_ ,�/;t/ Address 1F&_)1 SCQ41S'oA1 Am-- Well Contractor Yl / ��C.�( Address (,id't2 ✓®7/Y' Pump Contractor Address WELL CONTRACTOR ( To be filled in at time of pum.p test ) Type of Well bel,CZECWell Used For. Diameter of Well Size of Casing Depth of BedrockCPO � Depth of Casing into Bedrock 10 r Was it Seal-Tested? YES ( ') NO ( ) Date of Testing 6- ,!! � i Depth of Well 106_ Well Ended in What Material Co Depth to Water 16 Delivers Gallons Per Minute Drawdown feet after pumping hours at G.P.M S tch map of well location with tie down lines on reverse side of this fd Date of Completion XTLL CONTITACrORIS SIGNATURE PUMP INSTALLER ( To be filled in before installation ) Size and Name of Pump Type of Pump Used Water Pump Delivers G.P.M. Size of Tank Pipe Material Used in Well: Cast Iron ( ) Galvanized ( ) Plastic ( ') If plastic, test strength Well Pit ( ) or Pitless Adaptor ( ) Was sleeve used to protect pipe? YES ( ) NO ( ) Type or Name of Well Seal Date PUMP INSTALLERS SIGNATURE Date water analysis report was submitted to Board of Health D r of record and Building Inspector Date release was given to owner g p HEALT INSPECTOR NSPECTOR DA TIM � OFRO AREA CO MSEA LM OF Ey LU I a 0U) ui qLLI IG D gVURNED CALL WILL CALL Oliomwj. ANTS TO OAGENT! ❑ CALL ❑ BACK ❑ AQAIN ❑ SEE YOU ❑ INS ❑? AMPAD NO.23-176-400 SETS NO.23-376-200 SETS BOARD OF HEALTH Town of North Andovcr ,Mass ......- _. . llute 19 . ,Permit # APPLICATION FOR WELL & PUMP PERMIT a well Application is Application is hereby made for permit to drill `f made to install ()6) a pump system. r � r�{c�r �� • ._Lot # • S' . . Location: Address L-ibe-r z,jNr,, `" + Adds•s1123 RP � S uese- 'T %XCe COO , Tel . '3F,,(�- 1�� 7� reI Owner o 2�S+ ('03 Arrk,efjul\ Acicir. css ma c+, Tel . '38> -'`3'��- 3 Well Contractor;��;; a �,,MF/ �� 1� -r-- Tel . . Pump Contractor �(Ann,�- __ Address � Mf'. ` WELL CONTRACTOR (To be completed at time of hump test ) , Well used for Type of Well ' Diameter of Well Size of Casing Depth casing into Bed Rock Depth of Bed Rock Was Seal Tested? Yes ( ) No (_) Date of Testi-ng Well Ended in Wt- haterial ha Depth of wle� — De th to Water Delivers _ Gals . Per Min . for 4 hours p _ Drawdown feet after pumping __hours' at _ GI'M i . Date of Completion — . Signature l•lell Contractor PUMP INSTALLER (To be' filied in before instal.lati_on) Pump Type Used Size & Name Pump __.--------- — -- Fanl< Water Pump Delivers_ -- Pipe Material Used in Well : CIst Iron ( _) GnJv;inizcd (_) Plastic Well Pit (_) or Pitless .Adapter (_) Was sleeve used to protect pipe? Yes (_) NO(_) Iype or Name tiJell Seal Date ' ' t�cik�t�►'t,4�F�'��t♦'tti4�'c�4�M�M�M�M ��'riM�M�4�ti't�r�4tiM�'ri4iMti4�'rti4i4ti'r�';ti4ti4;';�'r.'rti'rti'r5`: ::i':::::":::::., Date Water analysis repor-t submitted to i3o��rd of liealth Date release given tD owner of record & Bldg . Insp Health Inspector 4 r-tirrs Trat In Accordance with the Provisions of Massachusetts G.L. Chapter 21 Section 16 VICTOR C. MCKINNEY PLAISTOW, N.A. is Authorized to Dig or Drill Wells in the Commonwealth of Massachusetts During the Period JULY 1, 19 $9to JUNE 30, 1990 Certificate No. Director A� Chlet E�pineer SERIAL N� 3584 e • V �yy� '� p �� �z�/ �ce.c-a�, %/��c�. � �� . � L►uuulu11�1eNU1� t►f Alasrltcllusfllr ' ' `- I �g98UC�11113t�1�8 • ,�f�telrrv�rne —'5j'iteiii'Lncalo "''` �,�—•-�—"� , ✓ Y . . .-� / , � ► ': ; C�Ildlllll}� �►111111►ftl) t l�'�O u�la nr +ull►1►I►�� /2a q Arils! NI Syslelll 1'ullU►ed lit CuulelNs.lfnllskile►1 Ito ., Dole illsperldr , 1 „ ('onumnwealth of Massachusetts Massachusetts I stem Pumping Record I System Uwper System Location eA +. Dale of Pumping: © -- a- � Quantity Pumped: r,1;4e�' gallons i Cesspool: No Yes U Septic Tank: No Yes �-1---J System Pumped by: 45(j& A/tl eJ License# Contents transferrred to : Greater Lawrence Sanitary District Dale: Inspector: e .\ COMMONW ALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS -� >� DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE R'1''TER STREET. BOSTON. MA 02108 617-292-5500 WILLIAM F.WELD TRUDY COXF Govemo- 30 Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address. 11 5(-N es of Owner: Date of Inspection: 1C:' •-. -( �= of different) � Name of Inspector: ).` oc�=�'1 I am a D �ppr{°ved system inspector *ursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: _511,( Mailing Address: %\IVA 1 c Ltv, QuC)I R !c r Telephone Number: C t 1 F; 4t7,11i—L7tr1 s Ifo 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Casst es _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Inspector's Signature: r ( EU Date: (C� --37~C? The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. A INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM P S: l-.=t found any information which indicates that the system violafes any of the failure criteria as defined in 310 CMR 15.303. 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. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Ceitifidde of Compliance (attached) indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming "septic tank as approved by the Board of Health. I (revixod 04/25/97) Piga 1 of 10 DEP on the World Wide Web: http://www.magnet.state.ma.us/dep Printed on Recycied Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: i.5_0 Owner: C' Date of Inspection: B) SYSTEM CONDITIONALLY PASSES (continued) _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed he pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval Board of Health). Describe observations: broken pipe(s) are replaced obstruction.is removed distribution,box is levelled or replaced _ The system required pumping more than four 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 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 the public health, safety and the environment. t) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering Vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. _ ystem and the SAS 113 within a Zone I of a public water supntYweil The system has a septic tank and soil absorption syl• The system has a septic tank and soil absorption s _ stem and the SAS is within 56 feet of a private water Supply V _ The system has a septic Tank and soil absorption system and the SAS it less than 1100 feet but 50 feet of more from a private water supply well, unless a well water analysis for coliform bacteria and 'volatile organic taittpoUridf indicates that the well is free from pollution from that facility and the presence of ammonia nittogen and nitrate nrtrogi iequal to or s less than 5 ppm. Method used to determine distance (approxiltafioH.fio4'valid). 3) OTHER (revised 04/25/97) Vigo 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) rr ` Property Address Owner: t Date of Inspection: ��� D) SYSTEM FAILS: You must indicate either "Yes" or"No as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No _ Backup of sewage into facility or system component due to an 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. M Any portion of a cesspool or privy is within a Zone I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 map* Ztsne Il of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treattront program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. x' (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART 8 CHECKLIST 4 Property Address: Owner: Date of Inspection: Check if the following have been done: You must indicate either "Yes" or"No"as to each of the following: Yes No LZ Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. ( The facility or dwelling was inspected for signs of sewage back-up. not receive non-sanitary The system does or industrial waste flow. y- The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)) (revised 04/2S/97) Page 4 of 10 x p - �:. �' T.� 41t b t y�k .•^ Q i A a k i � 'r�b r 1 a, c�tk w,L^+ , '� �, � 'i .,r rx � � �5,� �jS x °� 9,k' q� F('�'"dJ ^v r �•xA,:"V �' f��` *4xf- ��i-k T' _. Y`'- _�. Ar+�591,$ STE ! NS KTIQN FORly 4 t, - �� E.+M .t 1r 4 1 '" 1.c �' ! r3'�,?'Jt y� 7� �n •��„ >w'ti r� *'A2'� r "a wK"*" F. 7 `O P' ?r � �`x.��.•�>Y''a�'-.� ycs +"+r ��yJ�Myj�t b ,. y \.^•uc''V - , •k ! { i Riz t+"", Ar" : T a yI0��/, 1DIT)ONS t r .t� xtii xa iPyyvix C Er ;:> s q0 ��` r a rti•, r„ -t - rr 3 :-mar d 'tg�� '�n, � ,� I�'{V t .F,,-�F ..•'z:4 4"E��h �' �+ �d.�T�;LL���" .:4 �, s��.. � M1 �j *'ygY d Y'7, vt W..Na'. h &P � 'al. {' � *f '•'+ - Y ry(� k .. R 'Tk•�( ,Q[�Ap 'k t E i S YA^a'v' � . �` fid,# - f J � • ^� Rg 51114;' t 10 �� � ,'' �' -�` *�if;,a'°•/ 7�k ¢ ., flat r' y na61 xS { 0 2 - ear sa (8p ! � yc Vit: � 2,Ut W4 -�i ;, 'Y �.�v��StY•a''v'y,, e d�t�r,'�Fa'+�r'v"�'F�•`'��W�'���.'M1';4 d k�' a,a-`d"-k',.,��'t s-n^'"+et-€r>Q��Zh.:..�b 5+.�;.d wE�«. t+n�v�g 6 ��.t.� •. ,� .. m3"y�+r f t h �. wj3 A+�' r' �"�"°��'�" hia '4 P h ; s''�t a w 4 �•Y" is',x. as J e* J�1 9,y�1h�. ,`�" sr��i•£, �..z b � 44 t a Y�F K. r �� 's . . -TUMM.1ny�.r,, �zt ,�Mf�,.Y-, `r .pK� f "V r �."' indUSt Y t`k Q 1 T n '• re eat'' Orn � ' �� �` a t w� t it is 41- a �µ►�o��aTTty,«�,r�tg �sc���ed �o the j�(e ��syst�� �y�s pr r)o)�' � , a+ ate! g � `of�yai)atitg° t - r -x+, r -:'c r Y•'7 .^r•- A ,r .t i .. 6 `�;..l.aSt .,..,.�•r..r.� n �y�' #tyt2� '� �43 7-77.7;� .T Ok, geltLy a T s r E ri. 4 t i �yyr3•F rr,P4`�`����i:'� ;�- z } a" �,r< ."' „' d�-"`"'f>an.+Pu �c g. ss� .� .r <`a r- i :�( r tt N.:a r k.., .e•n n ♦... _ _- � ASi i.ast��;�.�•%�llps. ?�1T1'' M , a �.� �. �� �x�sr ,qtr a t r >•r��=��,e.a* ��.,�+ E � �,� r`� S h^im,r r4� lY" �>{� ; .+'`; 4r6, +r ' °I ,y C'E}+ w1pp�w Y N ln�y�N �t`aA`^ iO - - t ! '�`],z �.�� �;, ,a�"r � "✓fir e h � � €-aa, �' s.: � s'5�'t1I)A�1,�1��������.��Ur��Qitt�r�tt0►1 'Fry � 2".t�c�,"��"��T S�Y �V,i' � ",�� '� +�'!1 ... {w irq y° 9�fEY^7 a c i rIJL41 �n s s rk Te So pi YPEt r Op ���tp�;p� dl ►+ yktlo9s�li �Qn�system M" t}*.,a E'.st'" � ! 1 SFt1iyetr )yes aI_no)�l�f ygs,attach pneyiqusiipspgcuon recorc)s,: f any) �fiypplo + CRY pf !?Eosiat cxtrct� h. .! y Qtllef a r * 77- Iv. .' r APPRp ASAG� fi F4Rlportttt$�.ate installed (lf knoy ) so�rae pf�pfprrrtatiop: Qi t s 5 A t� �n��yftxW R�'•y�d� �'✓ 5.t TRF ^+' >1 1(y :•i "`,�,l:�y �r x ,s�r�,,F �t r�^,�,x•�'�+{t>< +. �hPri� r s s a r t '4114 at�h� jte lyes pr►)p) c-.:' t t �.: i-sw+.,r.'•^ Y' a-fr.: }i i'=-da ,ny,�aa , y. J. a•:, w ^�'+.w, 'a yR .p.•3- i 4 y, ,.,,`<_ilr�Vd��d�A�/ 5`4(97? '� �•r�Yd t .-t� r,��' ` 7€,e ; ,� � 1t1�g1� 5 ,app 10 � y'Y2n SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 150 Ak('\AA- Owner; Da_to of Inspection: p 1��'��— 1 BUILDING'SEWER: ✓�" (locate on site plan) ti Depth below grade: Material of constrxu, n: ir�r "4 V� r ooh (�painl,t�v I caCa ' Distance from�pryate water supply ..well or suction l,r, � Diameter_ Comments. (condi ion of joints, venting, evidence of leakage, etc.) ti7n lQa S -- SEPTIC TANK:_ (locate on site plan) Depth below grade: t Material of construction: _ oncrete _metal Fiberglass _Polyethylene _other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions:_ Sludge depth:_ Distance from top of sludge to bottom of outlet tee or baffle: y - Scum thickness:C0 4 C " Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom Qfo(�tlet tee r baffle: ��� � Now dimensions were determined: U 1J`t C r� c . �C_ut� .V S Comments: (recommendation for pumping, cond of inlet an outlet tees or baffl s, deRth of liqu d le el in relatioq toutlej �yst� �al tegrity, evidence of leakage, etc.) v >yt, . ( �� '� ��e' tt _ .c v. Cl_ - 1VlUr? _f�., C C� . —-td �� GREASE TRAP:AbaV\£. (locate on site plan) Depth below grade: Material of construction: _concrete _metal _,Fiberglass _,Polyethylene other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: {recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (rw*rpd 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: UA SV Owner: Q�C-ck,- C7 Date of Inspection; to-31-i TIGHT OR HOLDING TANK:VVA4 (Tank must be pumped prior to, or 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/da� Alarm level: Alarm in working order_Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: (n to if yel a( ddii�tnbu on is equal, evidence of solid carryover, evi ence of leakage int or t of bo�c, etc.) �•t- � �%� �`�� d6``���7 =oc V �_ c 14 ` r_ P_GL 7 )" 6 c�c.a e .CJ C- - watcc?e.stiff PUMP CHAMBER: (locate on site plan) Pumps in working order: (Yes or No) . Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (r6vieed 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: (C) �,q -�� S'� /vim ACA 'lti.�'X)t,Js-,C 1 � Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):.✓�"'� (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type. .. --- leaching pits, number:_ leaching chambers, number:_ leaching galleries, number. leaching trenches, number,length: i'7t� j leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: a Comments: (no, condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) CESSPOOLS: (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level.of ponding, condition of vegetation, etc.) PRIVY:,OC (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.) n (revised 04/25/87) Page a of 10 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: L. kt C�,k-A Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM:, include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) :)� )k->c_ =- '',uIL 3 C-AS 3 t i i (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM t ^ INFORMATION �(continuk Property Address: No('44k x a-v- Owner: Date of Inspgclion: la- Depth to Groundwater I Feet Please indicate all the methods used to determine High Groundwater Elevation: O'er btained from Design Plans on record Observation of Site (Abutting property,'observation hole, basement sump etc. etermmiine it from local conditions ]��Check with local Board of health ' Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) S c:� e ��,V-'-' �l cam„, (revised 04/15/97) Tego 20 of 10 TO: (978) 475 - 4786 Fax: (978) 475 - 5451 RATESON ENTERPRISES, INC. EXCAVRling r Wad•A Sew Wow-Septic SybtcnIs&Pumping Service 111 ,Argilla Road Andover, Mass. 01810 Title 5 Inspection Report property Address: - T Owner: C":) Tate of Inspection: My report contained herein does not constitute a guarantee of firtiare usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and l hereby disclaim any further operation of your current septic system. Neil J. Bateson Bateson Enterprises, Inc. n Page l I of 1 l Commonwealth of Massachusetts RE CEIVED City/Town of NORTH ANDOVER SAC USE � System Pumping Record AU2006 Form 4TOWN OFANDOVER DEP has provided this form for use by local Boards of Health. The sytemnn Ree- mu: be submitted to the local Board of Health or other approving authority. A. Facility information --- ---- Important: When filling out 1. System Location: forms the computer,use ,���Q. only the tab keys Address ___ _ — _--..-.._ to move your cursor-do not ---------.--_._. use the return City/Town - State Zip Code ---- -- - key. 2. System Owner: :, - ---r... - ------ - - -- --- ------- ----------- ---- Name Address(if different from location) Stat p Code ---_ - Telephone Number B. Pumping Record -- 1. Date of Pumping p =" -- 2. Quantity Pumped: ate Yl ----- -- Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): - - --- - 4. Effluent Tee Filter present? ❑ Yes e No If yes, was it cleaned? ❑ Yes 60110 5. Condition of System: 6. Sy em Pumped By: 1�T1[1_ ( LJ - ' Name -------....__--- --...------------------- ---------- Vehicle License Number Company 7. Location where contents were disposed: __ A,) Si ature of Haul - Date http://www.mass,gov/dep/water/ provals/t5forms.htm#inspect t t5form4.doc•06/03 System Pumping Record•Page 1 of ?